U World Renal-Urinary final PDF

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chronic kidney disease (CKD) have decreased glomerular filtration, resulting in retention of fluid, potassium, and phosphorus. Fluid retention is initially treated with sodium restriction and diuretic therapy. Dietary adjustments should also be made to reduce serum potassium and phosphorus. contain high potassium levels: Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges, coconuts, watermelons, and avocados) Dairy products also contain high phosphorus levels. Examples of allowable foods for CKD clients include apples, pears, grapes, pineapple, blackberries, blueberries, and plums. dietary restrictions. These include the following: 1. Sodium restriction involves avoiding high-sodium foods such as cured meats, pickled foods, canned soups, frankfurters, cold cuts, soy sauce, and salad dressings 2. Fluid intake must be monitored accurately and often is restricted 3. Potassium restrictions will vary depending on kidney function. Raw carrots, tomatoes, and orange juice are high-potassium foods that clients with advanced kidney disease or on hemodialysis should avoid. 4. Low-protein diet (0.6–0.8 g/kg/day) helps prevent kidney disease progression. If the client is already on dialysis, liberal protein intake is recommended to prevent malnutrition. Because renal damage often results in elevated blood pressure, clients with CKD are at risk for uncontrolled hypertension and hypertensive emergencies. Hypertensive encephalopathy is a type of hypertensive crisis characterized by nausea, vomiting, and headache. Treatment is urgent (ie, within 1 hour) to prevent damage to the heart, kidney, and brain. The client should check blood pressure at home, if possible, and then proceed to the emergency department for further assessment and treatment (eg, titration of antihypertensive medication). *Hypertension, elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 µmol/L]), nausea associated with azotemia, and pruritus associated with dry skin are expected for chronic kidney disease clients Potassium chloride (KCL) An electrolyte replacement to correct hypokalemia, is a high-alert drug that is never administered by the IV push, intramuscular, or subcutaneous routes. The recommended peripheral infusion rate is 5-10 mEq/hr. However, the nurse should always follow institution IV guidelines and policy and procedure for administering KCL. The nurse's priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site shortly after initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is expected. Slowing the infusion rate is effective in alleviating discomfort. KCL in concentrations 20-40 mEq/100 mL at a maximum rate of 40 mEq/hr should be administered through a central venous access device (CVAD) (eg, PICC, centrally inserted catheter) to prevent postinfusion phlebitis. Assess the site at least every hour for adverse reactions (eg, redness, pain, swelling, phlebitis, thrombosis, extravasation or infiltration), and stops the infusion if any occur. Severe hyperkalemia (potassium >7.0 mEq/L) Requires urgent treatment because cardiac muscle cannot tolerate very high potassium levels. Severe hyperkalemia increases the risk for life-threatening ventricular dysrhythmias (eg, ventricular tachycardia and fibrillation, asystole). Administration of IV 50% dextrose and regular insulin rapidly corrects an elevated serum potassium level by shifting potassium intracellularly. The insulin temporarily shifts the potassium from the extracellular fluid back into the intracellular fluid. The dextrose prevents hypoglycemia associated with the increase of insulin in the body and can be eliminated if the client has hyperglycemia. If the client has ECG changes (peaked T waves) from hyperkalemia, calcium gluconate should be given first to stabilize cardiac muscle.

