Urinary Tract Disorders -urolithiasis; presence of calculi (stones) in the urinary tract -nephrolithiasis; presence of calculi in the nephrons

-ureterolithiasis; presence of calculi in the ureters -stones result from a variety of metabolic disorders -exact mechanism not entirely understood -all people from urinary crystals at some time -formation of stones seems to involve (1. slow urine flow, 2. damage of lining to urinary tract, 3. decreased inhibitor substances) -exact cause unknown (most clients have contributing metabolic risk factor) -hypercalcemia; high serum calcium -hyperoxaluria; increased salt oxalate -hyperuricemia; to much uric acid -struvite; infected stone -cystinuria; increased cystine -clinical manifestations; renal colic, sever pain, N&V, pallor, diaphoresis, hematuria common, oliguria, anuria, bladder may be distended, vital signs -diagnostics; urinalysis, urine culture, microscopic examination, serum calcium/phosphate/uric acid, WBC, KUB x-ray, CT scan -interventions; pain relief, complimentary therapy, lithotripsy, surgery, increase fluid intake, prevention of obstruction (drugs for calcium/oxylate/uric acid/cystine containing stones), diet therapy, lifestyle changes, ambulation, infection prevention (drugs) -surgical management; ESWL, uteroscopic stone removal, percutaneous nephrolithotomy) -acute glomerulonephritis; often occurs after a UTI, symptoms start 10 days after infection, recovery usually complete and quick, also called acute nephrotic syndrome -assessment; history, assess for skin lesions and edema, respiratory assessment, cardiovascular assessment, vital signs, urinary patterns, weight, energy level, appetite -diagnostics; urinalysis, microscopic, glomerular filtration rate, 24hr urine analysis, serum albumin, blood/skin/throat cultures, other serologic tests, renal biopsy -interventions; treat underlying infections, prevent complications, client education, drugs, energy management -variant of acute nephritis -develops over several weeks or months -significant loss of renal function -client becomes ill quite quickly -signs and symptoms of renal failure often progresses to end-stage renal disease -Chronic glomerulonephritis; also called nephrotic syndrome (renal deterioration over 20+ years) -cause not known in many cases (changes in renal parenchyma may result from hypertension, infections and inflammation) -kidney tissue atrophies; significant loss of nephron function -assessment; history, respiratory changes, mental function, memory, skin -clinical manifestations; circulatory overload, slurred speech/ataxia/tremors/asterixis diagnostics; urinalysis, glomerular filtration rate, BUN, serum electrolytes, metabolic acidosis, x-ray, CT (renal biopsy rarely done) -interventions; slowing progression of disease and preventing complications is the goal, sufficent fluids, drugs, eventually client will require dialysis

Urinary Tract Infections -an infection to the urethra is called urethritis -if bacteria move to the bladder and multiply, a bladder infection is called cystitis -if the infection is not treated promptly, bacteria may travel further up the ureters to multiply and infect the kidneys called pyelonephritis -urine is normally sterile (free of bacteria, viruses and fungi and contains fluids, salt and waste) -an infection occurs when tiny organisms, usually bacteria from the digestive tract (most commonly E. coli), cling to the opening of the urethra and begin to multiply -routes of infection; ascending infection (bacteria enter the urinary tract up the urethra from fecal contamination), hematogenous spread (bacteria enter through the bloodstream), direct extension (by means of a fistula from the intestine) -clinical manifestations; lower UTI (dysuria, burning upon urination, frequency, urgency, nocturia, incontinence, suprapubic or pelvic pain, may have hematuria and back pain), upper UTI (chills, fever, flank or back pain, N&V, headache, malaise, painful urination), complicated UTI (clients with indwelling catheters may be asymptomatic and can progress to sepsis, clients may have lower resistance and lower response time to treatment) -geriatric considerations; higher incidence of chronic illness, frequent use of antimicrobial agents, presence of infected pressure ulcers, immobility and incomplete emptying of the bladder, use of a bedpan rather than a commode or bedpan -can present with atypical symptoms (anorexia, fatigue, confusion, weakness) -increased risk factors; women, kidney stones, medical conditions, suppressed immune systems, women who are sexually active, men with an enlarged prostate -diagnostics; WBC (positive indicates pyuria or WBC in the urine), urinalysis, urine C&S (midstream urine to determine organism and decide course of treatment), ultrasound, fluoroscopic study (can show any physical problems that can predispose children to urinary problems), intravenous pyelogram (special series of x-rays that use contrast dyes to highlight abnormalities), cystoscopy (involves insertion of a thin, flexible tube with a tiny camera on the end through the urethra into the bladder), CT scan -medications; antibiotics, nitrofurantoin (bacteriostatic), ciprofloxacin (bactericidal), antimicrobial agents (25% of women develop yeast infection), cephalosporins (bactericidal antibiotics), pyridium (urinary analgesic used for discomfort) -home remedies; baking soda, drinking water, cranberry juice -prevention; drink plenty of water, drinking cranberry juice, wipe from back to front, use enough lubrication during sex, avoid using the diaphragm as a form of birth control, avoid tight pants/hot tubs/bubble baths etc. Urinary Incontinence -not a normal part of aging -risk factors; pregnancy, menopause, GU surgery, pelvic muscle weakness, incompetent urethra, immobility, diabetes, stroke, age-related changes, morbid obesity, cognitive disturbances, medications) -seven types of urinary incontinence; stress (due to a strong urge to void that cannot be suppressed), reflex (due to hyperreflexia in the absence of normal sensation), overflow (associated with over distension of the bladder), functional (UTI or sever cognitive impairment which makes it difficult to know when to void), iatrogenic (due to medical factors ie. Medications), mixed (a combination of stress and urge incontinence) -teaching; not inevitable, treatable, management takes time, develop a voiding log or diary, behavioural interventions, medication teaching, strategies for promoting continecne)

