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The Urinary System and Dialysis Kidney Blood Flow Kidneys • Role is to maintain body fluid volume and composition, filter waste products for elimination. • Regulate blood pressure • Participate in acid-base balance • Produce erythropoietin for RBC synthesis • Metabolize vitamin D to an active form Kidneys Regulatory functions: Control fluid, electrolyte and acid base balance Hormonal functions: Control red blood cell formation, blood pressure and vitamin D activation Hormonal • • • • • Renin Prostaglandins Bradykinin Erythropoietin Vitamin D activation Ureters • Each kidney has a single ureter-connects renal pelvis with urinary bladder. • ½ inch diameter • 12 to 18 inches in length Urethra • Narrow tube- mucous membranes and epithelial cells • Men- 6 to 10 inches • Women- 1 to 1.5 inches • Tube for eliminating urine from the body. Urination removes bacteria from the urethra. Renal changes in older adult • Changes occur as part of the aging process. • Kidney smaller by 80 yr/old • Function decreases with aging. • Decreased bladder capacity • Reduced ability to retain urine. Patient history • Family history for risk • Personal history- age, previous renal problems, prescription drugs, OTC’s, work exposure • Diet history- intake or appetite changes • Changes in urination pattern or continence Physical assessment • • • • Inspection Auscultation Palpation Percussion Lab tests • • • • • Serum creatinine Blood urea nitrogen Urine culture and sensitivity 24 hr urine Urine- Creatinine clearance UA Strip Urinalysis • • • • • • • • • Color, odor, turbidity Specific gravity pH Glucose Ketones Protein Leukoesterase Nitrites Sediment Radiology • • • • • • Kidney, Ureter, Bladder x-rays Intravenous urography (IVP) CT, US VCUG Renal scan Cystoscopy IVP Renal biopsy • Determine cause for renal dysfunction and direct treatment • Percutaneous with US or CT • Monitor for bleeding, vital signs, hematuria, increasing pain or discomfort • Bed rest 2-6hrs Urolithiasis • Calculi in the urinary tract • Nephrolithiasis- stones in the kidney • Ureterolithiasis- stones in the ureter • • • • • Hypercalcemia Hyperoxaluria Hyperuricemia Struvite cystinuria Kidney Stones Kidney Stones Kidney Stones Physical assessment • Renal colic • Pain most intense when stone moving or ureter obstructed • Nausea, vomiting, pallor, diaphoresis • Obstruction is emergency • KUB or CT to determine Interventions • • • • PAIN RELIEF Lithotripsy Hydration Strain urine-to determine cause of stone • Surgical- if too large • Stent • Percutaneous nephrolithotomy Lithotripsy Chronic renal failure • Progressive, irreversible kidney injury • No return of kidney function • ESRD- kidney function too poor to sustain life • Stage I- diminished renal reserve • Stage II- renal insufficiency • Stage III- end stage renal disease Body changes • Elevates blood pressure • Increased triglycerides, total cholesterol and LDL levels • Heart failure • Anemia • GI upset Patient education for prevention • Observe for changes in urine- color, amount, discomfort • Adequate amount of fluids • Know family history • Control DM, HTN • Take medication as prescribed Interventions • • • • • • • • Nutrition therapy Protein restriction Sodium restriction Potassium restriction Vitamin supplementation Drug therapy Fluid restriction Dialysis Hemo vs peritoneal dialysis • • • • • • • • More efficient clearance Shorter treatment time Muscle cramps Hemodynamic changes Vascular access route Specially trained nurses Vascular access care Restricted diet • Easy access • Few hemodynamic complications • Hyperglycemia • Bowel perforation • Peritoneal adhesions • Intra-abdominal catheter • Simple • Less complex training • More flexible diet HD system • • • • • Dialyzer Dialysate Vascular access route HD machine Anticoagulation Types of access for HD • AV fistula • AV graft • Tunneled catheter • Hemo catheter • AV shunt • Subcutaneous device Care of the access • NO !!!! Blood pressure readings, venipunctures or IV lines in extremity with access • Assess for bruit and thrill frequently • Evaluate extremity for CMS and ROM • No heavy lifting with accessed arm • Observe for infection Care of HD patient • • • • • May hold medications until after treatment Monitor for side effects of treatment Weigh before and after treatment Assess access before and after treatment Observe access for bleeding after treatment Peritoneal dialysis • Occurs in the peritoneal cavity • Slower than HD- more time needed for same effect • For hemodynamically unstable and cannot tolerate anticoagulation • Not if pt. has abdominal adhesions or extensive intra-abdominal surgery • Diffusion and osmosis across semipermeable membrane and capillaries. • Solutes and water move from area of higher concentration in the blood to an area of lower concentration in the dialyzing fluid (diffusion) • Dialysate prescribed based on patient's fluid status • Heparin to tube to prevent clotting • Potassium and antibiotics in Dialysate Care of PD patient • • • • • • Mask self and patient Sterile gloves Observe Dialysate for color Frequent vital signs Weigh before and after treatment Strict I/O Kidney Transplant Kidney transplant • Treatment for ESRD • Candidates selected based on medical problems and risks • Donors- living related, living non-related, cadaveric • Immunosupressive medications long term Post operative • Ongoing physical and renal assessment • I/O strict Complications: • Rejection • Thrombosis • Infection • Urinary tract complication Rejection Hyperacute: • Within 48 hrs of surgery • Increased temp • Increased BP • Immediate removal of kidney Acute rejection: • 1wk to 2 yr • Oliguria or anuria • Temp over 100F • Increased BP • Elevated creat, BUN, K+ • Increased doses of immunosuppressive drugs Chronic rejection: • Gradual over months to years • Fluid retention • Changes in electrolytes • Conservative treatment until dialysis needed Thank you
