Urinary System

Urinary Tract Calculi

o Ensure adequate intravascular volume and cardiac output

o Closely monitor fluid intake during oliguric phase
o Hyperkalemia
Insulin and sodium bicarbonate
Calcium carbonate
Sodium polystyrene sulfonate (Kayexalate)
o Indications for renal replacement therapy (RRT)
Volume overload
Elevated serum potassium level
Metabolic acidosis
BUN level higher than 120 mg/dL (43 mmol/L)
Significant change in mental status
Pericarditis, pericardial effusion, or cardiac tamponade
o Renal replacement therapy (RRT)
Peritoneal dialysis (PD)
Intermittent hemodialysis (HD)
Continuous renal replacement therapy (CRRT)
Cannulation of artery and vein
Nursing Management
o Planning
The patient with AKI will
Completely recover without any loss of kidney function
Maintain normal fluid and electrolyte balance
Have decreased anxiety
Comply with and understand the need for careful follow-up care
o Nursing implementation
Monitor intake and output
Monitor electrolyte balance
Measure daily weight
Replace significant fluid losses
Use nephrotoxic drugs sparingly
o Evaluation
The expected outcomes are that the patient with AKI will
Regain and maintain normal fluid and electrolyte balance
Comply with the treatment regimen
Experience no untoward complications
Have complete recovery
Gerontologic Considerations
o More susceptible to AKI
Polypharmacy
Hypotension
Diuretic therapy
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Aminoglycoside therapy
Obstructive disorders
Surgery
Infection

ADDITIONAL ELECTROLYTE DISTURBANCES WITH CRD

Dialysis

Movement of fluid/molecules across a semipermeable membrane from one compartment to another

Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure
Treat drug overdoses
Begun when patients uremia can no longer be adequately managed conservatively
Initiated when GFR (or creatinine clearance) is less than 15 mL/min
Dialysis
Two methods of dialysis available
o Peritoneal dialysis (PD)
o Hemodialysis (HD)
ESKD treated with dialysis because
o There is a lack of donated organs
o Some patients are physically or mentally unsuitable for transplantation
o Some patients do not want transplants
Osmosis and Diffusion across Semipermeable Membrane
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o
Peritoneal Dialysis
o Peritoneal access is obtained by inserting a catheter through the anterior abdominal wall
o Technique for catheter placement varies
o Usually done via surgery
o Tenckhoff Catheter

o
o
o
o

Waiting period of 7 to 14 days preferable

Two to 4 weeks after implantation, exit site should be clean, dry, and free of redness/tenderness
Once site healed, patient may shower and pat dry
Dialysis Solutions and Cycles
Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25%
Electrolyte composition similar to that of plasma
Solution warmed to body temperature
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o Three phases of PD cycle

Inflow (fill)
Dwell (equilibration)
Drain
o Called an exchange
Inflow
Prescribed amount of solution infused through established catheter over about 10
minutes
After solution infused, inflow clamp closed to prevent air from entering tubing
Dwell
Also known as equilibration
Diffusion and osmosis occur between patients blood and peritoneal cavity
Duration of time varies, depending on method
Drain
Lasts 15 to 30 minutes
May be facilitated by gently massaging abdomen or changing position
o Complications
Exit site infection
Peritonitis
Hernias
Lower back problems
Bleeding
Pulmonary complications
Protein loss
o Effectiveness and Adaptation
Short training program
Independence
Ease of traveling
Fewer dietary restrictions
Greater mobility than with HD
Hemodialysis
o Obtaining vascular access is one of most difficult problems
Types of access
Arteriovenous fistulas and grafts
Temporary vascular access
o Vascular Access for Hemodialysis


o Dialyzers
Long plastic cartridges that contain thousands of parallel hollow tubes or fibers
Fibers are semipermeable membranes
o Hemodialysis Procedure
Two needles placed in fistula or graft
One needle is placed to pull blood from the circulation to the HD machine
The other needle is used to return the dialyzed blood to the patient
o Components of Hemodialysis

Continual Renal Replacement Therapy (CRRT)

o Alternative or adjunctive method for treating AKI
o Means by which uremic toxins and fluids are removed
o Acid-base status/electrolyte balance adjusted slowly and continuously
o Often used in hemodynamically unstable patients
o Hemofilter change every 24 to 48 hours
o Ultrafiltrate should be clear yellow
o Specimens may be obtained for evaluation
o Most common approaches: venovenous
Continuous venovenous hemofiltration (CVVH)
Continuous venovenous hemodialysis (CVVHD)
Q&A: A patient undergoes peritoneal dialysis exchanges several times each day. What should the nurse
plan to increase in the patients diet?
a) Fat
b) Protein
c) Calories
d) Carbohydrates

Kidney Transplantation

Very successful
One-year graft survival rate
o Cadaver transplants: 90%
o Live donor transplants: 95%
Advantages of kidney transplantation over dialysis
o Reverses many of the pathophysiologic changes associated with renal failure
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o Eliminates dependence on dialysis

o Less expensive than dialysis after the first year
Kidney Transplantation

o
Immunosuppressive Therapy
o Goals
Adequately suppress the immune response
Maintain sufficient immunity to prevent overwhelming infection
Complications
o Rejection
Acute rejection
Occurs days to months after transplantation
Chronic rejection
Process that occurs over months or years and is irreversible
Infection
CV Disease
Malignancies
Recurrance of Renal Disease
Steriod-Related Complications
Q&A: Six days after kidney transplantation from a deceased donor, a patient develops a temperature of
101.2 F (38.5 C), tenderness at the transplant site, and oliguria. The nurse recognizes that these
findings indicate
a) Acute rejection, which is not uncommon and is usually reversible.
b) Hyperacute rejection, which will necessitate removal of the transplanted kidney.
c) An infection of the kidney, which can be treated with IV antibiotics.
d) The onset of chronic rejection of the kidney with eventual failure of the kidney.