-neurogenic bladder; dysfunction that results from a lesion of the nervous system and leads to urinary caused by spinal cord injury, spinal tumour, MS, congenital disorders, infection, diabetes -assessment; I&O, residual urine volume, urinary analysis -complications; urinary stasis, catheterization, urolithiasis, hydronephrosis -management; medications, surgery, catheterization -nursing interventions; monitor I&O, sterile catheterization, encourage fluid intake, monitor for S&S of infection Acute Renal Disorders -role of the renal system (excretory, regulatory, metabolic, secretory) -remove metabolic waste (urea) -creatinine;; (end product of muscle metabolism, indicator of kidney function) -fluid balance; maintained through the ability to concentrate or dilute urine in response to osmolar changes in the blood -the kidney also plays a role in the maintenance of arterial blood pressure -decrease in renal perfusion or low renal artery pressure stimulates release of renin, aldosterone, and ADH -plays a role in electrolyte balance (sodium, potassium, calcium and magnesium) -acid base regulation (through the selective secretion of hydrogen ions and the reabsorption of bicarbonate ions) -hormone production; erythroprotein (stimulates the bone marrow to produce red blood cells, lack of this protein leads to anemia), vitamin D (activated by kidney; if not functioning properly will have decreased calcium absorption) -pre-renal; also known as pre-renal azotemia (results from inadequate blood flow to the nephron) -can be caused by hypovolemia, hypotension, ischemia, drug-induced, sepsis -most common; 70% of cases -factors outside the kidneys that reduce renal blood flow leading to decreased glomerular filtration rate -management; restore arterial blood flow (diuretics, fluid challenge, volume expanders, dopamine, improve cardiac output, decrease intravascular activity) -intra-renal; intra-renal azotemia, also known as the intrinsic renal area (direct damage to the nephron) -can be caused by acute tubular necrosis, glomerulonephritis, pyleonephritis, diabetic neuropathy, nephrolithiasis, toxemia in pregnancy, damage to renal tissue -management; maintain fluid balance, prevent further renal damage) -post-renal; results from urinary tract obstruction (urine flow is reduced or stopped due to partial or complete obstruction of the ureters, bladder or urethra from internal or external means) -can be caused by prostatic hyperplasia, prostate cancer, strictures, calculi formation, high rate among elderly -management; promote urinary drainage, identify blockage and remove -acute renal failure; rapid decline in renal function with progressive build up of metabolic wastes -can develop over hours or days -mostly related to hypovolemia, hypotension or a nephrotoxic agent -clinical course; oliguric phase (r/t decreased GFR, occurs within 1-7 days, lasts several days to weeks, severe decrease in urine output, the longer it lasts the poorer the prognosis), diuretic phase (lasts 1-3 weeks, gradual urine output of 1-5L/day, output increased but filtration still affected, monitor for hyponatremia- weakness, lethargy, confusion; hypokalemia- fatigue, weakness, leg cramps; hypovolemia), recovery phase (lasts 1-2 weeks but can take up to one year, recovery influenced by client's overall health, severity of renal failure and complications, can lead to chronic kidney disease) -collaborative goals of treatment; treat/eliminate cause, pre-renal (resolve hypovolemia), intra-renal

