12 Renal
Tuesday, July 28, 2009
9:25 PM
• Renal Disorders
○ Julie Mann, NP
○ N145
• Case #1
○ Mrs. Jones an 83 y/o female returns to the
clinic 3 days after discharge from the
hospital s/p (status post, after)
hysterectomy. Her family states she has
been increasing confused and complaining
about generalized abdominal discomfort.
○ What might be the cause of her confusion?
 Infection (symptom for elderly)
 UTI
○ What orders would you expect to receive for
Mrs. Jones?
 Sample of urine (WBCs, cultures)
○ What nursing considerations would you have
for Mrs. Jones?
 Fall risk.
 Infection.
 Someone with her to take antibiotics,
help.
• Case #2
○ Mary Jane is a recently married 25 year old
female who returns from her honeymoon to
Costa Rica with complaints of dysuria,
frequency, and urgency.
○ What might be going on with MaryJane?
 UTI
○ Why would she be at higher risk for this
condition?
 Sexually active (friction, high traffic).
○ What orders would you expect to receive for
MaryJane?
 UA (urine analysis).
○ What nursing considerations would you have
for MaryJane?
 Void after sex
 Hygiene.
• Urinary Tract Infections
○ Upper and Lower Urinary Tract Infections
 Upper UTI: Pylonephritis
 Kidney/ureters have an infection.
 Lower UTI: Cystitis
 Bladder gets infected
○ distal urethra, vagina, and perianal area
contains pathogens
○ urine in the bladder is sterile
• Cystitis
○ Uncomplicated (most common): health
adult, normal urinary system, caused by e.
choli
○ Complicated: r/t abnormality in urinary tract
(enlarged prostate, tumor, unable to void)
OR other health problem that compromises
defenses or responsiveness to treatment.
 Caused by Proteus mirabilis, Klebsiella,
and Enterobacter (gram neg.), and
Staph aureus (gram pos)
• Bodies Defenses
○ Washout phenomenon (usually void it out)
 Men longer urethra less likely to develop
vs women.
 Wash out pathogen.
○ IgA and Phagocytic blood cells
 Reside in ureters, help protect body.
 ○protective mucin layer of bladder: protects
against invasion
 May bind to water that is part of urine.
○ local immune response: normal flora in
periurethral area: Lactobacillus
 Help curb development of pathogens.
• Who’s at risk?
○ urinary obstruction and reflux
 Women with children, cough/strain,
urine refluxes back into urethra.
○ neurogenic disorders that interrupt
emptying
 Flacid bladder, unable to empty
• Case #3
completely.
○ women who are sexually active
○ postmenopausal women
 Low levels of estrogen interrupt mucin
lining.
○ men with diseases of the prostate
○ Elderly
 Unable to maintain mucin lining.
○ diabetes
○ pregnant women
 Obstruction/pressure on tissues
○ instrumentation and catheterization (point
towards the navel when harder to find on
women)
 Infection risk d/t tubes
• What mechanism caused Mrs. Jone’s UTI?
○ Likely from Instrumentation, catheter.
Almost 100% of indwelling catheter users
get UTI, antibiotics commonly used.
• What mechanism caused MaryJane’s UTI?
○ Sex & friction
• Clinical Manifestations
○ Frequency/urgency
○ lower abd. or back pain
○ burning and pain on urination
○ Urine may be cloudy and foul smelling
○ Very common for women, particular b/t 18-
40
○ Not common for men
○ Elderly have different symptoms (might not
have pain, larger infection)
 Will have confusion.
○ Sometimes blood in the urine.
○ Mrs. Logan is a 63 y/o multiparous female
(many pregnancies). (g 8, p 8) who presents
with c/o frequency of urination, small weak
stream, and states, “I feel like I don’t
completely empty my bladder.”
○ What might be going on with Mrs. Logan?
 Obstruction, possibly prolapsed uterus --
> pressure on urethra, unable to void.
○ What contributing factors might have led to
her condition?
 Blockage/prolapsed uterus.
