Urine formation, drug excretion, acid base balance, secretion of renin, activation

Functions of kidneys:
of vitamin D, production of erythropoiten

Glomerular filtration

Formation of urine: Tubular reabsorption

Tubular secretion

Destention of the bladder muscle sends sensory impulses to spinal cord which
Describe urination reflex activate the parasympathetic motor system to contract detrusor muscles & dialate
the internal urethral sphincter allowing it to relax (voluntarly) resulting in urination

What is the point of incontinance in the

The point where the external urethral sphincter relaxes
urination reflex?

It is initiated when 300 to 400 mL of urine form in the bladder, stimulating stretch
When is the micturitionreflex activated?
receptors within the wall.

Nocturia Urination during the night

Oliguria decreased urination (less than 400mL/24hrs)

Enuresis Bedwetting

Polyuria Excessive urination (more than 2000mL/24 hrs)

Anuria absence of urination

Nursing assessment of Urinary Collection of data about the patient's voiding patterns, habits, and difficulties and
Elimination a history of current or past urinary problems

Physical Assessment Nursing of Urinary Palpation of bladder,skin color & texture, vitals, lung sounds, edema, orthostatic
Elimination hypotension (<BP/>HR)

What is the normal daily Urine Output 1000 - 2000 mL every 24hrs

A freshly voided specimen is pale yellow, straw-colored, or amber, depending on

Characteristics of Urine; Color
its concentration.

Odor Normal urine smell is aromatic. As urine stands, it often develops an

Characteristics of Urine; odor
ammonia odor because of bacterial action.

Fresh urine should be clear or translucent; as urine stands and cools, it becomes
Characteristics of Urine: Turbidity
cloudy.

The normal pH is about 6.0, with a range of 4.6 to 8. (Urine alkalinity or acidity
may be promoted through diet to inhibit bacterial growth or urinary stone
Characteristics of Urine: pH
development or to facilitate the therapeutic activity of certain medications.) Urine
becomes alkaline on standing when carbon dioxide diffuses into the air.

Characteristics of Urine: Specific gravity This is a measure of the concentration of dissolved solids in the urine. The
normal range is 1.015 to 1.025.

Renal function tests: Serum Creatintine
Renal function tests: BUN
Renal function tests: Uric Acid
Renal function tests: Creatinine
clearance
Nursing Diagnoses associated with
Renal Function Tests
Cystoscopy
Intravenous Pyelogram (Excretory
Urography)
a high specific gravity usually indicates dehydration and a low specific gravity
indicates overhydration.
Measuring serum creatinine is a useful and inexpensive method of evaluating
renal dysfunction. Creatinine is a non-protein waste product of creatine
phosphate metabolism by skeletal muscle tissue. Creatinine production is
continuous and is proportional to muscle mass
Blood urea nitrogen (BUN) measures the amount of urea nitrogen, a waste
product of protein metabolism, in the blood. Urea is formed by the liver and
carried by the blood to the kidneys for excretion.
Adult: 7-20 mg/100 ml
Uric acid is the end product of purine metabolism. Purines are obtained from both
dietary sources and from the breakdown of body proteins. Organ meats such as
liver, kidneys, and sweetbreads, sardines, anchovies, lentils, mushrooms,
spinach, and asparagus are all rich sources of purines. The kidneys excrete uric
acid as a waste product.
A creatinine clearance test measures the rate at which the kidneys clear
creatinine from the blood. A creatinine clearance test compares the serum
creatinine with the amount of creatinine excreted in a volume of urine for a
specified time. A 24-hour time frame is most common. At the beginning of the
test, the patient empties his bladder and the urine is discarded. Then, all urine
voided during the specific time period is collected
Potential Fluid Volume Deficit
Potential fluid volume deficit
Potential alterations in nutritional requirements for specific nutrients - potassium,
sodium, and protein
Cystoscopy is the direct visual examination of the bladder, ureteral orifices, and
urethra with a cystoscope. It is used to view, diagnose, and treat disorders of the
lower urinary tract, interior bladder, urethra, male prostatic urethra, and ureteral
orifices
Intravenous pyelogram is the radiographic examination of the kidney and ureter
after a contrast material is injected intravenously. It is used to diagnose kidney
and ureter disease and impaired renal function.
 Retrograde pyelogram is the radiographic and endoscopic examination of the kidneys
Retrograde Pyelogram
and ureters after a contrast material is injected into the renal pelvis through the ureter.

