Alterations in Renal and Urinary Tract Function

1. Alterations in Renal and Urinary Tract Function Larry Santiago, MSN, RN

3. Review • Kidneys excrete urine and help regulate the water, electrolyte, and acid-base content of the blood • As blood passes through the glomerulus, water and dissolved substances are filtered through the capillary walls, resulting in glomerular filtrate • After passing through the tubules, final product is urine

6. Diagnostic Evaluation • Urinalysis and Urine Culture • Detects protein, glucose, and ketone bodies • Detects RBCs, WBCs, crystals, pus, and bacteria

8. X-ray and other imaging modalities • KUB (Kidney, ureters, and bladder) • Delineates size, shape, and position of the kidneys • Reveals abnormalities like renal calculi, cysts, tumors

9. Renal Ultrasound • Uses sound waves passed into the body through a transducer • Fluid accumulation, masses, congenital malformations, megaly, or obstructions can be identified • Requires a full bladder

11. Bladder Ultrasound • For measuring urine volume in the bladder • Indicated for urinary frequency, measurement of postvoiding residual urine volume, inability to void postoperatively

12. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) • Noninvasive techniques that provide excellent cross-sectional views of the kidney and urinary tract • Evaluates GU masses, renal and urinary tract trauma, metastatic disease, soft tissue abnormalities

13. Management of Patients With Upper or Lower Urinary Tract Dysfunction

14. Urinary Incontinence • Stress incontinence – involuntary loss of urine through an intact urethra because of intra-abdominal pressure (sneezing, coughing, etc.)

16. Urinary Incontinence 2 • Urge Incontinence – involuntary loss of urine associated with a strong urge to void that cannot be suppressed • Reflex incontinence – Hyperreflexia in the absence of normal sensations associated With voiding - Common with spinal cord injury

17. Assessment and Diagnostic Findings • Causes of Transient Incontinence (DIAPPERS) • Delirium • Infection of the urinary tract • Atrophic vaginitis, urethritis • Pharmacologic agents (anticholinergics, sedatives, alcohol, analgesics, diuretics) • Psychological factors (depression) • Excessive urine production (excessive intake, diabetes insipidus, ketoacidosis) • Restricted activity • Stool impaction

18. Pharmacologic Therapy • Ditropan (oxybutynin) and Antispas (dicyclomine) • Inhibit bladder contraction • Considered first-line meds for urge incontinence

19. Behavorial Strategies • Fluid management • Take fluid in small increments b/w breakfast and dinner • Avoid caffeine, carbonation, alcohol, artificial sweetener

20. Standardized Voiding Frequency • Timed voiding – set voiding frequency (such as q2h) • Prompted voiding – assist with BRP and positive reinforcement • Bladder retraining – incorporates a timed voiding schedule and urinary urge inhibition exercises to inhibit voiding

21. Pelvic Muscle Exercise • AKA Kegel exercises • Strengthens the voluntary pelvic muscles • For both men and women • Gently tighten the pelvic muscles for 5-10 second increments, then 10 seconds of rest • Perform 2-3 times a day, with 10-30 repetitions

22. Surgical Management • Women: Vaginal sling - Compresses urethra and increases resistance to flow • Men: Transurethral resection - Relieve symptoms of prostatic enlargement

24. Urinary Retention • Pathophysiology • May result from diabetes, prostate enlargement, urethral pathology, trauma, PG, CVA, SCI, MS, or Parkinson’s • Many meds can cause

25. Assessment and Diagnostic Findings • What was the time of the last voiding, and how much urine was excreted? • Is the patient voiding small amounts of urine frequently? • Is the patient dribbling urine? • Does the patient complain of pain or discomfort in the lower abdomen? • Is the pelvic area rounded and swollen?

26. Complications • Can lead to chronic infection • Unresolved infections • calculi, pyelonephritis, and sepsis

27. Nursing Management • Promoting normal urinary elimination • Promoting urinary elimination • Promoting home and community-based care

28. Neurogenic Bladder • Results from a lesion of the nervous system • Caused by spinal cord injury, spinal tumor, herniated vertebral disc, MS, congenital anomalies

29. Pathophysiology • Spastic Bladder • More common • Caused by any spinal cord lesion above the voiding reflex arc • Loss of conscious sensation and cerebral motor control

30. Pathophysiology 2 • Flaccid bladder • Caused by lower motor neuron lesion, commonly from trauma • Bladder continues to fill and becomes greatly distended

31. Medical management • Preventing overdistention of the bladder • Emptying the bladder regularly and completely • Maintaining urine sterility with no stone formation • Maintaining adequate bladder capacity with no reflux

32. Medical Management 2 • Continuous, intermittent, or self-catheterization, • Condom catheter • Low Calcium diet (to prevent calculi) • Increased fluid intake • Double voiding

33. Catheterization • Indwelling devices and infections • UTIs are 40% of nosocomial infections • 80% of those are indwelling catheter related • Pathogens include E. coli, Klebsiella, and Proteus

34. Suprapubic Catheterization • Inserting a catheter into the bladder through a suprapubic incision • Diverts the urine flow from the urethra when the urethral route is impassible

35. Nursing Management • Assessing the Patient and the System • Assessing for Age-Related Complications • Preventing Infection

36. Minimizing Trauma • Using an appropriate-sized catheter • Lubricating the catheter adequately with a water-soluble lubricant during insertion • Inserting the catheter far enough to prevent trauma when the balloon is inflated

37. Mr. Kennett says: “Chip and dip” for women “Ice the cake” for men

38. Bladder Retraining • Timed voiding schedule, usually every 2-3 hours • After voiding, bladder scan performed • Straight cath if >100cc remain in bladder

39. Assisting with Intermittent Self-Catheterization • Provides periodic drainage of urine from the bladder • Nurse must use aseptic technique • Patient can use clean technique at home • Emphasize importance of frequent catheterization (q 4-6 hours)

40. Dialysis • Removes fluid and uremic waste products from the body when the kidneys cannot do so • Methods include hemodialysis and peritoneal dialysis

41. Hemodialysis • For acute renal failure and chronic renal failure • Must undergo treatment for life or until a successful kidney transplant • Tx occurs 3-4 times a week for about 3-4 hours

42. Principles of Hemodialysis • Extracts toxic nitrogenous substances from the blood and to remove excess water • Toxins and wastes removed by diffusion (they move from an area of higher concentration to an area of lower concentration in the dialysate)

45. Vascular Access • Subclavian, Internal, Jugular, and Femoral Catheters Provides immediate access Insertion of double or multi-lumen catheter through the vein Can be used for several weeks

46. Vascular Access 2 • Fistula • Created surgically by joining an artery to a vein • Artery for arterial flow • Vein for reinfusion of the dialyzed blood

48. Complications of Hemodialysis • Arteriosclerotic cardiovascular disease • Heart failure, stroke, peripheral vascular insufficiency • Anemia, fatigue, GI problems • Insomnia • Hypotension • Painful muscle cramping

49. Pharmacologic Therapy • Antihypertensive therapy • Renagel • Nephrovite – multivitamin for renal failure, including Folic Acid and B vits is indicated for the control of serum phosphorus in patients with Chronic Kidney Disease on hemodialysis.

50. Nutritional Therapy • Restriction of Protein, Sodium, Potassium, and fluid intake • Protein 1 g/kg ideal body weight q day • Sodium 2-3mg/day • Potassium 1.5-2.5g/day