Genitourinary System

I. Anatomy and Physiology of the Genitourinary System GENITOURINARY SYSTEM The renal system consists of all the organs involved in the formation and release of urine. It includes the kidneys, ureters, bladder and urethra. The kidneys are bean-shaped organs which help the body produce urine to get rid of unwanted waste substances. When urine is formed, tubes called ureters transport it to the urinary bladder, where it is stored and excreted via the urethra. The kidneys are also important in controlling our blood pressure and producing red blood cells. Components of the renal system  Kidneys and ureters

The kidneys are large, bean-shaped organs towards the back of the abdomen (belly). They lie behind a protective sheet of tissue within the abdomen. The kidneys perform many vital functions which are important in everyday life. For example, they help us get rid of waste products by making urine and excreting it from the body. A special system of tubes within the kidneys allow substances such as sodium (salt) and chloride to be filtered. The kidneys regulate the amount of water in the body. Humans produce about 1.5 litres of urine a day. However, if we drink more water, we may produce more urine. On hot days, if we get dehydrated and sweat more, we may produce less urine. This is why it's very important to drink lots of water on hot summer days. The kidneys also produce renin (a hormone important in regulating blood pressure) and erythropoietin (helps produce red blood cells). Located in the lower part of our bellies, the right kidney is slightly lower in position than the left, allowing room for the liver. The kidneys are reddish brown in colour and measure about 10 cm in length, 5 cm width and 2.5 cm thick. On the side of the kidney with the smaller curve is an opening called the hilum, where blood vessels, nerves, and the ureters enter the kidney. On one end of the ureters is a funnel-shaped expansion, called the renal pelvis, where urine collects. The ureters carry urine to the bladder; they are 25–30 cm long tubes lined with smooth muscle. The muscular tissue helps force urine downwards. The ureters enter the bladder at an angle, so urine doesn't flow up the wrong way. The kidney can be divided into two distinct regions. There is an outer red-brown part (cortex) and inner lighter coloured part (medulla). The cortex is made up of special units called corpuscles, nephrons, and a system of straight and curvy collecting tubules supplied by many blood vessels. In the outer part of the kidney, there are many

nephrons which act as filtering units. Each nephron is supplied by a ball of small blood vessels, called glomeruli. A diagram of a single glomerulus is seen below. Blood is filtered through the small blood vessels to produce a mixture that is the precursor of urine. This mixture then passes through more tubules, where water, salt and nutrients are reabsorbed.

The inner part of the kidney (the medulla) is a continuation of the specialized nephrons in the kidney. A small blood vessel network called the vasa recta supplies the medulla. Each kidney is supplied by the renal arteries, which give off many smaller branches to the surrounding parts of the kidneys. Renal veins drain the kidney.  Bladder

The bladder is a pyramid-shaped organ which sits in the pelvis (the bony structure which helps form the hips). The main function of the bladder is to store urine and, under the appropriate signals, release it into a tube which carries the urine out of the body. Normally, the bladder can hold up to 500 mL of urine. The bladder has three openings: two for the ureters and one for the urethra (tube carrying urine out of the body). The bladder consists of smooth muscles. The main muscle of the bladder is called the detrusor muscle. Muscle fibres around the opening of the urethra forms a ring-like muscle that controls the passage of urine. When we want to urinate, stretch receptors in the bladder are activated, which send signals to our brain and tell us that the bladder is full. The ring-like muscle relaxes and the detrusor muscle contracts, allowing urine to flow. The blood supply of the bladder is from many blood vessels. Some of these blood vessels are named: the vesical arteries, the obturator, uterine, gluteal and vaginal arteries. In females, a venous network drains blood from the bladder arteries into the internal iliac vein. Nervous control of the bladder involves centres located in the brain and spinal cord.

 Urethra

The male urethra is 18–20 cm long, running from the bladder to the tip of the penis. The male urethra is supplied by the inferior vesical and middle rectal arteries. The veins follow these blood vessels. The nerve supply is via the pudendal nerve. The female urethra is 4–6 cm long and 6 mm wide. It is a tube running from the bladder neck and opening into an external hole located at the top of the vaginal opening. As the female urethra is shorter than the male urethra, it is more likely to get infections from bacteria in the vagina. The female urethra is supplied by the internal pudendal and vaginal arteries.

II.Diagnostic Tests and Table of Laboratory Values •

Serum Creatinine

Measures effectiveness of renal function. Creatinine is end product of muscle energy metabolism. In normal function, level of creatinine, which is regulated and excreted by the kidneys, remains fairly constant in the body. Normal Value: 0.6 – 1.2 mg/dl (50 – 110 µmol/dL How the test is performed o Blood is drawn from a vein, usually from the inside of the elbow or the back of the hand. The site is cleaned with germ-killing medicine (antiseptic). The health care provider wraps an elastic band around the upper arm to apply pressure to the area and make the vein swell with blood. o Next, the health care provider gently inserts a needle into the vein. The blood collects into an airtight vial or tube attached to the needle. The elastic band is removed from your arm. o Once the blood has been collected, the needle is removed, and the puncture site is covered to stop any bleeding. o In infants or young children, a sharp tool called a lancet may be used to puncture the skin and make it bleed. The blood collects into a small glass tube called a pipette, or onto a slide or test strip. A bandage may be placed over the area if there is any bleeding. How to prepare for the test The health care provider may tell you to stop taking certain drugs that may affect the test. Such drugs include: • • •

Aminoglycosides (for example, gentamicin) Bactrim Cimetidine

Heavy metal chemotherapy drugs (for example, Cisplatin) Nephrotoxic drugs such as cephalosporins (for example, cefoxitin) Blood Urea Nitrogen (BUN) • •

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Serves as index of renal function. Urea is nitrogenous end product of protein metabolism. Test values are affected by protein intake, tissue breakdown, and fluid volume changes. Normal Value: 7-18 mg/dl, patients over 60 years: 8-20 mg/dL

How the test is performed o Blood is drawn from a vein, usually from the inside of the elbow or the back of the hand. The puncture site is cleaned with antiseptic, and a tourniquet is placed around the upper arm to apply pressure and restrict blood flow through the vein. This causes veins below the tourniquet to fill with blood. o A needle is inserted into the vein, and the blood is collected in an airtight vial or a syringe. During the procedure, the tourniquet is removed to restore circulation. Once the blood has been collected, the needle is removed, and the puncture site is covered to stop any bleeding. o In infants and young children, the area is cleaned with antiseptic and punctured with a sharp needle or a lancet. The blood may be collected in a pipette (small glass tube), on a slide, onto a test strip, or into a small container. A bandage may be applied to the puncture site if there is any continued bleeding. How to prepare for the test Some drugs affect BUN levels. Before having this test, make sure the health care provider knows which medications you are taking. Drugs that can increase BUN measurements include: • • • • • • • • • • •

Allopurinol Aminoglycosides Amphotericin B Bacitracin Carbamazepine Cephalosporins Chloral hydrate Cisplatin Colistin Furosemide Gentamicin

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Guanethidine High-dose aspirin Indomethacin Methicillin Methotrexate Methyldopa Neomycin Penicillamine Polymyxin B Probenecid Propranolol

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Rifampin Spironolactone Tetracyclines

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Thiazide diuretics Triamterene Vancomycin

Drugs that can decrease BUN measurements include: Chloramphenicol Streptomycin Urinalysis and Urine Culture • •

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Urinalysis The urinalysis provides important clinical information on kidney function and helps diagnose other diseases, such as diabetes. Specific Gravity Evaluates ability of kidneys to concentrate solutes in urine. Normal value: 1.010 – 1.025 How the test is performed o The test requires a clean-catch urine sample. o To obtain a clean-catch sample, men or boys should clean the head of the penis. o Women or girls need to wash the area between the lips of the vagina with soapy water and rinse well. o As you start to urinate, allow a small amount to fall into the toilet bowl to clear the urethra of contaminants. Then, put a clean container under your urine stream and catch 1 to 2 ounces of urine. Remove the container from the urine stream. Cap and mark the container and give it to the health care provider or assistant. o For infants, thoroughly wash the area around the urethra. Open a urine collection bag (a plastic bag with an adhesive paper on one end), and place it on the infant. For boys, the entire penis can be placed in the bag and the adhesive attached to the skin. For girls, the bag is placed over the labia. Diaper as usual over the secured bag. This procedure may take a couple of attempts -- lively infants can displace the bag. The infant should be checked frequently and the bag changed after the infant has urinated into the bag. The urine is drained into the container for transport to the laboratory. How to prepare for the test •

Your health care provider will instruct you, if necessary, to discontinue drugs that may interfere with the test. Drugs that can increase specific gravity measurements include dextran and sucrose. Receiving intravenous dye

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(contrast medium) for an x-ray exam up to 3 days before the test can also interfere with results. Eat a normal, balanced diet for several days before the test.

Urine culture and Sensitivity The urine culture determines if bacteria are present in the urine, as well as their strains and concentration. Urine examination includes:

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Urine color

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Urine clarity and odor

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Urine pH and specific gravity

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Test to detect protein, glucose, and ketone bodies in the urine (proteinuria, glycosuria, and ketonuria)

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Microscopic examination of urine sediment after centrifuging to detect RBCs (hematuria), WBCs, casts (cylindruria), crystals (crystalluria), pus (pyuria), and bacteria (bacteriuria)

Creatinine Clearance Description: •

This test is the most accurate measurement of renal function that does not require the injection of dye or radiologic testing. It determines the glomerular filtration rete and tubular exrection ability of the kidney. How is it used? •

A creatinine clearance test is used to help evaluate the rate and efficiency of kidney filtration. It is used to help detect kidney dysfunction and/or the presence of decreased blood flow to the kidneys. In patients with chronic kidney disease or congestive heart failure (which decreases the rate of blood flow), the creatinine clearance test may be ordered to help monitor the progress of the disease and evaluate its severity.

When is it ordered? •

The creatinine clearance test may be ordered whenever a doctor wants to evaluate the filtration ability of the kidneys. It may be ordered when a patient has increased blood creatinine concentrations, a known or suspected kidney

disorder, or decreased blood flow to the kidneys due to a condition such as congestive heart failure.

Procedure: o Urine is taken from the patient ;The normal value is 90-110 ml/min and declines with age. o A 24-hour urine sample generally required. Occasionally, 6- or 12-hour urine collections can be done alternatively. The health care provider will instruct you, if necessary, to discontinue drugs that may interfere with the test. • • • •

On day 1, urinate into the toilet when you get up in the morning. Afterwards, collect all urine in a special container for the next 24 hours. On day 2, urinate into the container when you get up in the morning. Cap the container. Keep it in the refrigerator or a cool place during the collection period. Label the container with your name, the date, the time of completion, and return it as instructed.

For an infant: o Thoroughly wash the area around the urethra. Open a urine collection bag (a plastic bag with an adhesive paper on one end), and place it on the infant. For boys, the entire penis can be placed in the bag and the adhesive attached to the skin. For girls, the bag is placed over the labia. Diaper as usual over the secured bag. o This procedure may take a couple of attempts -- lively infants can displace the bag. The infant should be checked frequently and the bag changed after the infant has urinated into the bag. The urine is drained into the container for transport to the laboratory. o Deliver it to the laboratory or your health care provider as soon as possible upon completion. For an adult or child: o Blood is drawn from a vein, usually from the inside of the elbow or the back of the hand. The puncture site is cleaned with antiseptic. An elastic band is placed around the upper arm to apply pressure and cause the vein to swell with blood. o A needle is inserted into the vein, and the blood is collected in an air-tight vial or a syringe. During the procedure, the band is removed to restore circulation. Once

the blood has been collected, the needle is removed, and the puncture site is covered to stop any bleeding.

For an infant or young child: o The area is cleansed with antiseptic and punctured with a sharp needle or a lancet. The blood may be collected in a pipette (small glass tube), on a slide, onto a test strip, or into a small container. A bandage may be applied to the puncture site if there is any bleeding. o Both the blood and urine will be tested in a laboratory. Nsg. responsibility • •

The nurse should collect the urine specimen 12 or 24 hours as ordered.

Vanillylmandelic acid test: Description: •

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A test for catecholamine-secreting neuroblastoma) Procedure:

tumors

(pheochromocytoma

and

Performed on a 24-hour urine specimen; it is based on the finding that vanillylmandelic acid is the major urinary metabolite of norepinephrine and epinephrine.