Oxybutynin (Ditropan) An anticholinergic medication that is frequently used to treat overactive bladder. Common side effects include: New-onset constipation, Dry mouth, Flushing, Heat intolerance, Blurred vision & Drowsiness. Clients should be taught to prevent these side effects by increasing intake of fluids and bulk-forming foods (prevents dry mouth and constipation) and by avoiding locations or activities that may lead to hyperthermia. Saw palmetto A herbal preparation, is often used to treat benign prostatic hyperplasia. St John's wort has been used for centuries to treat depression. SIA a surgical connection of an artery to a vein created to provide vascular access for hemodialysis therapy in clients with kidney disease. Maturing of the fistula is aided by having the client perform hand exercises, such as squeezing a rubber ball, that increase blood flow through the vein. After the AVF is placed, it takes 2-4 months for it to mature to accommodate the repeated venipunctures necessary for hemodialysis access. A palpable thrill (vibration) over the fistula or an auscultated bruit (blowing or swooshing sound caused by turbulent blood flow) indicates a patent fistula. Absence of the thrill or bruit can indicate potential clot formation in the fistula. Client reports of numbness or tingling as well as decreased capillary refill can also signal potential clotting. Stress incontinence The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and urinary tract infections through bladder training. Teaching the client to empty the bladder every 2 hours when awake and every 4 hours at night reduces these risks Pelvic floor exercises (eg, Kegel exercises), which strengthen the sphincter and structural supports of the bladder, are an essential part of the teaching plan but it will take approximately 6 weeks for pelvic floor muscle strength to improve. Natural bladder irritants (eg, smoking, caffeine, alcohol) increase incontinence and should be eliminated. Dialysis treatment Prior, the nurse should assess the client's fluid status (weight, blood pressure, peripheral edema, lung and heart sounds), vascular access (arteriovenous fistula, arteriovenous grafts), and vital signs. The amount of fluid removed (ultrafiltration) is determined by calculating the difference between the last post-dialysis weight and the client's current pre-dialysis weight. After the client is connected to the dialysis machine, IV heparin is added to the blood from the client to prevent clotting that can occur when blood contacts a foreign substance. Giving subcutaneous heparin prior to initiation is not necessary. Many medications that are taken once daily can be held until after the dialysis treatment to prevent their removal. If blood pressure medications are given prior to dialysis, the client can develop hypotension during the dialysis and then uncontrolled hypertension (decreased drug concentrations). A thrill can be felt when palpating the fistula, and a bruit can be heard during auscultation when the fistula is functioning properly. Risks include medication removal, hemodialysis access dysfunction, hypotension, and fluid and electrolyte imbalances. Dialysis disequilibrium syndrome (DDS)

rare but potentially life-threatening complication that can occur in clients during the initial stages of hemodialysis (HD); it can be prevented by slowing the rate of dialysis. Associated with cerebral edema. Characteristic neurologic manifestations include nausea and vomiting, headache, restlessness, change in mentation, and seizure activity. If DDS is suspected, the health care provider should be contacted immediately and dialysis should be slowed or stopped. Metabolic acidosis Is due to an increase in the production or retention of acid (eg, lactic acidosis, ketoacidosis, renal failure) or the depletion of bicarbonate (HCO3-) via the kidneys or gastrointestinal tract. In metabolic acidosis, there is a decrease in pH (100.4 F (38 C) and chills, or abdominal pain unrelieved by analgesia. may require antibiotic therapy or the insertion of a urinary catheter to irrigate the bladder, remove clots, or drain the bladder Pink-tinged urine, frequency, and dysuria are expected for up to 48 hours following a cystoscopy. Clients are instructed to increase fluids, drink 4-6 glasses of water daily to help dilute the urine, and avoid alcohol and caffeine for 24-48 hours as these can irritate the bladder. Abdominal discomfort and bladder spasms may occur for up to 48 hours following the procedure. Clients are taught to take a mild analgesic (eg, acetaminophen, ibuprofen) and a warm tub/sitz bath (except with recurrent urinary tract infections) for pain relief. Irritation of the urethral and bladder lining from the insertion and manipulation of the cystoscope may cause a slight burning sensation with voiding for a day or two. Renal arteriogram A radiologic test performed to visualize renal blood vessels to detect abnormalities (renal artery stenosis or aneurysm). A contrast medium is injected into the femoral artery; therefore, the client should be taught to increase fluid intake after the procedure to flush the dye from the body. Increased output is an expected finding. Portable ultrasonic bladder scanners Used at the bedside to determine the amount of residual urine in the bladder. Amounts >100 mLshould be reported as the client may be experiencing urinary retention Urine culture values >10,000 organisms/mL can suggest UTI. Extracorporeal shock wave lithotripsy (ESWL) a noninvasive procedure used to break up kidney stones. It is typically done on an outpatient basis, although the client will require local or general anesthesia. The shock waves break up the stone(s) into a fine sand that can then be excreted in the urine. Ureteral stents are often placed after the procedure to help with the passage of the sand and prevent buildup within the ureter. The stents are removed within 1-2 weeks.