○ What are the risks associated with her
condition?
 Pain, UTI, unable to void (distended
bladder-->backflow into kidneys)

• Urinary Tract Obstruction
○ Any interference in the flow of urine at any
part of the urinary tract.
○ Classified by:
 cause (congenital or acquired)
 degree (complete[more dangerous] or
partial)
 duration (acute or chronic [can lead to
bilateral renal failure d/t backing up of
urine])
 level (upper or lower)
• Lower Obstruction
○ Compensatory Stage
 hypertrophy of the bladder muscle (push
harder)
 bladder wall thickens
 bladder muscle fatigue when chronic
○ Decompensatory Stage
 bladder may be overstretched and
fibrotic, high residual volumes, not as
functional (can't squeeze as efficiently --
>can't push out all of urine)
 overflow incontinence (leak urine [ie
when cough])
 Can scan to see how much pt is voiding,
or use catheter to pull off and measure.
 Need to remove obstruction if at all
possible.
• Who’s at risk?
○ Bladder CA
○ Neurogenic bladder
 Flacid/spastic bladder
○ Bladder stones
○ Prostatic hyperplasia or CA
 Either benign or otherwise.
○ urethral strictures
 Narrowing of urethra, sometimes by
inflammation.
○ congenital urethral defects
• Signs of obstruction
○ bladder distention (feel during palpation,
very uncomfortable)
○ Hesitancy (difficult to get stream started)
○ straining when initiating urination
○ small weak stream (if at all)
○ Frequency
○ feeling of incomplete bladder emptying
○ overflow incontinence
• Case #4
○ Heathcliff is a 32 y/o male MEPN student
that is so dedicated to his studies and his
patients that he often skips breaks during
his 12 hour clinical rotation and long class
days. He copes by drinking 4-5 venti lattes a
 day and eating his favorite comfort food, ○ Calcium Stones (oxylate [more common] or
macaroni and cheese. phosphate)
○ He presents to the ED with severe right flank  most stones are this type (80%)
pain that radiates to his groin. He is afebrile, ○ Magnesium ammonium phosphate stones
his vital signs are normal except his HR is  also called struvite stones
115. He states he feels nauseated and might ○ uric acid stones
vomit.  People who have gout
○ What might be going on with Heathcliff? ○ cystine stones
 Kidney Stone  Younger individuals
○ Why would he have tachycardia, & n/v? ○ Determines Treatment
 Severe Pain.
○ What behaviors put him at risk for this
condition?
 Not voiding, not hydrating
 high calcium not a factor (actually
calcium oxylate in body is a risk [ie.
From spinach])

• Renal Calculi (kidney stones)

○ supersaturated urine
 Water absorbed out of it.
○ unilateral formation
 Tend to form in one kidney
○ natural stone inhibitors
 Reason why some people don't develop
but others do.
• Types of Stones  Once occur, more likely to reoccur.
 ○Stone lodged any where above the
ureteralvesical junction = kidney stone
○ Mechanism of kidney damage by:
 hydronephrosis
 Hydroureter
• Complications
○ Hydroureter
 obstruction blocks the outflow from the
ureter and ureter dilates
○ Hydronephrosis
 urine filled dilation of the renal pelvis
and calices
 assoc. with progressive atrophy
○ Other probs - Electrolytes can't do their job.
○ Processes can reverse if stone removed if
caught before permanent damage.
• Who’s at risk for obstruction?
○ ureteral strictures (narrowing)
○ tumors that compress the ureters
○ Pregnancy
○ Renal Stones
• Clinical Manifestations
○ Renal colic
 acute, intermittent and excruciating
pain in the flank and upper outer
quadrant on affected side.
○ Radiating pain to the lower abdomen,
bladder, perineum, or scrotum
○ Cool and clammy skin
○ n/v (from pain response)
• Case #5
○ Mr. Johnson is a 68 y/o male with a pmh
(past medical history) significant for DM
(Diabetes Mellitus). He is recovering at home
s/p prostatectomy. He develops chills and
fever and complains of a constant ache in
his left flank and generally feels sick.