Nsg. responsibility  The nurse should tell the patient to catch the midstream flow of his/her urine •

KUB (kidney, ureter, bladder)

Description: A KUB is a plain frontal supine radiograph of the abdomen. It is often supplemented by an upright PA view of the chest (to rule out air under the diaphragm or thoracic etiologies presenting as abdominal complaints) and a standing view of the

abdomen (to differentiate obstruction from ileus by examining gastrointestinal air/water levels). Despite its name, a KUB is not typically used to investigate pathology of the kidneys, ureters, or bladder, since these structures are difficult to assess (for example, the kidneys may not be visible due to overlying bowel gas.) In order to assess these structures with X-ray, a technique called an intravenous pyelogram is utilized. KUB is typically used to investigate gastrointestinal conditions such as a bowel obstruction and gallstones, and can detect the presence of kidney stones. The KUB is often used to diagnose constipation as stool can be seen readily. The KUB is also used to assess positioning of indwelling devices such as ureteric stents and nasogastric tubes. KUB is also a routine projection done as a scout film for other procedures such as barium enemas. Actually, the KUB should be called a KUBU, the last U standing for "Urethra". Commonly, it is still referred to as KUB only. It should include on the upright projections both right and left visualizations of the diaphragm. In at least one projection, the symphysis pubis must be present as the lower end of the area of interest. If the patient is large, more than one film loaded in the Bucky in a "landscape" direction may be used for each projection. This is done to ensure that the majority of bowel can be reviewed. •

Demonstrates the size of kidney, ureter, and bladder for presence of cysts, tumors, and displacement or obstruction.

Procedure: •

X-Ray the kidney, ureter and bladder

Nsg. responsibility    

Establish/maintain fluid and electrolyte balance Prevent complication Provide emotional support Provide information about s\disease

Uric acid: Description:  It is the increased urate excreation, fluid depletion and a low urinary pH. How is it used?

The uric acid test is used to learn whether the body might be breaking down cells too quickly or not getting rid of uric acid quickly enough. The test also is used to monitor levels of uric acid when a patient has had chemotherapy or radiation treatments. What does the test result mean? Higher than normal uric acid levels mean that the body is not handling the breakdown of purines well. The doctor will have to learn whether the cause is the overproduction of uric acid, or if the body is unable to clear away the uric acid. Increased concentrations of uric acid can cause crystals to form in the joints, which leads to the joint inflammation and pain characteristic of gout. Uric acid can also form crystals or kidney stones that can damage the kidneys. Low levels of uric acid in the blood are seen much less commonly than high levels and are seldom considered cause for concern. Although low values can be associated with some kinds of liver or kidney diseases, exposure to toxic compounds, and rarely as the result of an inherited metabolic defect, these conditions are typically identified by other tests and symptoms and not by an isolated low uric acid result. Procedure: Urine is taken from the patient. Nsg. responsibility  The nurse should tell the patient to catch the midstream flow of his/her urine •

Bladder scanning: Description: •

This procedure is to inspect the bladder for any obstruction, tumor etc.

Procedure: •

The patient is scanned with the ultrasonography machine

Nsg. responsibility •

The nurse should tell the patient to empty bladder first before the procedure

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Computed Tomography Scan

A computerized axial tomography scan is an x-ray procedure that combines many xray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. Computerized axial tomography is more commonly known by its abbreviated names, CT scan or CAT scan. A CT scan is used to define normal and abnormal structures in the body and/or assist in procedures by helping to accurately guide the placement of instruments or treatments. A large donut-shaped x-ray machine takes x-ray images at many different angles around the body. These images are processed by a computer to produce crosssectional pictures of the body. In each of these pictures the body is seen as an x-ray "slice" of the body, which is recorded on a film. This recorded image is called a tomogram. "Computerized Axial Tomography" refers to the recorded tomogram "sections" at different levels of the body. Procedure: o All metallic materials and certain clothing around the body are removed because they can interfere with the clarity of the images. o Patients are placed on a movable table, and the table is slipped into the center of a large donut-shaped machine which takes the x-ray images around the body. o The actual procedure can take from a half an hour to an hour and a half. o If specific tests, biopsies, or intervention are performed by the radiologist during CT scanning, additional time and monitoring may be required. o It is important during the CT scan procedure that the patient minimizes any body movement by remaining as still and quiet as is possible. This significantly increases the clarity of the x-ray images. o The CT scan technologist tells the patient when to breathe or hold his/her breath during scans of the chest and abdomen. o If any problems are experienced during the CT scan, the technologist should be informed immediately. o The technologist directly watches the patient through an observation window during the procedure, and there is an intercom system in the room for added patient safety. Nursing responsibilities:  Promote / maintain the client’s dignity  Maintain the client’s sense of control  Assist the client to become comfortable in a new environment •

Magnetic Resonance Imaging

An MRI (or magnetic resonance imaging) scan is a radiology technique that uses magnetism, radio waves, and a computer to produce images of body structures. The MRI scanner is a tube surrounded by a giant circular magnet. The patient is placed on a moveable bed that is inserted into the magnet. The magnet creates a strong magnetic field that aligns the protons of hydrogen atoms, which are then exposed to a beam of radio waves. This spins the various protons of the body, and they produce a faint signal that is detected by the receiver portion of the MRI scanner. The receiver information is processed by a computer, and an image is produced.

Procedure: o All metallic objects on the body are removed prior to obtaining an MRI scan. o Occasionally, patients will be given a sedative medication to decrease anxiety and relax the patient during the MRI scan. o MRI scanning requires that the patient lie still for best accuracy. o Patients lie within a closed environment inside the magnetic machine. o Relaxation is important during the procedure and patients are asked to breathe normally. Interaction with the MRI technologist is maintained throughout the test. o There are loud, repetitive clicking noises which occur during the test as the scanning proceeds. o Occasionally, patients require injections of liquid intravenously to enhance the images which are obtained. o The MRI scanning time depends on the exact area of the body studied, but ranges from half an hour to an hour and a half. Nursing responsibilities: •

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Supply the MRI Medical History Questionnaire (S/N 1384) to the patient forcompletion if the patient is coherent and an accurate historian. Notify MRI personnel if the patient is unconscious, unresponsive, can not provide reliable history and there is no family that can provide information. The nursing staff is responsible for placement of an IV lock and assuring that theMRI Medical History Questionnaire is complete prior to transporting the patient to MRI. Nursing staff shall also key the order into the Invision system following computer prompts.

Intravenous Pyelogram (IVP)

An intravenous pyelogram (IVP) is an x-ray examination of the kidneys, ureters and urinary bladder that uses iodinated contrast material injected into veins.

An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging. When a contrast material is injected into a vein in the patient's arm, it travels through the blood stream and collects in the kidneys and urinary tract, turning these areas bright white. An IVP allows the radiologist to view and assess the anatomy and function of the kidneys, ureters and the bladder.

Procedure: o This examination is usually done on an outpatient basis. o The patient is positioned on the table and still x-ray images are taken. The contrast material is then injected, usually in a vein in the patient's arm, followed by additional still images. o You must hold very still and may be asked to keep from breathing for a few seconds while the x-ray picture is taken to reduce the possibility of a blurred image. The technologist will walk behind a wall or into the next room to activate the x-ray machine. o As the contrast material is processed by the kidneys a series of images is taken to determine the actual size of the kidneys and to capture the urinary tract in action as it begins to empty. The technologist may apply a compression band around the body to better visualize the urinary structures leading from the kidney. o When the examination is complete, you will be asked to wait until the radiologist determines that all the necessary images have been obtained. o An IVP study is usually completed within an hour. However, because some kidneys empty at a slower rate the exam may last up to four hours. •

Renal Angiography

Angiography is the use of an x-ray to look at arteries in order to detect blockage or narrowing of the vessels. In many cases, the interventional radiologist can treat the blockages such as those occurring in the arteries of the kidney by inserting a small stent which inflates and opens the vessel. This procedure is called angioplasty. For diagnosis and treatment of renal (kidney) vascular hypertension and renal insufficiency, CO² angiography is available to minimize contrast load in patients with preexisting renal insufficiency. How it works A contrast dye injected via a catheter threaded into the blood vessels of the kidneys makes them visible on a x-ray, allowing detection of any abnormalities affecting the blood supply to the kidneys.

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Preparation Clear liquids for 12 hours before the procedure. You may take your medicines.

Test procedure • • •

Local anesthesia is injected into your skin near an artery in your arm or leg. When the site is numbed, a catheter is inserted into the artery and threaded up through the aorta and into the renal artery. Dye is injected through the catheter, and a series of X-rays is taken. During the X-rays, you must remain absolutely still.

After the test • • • •

The catheter is removed, and pressure is applied to the catheter site to stop any bleeding. You will go to a recovery room for a short while so your vital signs can be checked. You may receive pain medication if the catheter insertion site is sore. You should restrict your activities and remain relatively quiet during the next 24 hours, after which you can resume normal activities. You must check the incision and report any excessive bleeding, soreness, or swelling to your doctor.

Nursing Responsibilities: 1.See all patients the day/night before their procedure and review chart, check labs* and EKG, obtain consent, write preprocedure note and place orders. 2.See all same day admit patients and out patients for workup as above (in conjunction with NPs). 3.CTA/MRA protocol first thing after conference when assigned to imaging. 4.Residents should arrive by 7:30 AM if not at conference or case review. Be ready to perform cases by 8:00. 5.Scheduling of cases, or add-on cases, should be referred to Fellows. 6.When preparting to do a case, make a treatment plan based on old studies and present it to an attending. 7.Perform procedures with supervision by Fellow/Attending. 8.A physician or nurse must be present in the procedure room at all times. 9.Fill post note at completion of procedure and call admitting resident.

10.Review your cases with an attending prior to dictation. 11.See in-house patients after all diagnostic procedures for follow up and write note in chart later that same day. 12.Attend all AM conferences. 13.Complete 2 angio teaching files per rotation and review them with an attending. *If labs are pending the evening before the procedure, find the results before 8:00 a.m. the day of the procedure. •

Renal Scanning

A renal scan is a nuclear medicine exam in which a small amount of radioactive material (radioisotope) is used to measure the function of the kidneys. The specific type of scan may vary, depending on the patient's specific needs. This article provides a general overview. A renal scan is similar to a renal perfusion scintiscan. It may be done along with that test. o You will be asked to lie on the scanner table. The health care provider will place a tourniquet or blood pressure cuff to the upper arm, which creates pressure and enlarges your arm veins. The inner elbow is scrubbed with numbing medicine (antiseptic) and a small amount of radioisotope is injected into a vein. The specific radioisotope used may vary, depending on the kidney function that is being studied. o The pressure on the upper arm is released, which allows the radioactive material to travel through the bloodstream. The kidneys are scanned a short time later. Several images are taken, each lasting 1 or 2 seconds. The total scan time takes about 30 minutes to 1 hour. o A computer analyzes the images and provides detailed information about particular kidney functions (such as how much blood the kidney filters over time).

After the scan, no recovery time is required. You may be asked to drink plenty of fluids and urinate frequently to help remove the radioactive material from the body.

DESCRIPTION •

Cystoscopy is a test that looks at the inner lining of the bladder and the tube from the bladder to the outside of the body (urethra). The cystoscope is a thin, lighted viewing tool that is put into the urethra and moved into the bladder.I t is performed by a urologist, with one or more assistants. The test is done in a special testing room in a hospital or the doctor's office.

