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Renal System

winter 2012
by

Molly McClelland

on 22 February 2017

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Transcript of Renal System

Renal System
Nephrolithiasis
Acute Renal Failure (ARF)
Chronic Renal Failure
Renal Diagnostics
Signs & symptoms:
Painful !!! (Treatment of pain is priority)
May become infected (Fever, Elevated WBC)
Nausea (r/t pain / volume deficit)
Assessment:
Get diet history
Determine family history (can run in families)
Ask about medications (some contribute to development of stones)
CKD - cont'd
Uremic waste (caused by the by-products of protein breakdown) builds up in system & can cause:
Sensory imbalances (ie...CNS damage )
Nitrogenous product accumulation (uremic frost)
Renal Disease
Causes:
Pre-renal: Hypovolemia, MI, Burns, Sepsis
Kidneys can still concentrate urine - rehydrate STAT (bolus then maintenance)
Spec. gravity will be high
No protein in urine
Intra-Renal: Damage to the tubules, ie...polycystic kidney disease, Nephrotoxic drugs, Kidney Failure
Tubular Casts / debris in urine (will only occur in intrarenal failure)
Protein in urine
Post-renal: Bladder / prostate problems, etc...
Difficulty urinating
Bladder pressure / low urine stream / flow
Treatment for Kidney Stones
1.) Analyze stone composition:
Necessary in order to determine treatment (diet alterations)
Strain urine to collect stone (if passable on own)
2.) If too large, may require surgey:
Extracorporeal Shock-wave therapy
Lithotripsy
Occurs suddenly / quickly
Causes:
Typically from outside the kidneys such as HTN, hypovolemia, nephrotoxins (if cause can be eliminated / addressed ARF may improve)
Provide supportive care (fluids, rest, etc) while kidneys recover
S/S:
Major electrolyte shifts
metabolic acidosis, fluid retention (S / S ???)
Elevated renal labs (which ones? Normals?)
Phases:
Oliguric : Replace fluid cautiously - with output from previous day plus 600 mL for insensible water loss. May see proteinuria, hypervolemia, pulmonary edema, Hyperkalemia
Diuretic: Massive urine outputs, F & E imbalances common, can lead to hypovolemia, hypotension, hyponatremia, hypokalemia,
May require dialysis (Hemo or peritoneal)
Needs to restrict fluids (if not on dialysis), use the 24 intake + 600 mL rule.
Tendency to retain significant amounts of water and sodium r/t < GFR
May be treated with erythropoietin shots to increase RBC's and supports patients health
Generally have high phosphate levels (avoid calcium / dairy products).
Diet important - avoid potassium containing foods (lots of fruits / veggies have potassium)
Serology
Urinalysis
Cystoscopy
IVP
Retrograde pheylogram
MRI
CT Scan
Ultrasound
Nursing Care p lithotripsy:
Monitor uo (to ensure sand / small fragments are not obstructing)
Tx pain (tender at site / slightly red at site)
Encourage fluids (b/w 2000 - 3000 qd)
Diet important - sometimes high Ca++ intake good. / Avoid coffee & dehydrating fluids
Alter Diet Based on composition of stone:
Purine & Uric Acid - found in organ meats & bony fish (sardines), shellfish, anchovies, asparagus, and mushrooms are foods high in purine.
Oxylate - found in chocolate, green leafy foods, tomatoes (also restrict protein in diet)
Calcium - found is dairy products & dried fruits
(if Ca++ is present, limit don't eliminate intake).
The End
Got Questions?
Bladder Stuff
Urinary Retention
Determine Cause
If temporary (post anesthesia / post partum) short-term intermittent straight cath.
If long term (SCI / neurogenic bladder) teach straight cath to patient.
Straight cath is done aseptic in hospital but clean at home
Watch for complications
Infection (r/t increased bacterial growth)
Kidney Stuff
Labs
Blood Urea Nitrogen (BUN) 8 - 20
Creatine 0.4 - 1.6
Elevations can lead to Azotemia, Uremia,
Renal Disease / Renal Failure
Kidney Transplants
Incontinence
Not normal with aging /Not a disease
Determine cause
Can try bladder retraining (void on a schedule).
Perform bladder scan to check for residuals (between 50 - 100 mL is WNL) immediately after voiding
Fix identified problem: ie..dehydration, fecal impactionn, restricted mobility, medications (esp. diuretics / sedatives / anticholinergics.
Tx cause
Fairly easy organ to donate / receive
Rejection can occur at any time. May require removal of organ.
Nurse assess for rejection.
Hyperacute (24 - 28 hours after transplant). Must be removed, can't fix this.
Acute rejection (first few months up to 1 year). Tx w/ cyclosporine, steroids, etc.
Long-term rejection > 1 yr. Keep on anti-rejection drugs.
ALWAYS assess UO. Keep > 30mL.
Assess for S/S infection
Dialysis:
Used for near to complete
renal failure
Hemodialysis
Continuous Ambulatory Peritoneal Dialysis (CAPD)
Can't have chronic GI disorders
Done at home
Infuse / dwell time / drain
Glomerulonephritis
Glomerulonephritis is a group of diseases that injure the glomeruli. Also called nephritis and nephrotic syndrome. Kidney's cannot get rid of wastes and extra fluid in the body. If the illness continues, the kidneys may stop working completely, resulting in kidney failure..
Acute:
Develops suddenly, often after infection somewhere else.
S/S = face swelling, esp. in the morning (periorbital edema)
hematuria (or brown urine), protienuria, oliguria (<30 mL / hr).
fever, chills, N & V, weakness, pallor, SOB
HTN, headache, visual changes, flank pain
Chronic: insidious, can cause complete renal failure
hematuria, proteinuria, HTN, angioedema, Frequent nighttime urination, Very bubbly or foamy urine, anorexia, N & V, fatigue, insomnia, Nighttime muscle cramps
Urinary Tract Infections (UTI's)
Nephrotoxic Drugs:
Some antibiotics, drugs & dye can lead to ARF
Asses for cardiac arrhythmias r/t > KCL associated with < UO
Takes several hours, 3 - 4 times weekly
Arterio-venous shunt
Risks - failure, infection, anemia, FE imbalance

