What changes in the kidney occur due to aging?

Older people have a reduced number of nephrons.

Kidney mass is reduced.

GFR(glomerular filtration rate) is reduced.

The concentration of urine. 

Higher specific gravity = higher concentration.

It can measure for dehydration.

-Urinalysis

-Culture and sensitivity

-24 hour urine

-Urinalysis identifies cells or crystals in the urine.

-USE MIDSTREAM CLEAN-CATCH TECHNIQUE.

-Creatinine and protein in urine are used to help identify kidney disease.

-Increased levels indicate kidney disease, UTI, or other serious conditions

-May need to be kept refrigerated or on ice.

-Note diet or med changes during collection period.

-Post notices that all urine is to be saved.

-Discard first urine, save ALL including the last specimen.

-If any urine is missed you must RESTART.

What is the normal result for a Urinalysis?

-color

-specific gravity

-PH

Color: Light straw to dark amber color with no foul odor

Specific Gravity: 1.005-1.030

PH: 4.5-8.0

Normal findings in the 24 hour urine test.

-Protein?

-Creatinine?

Protein:  150mg/24 hour period

Creatinine:  0.9 to 1.9 g/ 24 hour period

What does the IVP diagnostic study evaluate and how?

-Evaluates the urinary tract and renal function

-Contrast medium and xrays are used to evaluate

OBTAIN INFORMED CONSENT.

-Ask about ALLERGIES to iodine, seafood and xray contrast dye.

-Laxatives as ordered before procedure

-CLEAR LIQUIDS ONLY 8 HOURS BEFORE TEST

-Monitor VS

-Urinary Output

-Check injection site for redness, pain, warmth

-Apply warm packs to site if indicated

-Increase fluids

List sypmtoms of an allergic reaction to the dye in the IVP procedure.

-Dyspnea

-Tachycardia

-Itching

-Hives

-Flushing

REPORT THESE IF PRESENT AFTER IVP

NEED INFORMED CONSENT.

-Teach/assist with bowel preparation as ordered.

-NPO 8 HOURS BEFORE PROCEDURE

-Administer sedation and other meds as ordered

-Warm sitz baths and meds help relieve discomfort

-Increase fluids

-Laxatives may be ordered to prevent constipation or straining

Any condition that increases bladdre pressures or reduces resistance with in the urethra.

-Pelvic muscle relaxation

-Imparied nerual control

-Bladder problems

1-May be treated with drugs to inhibit detrusor muscle contractions and increase capacity.

-Detrol/ Ditropan

2-Estrogen therapy may be used.

3-Surgery may be performed.

-Bladder neck suspension

-Prostatectomy

Multiple pregnancies, decreased estrogen, prostate surgery.

-Loss of small amt of urine when pressure increases as in sneezing, laughing, etc.

Decreased bladder capacity, bladder irriation, CNS disorders.

-Involuntary urine loss associated with a strong need to void RIGHT NOW.

Neurologic disorders or trauma, enlarged prostate, fecal impaction, anticholinergic drug effects.

-Urinary retention with bladder overdistention and frequent loss of small amounts of urine.

Neurologic disorders or trauma.

-Involuntary loss of moderate amt of urine occuring with out warning.

Physical disability, impaired mobility, neurologic disorders, diuretic therapy or sedation, lack of facilities, privacy or caregiver assistance.

-Inability to get tot toilet facilities to urinate.

-Benign Prostatic Hypertrophy

-Acute inflammation

-Surgery

-Medications

-Neurologic Diseases

-Voluntary urinary retention

What can cause a UTI in females?

(urinary tract infection)

-Short urethra

-Proximity to vagina and anus

-Tissue trauma/contamination during intercourse

-Personal hygiene practices

-Voluntary urinary retention

-Diaphragm use for birth control

What can cause a UTI in males?