A renal ultrasound is a noninvasive procedure that involves the use of ultrasound to

visualize the renal parenchyma and renal blood vessels. It is used to characterize renal
Renal Ultrasound masses and infections, visualize large calculi; detect malformed kidneys; provide
guidance during other procedures, such as biopsy; and monitor the status of renal
transplants and kidney development in children with congenital processes

It is an invasive procedure that involves obtaining a small piece of renal tissue for
microscopic examination. Tissue sample may be obtained by needle and syringe
Renal Biopsy through a skin puncture or small incision, during an open surgical procedure during
which a wedge of tissue is removed, or through a cystoscope during which a brush is
used to obtain a tissue fragment.

Continuous and unpredictable loss of urine, resulting form surgery, trauma, or physical
malformation.
Total incontinence

Nursing Interventions: Keep skin clean & dry, condom cath

Involuntary loss of less than 50mL of urine. r/t increase in intra-abdominal pressure.
Stress incontinence Occurs during coughing, sneezing, laughing, or other physical activities. Childbirth,
menopause, obesity, or straining from chronic constipation can also result in urine loss

Involuntary loss of urine is associated with overdistention and overflow of the bladder.
The signal to empty the bladder may be underactive or absent, the bladder fills, and
Overflow incontinence
dribbling occurs. It may be due to a secondary effect of some prostatic or neurologic
conditions

is urine loss caused by the inability to reach the toilet because of environmental
Functional incontinence barriers, physical limitations, loss of memory, or disorientation.

Common cause in elderly; instituionalized

What are the causes of disorders Infection, obstructions, cancer, heriditary diseases, chronic disease, traumatic
of the urinary tract? diseases & metabolic diseases

Factors of UTI's stasis, past history, contamination, female, reflux, instruments, aging

Dysuria, urgency, frequency, incontinence, hematuria, cloudy, foul smelling urine and
Signs & symptoms of UTI's
confusion in the elderly

Impaired urinary elimination; frequency

NANDA diagnoses of UTI's Pain/Discomfort

Health maintenance, altered

Urethral Strictures Narrowing of urethral lumen by scar tissue

Renal Calculi Nephrolithiasis is the formation of crystal aggregates in the urinary tract results in
 kidney stones, formed by one of four substances: (1) calcium, (2) uric acid, (3)
magnesium ammonium phosphates (or struvite), or (4) cystine. More common in men,
average onset 30-50yrs often w/ family history/dietary factors.

Signs and symptoms of Renal Pain to the costrovertebral angele, groin, flank, genitala, renal colic. Hematuria, anuria,
Calculi restlessness, absent bowel sounds, N/V, diarrhea

Nursing diagnoses for Renal

Acute pain, risk for infection, deficient knowledge
Calculi

Distention (dilation) of the kidney with urine, caused by backward pressure on the
Hydronephrosis kidney when the flow of urine is obstructed. The elevated pressure from obstruction
may ultimately damage the kidney and can result in loss of its function

Signs and symptoms Can begin quickly causing renal colic, pain, pressure, and distention of the bladder.
Hydronephrosis Can also start of as asymptomatic & slowly progress

Nursing interventions for

Monitor I&O,
Hydronephrosis

Most common following infections by strains of group A, beta-hemolytic streptococci. In

this situation, there is an abnormal immune reaction, causing immune complexes to
become entrapped in the glomerular membrane, inciting an inflammatory response.
Glomerulonephritis
The capillary membrane swells and is then permeable to plasma proteins and blood
cells. Usually follows a strep infection by 10 days to 2 weeks (the time needed for
formation of antibodies).

Oliguria is an early symptom, Na and H20 retention causes edema, particularly of the
Signs and symptoms face and hands, along with hypertension. Proteinuria and hematuria follow from the
Glomerulonephritis increased capillary permeability. This may give a smoky hue to the urine ("cola"
colored).