PROCEDURE o You should empty your bladder just before the test. You may be given medicine to prevent a urinary tract infection that could be caused by the test. o You will need to take off all or most of your clothes, and you will be given a cloth or paper covering to use during the test. o About an hour before the test, you may be given a sedative to help you relax. An intravenous (IV) needle may be placed in a vein in your arm to give you other medicines and fluids. You will lie on your back on a special table with your knees bent, legs apart, and your feet or thighs may be supported by stirrups. Your genital area is cleaned with an antiseptic solution, and your abdomen and thighs are covered with sterile cloths. o If a local anesthetic is used, the anesthetic solution or jelly is inserted in your urethra. o If a general anesthetic is used, you will be put to sleep either with a medicine given through an IV or by inhaling gases through a mask, or both methods may be used. o If a spinal anesthetic is used, the area on the back where the needle will be inserted is first numbed with a local anesthetic, then the needle is guided into the spinal canal and the anesthetic is injected. A spinal anesthetic may prevent movement of the legs until the anesthetic wears off. o After the anesthetic takes effect, a well-lubricated cystoscope is inserted into your urethra and slowly advanced into your bladder. If your urethra has a spot

that is too narrow to allow the scope to pass, other smaller instruments are inserted first to gradually enlarge the opening. o After the cystoscope is inside your bladder, either sterile water or saline is injected through the scope to help expand your bladder and to create a clear view. A medicine may also be injected through the scope to reduce chances of infection. Tiny instruments may be inserted through the scope to collect tissue samples for biopsy; the tissue samples then are sent to the laboratory for analysis. o The cystoscope is usually in your bladder for only 2 to 10 minutes. But the entire test may take up to 45 minutes or longer if other X-ray tests are done at the same time. o If a local anesthetic is used, you may be able to get up immediately after the test. If a general anesthetic is used, you will stay in the recovery room until you are awake and able to walk (usually an hour or less). You can eat and drink as soon as you are fully awake and can swallow without choking. If a spinal anesthetic was used, you will stay in the recovery room until sensation and movement below your chest returns (usually about an hour). RESULTS Normal  The urethra, bladder, and ureters are normal.  There are no polyps or other abnormal tissues, swelling, bleeding, narrow areas (strictures), or structural abnormalities. Abnormal  There is welling or narrowing of the urethra because of previous infections or an enlarged prostate gland.  There are bladder tumors (cancerous or benign), polyps, ulcers, urinary stones, or inflammation of the bladder walls.  Abnormalities in the structure of the urinary tract present since birth (congenital) are seen.  Pelvic organ prolapse is present in a woman. IMPORTANCE A cystoscopy can check for stones, tumors, bleeding, and infection. Cystoscopy can see areas of the bladder and urethra that usually do not show up well on X-rays. Tiny surgical instruments can be put through the cystoscope to remove samples of tissue (biopsy) or samples of urine. Cystoscopy also can be used to treat some bladder problems, such as removing small bladder stones and some small growths. •

Kidney Biopsy

DESCRIPTION A kidney biopsy is done using a long thin needle put through the back (flank) into the kidney. This is called a percutaneous kidney biopsy. A tissue sample is taken and sent to a lab. It is look at under a microscope. The sample can help your doctor see how healthy your kidney is and look for any problems. A kidney biopsy may be done to check for kidney problems. It may also be done after other tests for kidney disease, such as blood and urine tests, ultrasound, or a computed tomography (CT) scan, show a kidney problem. If kidney cancer is suspected, a biopsy may not be done because of the chance of spreading the cancer. Biopsy results are ready in 2 to 4 days. If tests are done to find infections, it may take several weeks for the results to be ready. PROCEDURE o A kidney biopsy is done by a urologist, nephrologist, or a radiologist in a clinic or a hospital. A kidney biopsy is often done by a radiologist using ultrasound, fluoroscopy, a CT scan, or magnetic resonance imaging (MRI) to help guide the biopsy needle. o You will need to take off all or most of your clothes. You will wear a gown. Before the biopsy, you may be given a sedative through an intravenous (IV) line in a vein in your arm. The sedative will help you relax and lie still during the biopsy. o You will be asked to lie facedown on an examination table. A sandbag, a firm pillow, or a rolled towel will be placed under your body to support your belly. It is very important that you follow your doctor's directions about breathing, holding your breath, and lying still while the biopsy is being done. o Your doctor will examine your back and may mark the biopsy site by making a slight dent in your skin with a pencil or tool. The biopsy may be done on either the right or the left kidney. The site will be cleaned with a special soap. Your doctor then gives you local anesthetic to numb the area where the biopsy needle will be inserted.

o Your doctor puts the biopsy needle through the skin while looking at your kidney with ultrasound. You will be asked to hold your breath and stay very still while the needle is put into the kidney. o The needle is removed after the tissue sample is taken. Pressure is put on the biopsy site for several minutes to stop the bleeding. Then a bandage is put on the site. The biopsy takes 15 to 30 minutes. o After the biopsy, you will rest in bed for 6 to 24 hours. Your pulse, blood pressure, and temperature will be checked often after the biopsy. o If no problems develop, you can go home. To prevent bleeding at the biopsy site, lie flat on your back for the next 12 to 24 hours. You may eat your normal diet. Do not take aspirin or anti-inflammatory medicines for a week after the biopsy. You may do your regular activities, but do not do strenuous activities, such as heavy lifting, hard running, motorcycle riding, contact sports, or other activities that might jar or jolt your kidney, for 2 weeks after the biopsy. Also, drink more fluids so you will not be dehydrated.

RESULTS Normal The structure and cells of the kidney look normal. There are no signs of inflammation, scar tissue, infection, or cancer.

Abnormal The sample may show signs of scarring due to infection, poor blood flow, glomerulonephritis, a kidney infection (pyelonephritis), or signs of other diseases that affect the body, such as systemic lupus erythematosus. Kidney tissue may show tumors that were not expected, such as Wilms' tumor (which occurs in early childhood) and renal cell cancer (which is most common after age 40). DESCRIPTION •

Complete Blood Count (CBC) gives important information about the kinds and numbers of cells in the blood, especially red blood cells, white blood cells, and platelets. A CBC helps your health professional check any symptoms, such as weakness, fatigue, or bruising, you may have. A CBC also helps him or her diagnose conditions, such as anemia, infection, and many other disorders.

A CBC test usually includes: 









White blood cell (WBC, leukocyte) count. White blood cells protect the body against infection. If an infection develops, white blood cells attack and destroy the bacteria, virus, or other organism causing it. White blood cells are bigger than red blood cells but fewer in number. When a person has a bacterial infection, the number of white cells rises very quickly. The number of white blood cells is sometimes used to find an infection or to see how the body is dealing with cancer treatment. White blood cell types (WBC differential). The major types of white blood cells are neutrophils, lymphocytes, monocytes, eosinophils, and basophils. Immature neutrophils, called band neutrophils, are also part of this test. Each type of cell plays a different role in protecting the body. The numbers of each one of these types of white blood cells give important information about the immune system. Too many or too few of the different types of white blood cells can help find an infection, an allergic or toxic reaction to medicines or chemicals, and many conditions, such as leukemia. Red blood cell (RBC) count. Red blood cells carry oxygen from the lungs to the rest of the body. They also carry carbon dioxide back to the lungs so it can be exhaled. If the RBC count is low (anemia), the body may not be getting the oxygen it needs. If the count is too high (a condition called polycythemia), there is a chance that the red blood cells will clump together and block tiny blood vessels (capillaries). This also makes it hard for your red blood cells to carry oxygen. Hematocrit (HCT, packed cell volume, PCV). This test measures the amount of space (volume) red blood cells take up in the blood. The value is given as a percentage of red blood cells in a volume of blood. For example, a hematocrit of 38 means that 38% of the blood's volume is made of red blood cells. Hematocrit and hemoglobin values are the two major tests that show if anemia or polycythemia is present. Hemoglobin (Hgb). The hemoglobin molecule fills up the red blood cells. It carries oxygen and gives the blood cell its red color. The hemoglobin test measures the amount of hemoglobin in blood and is a good measure of the blood's ability to carry oxygen throughout the body.

PROCEDURE Your health professional drawing blood will: 

    

Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein. Clean the needle site with alcohol. Put the needle into the vein. More than one needle stick may be needed. Attach a tube to the needle to fill it with blood. Remove the band from your arm when enough blood is collected. Put a gauze pad or cotton ball over the needle site as the needle is removed.



Put pressure to the site and then a bandage.

 If this blood test is done on a baby, a heel stick will be done instead of a blood draw from a vein. RESULTS White blood cell (WBC, leukocyte) count Men and nonpregnant women Pregnant women

4,500–11,000/mcL3 or 4.5–11.0 x 109/liter (SI units) 1st trimester: 6,600–14,100/mcL or 6.6–14.1 x 109/L 2nd trimester: 6,900–17,100/mcL or 6.9–17.1 x 109/L 3rd trimester: 5,900–14,700/mcL or 5.9–14.7 x 109/L Postpartum: 9,700–25,700/mcL or 9.7–25.7 x 109/L

White blood cell types (WBC differential) Neutrophils

50%–62%

Band neutrophils

3%–6%

Lymphocytes

25%–40%

Monocytes

3%–7%

Eosinophils

0%–3%

Basophils

0%–1%

Red blood cell (RBC) count Men 4.7–6.1 million RBCs per microliter (mcL) or 4.7–6.1 x 1012/liter (SI units) Women

4.2–5.4 million RBCs per mcL or 4.2–5.4 x 1012/L

Children

4.0–5.5 million RBCs per mcL or 4.6–4.8 x 1012/L

Newborn

4.8–7.1 million RBCs per mcL or 4.8–7.1 x 1012/L

Hematocrit (HCT) Men Women Pregnant women

42%–52% or 0.42–0.52 volume fraction (SI units) 37%–47% or 0.37–0.47 volume fraction 1st trimester: 35%–46% 2nd trimester: 30%–42% 3rd trimester: 34%–44%

Children Newborns

Postpartum: 30%–44% 32%–44% 44%–64%

Hemoglobin (Hgb) Men Women Pregnant women

14–18 grams per deciliter (g/dL) or 8.7–11.2 millimoles per liter (mmol/L) (SI units) 12–16 g/dL or 7.4–9.9 mmol/L 1st trimester: 11.4–15.0 g/dL or 7.1–9.3 mmol/L 2nd trimester: 10.0–14.3 g/dL or 6.2–8.9 mmol/L 3rd trimester: 10.2–14.4 g/dL or 6.3–8.9 mmol/L

Children Newborns •

Postpartum: 10.4–18.0 g/dL or 6.4–9.3 mmol/L 9.5–15.5 g/dL 9.5–15.5 g/dL

HGB

Alternative Names 

Hb electrophoresis; Hgb electrophoresis

Definition

Hemoglobin electrophoresis is a test that measures the different types of the oxygen-carrying substance (hemoglobin) in the blood. How the Test is Performed o Blood is drawn from a vein, usually from the inside of the elbow or the back of the hand. The area is cleaned with antiseptic, and an elastic band is placed around the upper arm to apply pressure and restrict blood flow through the vein. This causes veins below the elastic band to fill with blood. o A needle is inserted into the vein, and the blood is collected in an air-tight vial or a syringe. During the procedure, the band is removed to restore circulation. Once the blood has been collected, the needle is removed, and the puncture site is covered to stop any bleeding. o In an infant or young child, the area is cleansed with antiseptic and punctured with a sharp needle or a lancet. The blood may be collected in a small glass tube (pipette), on a slide, onto a test strip, or into a small container. Cotton or a bandage may be applied to the puncture site if there is any continued bleeding. How to Prepare for the Test No special preparation is necessary for this test. How the Test Will Feel When the needle is inserted to draw blood, some people feel moderate pain, while others feel only a prick or stinging sensation. Afterward, there may be some throbbing. Why the Test is Performed You may have this test if your health care provider suspects that you have a disorder caused by abnormal forms of hemoglobin (hemoglobinopathy). Many different types of hemoglobin (Hb) exist. The most common ones are HbA, HbA2, HbF, HbS, HbC, Hgb H, and Hgb M. Healthy adults only have significant levels of HbA and HbA2. Some people may also have small amounts of HbF (which is the main type of hemoglobin in an unborn baby's body). Certain diseases are associated with high HbF levels (when HbF is more than 2% of the total hemoglobin). HbS is an abnormal form of hemoglobin associated with sickle cell anemia. In people with this condition, the red blood cells have a crescent or sickle shape. These misformed cells then break down, or can block small blood vessels. HbC is an abnormal form of hemoglobin associated with hemolytic anemia. The symptoms are much milder than they are in sickle cell anemia.