-More alkaline urine (less acidic)

-Incomplete bladder empyting

-Urinary retention

-Changes in vaginal PH(women)

-Decreased prostatic secretions(MEN)

-Higher incidence of diabetes and glucosuria

Glucose in the urine promotes bacterial growth.

SUGAR LIKES BACTERIA!

-Dysuria

-Frequency

-Urgency

-Nocturia

-Pyuria(pus)

-Hematuria(blood)

-Flank Pain

-Costovertebral tenderness

-Vomitting

-Diarrhea

-Fever

-Shaking

-Chills

-Malaise

-ANTIBIOTICS!

-  3, 7, or 10 day course of antibiotics.

(sulfonamides)

-Anti-Infectives(for chronic infections)

-Analgesics(to relieve pain)

It is considered an upper UTI.

-Inflammation of the renal pelvis and parenchyma (functional portion of the kidney)

SAME AS A UTI!

Antibiotics, Anti-Infectives and Analgesics can be used.

Sulfonamide = ANTIBIOTIC!

USED FOR UTI'S

An inflammatory condition that primarly affects the glomerulus.

-Usually follows an infection of strep.

-Immune complexes become trapped in the glomerular membrane which causes an imflammatory response and draws WBC's to the area.

-Hemturia

-Proteinuria

-Edema

-Hypertension

-Fatigue

-Anorexia

-Nausea

-Vomitting

-Headache

-Elevated BUN and creatinine

Identify and treat underlying cause!

Dietary management.

-Possible Na restriction

-Proteins may be increased when they are being lost in the urine

-If azotemia is present -Protein is restriced!

(azotemia = elevated BUN levels)

NEPHROTIC SYNDROME:

Low Na diet with moderate protein restriction

-Throat/Skin cultures

-ASO titer

-Erythrocyte sedimentation rate(ESR)

-BUN/Serum Creatinine

-GFR/Creatinine clearance

-Serum electrolytes

-Urinalysis

-KUB xray

-

-Painless Hematuria (blood in urine)

-Frequency to urinate

-Urgency (gotta go right now!)

-Dysuria (painful urination)

1. Excretes metabolic wastes

2. Excretes or conserves water and solutes

3. Regulates acid-base balance

4. Regulates blood pressure

What is the purpose of the ureters?

Hollow, muscular organ that holds urine.

It controls the release or urine.

1. Renin-Angiotensin-Aldosterone system

2. Production of erythropoietin

3. Activation of vitamin D (important for calcium regulation)

Inflammation of the renal pelvis and parenchyma.

1. Empty bladder every 2-4 hours while awake

2. Maintain intake of 8-10 glasses/day

3. Cleanse front to back after voiding

4. Void before and after sexual intercourse

5. Avoid bubble baths, feminie hygiene, sprays, douches

6. Wear cotton undergarments

-Proteinuria

-Low serum albumin levels

-High blood lipid levels

-Edema

A client is complaining of pain in the right flank region. Which of the follow-up question would be most important for the nurse to ask?

1. Have you noticed any changes in your urine?

2. Do you have diabetes?

3. Has your appetite or weight changed recently?

4. Does the pain wake you from sleep?

Digoxin 0.25 mg daily has been prescribed for an 80 y.o. client. The nurse observes closely for:

1. evidence of drug excretion without the desire effect.

2. excretion of the drug unchanged in the urine.

3. impaired urinatio due to effects of the drug.

4. manifestations of drug toxicity due to impaired excretion.

4. manifestations of drug toxicity due to impaired excretion.

--Renal function declines with aging as nephron units are lost. This affects drug excretion, increasing the risk of toxicity. Doses of drugs such as digoxin often need to be lower for older adults

The nurse, preparing a client who is scheduled for a creatinine clearance test, includes which of the following in the instructions? Select all that apply

1. note time of the first saved urin sample as the start of the 24 hour collection

2. save a portion of each voiding for 24 hours.

3. empty the bladder at the start time and discard this urine.

