Renal And Urinary Systems' Work

Renal and urinary systems are essential to life and help our body maintain a state of homeostasis by regulating fluid and electrolytes, removing wastes and carrying out a number of functions. The kidney’s assist in urine formation, control water balance and blood pressure, secrete important prostaglandins and regulate red blood cell formation. Dysfunction of the kidneys and urinary tract are common and can range from mild to life-threatening and thus these systems must be assessed and understood. Acute kidney injury is a potentially life-threatening metabolic complication that can occur that causes severe fluid and electrolyte imbalances. In this paper acute kidney injury will be outlined along with its treatment and nursing implications. Varies types of dialysis will also be explained and understood and MRSA will be explained along with its nursing implications.

Acute kidney injury is a rapid loss of kidney function due to some type of injury to the kidney. A number of conditions can cause acute kidney injury, these include obstruction of a renal artery or vein, obstruction of the kidney by a clot, tumor or kidney stone, hypovolemic shock, hypotension and heart failure or decreased cardiac output. (Hinkle & Cheever, 2017) The causative agents can be described as pre-renal, intra-renal and post-renal failure. Acute kidney injury is associated with metabolic complications, specifically metabolic acidosis as well as fluid and electrolyte balances. Creatinine levels tend to rise by 50% with AKI and urine volume disturbances may occur. Urine impediments include nonoliguira (800 ml/day), oliguria (less than 0.5 ml/kg/hr) or anuria (less than 50 ml/day). (Hinkle & Cheever, 2017)

Pre-renal AKI is the most common form of AKI and is the result of impaired blood flow to the kidneys caused by volume depletion. It can result from volume depletion from GI losses or hemorrhage, it can be the result of impaired cardiac efficiency from an MI and can result from vasodilation from anaphylaxis or sepsis. Intra-renal AKI is caused by damage to the kidney tubules. This is the result of prolonged renal ischemia, infectious processes such as glomerulonephritis and the use of nephrotoxic agents, like, NSAIDs and aminoglycoside antibiotics. Post-renal AKI is the result of an obstruction (kidney stone, blood clots, tumors, etc.) distal to the kidneys. When the kidney becomes obstructed, pressure rises and the GFR begins to drop resulting in acute kidney injury. (Hinkle & Cheever, 2017)

There are four stages of AKI: initiation, oliguria, diuresis and recovery. The initiation period is the injury that occurs to the kidneys and the start of AKI. The oliguria period is when there is an increase of serum concentration of substances that are usually excreted by the kidneys such as urea, creatinine, uric acids, potassium and magnesium. When these substances build up, life threatening hyperkalemia can develop. The diuresis period is when increased urine output begins and signifies that the glomerular filtration has begun to recover. During this phase laboratory levels begin to stabilize, and symptoms subside. Signs of dehydration during this phase should be monitored by the nurse due to the increased fluid loss. The last phase is the recovery period which can take anywhere from three to twelve months, during this phase renal function improves and the GFR may have been reduced slightly. (Hinkle & Cheever, 2017) The clinical manifestations of AKI include dry mucus membranes, drowsiness, headache, muscle twitching, and seizures. The patient will appear acutely ill and lethargic on admission. (Hinkle & Cheever, 2017)

In acute kidney injury, BUN and GFR labs decrease. With the decline in GFR, hyperkalemia is a significant risk for the patient. When protein catabolism occurs, potassium is released into the body causing sever hyperkalemia. Hyperkalemia can cause dysrhythmias, tachycardia and cardiac arrest if left untreated. Other symptoms include abdominal pain, irritability and muscle weakness. Because hyperkalemia is the most life-threatening fluid and electrolyte imbalance, lab values, EKG and clinical status should be monitored closely. Metabolic acidosis eventually occurs because the kidneys cannot excrete the normal metabolic weight of substances from the body, this is evidenced by a decreased pH and CO2 levels. Phosphate levels tend to increase, and calcium levels tend to drop. Anemia is often seen due to the reduced erythropoietin production and blood loss through the GI tract. (Hinkle & Cheever, 2017)