Other, less common, abnormal Hb molecules cause anemias. Normal Results In adults, these hemoglobin molecules make up the following percentages of total hemoglobin: • • • • •

Hgb A1: 95% to 98% Hgb A2: 2% to 3% Hgb F: 0.8% to 2% Hgb S: 0% Hgb C: 0%

In infants and children, these hemoglobin molecules make up the following percentages of total hemoglobin: • • •

Hgb F (newborn): 50% to 80% Hgb F (6 months): 8% Hgb F (over 6 months): 1% to 2%

What Abnormal Results Mean The presence of significant levels of abnormal hemoglobins may indicate: • • •

Hemoglobin C disease Rare hemoglobinopathy Sickle cell anemia

This test also may be performed if the health care provider suspects the condition thalassemia. Risks • • • • •

Excessive bleeding Fainting or feeling lightheaded Blood accumulating under the skin (hematoma) Infection Multiple punctures to find veins

Considerations You may have false normal or abnormal results if you've had a blood transfusion within the previous 12 weeks.

Veins and arteries vary in size from one patient to another, and from one side of the body to the other. Getting a blood sample from some people may be more difficult than from others. •

Platelet Count

Alternative Names 

Thrombocyte count

Definition A platelet count is a test to measure how many blood cells, called platelets, you have in your blood. Platelets help the blood clot. How the Test is Performed o Blood is drawn from a vein, often on the inside of the elbow. The puncture site is cleaned with antiseptic, and an elastic band is placed around the upper arm to apply pressure and restrict blood flow through the vein. This causes veins below the band to fill with blood. o A needle is inserted into the vein, and the blood is collected in a vial or a syringe. The band and needle are removed, and the puncture site is covered to stop any bleeding. o For infants and young children, the area is cleansed with antiseptic and punctured with a sharp needle or a lancet. The blood may be collected in a pipette (small glass tube), on a slide, onto a test strip, or into a small container. Cotton or a bandage may be applied to the puncture site if there is any continued bleeding. How to Prepare for the Test No preparation is necessary. How the Test Will Feel When the needle is inserted to draw blood, some people feel moderate pain, while others feel only a prick or stinging sensation. Afterward, there may be some throbbing. Why the Test is Performed he number of platelets in your blood can be affected by many diseases. Platelets may be counted to monitor or diagnose diseases, or identify the cause of excess bleeding.

Normal Results 150,000 to 400,000/mm3 What Abnormal Results Mean If the number of platelets is below normal (thrombocytopenia), the cause may be: • • • • • • • •

Cancer chemotherapy Disseminated intravascular coagulation (DIC) Hemolytic anemia Hypersplenism Idiopathic thrombocytopenic purpura (ITP) Leukemia Massive blood transfusion Prosthetic heart valve

If the number is higher than normal (thrombocytosis), the cause may be: • • • • • •

Anemia Certain malignancies Early CML Polycythemia vera Post-splenectomy syndrome Primary thrombocytosis

A platelet count may be performed under many conditions and to assess many diseases. Risks • • • • •

Excessive bleeding Fainting or feeling light-headed Hematoma (blood accumulating under the skin) Infection (a slight risk any time the skin is broken) Multiple punctures to locate veins

Considerations Drugs that can lower platelet counts include chemotherapy drugs, chloramphenicol, colchicine, H2 blocking agents, heparin, hydralazine, indomethacin, isoniazid, quinidine, streptomycin, sulfonamide, thiazide diuretic, and tolbutamide. Veins and arteries vary in size from one patient to another and from one side of the body to the other. Obtaining a blood sample from some people may be more difficult than from others.

•

Erythropoietin Test

Alternative Names 

Serum erythropoietin; EPO

Definition The erythropoietin test measures the amount of a hormone called erythropoietin ((EPO) in blood. The hormone acts on stem cells in the bone marrow to increase the production of red blood cells. It is made by cells in the kidney, which release the hormone when oxygen levels are low. How the Test is Performed o Blood is drawn from a vein, usually from the inside of the elbow or the back of the hand. The site is cleaned with germ-killing medicine (antiseptic). The health care provider wraps an elastic band around the upper arm to apply pressure to the area and make the vein swell with blood. o Next, the health care provider gently inserts a needle into the vein. The blood collects into an airtight vial or tube attached to the needle. The elastic band is removed from your arm. o Once the blood has been collected, the needle is removed, and the puncture site is covered to stop any bleeding. o In infants or young children, a sharp tool called a lancet may be used to puncture the skin and make it bleed. The blood collects into a small glass tube called a pipette, or onto a slide or test strip. A bandage may be placed over the area if there is any bleeding. How to Prepare for the Test No special preparation is necessary. How the Test Will Feel When the needle is inserted to draw blood, some people feel moderate pain, while others feel only a prick or stinging sensation. Afterward, there may be some throbbing. Why the Test is Performed This test may be used to help determine the cause of anemia, polycythemia (high red blood cells) or other bone marrow disorders.

A change in red blood cells will affect the release of EPO. For example, persons with anemia have too few red blood cells, so more EPO is produced. Normal Results The normal range is 0-19 milliunits per milliliter (mU/mL). Note: Normal value ranges may vary slightly among different laboratories. Talk to your doctor about the meaning of your specific test results. What Abnormal Results Mean Increased EPO levels may be due to secondary polycythemia, an overproduction of red blood cells that occurs in response to an event such as low blood oxygen levels. This may happen at high altitudes or, rarely, because of a tumor that releases EPO. Lower-than-normal EPO levels may be seen in chronic kidney failure, anemia of chronic disease, or polycythemia vera.

Risks Veins and arteries vary in size from one patient to another and from one side of the body to the other. Obtaining a blood sample from some people may be more difficult than from others. Other risks associated with having blood drawn are slight but may include: Excessive bleeding Fainting or feeling light-headed Hematoma (blood accumulating under the skin) Infection (a slight risk any time the skin is broken) CT SCAN • • • •

•

Alternative Names 

CAT scan; Computed axial tomography scan; Computed tomography scan

Definition Computed tomography (CT) is an imaging method that uses x-rays to create cross-sectional pictures of the body. How the Test is Performed

o You will be asked to lie on a narrow table that slides into the center of the CT scanner. Depending on the study being done, you may need to lie on your stomach, back, or side. o Once inside the scanner, the machine's x-ray beam rotates around you. (Modern "spiral" scanners can perform the exam in one continuous motion.) o Small detectors inside the scanner measure the amount of x-rays that make it through the part of the body being studied. A computer takes this information and uses it to create several individual images, called slices. These images can be stored, viewed on a monitor, or printed on film. Three-dimensional models of organs can be created by stacking the individual slices together. o You must be still during the exam, because movement causes blurred images. You may be told to hold your breath for short periods of time. o Generally, complete scans take only a few minutes. The newest multidetector scanners can image your entire body, head to toe, in less than 30 seconds. How to Prepare for the Test • •

Certain exams require a special dye, called contrast, to be delivered into the body before the test starts. Contrast can highlight specific areas inside the body, which creates a clearer image. Some people have allergies to IV contrast and may need to take medications before their test in order to safely receive this substance.

How the Test Will Feel The x-rays are painless. Some people may have discomfort from lying on the hard table. Contrast give through an IV may cause a slight burning sensation, a metallic taste in the mouth, and a warm flushing of the body. These sensations are normal and usually go away within a few seconds. Why the Test is Performed CT rapidly creates detailed pictures of the body, including the brain, chest, spine, and abdomen. The test may be used to: • • •

Guide a surgeon to the right area during a biopsy Identify masses and tumors, including cancer Study blood vessels

Normal Results Results are considered normal if the organs and structures being examined are normal in appearance.

What Abnormal Results Mean The significance of abnormal results depends on the part of the body being studied and the nature of the problem. Consult your health care provider with any questions and concerns. Risks CT scans and other x-rays are strictly monitored and controlled to make sure they use the least amount of radiation. CT scans do create low levels of ionizing radiation, which has the potential to cause cancer and other defects. However, the risk associated with any individual scan is small. The risk increases as numerous additional studies are performed. In some cases, a CT scan may still be done if the benefits greatly out weigh the risks. For example, it can be more risky not to have the exam, especially if your health care provider thinks you might have cancer. An abdominal CT scan is usually not recommended for pregnant women, because it may harm the unborn child. Women who are or may be pregnant should speak with their health care provider to determine if ultrasound can be used instead. The most common type of contrast given into a vein contains iodine. If a person with an iodine allergy is given this type of contrast, nausea, sneezing, vomiting, itching, or hives may occur. If you absolutely must be given such contrast, your doctor may choose to treat you with antihistamines (such as Benadryl) or steroids before the test. The kidneys help filter the iodine out of the body. Therefore, those with kidney disease or diabetes should receive plenty of fluids after the test, and be closely monitored for kidney problems. If you have diabetes or are on kidney dialysis, talk to your health care provider before the test about your risks. Rarely, the dye may cause a life-threatening allergic response called anaphylaxis . If you have any trouble breathing during the test, you should notify the scanner operator immediately. Scanners come with an intercom and speakers, so the operator can hear you at all times. •

Partial thromboplastin time

Alternative Names 

APTT; PTT; Activated partial thromboplastin time

Definition

Partial thromboplastin time (PTT) is a blood test that looks at how long it takes for blood to clot. It can help tell if you have bleeding or clotting problems. How the Test is Performed The health care provider uses a needle to take blood from one of your veins. The blood collects into an air-tight container. You may be given a bandage to stop any bleeding. If you are taking a medicine called heparin, you will be watched for signs of bleeding. The laboratory specialist will add chemicals to the blood sample and see how many seconds it takes for the blood to clot.

How to Prepare for the Test The health care provider may tell you to stop taking certain drugs before the test. Drugs that can affect the results of a PTT test include antihistamines, vitamin C (ascorbic acid), aspirin, and chlorpromazine (Thorazine). Do not stop taking any medicine without first talking to your doctor. How the Test Will Feel When the needle is inserted to draw blood, some people feel moderate pain, while others feel only a prick or stinging sensation. Afterward, there may be some throbbing. Why the Test is Performed Your doctor may order this test if you have problems with bleeding or blood clotting. The test may also be used to monitor patients who are taking heparin, a blood thinner. A PTT test is usually done with other tests, such as the prothrombin test. Normal Results The normal value will vary between laboratories. In general, clotting should occur between 25 to 35 seconds. If the person is taking blood thinners, clotting takes up to two and a half times longer. What Abnormal Results Mean An abnormal (too long) PTT result may be due to:

• • • • • • • • •

Cirrhosis Disseminated intravascular coagulation (DIC) Factor XII deficiency Hemophilia A Hemophilia B Hypofibrinogenemia Malabsorption Von Willebrand's disease Lupus anticoagulants

Risks This test is often done on people who may have bleeding problems. The risks of bleeding and hematoma in these patients are slightly greater than for people without bleeding problems. In general, risks of any blood test may include: • • • • •

Excessive bleeding Fainting or feeling light-headed Hematoma (blood accumulating under the skin) Infection (a slight risk any time the skin is broken) Multiple punctures to locate veins

Considerations When you bleed, the body launches a series of activities that help the blood clot. This is called the coagulation cascade. There are three pathways to this event. The PTT test looks at special proteins, called factors, found in two of these pathways. •

Prothrombin time

Descriptions: Prothrombin time (PT) is a blood test that measures how long it takes blood to clot. A prothrombin time test can be used to check for bleeding problems. PT is also used to check whether medicine to prevent blood clots is working. The normal range is 10 – 12 sec. Procedure o

The prothrombin time is most commonly measured using blood plasma.

o

Blood is drawn into a test tube containing liquid citrate, which acts as an anticoagulant by binding the calcium in a sample.

o

The blood is mixed, then centrifuged to separate blood cells from plasma.

o

The plasma is analyzed by a medical technologist on an automated instrument at 37°C,

o

An excess of calcium is added (thereby reversing the effects of citrate), which enables the blood to clot again.

o

For the prothrombin time test the appropriate sample is the blue top tube, or sodium citrate tube, which is a liquid anticoagulant.

o

The prothrombin ratio is the prothrombin time for a patient, divided by the result for control plasma.

Nursing Responsibilities  No preparation is necessary.  Specimen should not be obtained after meal since lipenia may interfere with

photoelectric measurements of clot formation  check to see if the patient is taking any medications that may affect test

results.This precaution is particularly important if the patient is taking warfarin, because there are a number of medications that can interact with warfarin to increase or decrease the PT time  Aftercare consists of routine care of the area around the puncture mark. Pressure

is applied for a few seconds and the wound is covered with a bandage.