○ What might be going on with Mr. Johnson?
 Inflammation over kidneys.
○ What might have put him at a higher risk of
developing his condition
 Instrumentation to urinary tract (three
way catheter, continuous irrigation of
bladder)
• Acute Pyleonephritis
○ Infection of the kidney parenchyma and
renal pelvis
○ Same agents as for lower UTI’s, ascending
up
○ May be acute or chronic (aren't as
symptomatic)
• Who’s at risk?
○ DM (don't heal very well)
○ urinary tract instrumentation and
catheterization
○ vesicoureteral reflux (occurs at base of
ureter and top of the bladder, when bladder
becomes overfilled, small amount refluxes
into bladder)
○ Pregnancy (blockage/pressure on ureters)
 Higher risk for preterm labor (therefore,
follow condition closely)
○ neurogenic bladder (spastic/flaccid bladders,
not voiding as well, backup of urine)
• Clinical Features
○ Acute:
 shaking chills and fever
 constant ache in flank area (usually
unilateral, sometimes bilateral--> super
sick)
 lower UTI infection symptoms
(frequency, urgency, etc)
 malaise
 feeling of being ill
○ Chronic:
 may be same as acute or more
commonly more insidious.
 polyuria
 Nocturia (wake up at night to go to
bathroom)
 Proteinuria (protein spills into urine)
 significant cause of renal failure
• Case #6
○ Mr. Peabody a 72y/o man with a pmh
significant for diabetes, HTN, and ASHD
(athersclerotic heart disease). He presents
to his primary care doctor with SOB and
edema. The physician runs some lab work
and finds elevated renal function tests (BUN
up), low hemoglobin, and hyperkalemia.
○ What might be causing Mr. Peabody’s
symptoms?
 Renal Failure (chronic - chronic
predisposition)
○ What contributed to the development of this
condition?
 Diabetes, HTN, ASHD.
○ Is this an acute or chronic condition?
 Chronic
• Renal Failure
○ Renal Insufficiency: a decline in renal
function down to 25% of normal GFR
(glomerular filtration rate) --> strain/stress
on kidneys
○ Renal Failure: significant loss of renal
function <25%. <10% is end stage renal
failure
 fail to regulate fluid, electrolyte and pH
balance
 occurs as an acute or chronic condition
• Acute Renal Failure Causes
○ PreRenal (most common)
• Hypovolemia (ie. large blood loss,
anaphylactic shock)
• decreased vascular filling
• heart failure and cardiogenic shock
• decreased renal perfusion
○ IntraRenal
 • Acute tubular necrosis (no more blood ○ Symptoms caused by decline in renal
supply, nephrotoxic drug [diuretics]) function and accumulation of toxins
○ Post-Renal ○ Who’s at risk?
• bilateral ureteral obstruction  DM (long term damage to kidneys)
 One kidney can compensate.  HTN (long term damage to kidneys)
• bladder outlet obstruction (pressure on  Glomerulonephritis
tubules)  other kidney diseases
• Acute renal failure  Polycystic renal disease & more!
○ Abrupt reduction in renal function
○ Elevated BUN (blood urea [urea backs up
first] nitrogen) and Creatinine levels
○ Oliguria: less than 30/ml day (reduction in
renal output)
○ Most types are reversible
○ Recovery in 3 phases
 Oliguria
 Diuresis over several days (once
underlying cause is gone)
 Recovery (several months b4 fully
recovered)
• Chronic renal failure
○ Hard to treat.
○ Progressive and irreversible loss of nephrons
 Electrolyte balance shot. Some
hormones as well.
 Asotemia Urea builds in blood-->
symptoms of urea in blood Uremia (very
itchy, confusion, headaches, see below)
○ Decreases GFR
○ decreased tubular reabsorptive capacity
○ decreased endocrine functions of the
kidneys
○ Erythropoietin hormone released --> Anemia