The kidneys have an astonishing ability to recover from injury, nonetheless, medical and nursing management are needed. Medical management includes eliminating the underlying cause (whether it be shock, infection or a kidney stone), maintaining fluid and electrolyte balance without causing fluid excess, treating the nutritional imbalances, treating the anemia with erythrocyte stimulating agents (Epoetin Alpha), and dialysis. Dialysis may be indicated in the AKI patient to prevent or treat hyperkalemia, and to prevent pulmonary edema, pericarditis and metabolic acidosis. (Hinkle & Cheever, 2017) The elevated potassium levels that occur with AKI can be decreased with the administration of a cation-exchange resin such as a Kayexalate. This medication works by exchanging the potassium ions with sodium ions, which in turn lowers potassium levels. (Hinkle & Cheever, 2017)

AKI can cause nutritional imbalances because of the nausea and vomiting that accompanies the disease process along with impaired glucose, inadequate protein synthesis and increased tissue catabolism. (Hinkle & Cheever, 2017) Nutrition is directed towards avoiding uremic symptoms and ensuring caloric requirements are met. Proteins are avoided, and high-carbohydrate meals are encouraged because carbohydrates have a protein sparing effect. High-carbohydrate foods include bagels, pastas, soda, and sweet potatoes. The patient should also be taught to avoid high potassium containing foods such as bananas, coffee, spinach and grapefruit to decrease the risk of developing or worsening hyperkalemia.

Nursing management for AKI includes monitoring fluid and electrolyte balances, reducing the patients metabolic rate, promoting pulmonary function, preventing infection, providing adequate skin care and providing psychosocial support. The nurse monitors fluid and electrolyte balances by monitoring labs, monitoring intake and output, monitoring weights, and for signs of edema. The nurse can decrease the patients metabolic rate by enforcing bed rest and taking steps to avoid infection because fever increases metabolic demand. Due to the risk of pulmonary edema commonly seen in AKI, the patient should be reminded to turn, cough and deep breath and the lungs should be auscultated frequently for crackles. The patient should also be taught how to use an incentive spirometer and the importance of it. Aseptic technique should be maintained when inserting catheters and IVs to reduce the risk of infection. Adequate skin care should be performed due to the dry skin that occurs with AKI. Lastly, psychosocial support should be offered to the patient and their family, especially if dialysis is required. Dialysis can be a scary thing for the patient and their family, thus psychosocial support should be offered.

Hemodialysis extracts toxic nitrogenous substances from the blood and removes excess fluid. It functions through the use of a dialyzer (or artificial kidney) which filters the blood and removes uremic toxins. The patients’ blood is diverted through a pump into the machine where the toxins are filtered from the blood and then the blood is returned to the patient. (Hinkle & Cheever, 2017) The disadvantages or complications of hemodialysis are disturbances in lipid metabolism, anemia due to blood loss, itching caused by phosphorus deposits in the skin and sleep disturbances. Nursing interventions for hemodialysis patients include promoting pharmacologic therapy, promoting nutritional therapy and meeting the patient’s psychosocial needs. Medications are removed from the body during hemodialysis, thus dosage or timing of medications may require adjustment. The patient must know when or not when to take certain medications on dialysis days; for instance, the patient should be taught not to take hypertension medications before dialysis because it can cause dangerous hypotension. (Hinkle & Cheever, 2017) Proper diet for the patient on dialysis is important because of the effects of uremia. The patient should be taught to limit sodium intake to prevent edema and to limit protein to decrease the buildup up of nitrogenous wastes. Potassium containing foods should also be avoided. Patients on dialysis often have financial problems, have difficulty holding jobs due to dialysis and have a fear of dying. The patient should be allowed to express their feelings, this builds report between nurse and patient and can help the patient better cope with the circumstance.