III. Renal Diseases A. UTI Urinary tract infection, (UTI) is an infection of one or more of the structures in the urinary tract. Most UTI’s happen from bowel organisms, (E-coli). Women are more prone to UTI’s because of the shortness of their urethra.

CYSTITIS Infections of the lower urinary tract are called cystitis. This is an inflammation of the urinary bladder related to a superficial infection that doesn’t extend to the bladder mucosa, most often caused by ascending infection from the urethra; it can also be caused by sexual intercourse. •

Causes o o o o o o o o o

•

Stagnation of urine in the bladder Obstruction of the urethra Sexual intercourse Incorrect aseptic technique during catheterization Incorrect perineal care Kidney infection Radiation Diabetes mellitus Pregnancy

Other causes o Cystitis is usually due to a bacterial infection of the urine. Occasionally, in children it can be caused by a virus. o The infection is more common in women because a woman's anatomy is designed in such a way that it makes it easier for bacteria to enter the bladder.

Sexual intercourse, using spermicidal creams, and using diaphragms all increase the risk of developing Bladder Infection. o People who have a catheter in their bladder or who have to periodically catheterize them have a higher risk of developing bladder infection. o People with Bladder Cancers or abnormal connections between their bladder and intestines also have a higher risk of developing Bladder Infection. o

•

Pathophysiology •

•

•

Bacterial infection from a second source spreads to the bladder, causing an inflammatory response. • Cell destruction from trauma to the bladder wall, particularly the trigone area, initiates an acute inflammatory response. Complications •

Chronic cystitis (recurrent or persistent inflammation of the bladder)

•

Urethritis (inflammation of the urethra)

•

Pyelenophritis (Infections of the upper urinary tract)

Clinical manifestations

Any changes in the clients voiding habits should be assessed as a possible UTI. The most common clinical manifestation of cystitis is burning pain of urination (dysuria), Frequency, urgency, voiding in small amount, inability to void, incomplete emptying of the bladder, cloudy urine and hematuria ( blood in urine). Asymptomatic bacteriuria (bacteria in urine). •

Nursing Diagnosis

Impaired Urinary Elimination. The primary diagnosis when a client is experiencing problems related to cystitis is Impaired Urinary Elimination related to irritation of the bladder mucosa.

Acute Pain. Another common nursing diagnosis for clients with cystitis is Acute Pain related to irritation and inflammation of bladder and urethral mucosa. •

How to diagnose

•

o Often times, treatment may be based on the symptoms alone, without additional tests. o Urinalysis (in which the urine is tested for the presence of an infection) is the most common method of diagnosis. o Blood and Urine cultures may also be required. o In women with frequent infections (more than three a year), a full examination of the urinary tract (usually by a specialist) needs to be done. Also, it is sometimes recommended that all men who develop any type of urinary infection, including Bladder Infections, need to be seen by a specialist. Diagnostic test findings  Urine culture and sensitivity: positive identification of organisms (Escherichia coli, Proteus vulgaris, Streptococcus faecalis)  Urine chemistry: hematuria, pyuria,; increased protein, leukocytes, specific gravity  Cytoscopy: obstruction or deformity

•

Assessment findings 

Frequency of urination



Urgency of urination



Burning or pain on urination



Lower abdominal discomfort



Dark, odoriferous urine



Flank tenderness or suprapubic pain



Nocturia (need to get up during the night in order to urinate, thus interrupting sleep)



Low-grade fever



Urge to bear down during urination



Dysuria (refers to painful urination)



Dribbling

•

Medical management  Diet: acid-ash diet with increased intake of fluids and vitamin C  Activity: as tolerated  Monitoring: vital signs and intake and output  Laboratory studies: specific gravity, urine culture and sensitivity  Treatment: Sitz baths  Antibiotics: co- trimoxizole (Bactrim), cephalexin (Keflex)  Analgesic: oxycodone (Tylox)  Urinary antiseptic: Phenazopyridine (Pyridium)  Antipyretic: acetaminophen (Tylenol)

•

Nursing interventions  Maintain the patients diet  Encourage fluids (cranberry or orange juice) to 3qt (3L)/day  Assess renal status  Monitor and record vital signs, I/O, and laboratory studies  Administer medications, as prescribed  Allay patient’s anxiety  Maintain treatments: sitz baths, perineal care  Encourage voiding every 2 to 3 hours  Individualize home care instructions o Avoid coffee, tea, alcohol and cola o Increase fluid intake to 3 qt (3L)/ day using orange juice and cranberry juice o Void every 2 to 3 hours and after intercourse

o Perform perineal care correctly o Avoid bubble baths, vaginal deodorants ant tub baths

•

Evaluation

The client will have return of normal voiding habits within 3 days of starting antibiotic treatment as evidenced by an absence of fever, pain, burning, frequency, and urgency.

The client will be able to urinate with minimal or no discomfort within 24 hours after treatment begins and will return to normal voiding habits within 3 days, as evidenced by an absence of pain and burning on urination.

PYELENOPHRITIS Infections of the upper urinary tract are called pyelonephritis. This is an infection of renal pelvis, tubules, (tubes), in the kidneys. The bacteria may enter through the bladder via the ureters or through blood stream. Pyelonephritis describes a syndrome caused by the inflammation (irritation, swelling, pain, damage) of the tubes (renal tubules) that carry urine from the kidneys to the bladder (upper urinary tract) and the renal (kidney) interstitium (tissue surrounding the renal structures). Many times this upper UTI is caused by reflux of urine up through the ureters from a faulty valve, that is suppose to prevent this from happening. Sign and symptoms are chills and fever; flank pain. A urinalysis will show bacteria, pus. The s/s are pretty much the same as for the lower UTI except the bacteria in the urine found on the urinalysis are coated with antibodies that happens only in the renal pelvis. An upper UTI is more serious due to the fact it can cause damage and death to tissues in the kidneys if not treated. Pyelonephritis can be acute (sudden) or chronic (prolonged) in nature. Acute pyelenophritis often occurs after bacterial contamination of the urethra or after introduction of an instrument, such as catheter or a cytoscope. Chronic pyelenophritis is more likely to occur after chronic obstruction with reflux or chronic disorders. It is slowly progressive and usually is associated with recurrent acute attacks, although the client may not have a history of acute pyelenophritis. •

Causes o Enteric bacteria

o o o o o o o o •

Pathophysiology • •

•

•

Bacterial infection from a second source spreads to the renal pelvis, causing an inflammatory response. Cell destruction from trauma to the renal pelvis initiates an acute inflammatory response.

Complications • Chronic renal failure • Hypertension • Septicemia Clinical manifestations •

•

Ureterovesical reflux Urinary tract obstruction Pregnancy Trauma UTI Incorrect aseptic technique Diabetes mellitus Staphylococcal or streptococcal infections

Characterized by enlarged kidney, focal parenchyma abscesses and accumulation of polymorph nuclear lymphocytes around and in the renal tubules.

Nursing Diagnosis

Risk for Deficient Fluid Volume. A common diagnosis is Risk for Deficient Fluid Volume related to fever, nausea, vomiting, and possible diarrhea.

Acute Pain. Another common nursing diagnosis is acute pain related to an inflammatory process in the kidney and possible colic.

Readiness for Enhanced Self- Care. Client teaching is important to promote self-care and to prevent recurrent teachings. Write the diagnosis Readiness for Enhanced SelfCare to prevent recurrent infections. •

Diagnostic test findings

 Excretory urography (which consists of imaging the kidneys and urinary tracts before and after the administration of intravenous contrast material): atrophy, blockage, or deformity of kidney  Urine culture and sensitivity: bacteria  Urine chemistry: pyuria, hematuria; leukocytes, WBCs, and casts; specific gravity greater than 1.025; albiminuria  Hematology( study of blood): increased WBCs  24-hour urine collection: decrease creatinine clearance •

Assessment findings 

Elevated temperature



Chills



Nausea and vomiting



Flank pain



Chronic fatigue



Bladder irritability



Hypertension



Dysuria



Burning on urination



Frequency of urination



Urgency of urination



Headache



Anorexia



Weight loss



Odoriferous, concentrated urine

•

Medical management  Diet: soft, high-calorie, low protein  IV therapy: saline lock, electrolyte and fluid replacement  Activity: as tolerated  Monitoring: vital signs, I/O, urine pH, and specific gravity  Laboratory studies: WBCs, urine protein, and urine culture and sensitivity  Treatments: warm, moist compress to flank  Fluid intake: 3qt (3L)/day  Analgesic: meperidine (Demerol)  Antibiotics: cefazolin (Ancef0, cefoxitin (Mefoxin), co- trimoxizole (Bactrim)  Urinary antiseptics: phenazopyridine (Pyridium)  Antiemetic: prochlorperazine (Compazine)  Alkalinizers: potassium acetate, sodium bicarbonate  Sedative: oxazepam (Serax)  Peritoneal dialysis and hemodialysis

•

Nursing interventions            

Maintain the patient’s diet Encourage fluids 3qt (3L)/ day Assess renal status and fluid balance Monitor and record vital signs, I/O, laboratory studies, daily weight, specific gravity, and urine for blood, protein, and pH Administer medications, as prescribed Allay the patient’s anxiety Provide hot, moist compresses and warm baths Prevent chilling Provide rest periods Provide skin, mouth and perineal care Encourage frequent voiding Individualize home care instructions o Void frequently

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o Return to the physician immediately if symptoms reoccur o Take prescribed medications for entire duration of prescription Evaluation

The client will maintain fluid balanced intake and output, maintenance of adequate hydration, and an absence of manifestations of dehydration.

The client will be able to report either that there is no pain or that pain is controlled.

The client will have the knowledge of the treatment regimen and understand how to prevent recurrent infections as evidenced by the client’s statements and no recurrence of infection.

B. Glomerulonephritis Description of the Disease:

Glumerulonephritis is a disease that affects the glumeruli of both kidneys. Etiologic factors are many and varied; they include immunologic reactions (lupus erythematosus, streptococcal infection), vascular injury (hypertension), metabolic disease (diabetes mellitus), and disseminated intravascular coagulation (DIC). Glomerulonephritis exists in acute, latent and chronic forms.

Medical Surgical Nursing Concepts and Clinical Practice 4th Ed. By Phipps, Long, Woods and Cassmeyer p. 1410

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Acute glomerulonephritis Acute glomerulonephritis is inflammation of the glumerular capillary membrane. Acute glumerulonephritis can result from systemic diseases or

primary glomerular diseases, but acute postreptococcal glomerulonephritis (also known as acute ploriferative glomerulonephritis) is the most common form.

Medical Surgical Nursing 3rd Ed. By Priscilla Lemone and Karen Burke p. 747

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Chronic Glumerulonephritis Chronic Glumerulonephritis is typically the end stage of other glomerular disorders such as RGPN, lupus nephritis, or diabetic nephropathy. In many cases, however, no previous glomerular disease has been identified.

Slow, progressive destruction of the glomeruli and a gradual decline in renal function are characteristics of chronic glomerulonephritis. The kidneys decrease in size symmetrically, and their surfaces become granular or roughened. Eventually entire nephrons are lost.

Medical Surgical Nursing 3rd Ed. By Priscilla Lemone and Karen Burke p. 748

Causes or Risk Factors • • • • • • • • •

Diabetes Vasculitis High Blood Pressure Strep Throat Immune Disorders Genetic Disorders Heart Valve Disorders Family History of Glomerulonephritis Infections

• Post-streptococcal glomerulonephritis. Glomerulonephritis may develop after a strep infection in your throat or, rarely, on your skin (impetigo). Post-infectious glomerulonephritis is becoming

less common, most likely because of rapid and complete antibiotic treatment of most streptococcal infections. • Bacterial endocarditis. Bacteria can occasionally spread through your bloodstream and lodge in your heart, causing an infection of the valvular tissues inside the heart. Those at greatest risk are people with a heart defect, such as a damaged or artificial heart valve. • Viral infections. Among the viral infections that may trigger glomerulonephritis are the human immunodeficiency virus (HIV), which causes AIDS, and the hepatitis B and hepatitis C viruses, which affect the liver and can become chronic infections. Complications:

• • • • • • • • •

Nephrotic Syndrome Sepsis High Blood Pressure Congestive Heart Failure Pulmonary Edema Nephritic syndrome Malignant Hypertension Chronic Kidney Failure End Stage Kidney Disease

http://www.healthline.com/channel/urinary-tract-infections.html

Clinical Manifestations: •

Acute Glomerulonephritis:

Complaints commonly voiced by the patient include shortness of breath, mild headache, weakness, anorexia, and flank pain. The usual signs associated with acute glumerulonephritis are the following:

1. Proteinuria 2. Hematuria 3. Increased urine specific gravity

4. 5. 6. 7. 8. 9.