Sudden interruption of kidney function resulting from obstruction, reduced circulation,

or disease of the renal tissue

Results in retention of , fluids; UOP < 400mL/d or 30mL/hr

Acute Renal Failure Build up of toxins on blood: end products of protien metabolism (azotemia). Usually
reversible with medical treatment

May progress to end stage renal disease, uremic syndrome, and death without
treatment

Results form gradual, progressive loss of renal function

Occasionally results from rapid progression of acute renal failure

Symptoms occur when 75% of function is lost but considered cohrnic if 90-95% loss of
Chronic Renal Failure
function

Dialysis is necessary D/T accumulation or uremic toxins, which produce changes in

major organs
 PRERENAL

Hypovolemia, shock, blood loss, embolism, pooling of fluid d/t ascites or burns,
cardiovascular disorders, sepsis

Causes of Acute Renal Failure INTRARENAL

Nephrotoxic agents, infections, ischemia and blockages, polycystic kidney disease

POSTRENAL

Stones, blood clots, BPH, urethral edema from invasive procedures

Onset – 1-3 days with ^ BUN and creatinine and possible decreased UOP

OLIGURIC PHASE – UOP < 400/d, Longer the phase lasts poorer prognosis

DIURETIC PHASE – UOP ^ to as much as 1-3L/d but no waste products, can not
Stages of Acute Renal Failure
concentrate urinr, excess waste eliminated in blood

RECOVERY PHASE – things go back to normal or may remain insufficient and

become chronic lasting up to 1 yr

Monitor I/O, including all body fluids

Monitor lab results

Acute Renal Failure Nursing
Watch hyperkalemia symptoms: malaise, anorexia, parenthesia, or muscle weakness,
interventions
EKG changes

watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions

Chronic Renal Failure signs and Edema, SOB; cracles, wheezing. Blood vessle distention of neck, may be
symptoms polyuric, oliguric, anuric.

Urethral Strictures Narrowing of urethral lumen by scar tissue

Nephrolithiasis is the formation of crystal aggregates in the urinary tract results in

kidney stones, formed by one of four substances: (1) calcium, (2) uric acid, (3)
Renal Calculi
magnesium ammonium phosphates (or struvite), or (4) cystine. More common in
men, average onset 30-50yrs often w/ family history/dietary factors.

Pain to the costrovertebral angele, groin, flank, genitala, renal colic. Hematuria,
Signs and symptoms of Renal Calculi
anuria, restlessness, absent bowel sounds, N/V, diarrhea

Nursing diagnoses for Renal Calculi Acute pain, risk for infection, deficient knowledge

Distention (dilation) of the kidney with urine, caused by backward pressure on the
kidney when the flow of urine is obstructed. The elevated pressure from
Hydronephrosis
obstruction may ultimately damage the kidney and can result in loss of its
function

Signs and symptoms Hydronephrosis Can begin quickly causing renal colic, pain, pressure, and distention of the
 bladder.

Can also start of as asymptomatic & slowly progress

Nursing interventions for

Monitor I&O,
Hydronephrosis

Most common following infections by strains of group A, beta-hemolytic

streptococci. In this situation, there is an abnormal immune reaction, causing
immune complexes to become entrapped in the glomerular membrane, inciting
Glomerulonephritis
an inflammatory response. The capillary membrane swells and is then permeable
to plasma proteins and blood cells. Usually follows a strep infection by 10 days to
2 weeks (the time needed for formation of antibodies).

Oliguria is an early symptom, Na and H20 retention causes edema, particularly of

the face and hands, along with hypertension. Proteinuria and hematuria follow
Signs and symptoms Glomerulonephritis
from the increased capillary permeability. This may give a smoky hue to the urine
("cola" colored).

Sudden interruption of kidney function resulting from obstruction, reduced

circulation, or disease of the renal tissue

Results in retention of , fluids; UOP < 400mL/d or 30mL/hr

Acute Renal Failure Build up of toxins on blood: end products of protien metabolism (azotemia).
Usually reversible with medical treatment

May progress to end stage renal disease, uremic syndrome, and death without
treatment

Results form gradual, progressive loss of renal function

Occasionally results from rapid progression of acute renal failure

Symptoms occur when 75% of function is lost but considered cohrnic if 90-95%
Chronic Renal Failure
loss of function