In peritoneal dialysis or PD, a sterile dextrose dialysate is infused into the peritoneal cavity by gravity and clamped off. After a dwell time the drainage tube is unclamped and the fluid from the peritoneal cavity drains by gravity into a bag. PD involves a series of steps, an exchange is the entire cycle including the fill, dwell, and drainage of the dialysate. Drainage is normally colorless or straw colored; bloody drainage is common after the first few exchanges after insertion of a new catheter. (Hinkle & Cheever, 2017) Complications of PD include peritonitis, leakage, and bleeding. Peritonitis is the most common complication of PD and is characterized by cloudy drainage and abdominal pain. To avoid peritonitis meticulous care must be performed to avoid contamination, the patient or care giver should be taught proper hand hygiene and to wear a mask whenever connecting or disconnecting tubing. (Hinkle & Cheever, 2017) Leakage of dialysate through the catheter site can occur, thus the patient should be taught about good hygiene and the signs of skin breakdown. Bleeding when catheters are first introduced is normal, along with while young woman are menstruating, besides those two instances, bleeding should not occur, thus the nurse should monitor for unusual bleeding. (Hinkle & Cheever, 2017)

A teaching plan for AKI would be teaching the patient about the risks of hyperkalemia. I would teach the patient the symptoms of hyperkalemia (tachycardia, dysrhythmias, weakness etc.) and if they have a prescription for kayexalate id educate them on that medication. Id teach the patient that kayexalate reduces potassium by exchanging sodium ions for potassium ions in the intestinal tract. (Hinkle & Cheever, 2017) It can be administered orally or by enema and some side effects of the medication are loss of appetite, upset stomach, nausea, vomiting and cramping. I would have the patient repeat back to me some symptoms of hyperkalemia and tell me the purpose of kayexalate to verify that the teaching has been understood. I would provide the patient with a hospital approved article that explains hyperkalemia and its symptoms.

MRSA is a common pathogen that is resistant to methicillin. MRSA is easily transmitted from health care workers to patients because MRSA has an affinity for skin colonization. (Hinkle & Cheever, 2017) MRSA can cause local inflammatory symptoms (redness, pain, heat and swelling) and may be accompanied by a fever. Lab values will be indicative for infection with an elevated white blood cell count and the patient will test positive for MRSA. Patients are at increased risk for contracting MRSA if IV therapy, catheters, surgeries or invasive procedures are performed while the patient is in the hospital. MRSA can be avoided by instilling contact precautions when directed, by using standard precautions (hand hygiene and gloves) with all patients and maintaining aseptic technique when inserting IV’s and catheters. The use of aseptic technique in surgical suits also decreases risk for MRSA. Patients receiving dialysis are at an increased risk for MRSA due to IV therapy multiple times a week, thus aseptic technique should be top priority.

In conclusion, AKI is a form of kidney dysfunction that can be mild or life-threatening. It can cause severe fluid and electrolyte issues resulting in metabolic acidosis, dehydration, edema and hyperkalemia. Hyperkalemia should be avoided and monitored for by assessing lab values, monitoring EKG’s and observing for new symptoms in the patient. AKI is manifested by drowsiness, dry mucus membranes, lethargy, muscle aches and twitching, headache and potential seizures. (Hinkle & Cheever, 2017) Treatment of AKI is directed towards fixing the main causative agent (clot, shock, injury, etc.), replacing fluids and electrolytes, monitoring for and fixing anemia, and if indicated dialysis. AKI can be prevented by assessing renal function, preventing and treating infections promptly, avoiding and treating dehydration, preventing toxic drug effects and treating hypotension in known patients. (Hinkle & Cheever, 2017)

There are two types of dialysis, hemodialysis and PD. Hemodialysis is done multiple times a week and involves removing the patients’ blood and wastes and returning the blood to the patient. Hemodialysis poses a risk for anemia and infection at the port site. PD uses a separate technique involving a sterile solution into the peritoneal cavity and gravity. PD poses a large risk for infection, specifically peritonitis. Nursing interventions for dialysis include promoting nutritional and pharmacological therapy, meeting psychosocial needs, and monitoring for potential complications. MRSA is an infection that is resistant to many antibiotics and is very contagious. Standard and contact precautions must be used to protect the patient and medical staff from spreading or contracting MRSA. Steps to prevent AKI and MRSA in our patients is of top priority.