Mild generalized edema Elevated antistreptolysin O titer Hypertension Decreased urinary output Elevated serum urea nitrogen Elevated serum creatinine levels

Signs and symptoms reflect damage to the glomeruli with leaking protein and red blood cells into the urine, varying degrees of decreased glomerular filtration with retention of metabolic waste products, and fluid overloading of varying severity.

Urinalysis provides important data such as the presence of proteinuria, hematuria and cell debris.

Medical Surgical Nursing Concepts and Clinical Practice 4th Ed. By Phipps, Long, Woods and Cassmeyer p. 1411

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Chronic Glumerolunephritis Symptoms: • • • • • • • • • •

Headache especially in the morning Dyspnea on exertion Blurring of vision Lassitude Cola-colored or diluted iced-tea-colored urine from red blood cells in your urine (hematuria) Foam in the toilet water from protein in your urine (proteinuria) High blood pressure (hypertension) Fluid retention (edema) with swelling evident in your face, hands, feet and abdomen Fatigue from anemia or kidney failure Less frequent urination than usual

Signs: • • • •

Edema Nocturia Weight loss Urinalysis may show albumin, casts and blood, despite normal renal function

• • • • •

test Few nephrons remain intact Hematuria Proteinuria decrease Specific gravity of the urine becomes fixed at 1.010 (same as plasma) Nonprotein level in the blood increases

Medical Surgical Nursing Concepts and Clinical Practice 4th Ed. By Phipps, Long, Woods and Cassmeyer p. 1415

Nursing Diagnosis:

Medical Surgical Nursing Concepts and Clinical Practice 4th Ed. By Phipps, Long, Woods and Cassmeyer p. 1411

Medcal Surgical Nursing Clinical Management for Positive Outcomes 8th Ed. By Black and Hawks p. 796 Diagnostic procedures: Management of all types of glomerulonephritis, acute, chronic, primary and secondary, focuses on identifying the underlying disease process and preserving kidney function. In most glomerular disorders, there is no specific treatment to achieve a cure. •

throat or skin cultures – detect infection by group A beta hemolytic streptococci. Although poststreptococcal glomerulonephritis typically follows the acute infection by 1 to 2 weeks, treatment to eradicate any remaining organisms is initiated to minimize antibody production.

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Antistreptolysin O (ASO) titer and other tests detect streptococcal exoenzymes (bacterial enzymes that stimulate the immune response in acute poststreptococcal glomerulonephritis). Other titers such as antistreptokinase ASK) or antideoxyribonuclease B (ADNAase B) may be obtained as well. Erythrocyte sedimentation rate (ESR) is a general indicator of inflammatory response. It may be elevated in acute poststreptococcal glomerulonephritis and in lupus nephritis. KUB (Kidney, Ureter, Bladder) abdominal X-ray may be done to evaluate kidney size and rule out other causes of the client’s manifestations. The kidneys may be enlarged in acute glomerulonephritis, whereareas bilateral small kidneys are typical of late chronic glomerulonephritis. Kidney Scan a nuclear medicine procdure, allows a visualization of the kidney after IV administration of a radioisotope. In glomerular diseases, the uptake and excretion of the radioactive material are delayed. Biopsy microscopic examination of kidney tissue, is the most reliable diagnostic procedure for glomerular disorders. Biopsy helps determine the type of glomerulonephritis, the prognosis, and appropriate treatment. Renal Biopsy is usually done percutaneously, by inserting a biopsy needle through the skin into the kidney to obtain a tissue sample. Open biopsy, which requires surgery, may also be done. Blood Urea Nitrogen (BUN) measures urea nitrogen, the end product of protein metabolism. serves as index of renal function. Urea is nitrogenous end product of protein metabolism. Test values are affected by protein intake, tissue breakdown and fluid volumes chages. The BUN test is performed on a sample of the patient's blood, withdrawn from a vein into a vacuum tube. The procedure, which is called a venipuncture, takes about five minutes.

Serum Creatinine 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. • Urine creatinine also is an indicator of renal function and the GFR. Urine creatinine levels decrease when renal function is impaired as it is not effectively eliminated from the body. • Creatinine clearance is a specific indicator of renal function used to evaluate the GFR. The clearance, or amount of blood cleared of creatinine in 1 minute, depends on the amount and pressure of blood being filtered and the filtering ability of the glomeruli. Levels normally decline with aging as the GFR decreases in the older adult. Disorders such as glomerulonephritis affect gomerular filtration, decreasing the creatinine clearance. • Serum electrolytes are evaluated because impaired kidney functions alters their excretion. Monitring serum electrolytes is particularly important to prevent complications associated with imbalances. • Urinalysis A urinalysis is a group of manual and/or automated qualitative and semiquantitative tests performed on a urine sample. A routine urinalysis usually includes the following tests: color, transparency, specific gravity, pH, protein, glucose, ketones, blood, bilirubin, nitrite, urobilinogen, and leukocyte esterase. Some laboratories include a microscopic examination of urinary sediment with all routine urinalysis tests. If not, it is customary to perform the microscopic exam, if transparency, glucose, protein, blood, nitrite, or leukocyte esterase is abnormal. Medical Surgical Nursing 3rd Ed. By Priscilla Lemone and Karen Burke p. 749-750

Treatment, Surgery and Medications: Treatment:

Bedrest may be ordered during the acute phase of poststreptococcal glomerulonephritis. When the edema of nephritic syndrome is significant or the client is hypertensive, sodium intake may be restricted.

Dietary protein may be restricted if azotemia is present. When proteins are restricted, those included in the diet should be complete or high-value proteins. Complete protein supply the essential amino acids required for growth and tissue maintenance. Complete and incomplete proteins are compared in this table:

Plasma exchange therapy (plasmapharesis), a procedure to remove damaging antibodies from the plasma, is used in conjunction with immunosuppressive therapy to treat RPGN and Good pasture’s syndrome. Plasma and glomerular-damaging antibodies are removed using a blood cell separator. The RBCs are then returned to the client along with albumin or human plasma removed. This procedure is usually done in a series of treatments. Potential complications of plasma exchange therapy include those associated with IV catheters, fluid volume shifts, and altered coagulation. Renal failure resulting from a glomerular disorder may necessitate dialysis to restore fluid and electrolyte balance and remove waste products from the body. Medical Surgical Nursing 3rd Ed. By Priscilla Lemone and Karen Burke p. 751-752

Medications:

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Although no drugs are available to cure glomerular disorders, medications are used to treat underlying disorder, reduce inflammation, and management symptoms.

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Antibiotics are prescribed for the client with poststreptococcal glomerulonephritis to eradicate any remaining bacteria, removing the stimulus for antibody production. Nephrotoxic antibiotics, such as aminoglycoside antibiotics, streptomycin and some cephalosporins, are avoided

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Aggressive immunosuppressive therapy is used to treat acute inflammatory processes such as rapidly progressive glumerulonephritis. When begun early, immunosuppressive therapy significantly reduces the risk of end-stage renal disease and renal failure.

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Predinosone, a glucocorticoid, is prescribed in relatively large doses of 1 mg per kg of body weight per day (e.g., a 160 pound man would receive 70 to 75 mg per day). Other immunosuppressive agents such as cyclophosphamide (Cytoxan) or azathioprine (Imuran) are prescribed in conjunction with corticosteroids. Corticosteroids use in streptococcal glumerulonephritis may actually worsen the condition, so is avoided.

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Oral glucocorticoids such as prednisone also are used in high doses to induce remission of nephritic syndrome. When glucocorticoids alone are ineffective, other immunosuppressive agents such as cyclophosphamide or Clorambucil (Leukeran) may be used to induce or maintain remission.

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ACE inhibitors may be ordered to reduce protein loss associated with nephritic syndrome. These drugs reduce proteinuria and slow progression of renal failure. They have a protective effect on the kidney in clients with diabetic nephropathy. Nonsteroidal anti-inflammatory drugs (NSAIDs) also reduce proteinuria ijn some clients, but can increase salt and water retention.

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Antihypertensives may be prescribed to maintain the blood pressure within normal levels. BP management is important because systemic and renal hypertensions are associated with a poorer prognosisin clients with glumerular disorders.

Medical Surgical Nursing 3rd Ed. By Priscilla Lemone and Karen Burke p. 750-751

Surgery: Kidney Transplantation - Kidney transplantation is a surgical procedure to remove a healthy, functioning kidney from a living or brain-dead donor and implant it into a patient with nonfunctioning kidneys. Purpose Kidney transplantation is performed on patients with chronic kidney failure, or end-stage renal disease (ESRD).

Nursing Responsibilities: • • • • • • • •

Maintain patient's diet Monitor blood pressure, vital signs and laboratory findings Provide client a rest period Increased fluid intake Assist client on cutting back on protein and potassium consumption may slow the buildup of wastes in the client's blood. Teach client on how to restrict salt intake. This prevents or minimize fluid retention, swelling and hypertension. If client has diabetes, nurse should take note that client should maintain a healthy weight and control the client's blood sugar levels and blood pressure as this may help slow kidney damage. Assist client in voiding.

Evaluation: • • • • • •

Client will have better understanding of the disease Client will meet adequate nutrition regardless of present diet Maintenance of client's blood pressure Normal laboratory findings The client will be able to report either that there is no pain or that pain is controlled The client will maintain fluid balanced intake and output, maintenance of adequate hydration, and an absence of manifestations of dehydration.

http://www.mayoclinic.com/health/glomerulonephritis

C. RENAL FAILURE • •

Renal Failure is the loss of function in both kidneys. It has 5 stages that are based on the presence or absence of symptoms and on progressively decreasing GFR. The stages are as follow: o Stage 1: Kidney damage with normal or near normal glomerular filtration rate, at or above 90mL/min o Stage 2: Glomerular filtration rate between 60 and 89mL/min, with evidence of kidney damage. This stage is considered one of diminished renal reserve. Remaining nephrons are highly susceptible to failing themselves as their load becomes overwhelming. Additional renal insults hasten the decline.

Stage 3: Glomerular filtration rate between 30 and 59mL/min. This stage is considered one of renal insufficiency. Nephrons continue to die. o Stage 4: Glomerular filtration rate between 15 and 29mL/min, with fewer nephrons remaining. o Stage 5: End-stage renal failure; glomerular filtration rate of less that 15mL/min. few functioning nephrons remain. Scar tissue and tubular atrophy are present throughout the kidneys. Glomerular filtration rate (GFR) is a measurement of the amount of glomerular filtrate (a substance similar to blood plasma but without proteins) formed in the kidneys each minute. It is used to evaluate the kidneys’ ability to remove waste products from the body. o

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GFR cannot be directly measured. Instead, it is estimated from the measurements of other body waste products. These measurements may include: o Cystatin C test o Serum creatinine test o Creatinine clearance test o Prediction equations Renal failure is also categorized as acute renal failure, which occurs suddenly and is usually reversible or chronic renal failure, which is associated with progressive, irreversible loss of renal function. Chronic renal failure usually develops after years of renal disease or damage, but may occur rapidly in some situations. Chronic renal failure inevitable leads to renal dialysis, transplantation or death.

ACUTE RENAL FAILURE •

Description: o Abrupt loss of kidney function over a period of hours to a few days. o Characterized by oliguria (daily output of urine that between 100 and 400mL only) and anuria (urine output of less than 100mL). There is also a decrease in GFR and elevation of the Serum Creatinine and BUN levels.