4. avoid puting any toilet paper in the saved urine.

5. prevent feces from contaminating the saved urine.                   Review page 734 box 28-3

The nurse reviewing a urinalysis (UA) results for a client notes that there is 2+ protein in the urine. The most appropriate response by the nurse is to:

1. do nothing, as this is within normal limits for the UA

2. limit the clients protien intake.

3. report the result to the physician

4. request a repeat urinalysis to verify

Define renal calculi.

Kidney stones

-Masses of crystals formed from materials normally excreted in the urine.

-Kidney/Pelvis- dull achy flank pain

-Ureter- renal colic, pain radiating to suprapubic area, nausea, vomitting, pallor, cool clammy skin, hematuria.

-Bladder- Dull suprapubic pain, hematuria

-Medications: narcotic analgesics & thiazide diuretic

-Dietary Management: Increae fluids (2.5-3L)  Review table 29-3 page 757

-Surgery: Lithotripsy, cytoscopy, nephrolithotomy, nephrectomy.

- #1 IS PAIN MANAGEMENT

-Increase fluids

-Monitor output

-Strain ALL urine

-Patient teaching

-Straining for urine allows us to save recovered stones for lab analysis.

-Lab analysis can help direct treatment to prevent further stone formation.

How would you explain the ESWL procedure to a client?

(Extracorporeal shock-wave lithrotripsy)

An obstruction causes urine back up from bladder into ureters and kidney.

-CT scan

-Ultrasound

-Cytoscopy

-Flank pain

-Hematuria, pyuria (pus in urine)

-Fever, Nausea, Vomitting, Abdominal Pain

-Decreased urine output

-Increase fluid and sodium

-Cyst puncture/ abscess drainage

-Antihypertensives

-Dialysis

-Kidney transplant

-Genetic counseling

Blunt or penetrating injuries.

-Contusions

-Hematomas

-Lacerations

-Pain

-Hematuria

-Anuria

-Grey Turner's sign

-May have signs of shock

1. Prerenal - Decreased blood flow to glomeruli (ischemia-hemmorhage, heart failure, shock)

2.Intrarenal - Trauma, surgery, infections, nephrotoxins drugs & contrast dyes.

3. Postrenal - obstruction below kidneys causing urine to back up.

1. Initiation Phase

2. Maintenance Phase

3. Recovery Stage

-Short (1-3 days)

-Increased BUN, creatinine

-Normal to decreased urine output

-Follows onset stage and ocntinues for up to 14 days. Urine output decreased < 400mL/day

-Increased BUN, creatinine, potassium, phosphorus

-Decreased bicarbonate and calcium

-Anemia

-Urine output > 400mL/day; may rise above 4 Liters/ day

-Lasts 1 to 12 months

-As renal tissue recovers, serum electrolytes, BUN and creatinine retrun to normal

-Treat underlying cause

-Fluid and dietary restrictions

-Restoration of electrolyte balance

-Drug therapy

-Diet

-Temporary hemodialysis

-Given through AV fistula (connection between artery/vein)

-Electrolytes, waste products and excess water are removed from the body by diffusion and filtration.

-Uremia (urine in blood)

-Nausea, Vomitting

-Weakness, Fatigue

-Lethargy, Confusion

-BUN

-Creatinine

-Urinalysis

-Electrolytes

-Kidney biopsy

-Multisystem effect (uremia)

-Azotemia (nitrogen metabolites - urea, creatinine, and uric acid)

-Dialysis or kidney transplant is necessary!

-Maintain intake/ output

-Daily weights

-Vitals q 4 hours

-Assess lung sounds, heart sounds

-Edema, neck vein distention

-Fluid / dietary restrictions

-Emotional support

-Eductaion regarding dialysis

What does the nursing evaluation and care of a patient with a dialysis shunt entail?