Dialysis is necessary D/T accumulation or uremic toxins, which produce changes

in major organs

PRERENAL

Hypovolemia, shock, blood loss, embolism, pooling of fluid d/t ascites or burns,
cardiovascular disorders, sepsis

INTRARENAL
Causes of Acute Renal Failure
Nephrotoxic agents, infections, ischemia and blockages, polycystic kidney
disease

POSTRENAL

Stones, blood clots, BPH, urethral edema from invasive procedures

Stages of Acute Renal Failure Onset – 1-3 days with ^ BUN and creatinine and possible decreased UOP
 OLIGURIC PHASE – UOP < 400/d, Longer the phase lasts poorer prognosis

DIURETIC PHASE – UOP ^ to as much as 1-3L/d but no waste products, can not
concentrate urinr, excess waste eliminated in blood

RECOVERY PHASE – things go back to normal or may remain insufficient and

become chronic lasting up to 1 yr

Monitor I/O, including all body fluids

Monitor lab results

Acute Renal Failure Nursing
Watch hyperkalemia symptoms: malaise, anorexia, parenthesia, or muscle
interventions
weakness, EKG changes

watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions

Chronic Renal Failure signs and Edema, SOB; cracles, wheezing. Blood vessle distention of neck, may be
symptoms polyuric, oliguric, anuric.

EARLY STAGE: Diminished renal reserve 50% nephron loss

Kidney function is mildly reduced while the excretory and regulatory function are
sufficiently maintained to preserve a normal internal environment. The patient is
usually problem free.

RENAL INSUFFCIENCY:75% impaired renal capacity decreased urinary

Chronic Renal failure pathophysiology concentrating ability, anemia, BUN/creatinine levels increase. Factors that can
exacerbate the disease at this stage by increasing nephron damage are:
infection, dehydration, drugs

ESRD:90% of the nephrons are damaged Renal function has so deteriorated that
chronic and persistent abnormalities; Uremic Syndrome

Patient requires artificial support to sustain life, i.e. dialysis, transplant

Chronic Renal failure electrolyte Na+2 - Hypernatriemia >145mEq/L: fever, restless, increased fluid retention,
distubances ^BP, edema, decreased UOP

- hyponatremia

<135mEq/L lethargy, headache, CONFUSION, seizures

K+ - Hypokalemia

<3.5mEq/L fatigue, weak irregular pulse, poly uria, hyperglycemia, bradiacardia

- Hyperkalemia

>5.5mEq/L muscle weakness, urine changes (oliguria or anuria), respiratory

distress, decreased cardiac contrantibility, EKG changes, reflexes flaccid
 Ca+2 - Hypercalcemia

>11mg/dl anorexia, N/V, fatigue, constipation, dehydration, bradycardia

- Hypocalcemia

<8.5mg/dl convulsions, arrythmias, tetny,and spasms

Disturbance in removal of waste products - azotemia: weakness, fatigue,

confusion, N/V, urea crystals (itching skin)

Chronic renal failure symptoms: Disturbance in maintaining acid/base balance - Kussmaul’s respirations (deep &
fast) from acidosis, headache, N/V, fatigue, weakness

Disturbance in hematolgic function -anemia, decrease in RBC survival time

Fluid and dietary restrictions

Maintain E-lytes
Chronic Renal Failure Theraputic
Dialysis to jump start renal function
Interventions:
May need to stimulate production of urine with IV fluids, Dopomine, diuretics, etc.
Ace inhibitors, calcium channel blokers > hypertension

Skin integrity impairment, Potential alterations in nutritional requirements,

Renal Failure Nursing Diagnoses Potential Fluid Volume Deficit, Potential for injury related to weakness and
confusion

A cluster of symptoms related to the retention of nitrogenous substances in the

Uremic Syndrome
blood. Symptoms include: fatigue, confusion, N/V, diarrhea, gastritis, itchy skin

PROTIEN & PHOSPHORUS restriction SLOWS progression.

Protien - 0.6 to 1.0g/kg of ideal body weight. <5-6oz (men) & <4oz (women)
Pre-End Stage Renal Disease Diet
Guidelines
Phosphorus - 8-12mg/kg ideal weight or Limit milk to 1/2 cup, 1oz cheese or any
other high phosphorus foods to 1 serving per day.