(supportive therapy), post-renal (resolve obstruction), treat acute complications, promote homeostasis of fluids and electrolytes, decrease nitrogenous waste production, promote adequate nutrition, symptom management -renal emergencies (metabolic acidosis, hyperkalemia, anemia, fluid overload, hyper/hypotension, hyperuremia, drug overdose/toxicity, bleeding, pericarditis, pericardial tamponade -history and assessment; history and physical, fluid retention, metabolic acidosis, sodium balance -diagnostics; blood (BUN, creatinine, electrolytes, CBC, albumin) urine (specific gravity, osmalarity, protein, glucose, C&S, GFR), KUB, ultrasound, arteriogram, retrograde pyleogram, ECG, biopsy -collaborative interventions; medical approach (supportive therapy- IV, electrolyte replacement, blood products; dialysis), surgical approach (removal of blockage, insertion of devices- suprapubic catheters, stents, nephrostomy tubes; insertion of access devices; renal transplant), pharmacological approach (IV, antibiotics, steroids, phosphate binders, antihypertensives, diuretics, dopamine, sodium bicarbonate), nutritional considerations (fluid restrictions, protein restrictions, sodium/potassium/phosphate restrictions, increase CHO and fat, diet specific to type of renal calculi), diagnostics and treatment of underlying cause, symptom management -kidney surgery; pre-op considerations (assessment, lab values, surgical history, complication potential), post-op considerations (pain relief, monitor I&O, S&S of bleeding, sterile catheterization, encourage leg exercises and early ambulation), post-op complications (hemorrhage, shock, abdominal distention, paralytic ileus, infection, thromboembolism) -patient teaching; care of drainage system, strategies to prevent complication, S&S, follow-up, health promotion, psychosocial considerations, living with renal challenges -nursing considerations; maintain kidney function, control symptoms, prevent complications, accurate I&O, monitor labs, assess for infection -nursing skills; urinary access devices (indwelling catheters, intermittent catheterization), vascular access (peripheral, central venous access devices, arteriovenous fistulas), blood administration, dialysis -ARF in children; most common cause is dehydration or poor perfusion -treatment is similar to that of adults -hemolytic uremic syndrome in children; called thrombotic thrombocytopenia purpura in adults (acute renal disease characterized by acute renal failure, hemolytic anemia, thrombocytopenia) -usually follows acute GI or upper respiratory tract infection -S&S; oliguric or anuric, seizures, stupor, pulmonary edema -lasts 1-2 weeks Chronic Kidney Disease -renal failure; results when kidneys cannot remove wastes or perform regulatory functions -systemic disorder that results from many different causes -chronic renal failure is progressive (irreversible deterioration of renal function results in azotemia (an excess of urea or other nitrogenous compounds in the blood) -symptoms are often not apparent until stage 4 of the disease -causes; diabetes mellitus, hypertension, chronic glomerulonephritis (major cause of ESRD, nonbacterial inflammatory process that primarily affects the glomerular capillaries, streptococcal/pneumoccocal/viral infection, antigen-antibody complexes develop, acute- changes occur over days-weeks; chronic- changes occur over months-years; S&S- hypertension, proteinuria, hematuria, oliguria, edema), pyleonephritis, polycystic kidney disease (inherited, nephrons become cystic- distension causes renal tissue damage; S&S- hematuria, hypertension, abdominal fullness, polyuria, proteinuria), obstruction of the urinary tract, hereditary lesions, vascular disorders (cardiovascular disease; atherosclerotic process- usually associated with aging and develops slowly, causes decreased blood flow- leads to ischemia of renal tissue, S&S vary but include nocturia,

proteinuria, azotemia), medication/toxic agents -pathophysiology of CRF; as renal function declines, the end products of protein metabolism accumulates in the blood, the greater the buildup of waste the more sever the symptoms, rate of decline of renal function and progression of chronic renal failure is related to underlying disorders, urinary excretion of protein and presence of hypertension -stages of CKD -Stage I and II -Glomerular Filtration Rate (mL/minute) -Normal- 125 -Stage I- 90-130 -Stage II- 60-90 -no symptoms but 30% decrease in kidney function -urea and creatinine normal -Stage III -GFR- 30-60 -kidney insufficiency begins -increased creatinine levels, excess urea, anemia -80% renal tissue damage before symptoms occur -Stage IV -GFR- 15-30 -Stage V ` -GFR- <15 -end stage renal disease -renal function severely impaired -elevated urea and creatinine levels -90-95% of nephrons have stopped functioning -electrolyte imbalances -clinical manifestations; high BP, passage of bloody, cloudy or tea coloured urine, foaming in the urine, protein in the urine, edema, fatigue, N&V, poor appetite and weight loss, bad taste in the mouth, hiccups from uremic toxins -diagnostic findings; GFR, sodium and water retention (at risk for edema, HF and hypertension), acidosis (metabolic acidosis occurs because kidneys cannot excrete increased loads of acid), anemia, calcium and phosphorous imbalance -collaborative care; maintain kidney function with medications (antihypertensives, diuretics, erythroprotein, antacids, antiseizure agents), diet (protein and sodium restrict), healthy living (smoking cessation, exercise), psychosocial effects of renal function loss, sexual dysfunction -end stage kidney failure is irreversible -treatment; dialysis, transplant, conservative (medically managed) -dialysis; movement of fluid and molecules across a semi-permeable membrane which separates two solutions -hemodialysis; rapid removal of fluid, urea, creatinine, potassium -blood circulated through a filter -client requires vascular access -on a machine for 4 hours 3x per week -restricted diet (protein, phosphate, potassium and fluid restriction -many medications; antihypertensives, EPO, phosphate binders, vitamins -peritoneal dialysis; peritoneum is used as a semi-permeable membrane -less complicated than hemodialysis -client is taught to do procedure at home

-daily treatments; 2L of special socultion instillied into peritoneum, dwells for specified time, drained out and replaced -fewer dietary restrictions and less cardiovascular stress -initially maintains residual kidney function -fewer medications -infections are common -protein loss -weight gain r/t glucose in dialysis solution -continuous renal replacement therapies; indicated for patients who have acute or chronic renal failure and are too unstable for traditional hemodyalisis