-DO NOT use affected arm for BP

-DO NOT use affected arm for labs

-Auscultate to hear bruit

RESTRICT FLUID

RESTRICT PROTEIN

RESTRICT SODIUM

RESTRICT POTASSIUM

RESTRICT FLUID

RESTRICT PROTEIN

RESTRICT SODIUM

RESTRICT POTSSSIUM

(Once pt is to dialysis , increase protein, calories, calcium)

-Pallor

-Uremic skin color (yellow/green)

-Dry skin

-Pruritis

-Ecchymoses

-Anemia

-Impaired clotting

-Increased risk of infection

-Hyperkalemia

-Acidosis

-Hyperlipidemia

-Hyperuricemia

-Malnutrition

INCREASE fluids

DECREASE sodium

A 79 year old client with benign prostatic hypertrophy has not voided in the past 8 hours. The FIRST actionby the LPN would be to:

1. provide 500 mL fluids orally

2. perform a catheterization with a 14 Fr. straight cath.

3. Palpate lower abdomen

4. notify the physician

A 50 year old woman experiences stress incontinence.  Which of the following assessment findings indicates a risk factor for this condition?

1. total abdominal hysterectomy 9 years ago.

2. smokes one pack of cigarettes per day

3. exercises four times a week

4. history of two pregnancies

An LPN evaluates for residual urin on a client; 30 mL of clear yellow urin is returned.  The appropriate action by the nurse would be to:

1. notify the physician

2. document the finding in the medical record

3. implement measures to assist the client void

4. increase the client's fluid intake

2. document the finding 

-50ml or less is normal

THe nurse establishes a nursing diagnosis of Urinary Incontinence related to weak pelvic floor muscles for a 69 year old client.  Which of the following would be appropriate nursing intervention?

1. encourage client to drink orange juice and tea at each meal.

2. schedule furosemide (Lasix) 40mg at 8pm daily

3. teach to perform kegel exercises every 2 hours while awake

4. restrict fluid intake to 500 mL/ day

3. teach to perform kegal exercises every 2 hours while awake.

The nurse teaching a client to help prevent urinary tract infections includes which of the following instructions? select all that apply

1. drink at least one 8 ounce glass of orange juice daily

2. increase your water intake to 6 or more glasses per day

3. after voiding or defecating, wipe from back to front

4. wear cotton briefs under clothing

5. void before and after sexual intercourse

A 19 year old is admitted with acute glomerulonpehritis. The nurse expects to obtain which of the following assesment findings?

1. "strep throat" 2 weeks ago

2. pneumonia 1 week ago

3. gastroenteritis

4. infulenza 3 weeks ago

1. strep throat 2 weeks ago

-glomerulonephritis is known to follow a strep infection

For a client with a uretral calculus, a priority nursing action is to

1. wash hands

2. restrict fluids

3. strain all urine

4. collect a sterile urine specimen

A female client is discharged after a right nephrotomy to remove a urinary calculus.  Discharge teaching should include:

1. maintaining oral fluid intake of 1500mL/day

2. avoiding all sources of calcium

3. signs and symptoms of urinary tract infection

4. maintaining alkaline urine

3. signs/ symptoms of UTI

-this patient would be at risk for a UTI following this procedure

A client is diagnosed with chronic kidney disease.  The nurse explains that dietary management of a client with chronic kidney disease includes:

1. a high protein, low carb diet

2. a low protein, high carb diet

3. a high fat, moderate-sodium diet

4. a low fat, high sodium diet

A client has arteriovenous (AV) fistula in his left arm for hemodialysis access.  THe nurse recognizes the need for further teaching if the client states:
1. "My wife gets the best blood pressure in my left arm."

2. "I check my fistula for pulsations."

3. "I remind the lab personnel to take blood from my right arm."

4. "I sleep on my left side with my left arm extended." 

1. "My wife gets the best blood pressure in my left arm."

-Patients on hemodialysis SHOULD NOT have BP or labs drawn from the affected arm!