The client will be encouraged to drink large amounts of fluids to facilitate washing out of the stone fragments and sand created by the shock waves. Infection is a serious complication after the procedure as the breakup of stones can release organisms and cause sepsis. Pain can be severe and require analgesics. Hematuria is common, and the urine should go from bright red to pink-tinged over several hours. Hematuria is concerning if the urine remains bright red over a prolonged period (>24 hr). Bruising on the back or abdomen after the procedure is normal. The client may need to rest for the remainder of the day following anesthesia, but ambulation is encouraged to facilitate removal of stone fragments. Pessary a vaginal support device recommended for pelvic organ prolapse. Pessaries are fitted by an HCP; many clients can then remove, clean, and replace these themselves. Clients can remain sexually active with a pessary in place. Increased vaginal discharge is a common side effect. However, if an odor is present, the client should be instructed to notify the HCP to be treated for a possible infection. Phenazopyridine hydrochloride (Pyridium) a urinary analgesic prescribed to relieve symptoms of dysuria associated with a urinary tract infection. An expected side effect of the drug is orange-red discoloration of urine. suggest that the client use sanitary napkins and wear eyeglasses while taking the medication. Ketorolac (Toradol) a highly potent nonsteroidal anti-inflammatory drug (NSAID) often used for pain and available in intravenous form. However, NSAIDs (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. Also, the client should not be given 2 types of NSAIDs simultaneously (eg, naproxen plus ibuprofen) as they can be toxic to the stomach and kidneys. Acute urinary retention Best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis. Carefully assess for hypotension and bradycardia, which are potential complications. Percutaneous nephrolithotripsy a procedure to remove large kidney stones from the renal pelvis. Post procedure, a nephrostomy tube may be placed to prevent obstruction by stone fragments and to promote healing of injured tissue. Gentle irrigation of the nephrostomy tube with sterile normal saline may be necessary to maintain tube patency. Bladder cancer the most common presenting symptom of bladder cancer Painless hematuria. Cigarette smoking or other tobacco use is the primary risk factor. Occupational carcinogen exposure is the second most common risk factor. Occupational exposures include printing, iron and aluminum processing, industrial painting, metal work, machining, and mining. Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols and vapors). erythropoietin (Epogen/Procrit, epoetin) Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administering erythropoietin. Administered intravenously or in any subcutaneous area. Iron in the form of iron sucrose (Venofer) or ferric gluconate (Ferrlecit) may be prescribed to promote an adequate response to erythropoietin. Adequate stores of iron, vitamin B12, and folic acid are required for

the erythropoietin to work. dose should be held if the client has a hemoglobin level >11 g/dL (110 g/L) or uncontrolled hypertension.

Scleroderma an overproduction of collagen that causes tightening and hardening of the skin and connective tissue. This is a progressive disease without a cure, and treatment is aimed at managing complications. Renal crisis is a life-threatening complication that causes malignant hypertension (abrupt onset of hypertension and headache) due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with treatment, this can be fatal. Raynaud phenomenon can develop secondary to scleroderma. It is characterized by vasospasm-induced color changes in the fingers, toes, ears, and nose. This requires urgent treatment (eg, immersing hands in warm water) but is not life-threatening. Pulmonary fibrosis is a progressive complication of scleroderma that is defined as scarring of lung tissue, which then causes reduced function, dry cough, and dyspnea. Some clients may be placed on oxygen. This is not immediately life-threatening. Heartburn and dysphagia (difficulty swallowing) are common symptoms associated with scleroderma. This is due to the disease process of internal scarring, and it is not life-threatening. **Potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone), ACE inhibitors (eg, lisinopril, ramipril), and angiotensin II receptor blockers (eg, losartan, valsartan, candesartan) cause hyperkalemia. Therefore, these should be held in clients with underlying hyperkalemia **Iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury. Metformin (Glucophage) can worsen lactic acidosis in the presence of kidney injury. Metformin should be withheld prior to the contrast exposure and can be resumed when kidney function is within normal limits. ** NPO status preoperatively, dehydration, intraoperative fluid losses, antibiotic therapy, and advanced age can negatively affect renal function. An elevated serum creatinine level preoperatively increases the risk for postoperative kidney injury. ** Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration (hypernatremia, elevated BUN) can impair wound healing. ** Pain in pyelonephritis is dull, constant, and maximal at the costovertebral angle area. Pain from renal stones is excruciating, sharp, and often radiates toward the groin from the flank. Suprapubic pain indicates bladder distension or cystitis. Spasms can be seen with infection (cystitis) or manipulation of the bladder....