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Cause or Risk Factor: o Causes of acute renal failure have been separated into three general categories: prerenal, intrarenal, postrenal. Identification of the cause of Renal Failure is important in the management of the disease. Identification may be accomplished by a study of the patient’s history and the quantity and quality of his/her urine. o Prerenal Causes:  Most common cause of acute renal failure. Prerenal failure occurs as a result of conditions unrelated to the kidney but that damage the kidney by affecting renal blood flow. Factors that contribute to decreased renal blood flow are as follows:

 Circulatory Volume Depletion, as may occur with diarrhea, vomiting, hemorrhage, excessive use of diuretics, burns, renal salt-wasting conditions  Volume Shifts, as from third-space sequestration of fluid, vasodilation, or gram negative sepsis  Decreased cardiac output as during cardiac pump failure, pericardial tamponade, or acute pulmonary embolism.  Decreased peripheral vascular resistance as from spinal anesthesia, septic shock, or anaphylaxis.  Vascular obstruction, such as bilateral renal artery occlusion or dissecting aneurysm. o Intrarenal Causes:  Occurs as a result of primary damage to the kidney tissue itself. It has many causes including glomerulonephritis, acute pyelonephritis, and myoglobinuria.  Kidney cell damage usually occurs with as a result of tubular ischemic tubular necrosis. Tubular necrosis can result from a decrease renal blood flow or a result of the direct action of nephrotoxic drugs, such as heavy metals and organic solvents. Aminoglycoside antibiotics such as gentamicin, are also nephrotoxic. Radiopaque contrast media use for viewing the cardiac chambers or the GI tract can be nephrotoxic in susceptible individuals. Ingestion of toxic amounts of analgesic mixtures, especially codeine and caffeine, may lead to acute tubular necrosis. o Postrenal Cause  Postrenal causes of ARF arise from a1n obstruction in the urinary tract, anywhere from the tubules to the urethral meatus. Common sources of obstruction include prostatic hypertrophy, calculi, invading tumors, surgical accidents, ureteral or urethral strictures or stenosis and retroperitoneal fibrosis. Spinal cord injury may lead to decreased bladder emptying and a functional obstruction. •

Complications o Fluid and electrolyte Imbalance o Acidosis o Increased susceptibility to secondary infection o Anemia o Platelet dysfunction o Gastrointestinal complications o Increase incidence of pericarditis o Uremic encephalopathy characterized by apathy, defective recent memory, episodic obtundation, dysarthria, tremors, convulsions and coma. o Impaired wound healing.

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Clinical Manifestations o Nonoliguric Renal Failure  Urine excretion of 2L/day  Low urine specific gravity  Hypertension  Tachypnea  Dry Mucous Membranes  Poor skin turgor  Orthostatic Hypotension o Oliguric Renal Failure  Urine production of less than 400mL/day  High urine specific gravity  Contains hyaline and granular casts  Edema and weight gain  Hemoptysis resulting from elevated left ventricular end-diastolic pressure, weakness from anemia, and hypertension.  Anemia  Hypertension  High sodium concentration  Definite proteinuria  Hematuria, RBC and hemoglobin casts in the urine  Elevated levels of creatinine, phosphokinase, potassium

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Nursing Diagnosis o Deficient fluid volume related to fluid loss from a variety of causes o Excess fluid volume related to inability of the kidneys to produce urine secondary to ARF o Imbalance Nutrition: Less than body requirements related to anorexia and altered metabolic state secondary to renal failure. o Risk for impaired skin integrity related to poor cellular nutrition and edema. o Risk for infection related to lowered resistance o Anxiety related to unknown outcome of disease process

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Diagnostic Procedures o Laboratory finding of azotemia (increased nitrogenous compounds in the blood), and elevated BUN and creatinine confirm diagnosis o Laboratory finding of hyperkalemia (increased potassium in the blood) and acidosis are common. o Urinalysis shows casts

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Treatment, Surgery and Medication

o Prevention of the oliguric phase results in a better prognosis. Prevention of oliguria involves:  Aggressive plasma volume expansion  Diuretics to increase urine production  Vasodilators, especially dopamine, given to increase renal blood flow.  Dietary restrictions on potassium and protein are often implemented in acute renal failure. High-carbohydrate intake prevents the metabolism of proteins and reduces nitrogenous waste production. Give the patient a high-calorie, low protein, sodium, magnesium, phosphate, and potassium diet should be given. Protein must be of high biologic value, containing essential amino acids to reduce nitrogenous waste products.  The patient must under go continuous renal replacement therapy (CRRT)for:  Continuous arteriovenous hemofiltration  Continuous venovenous hemofiltration  Continuous venovenous hemodialysis  Continuous arteriovenous ultrafiltration  Slow continuous ultra filtration  NOTE: CCRT removes plasma water and dissolved contents from the patient’s blood across a membrane. Slow continuous removal of waste products and water through CRRT is less stressful to the client than shorter, more efficient dialysis treatment.  Antibiotic therapy to prevent or treat infections may be necessary because of high rate sepsis seen with acute renal failure  Continuous peritoneal dialysis is often employed during the oliguric stage of acute renal failure to give the kidneys time to recover. Dialysis also prevents the build up of nitrogenous wastes, stabilizes electrolytes, and fluid overload.  Cautious use of diuretics such as furosemide and mannitol. •

Nursing Responsibility o Careful maintenance of electrolyte and fluid balance o Check vital signs, skin turgor, and mucous membranes every 4 hours o Obtain daily weight measurements using the same scale at same time of the day o Monitor for abnormalities in heart sounds, cardiac output, breath sounds and mental status o Give sodium bicarbonate, sodium lactate or sodium acetate to correct metabolic acidosis o Alleviate patients thirst with careful oral hygiene, judicious use of ice chips, lip ointments and appropriate diversionary techniques.

o Place allotted water in a spray bottle may help spread out the amount taken o Administer medication with meals to conserve fluid for the client o Work with the client and dietitian to plan a diet that is acceptable. Provide a pleasant environment at mealtime. o Medications to alleviate the discomfort of nausea and stomatitis may be useful. o To prevent skin breakdown, meticulous skin care, frequent turning and special mattresses are important. o Teach patient range of motion exercise to facilitate movement and increase circulation o Monitor patient carefully for infectious processes; if these occur, they should be treated aggressively. o Give frequent careful explanations and provide emotional and psychological support to the client and family to relieve anxiety. •

Evaluation o Fluid Balance must be maintained. If fluid volume excess develops it is managed with dialysis or CRRT to reduce body weight and to balance intake and output. o Intact skin should be maintained o The client and family will be less anxious and be able to cope with the information provided. o Clients with ARF recover within 4 to 10 weeks of correction of the underlying problem. o Renal function may continue to improve for up to 12 months after the onset of ARF. The client is particularly vulnerable to additional renal injury during this time.

CHRONIC RENAL FAILURE •

Description o Chronic renal failure is the irreversible and progressive reduction of functioning renal tissue. When the remaining kidney mass can no longer maintain the body’s internal environment renal failure is the result. o It also known as the end stage renal disease and stage 5 CKD o It can develop insidiously over many years or it may result from an episode of ARF from which the client has not recovered.

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Cause or Risk Factor o Chronic glomerulonephritis, ARF, polycystic kidney disease, obstruction, repeated episodes of pyelonephritis and nephrotoxins.

o Systemic diseases such as diabetes mellitus, hypertension, lupus erythematosus, polyarteritis, sickle cell disease, and amyloidosis •

Complications o Severe azotemia and uremia are present. Metabolic acidosis worsens which significantly stimulates respiratory rate. o Hypertension, anemia, osteodystrophy, hyperkalemia, uremic encephalopathy, and pruritus are common complications, o Decreased production of erythropoietin may lead to cardiorenal anemia syndrome, a self-perpetuating triad of anemia, cardiovascular disease and renal disease that ultimately leads to increased morbidity and mortality. o Congestive heart failure may develop o Without treatment coma and death may develop

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Clinical Manifestations o Increased BUN, serum creatinine and uric acid o Dilute Polyuria o Dehydration o Hyponatremia o Decreased Libido o Infertility o Delayed wound healing o Infection o Erratic Blood glucose levels o Anemia, pallor o Osteodystrophy o Hypocalcemia o Metabolic acidosis o Hyperphosphatemia o Hyperkalemia o Hypertension o Heart Failure o Edema o Peripheral Nerve Changes o Pericarditis o CNS changes o Pruritus o Bleeding tendencies o Altered taste

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Nursing Diagnosis o Deficient/ Excessive fluid volume related to impaired renal function, fluid shifts between dialysate and blood, and blood loss during hemodialysis.

o Imbalance Nutrition: Less than body requirements related to anorexia and nausea o Constipation related to medication, fluid and dietary restrictions and decreased activity level o Fatigue related to anemia and altered metabolic state o Risk for impaired skin integrity related to edema dry skin and pruritus. o Readiness for enhanced self care related to learning to live with a chronic illness, uncertain future, many stressors, role reversal, and effects of long term dialysis. •

Diagnostic Procedures o Radiographs or ultrasound will show small, atrophied kidneys o Elevated BUN and Serum creatinine with a decreased GFR o Reduced hematocrit and hemoglobin o Low plasma pH o Elevated respiratory rate indicates respiratory compensation for metabolic acidosis.

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Treatment, Surgery and Medications o Renal Anemia Management Period (RAMP) is defined as the following the time following the onset of CRF when early diagnosis and treatment of anemia will slow kidney disease progression, delay cardiovascular complications, and improve quality of life. Treatment of anemia is by administration of recombinant human erythropoietin. This drug improves the quality of life and reduces the need for transfusions. It also significantly improves cardiac function. o Treatment is geared towards correcting fluid and electrolyte imbalances o Treatment includes dialysis or renal transplantation  Renal transplantation is the surgical implantation of a human kidney from a compatible donor to a recipient.  The kidney is surgically placed extraperitoneally in the iliac fossa. The renal artery is anastamosed to the recipient’s hypogastric internal or external iliac artery and the renal vein is anastamosed to the recipient’s iliac vein.  Selection of transplant recipients is based on careful evaluation of the client’s medical, immunologic, and psychosocial status. A recipient must be:  Younger than 70 years old  Has an estimated life expectancy of 2 years or more  Is expected to have an improved quality of life after transplantation  Bilateral nephrectomy may be performed before the transplantation procedure for persistent or active bacterial pyelonephritis,

uncontrolled, renin-mediated hypertension, polycystic kidneys or rapidly progressive glomerulonephritis.  The source of kidneys for transplantation is a living related donor who matches the client closely. The donor must have compatible:  ABO blood group  Tissue-specific antigen  Human leukocyte histocompatibility  Contraindications of Renal Transplantation  Infection  Active malignancy  Liver disease  Psychological disorders  Advance atherosclerosis  Hypertension  Respiratory disease  Gastrointestinal bleeding  Complications:  Graft Rejection  Spontaneous rupture of kidneys may occur  Urinoma  Reduced renal function  Urinary, bladder, or pelvic leaks, obstructions, reflux and lymphoceles  Hypertension  Dysrhytmias and heart Failure  Pnuemonia, Pulmonary embolism, pulmonary edema o Improve Renal Function by:  Improving blood pressure by medication, weight control and diet  Protein restriction o Alleviate extrarenal manifestations as much as possible by:  Applying topical emollients and lotions, taking antihistamines, intravenous lidocaine and ultraviolet B light to alleviate pruritus.  Treatment with epoetin alfa three times a week to stimulate the production of RBC to treat anemia. Supplemental iron, vitamin B12 and folic acid are usually administered as well.  Hyperlipidemia is treated with statins to minimize the risk of myocardial infarction and stroke. o Elemental diets, enteral feeding, or TPN may be used instead of or in addition to regular food intake. •

Nursing Responsibilities o Fluid Status must be known and fluid intake carefully regulated.

o Monitor fluid status by daily weight measurement, orthostatic blood pressure, skin turgor, mucous membrane moistness, and meticulous intake and output comparisons. o Help the client follow the recommended fluid allowance. Relieve thirst by moistening lips by using lip balms, performing frequent oral hygiene, eating ice chips or using spray bottles rather than drinking. o During dialysis monitor the client’s vital signs including postural blood pressure, pulse rate weight and intake and output o Help the client consume adequate nutrition while minimizing uremic toxicity. o Take measures to relieve nausea and vomiting, stomatitis, and other gastrointestinal manifestations. o Help the client select and prepare foods and learn where to obtain special foods if necessary. Exercise also improves appetite. o Bran which is limited in potassium or phosphorus can be used to alleviate constipation. Stool softeners are often administered regularly can also alleviate constipation o Iron and erythropoietin therapy to increase energy levels. Exercise is an important strategy to reduce fatigue and improve quality of life. o Moisturizing oils in the bath water or applied directly to the skin help to correct dryness. Avoid products that alcohol or perfume because they increase dryness and pruritus. o If edema is present avoid sustained pressure on the area o Observe for poor circulation and areas of breakdown or infection o Explain procedures and tests that are to be done to alleviate anxiety. o Closely monitor patients who have undergone transplantation surgery for fluid and electrolyte imbalance, infection, graft rejection and other complications. •

Evaluation o The client is expected to improve physically and mentally when dialysis begins. o The clients weight and blood pressure should begin to stabilize if dietary and fluid restrictions are followed and as fluid balance stabilizes o The client should report regular, normal bowel movements. o The client should report less fatigue and increased energy and activity as hematocrit values approach normal levels o Skin should remain contact o The client should understand and adapt to the treatment regimen and be successfully maintained with peritoneal dialysis or hemodialysis. o Clients having peritoneal dialysis should be able to demonstrate successful performance of the dialysis procedure and care of the vascular access site or peritoneal catheter. The should remain free from complications of dialysis

D. DIALYSIS

It is the diffusion of solutes and osmosis of water through a passive, porous membrane from the plasma to the dialysis solution and vice-versa in response to a concentration or pressure gradient.