Done to remove fluids & waste products
Hemodialysis
AV Fistula:
Audible bruit & thrill indicates proper function
Remains in place
Keep site dressed with bandage, clean and dry.
Do not take BP or venipunctures in same arm
Stages of ARF
Initiating -
can last hours to days
.

Oliguric -
caused by a < GFR. Usually occurs within 1 – 7 days of the initial insult. (However, in 50% of the cases, oliguria is not present, making the diagnosis difficult). Oliguria usually lasts 10 – 14 days but can last for months – the longer it lasts, the worse the prognosis. .

Diuretic -
able to excrete wastes, unable to concentrate urine.
Hypovolemia and hypotension occur. Hyponatremia, hypokalemia and dehydration can also occur r/t fluid loss. Severe uremia still noted as evidenced by low creatinine clearances, elevated BUN’s and persistent S/S. However, the acid-base, electrolyte and waste product imbalances all being to normalize towards the end of this stage which can last 1 – 3 weeks

Recovery -
GFR begins to increase, BUN and serum creatinine levels to plateau and then decrease. Major improvements can occur in the first 1 -2 weeks of recovery but renal function may take up to 12 months in order to stabilize.

Chronic Kidney Disease
CAPD
Risk for Infection (peritonitis)
Risk for scarring
Renal / Urological Ostomies
Nephrostomy






Cutaneous Ureterostomy




Ileal Conduit






Vesicostomy
Bladder Cancer
S/S = Hematuria, general malaise, polyuria, low back pain
Assessment: smoking history, family hx, long term catheter use, radiation, some water
Tx = Surgery, radiation, chemotherapy
Prevention is high nursing priority
Acidify urine to reduce bacterial growth - tx = Vitamin C containing foods or vitamins (at least 1,000 mg daily). Some juices are alkaline (like cranberry).
Teach female clients to wipe from front to back after toileting.
Avoid prolonged time underwater (bathing / swimming)
Keep hydrated & urinate often
Fully empty bladder
Use straight catheters over indwelling when possible.
S/S
Painful urination
Incontinence
> WBC, gen. malaise
> Sediment, WBC in urine.
Different in elderly
Renal / Urological System
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