Urinary System
Urinary Tract Calculi Fluid volume With decreased urine output,
fluid retention occurs Neck veins distended Bounding pulse Edema
Hypertension Fluid overload can lead to heart failure, pulmonary
edema, and pericardial and pleural effusions Metabolic acidosis
Serum bicarbonate level decreases Severe acidosis develops Kussmaul
respirations Sodium balance Increased excretion of sodium
Hyponatremia can lead to cerebral edema Potassium excess Usually
asymptomatic ECG changes Diuretic phase Daily urine output is 1 to
3 L May reach 5 L or more Monitor for hyponatremia, hypokalemia,
and dehydration Recovery phase May take up to 12 months for kidney
function to stabilize Q&A: Which assessment would indicate to
the nurse that a patient has oliguria related to an intrarenal
acute kidney injury? a) Urinary sodium levels are low.b) The serum
creatinine level is normal.c) Oliguria is relieved after fluid
replacement. d) Urine testing reveals a specific gravity of 1.010.
Rationale: The urine specific gravity in oliguria of intrarenal
acute kidney injury will be fixed at 1.010. This value reflects
tubular damage with loss of concentrating ability by the kidneys.
The serum creatinine level is above normal in oliguria of
intrarenal acute kidney injury. Urinary secretion of sodium
increases with oliguria of intrarenal acute kidney injury. Prerenal
oliguria related to hypovolemia will usually respond to fluid
replacement. Diagnostic studies Thorough history Serum creatinine
Urinalysis Kidney ultrasonography Renal scan Computed tomography
(CT) scan Renal biopsy Contraindicated Magnetic resonance imaging
(MRI) Magnetic resonance angiography (MRA) with gadolinium contrast
medium Nephrogenic systemic fibrosis Contrast-induced nephropathy
(CIN) Collaborative care Primary goals Eliminate the cause Manage
signs and symptoms Prevent complications Ensure adequate
intravascular volume and cardiac output Closely monitor fluid
intake during oliguric phase Hyperkalemia Insulin and sodium
bicarbonate Calcium carbonate Sodium polystyrene sulfonate
(Kayexalate) Indications for renal replacement therapy (RRT) Volume
overload Elevated serum potassium level Metabolic acidosis BUN
level higher than 120 mg/dL (43mmol/L) Significant change in mental
status Pericarditis, pericardial effusion, or cardiac tamponade
Renal replacement therapy (RRT) Peritoneal dialysis (PD)
Intermittent hemodialysis (HD) Continuous renal replacement therapy
(CRRT) Cannulation of artery and vein Nursing Management Planning
The patient with AKI will Completely recover without any loss of
kidney function Maintain normal fluid and electrolyte balance Have
decreased anxiety Comply with and understand the need for careful
follow-up care Nursing implementation Monitor intake and output
Monitor electrolyte balance Measure daily weight Replace
significant fluid losses Use nephrotoxic drugs sparingly Evaluation
The expected outcomes are that the patient with AKI will Regain and
maintain normal fluid and electrolyte balance Comply with the
treatment regimen Experience no untoward complications Have
complete recovery Gerontologic Considerations More susceptible to
AKI Polypharmacy Hypotension Diuretic therapy Aminoglycoside
therapy Obstructive disorders Surgery Infection
ADDITIONAL ELECTROLYTE DISTURBANCES WITH CRD
Dialysis Movement of fluid/molecules across a semipermeable
membrane from one compartment to another Used to correct
fluid/electrolyte imbalances and to remove waste products in renal
failure Treat drug overdoses Begun when patients uremia can no
longer be adequately managed conservatively Initiated when GFR (or
creatinine clearance) is less than 15 mL/min Dialysis Two methods
of dialysis available Peritoneal dialysis (PD) Hemodialysis (HD)
ESKD treated with dialysis because There is a lack of donated
organs Some patients are physically or mentally unsuitable for
transplantation Some patients do not want transplants Osmosis and
Diffusion across Semipermeable Membrane Peritoneal Dialysis
Peritoneal access is obtained by inserting a catheter through the
anterior abdominal wall Technique for catheter placement varies
Usually done via surgery Tenckhoff Catheter Waiting period of 7 to
14 days preferable Two to 4 weeks after implantation, exit site
should be clean, dry, and free of redness/tenderness Once site
healed, patient may shower and pat dry Dialysis Solutions and
Cycles Available in 1- or 2-L plastic bags with glucose
concentrations of 1.5%, 2.5%, and 4.25% Electrolyte composition
similar to that of plasma Solution warmed to body temperature Three
phases of PD cycle Inflow (fill) Dwell (equilibration) Drain Called
an exchange Inflow Prescribed amount of solution infused through
established catheter over about 10 minutes After solution infused,
inflow clamp closed to prevent air from entering tubing Dwell Also
known as equilibration Diffusion and osmosis occur between patients
blood and peritoneal cavity Duration of time varies, depending on
method Drain Lasts 15 to 30 minutes May be facilitated by gently
massaging abdomen or changing position Complications Exit site
infection Peritonitis Hernias Lower back problems Bleeding
Pulmonary complications Protein loss Effectiveness and Adaptation
Short training program Independence Ease of traveling Fewer dietary
restrictions Greater mobility than with HD Hemodialysis Obtaining
vascular access is one of most difficult problems Types of access
Arteriovenous fistulas and grafts Temporary vascular access
Vascular Access for Hemodialysis Dialyzers Long plastic cartridges
that contain thousands of parallel hollow tubes or fibers Fibers
are semipermeable membranes Hemodialysis Procedure Two needles
placed in fistula or graft One needle is placed to pull blood from
the circulation to the HD machine The other needle is used to
return the dialyzed blood to the patient Components of Hemodialysis
Continual Renal Replacement Therapy (CRRT) Alternative or
adjunctive method for treating AKI Means by which uremic toxins and
fluids are removed Acid-base status/electrolyte balance adjusted
slowly and continuously Often used in hemodynamically unstable
patients Hemofilter change every 24 to 48 hours Ultrafiltrate
should be clear yellow Specimens may be obtained for evaluation
Most common approaches: venovenous Continuous venovenous
hemofiltration (CVVH) Continuous venovenous hemodialysis (CVVHD)
Q&A: A patient undergoes peritoneal dialysis exchanges several
times each day. What should the nurse plan to increase in the
patients diet?a) Fatb) Proteinc) Caloriesd) Carbohydrates
Kidney Transplantation Very successful One-year graft survival
rate Cadaver transplants: 90% Live donor transplants: 95%
Advantages of kidney transplantation over dialysis Reverses many of
the pathophysiologic changes associated with renal failure
Eliminates dependence on dialysis Less expensive than dialysis
after the first year Kidney Transplantation Immunosuppressive
Therapy Goals Adequately suppress the immune response Maintain
sufficient immunity to prevent overwhelming infection Complications
Rejection Acute rejection Occurs days to months after
transplantation Chronic rejection Process that occurs over months
or years and is irreversible Infection CV Disease Malignancies
Recurrance of Renal Disease Steriod-Related Complications Q&A:
Six days after kidney transplantation from a deceased donor, a
patient develops a temperature of 101.2 F (38.5 C), tenderness at
the transplant site, and oliguria. The nurse recognizes that these
findings indicatea) Acute rejection, which is not uncommon and is
usually reversible.b) Hyperacute rejection, which will necessitate
removal of the transplanted kidney.c) An infection of the kidney,
which can be treated with IV antibiotics.d) The onset of chronic
rejection of the kidney with eventual failure of the kidney.
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