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Types of Dialysis • Hemodialysis • Peritoneal Dialysis

 HEMODIALYSIS • • •

Involves shunting the patient’s blood from the body through a machine in which diffusion, osmosis and ultrafiltration occur and back into the patient’s circulation. Used for clients with acute or irreversible renal failure and fluid and electrolyte imbalances. It is usually the treatment of choice when toxic agents, such as barbiturates after an overdose, need to be removed from the body quickly.

ACCESS TO THE BLOODSTREAM A. External Arterio-venous Cannula or Shunt -Teflon cannula tips are placed in an artery and nearby vein. These cannula tips are connected by silicone rubber tubing and a Teflon bridge to complete the shunt -It ahs a short life-span (9 months) due to clotting and infection B. External Arterio-venous Fistula -anastomosing an artery directly to a vein (usually radial artery and cephalic vein at the wrist) -blood is shunted from the artery to the vein causing the vein to enlarge (ripening) after a few weeks -average life is 4 years; circumvented problems of infection, clotting and possible hemorhhage -disadvantages are painful venipuncture, formation of aneurysms; achieving hemostatis post dialysis and ischemia of the hand. NURSING RESPONSIBILITIES FOR HEMODIALYSIS Before:

1. Measure and record baseline vital signs as weight, temperature, pulse rate, respiration, blood pressure. 2. Measure pre treatment result of BUN, creatinine, Na, K levels and Hematocrit. During: 1. 2. 3. 4. 5.

Sterile techniques for needle and shunt connections. Anchor connections securely. Check equipments for readiness, safety and gauge settings. Monitor vital signs every 15 minutes for 1 hour then every 30 minutes thereafter. Watch out for rapid shifts in volume or electrolytes that may result in hypovolemia, angina, dysrhythmias, nausea and muscle cramps due to dialysis disequilibrium syndrome wherein the osmotic gradient produced across the blood-brain barrier by the efficient removal of urea from the blood but not from the brain tissues. Urea draws in water from the ECF and can cause cerebral edema.

After: 1. 2. 3. 4. 5. 6.

Measure and record vital signs and weight. Precautions against infection. Routine care to shunt or fistula. Avoid trauma to sites. Do not use arm with shunt or fistula for blood pressure taking and needlesticks. Record BUN, creatinine Na, K levels to note of treatment.

Between Treatments 1. 2. 3. 4.

Follow diet (Low Na, K, low protein) and fluid restrictions. Take medications as ordered Limit weight gain to 0.5 kg/ day between treatment Care of access site: a. No BP or IV punctures on arm with shunt / fistula. b. Cleanse site aseptically with Peroxide. c. Clean shunt with alcohol sponges from exist site. d. Cover with dry sterile dressing e. Avoid trauma to site, wear loose sleeves, avoid temperature extremes, avoid lifting heavy objects, and avoid prolonged immersion of arm in water.

POSSIBLE COMPLICATIONS OF HEMODIALYSIS 1. Blood clots -due to decreased blood flow which results from: a. systemic hypotension

b. infection of shunt/fistula c. compression of shunt/fistula d. tight bandages/restrictive clothing e. phlebitis from puncture of involved veins f. prolonged inflation of BP cuff -how do you detect clots: a. absence of dark/separated blood in the tubing

2. Infection on site of cannula insertion - signs of infection a. redness b. tenderness c. swelling d. excessive warmth of skin Complication of Dialyzer Reuse 1. pyrogenic reactions 2. bacteremia

3. Membrane repture 4. occlusion of hollow fibers

EVALUATION: Successful achievement of patient outcomes for the patient receiving hemodialysis is indicated by the following:  lack of excessive fluid weight gain between dialysis treatment  states that no pain is present and that discomfort experienced during dialysis is decreased  participates in a program to maintain prescribed activity level  eats according to preference during therapy  correctly explains dialysis, care of venous access, common side effects and recommended work or activity schedule.

 PERITONEAL DIALYSIS

A catheter is placed in the peritoneum cavity by paracentesis. Two liters of sterile dialysis solution are allowed to run into the peritoneal cavity through the catheter for 1020 minutes. Equilibrium between the dialysis fluid and the highly vascular semipermeable peritoneal membrane takes place. The peritoneum acts as the semipermeable membrane. This is called the “dwell time” which is generally 30-45 minutes. The fluid is then allowed to drain by gravity into a closed, sterile connecting system. Cycle is repeated successfully over a period of 1-2 days. Types of Peritoneal Dialysis: 1. Continuous Cycling Peritoneal Dialysis -connecting the peritoneal catheter to an automated peritoneal dialysis machine that perform 3-5 cycles during the night while patient sleeps; last bag of solution remains in abdomen during daytime. 2. Continuous Ambulatory Peritoneal Dialysis - a permanent dialysis catheter is inserted into the abdomen; a connector joins the transfer set to the bag of the fluid. Plastic bags are used; performs 3 -5 exchanges daily; last bag of solution remains in the abdomen overnight. 3. Intermittent Peritoneal Dialysis - connected for about 10 hour, with cycle changing every 30 -60 minutes; abdomen is left “dry” between sessions. NURSING RESPONSIBILITIES IN PERITONEAL DIALYSIS Before: 1. have patient empty the bladder to avoid puncturing it during catheter insertions 2. measure and record weight, abdominal girth, temperature, pulse, respiration, blood pressure 3. measure and record blood chemistry values like BUN, creatinine, Na, K, Hematocrit 4. sterile technique during insertion of catheter 5. after insertion of catheter, observe for perforation of bowel (dialysate outflow stained with feces or blood) or bladder (pink or blood tinged) 6. warm dialysate up to 37°C before infusion 7. flush tubing to remove air, connect to catheter, anchor connections and tubings securely and be sure there are no kinks on the tubings During: 1. measure and record output, weight regularly and TPR, BP every 10 min. till stable then every 2-4 hours as ordered

2. keep accurate record of dialysis cycles (inflow, dwell, outflow times). Record strength of solutions used, additions made, and fluid balance (amount retained or lost) 3. observe for peritonitis (collect samples of dialysate for culture and sensitivity tests whenever solution is turbid, bloody, or has an odor or when routinely ordered). 4. observe for respiratory embarrassment (dyspnea and rales) which results from abdomen being too full of fluid or leakage of dialysate into the thoracic cavity through defect in the diaphragm. 5. Have client change position frequently, do ROM exercises, and do deep breathing. After: 1. determine fluid balance (measure weight, TPR, BP, abdominal girth) 2. check blood chemistry (BUN, creatinine, Na, K) 3. maintain adequate nutrition, adhering to high protein diet which is needed to replace those lost during the procedure 4. facilitate learning -the teaching plan should include: a. the process of dialysis and how the dialysis relates to the patient’s own body needs b. signs and symptoms of infection of eth peritoneal cavity or catheter site and when to obtain care if these occur c. appropriate care of the permanent peritoneal catheter d. common side effects of treatment, means of controlling mild symptoms and means of obtaining medical attention for severe or persistent complications e. changes in medication schedule required before and after dialysis f. a work and activity schedule as physical capabilities permit with minimal interference from scheduled dialysis time. Cycle-related problems: 1. inflow problems- obstructed catheter (clots, fibrin, omentum, catheter malposition), leakage of fluid around catheter insertion site. 2. Dwell time problems- prolonged time may cause water depletion or hyperglycemia 3. Outflow problems- kinks in tubing or catheter, catheter occluded by loops of bowel, constipation

PROCEDURE PROCEDURE

RATIONALE

1. warm dialysate solution to body Avoid hypothermia and shock during temperature procedure 2. apply mask, then prepare dialysis Avoid introducing administration set. Have client wear peritoneal cavity mask during connection and disconnection of administration set. 3. place drainage bag below client

pathogens

into

Facilitates drainage by gravity

4. connect outflow tubing to drainage Provides route for bag dialysate solution.

removal

of

5. connect dialysis infusion lines to the bag 6. place client in supine position when Promote comfort and relaxation. equipment and solutions are ready When tube is new, supine position helps prevents hernia. 7. prime infusion tubing by allowing Maintains integrity of system and solution to fill tube. prevents air from entering the line 8. check patency of catheter:

Ensure that catheter is ready for use and that client will tolerate initiation of a. rapidly instill 500 ml of dialysate treatment into client’s peritoneal cavity b. immediately unclamp the outflow line, and let fluid drain into the collection bag

9. open the clamps on the infusion Fluid dwell time varies, dependent on lines, and infuse the prescribed concentration off electrolytes to be amount of dialysate over 5 to 10 min.; removed allow solution to dwell for prescribed interval (10 min. to 4 hours). Remove and discard gloves, and perform hand hygiene. 10. when dwell time is completed, Position helps to eliminate all of open the outflow clamps and allow dialysate the solution to drain into the collection bag. Client may need to change position, roll from side to side. 11. repeat the cycles of infusion-dwell Prescribed cycling is necessary to –drainage (using new batches of achieved desired fluid and electrolyte solution each cycle) until the balance prescribed amount of dialysate and the prescribed number of cycle have been achieved. 12. when dialysis treatment is Avoid introducing pathogens into the completed, disconnect the inflow line peritoneal cavity. from the catheter, place a sterile cap over the catheter end, then discard gloves.

COMPLICATIONS OF PERITONEAL DIALYSIS COMPLICATIONS 1. peritonitis

SIGNS AND SYMPTOMS

INTERVENTIONS

Abdominal pain

Aseptic technique

Elevated temperature

Culture and sensitivity of dialysate Antibiotic treatment Possible catheter

removal

of

2. Exit site infection

Redness

Assess response cleansing agents

Swelling

to

Heat

Continue thorough daily site care

Pain

Antibiotics as ordered

3.Abdominal Pain

If related to rapid inflow, decrease rate of infusion during initial exchanges

4.Air in the peritoneal Shoulder pain cavity Distended abdomen

Prime new carefully

tubing

Do not system

vented

5.Overheated dialysate

6.Inadequately dialysate

Increased temperature

Drain solution

Abdominal pain

Treat for hypothermia

Cardiac disrythmias

Evaluate procedure

warm Hypothermia

warming

Drain solution Treat for hypothermia Evaluate procedure

7. Fluid Overload

use

Dyspnea Altered mental status Alteration sounds

in

warming

Calculate fluid balance accurately

Use a more hypertonic breath dialysate Limit fluid intake Shorten dwell time Correct

catheter

malfunction Monitor weight, V.S and cardiorespiratory status frequently 8. Fluid Deficit

Alteration in fluid and Calculate fluid balance electrolyte balance accurately Discontinue use hypertonic solution Replace fluid sodium losses

of and

Monitor V.S and weight closely Lengthen dwell time 9. Hypokalemia

Decreased potassium

level

of Monitor potassium

serum

Add potassium to dialysate for clients with normal levels Increase dietary intake of Potassium if with chronic problem 10. Drainage of Fluid

Inadequate outflow

Small amount of Heparin is added to the dialysate Turn patient from side to side to reposition the catheter in the peritoneal cavity Raise head of bed Apply firm pressure to the abdomen using both hands