Renal Failure

Case Study Part 3: Renal Failure

Clinical Course Day 2:

You call the hospitalist regarding the labs above and the following orders are placed: Decrease the IV fluids, D/C insulin drip, Start insulin sliding scale with glucometer readings every 2 hours, increases oxygen to 4 Liters O2 per NC with titration to maintain SpO2 >92%, Lasix 40mg IV x 1 now. You inform him that the newest vital signs are: T:100.9; HR: 114; R: 32; B/P: 122/64. Urine output 45cc/hr.

Basic Metabolic Profile, CBC, UA, ABG and BNP ordered:

Labs and Diagnostics:

Na 134 meq/L K 3.5 meq/L Cl 109 meq/L HCO3 17 meq/L BUN 66 mg/dL Cr 3.0 mg/dL

eGFR 36 cc/min WBC 16.8 x 103/mm3 Hb 11.6 g/dl / Hct 37% Glucose 180 mg/dL

URINALYSIS

Clear, dark yellow urine; Microscopy was negative for cells, casts, pigments, and crystals

SG 1.032 (-) bacteria (+) glucose (-) protein (-) Nitrate (-) RBC (-) WBC

Urine sodium 8 mEq/L. FeNa <1%

BNP 975 pg/ml Troponin I High Sens. 15 pg/ml

ABG: pH= 7.30; PaCo2=12; PaO2= 88; HCO3: 18 BE: 1

Answer the following questions based on the information above:

10) The patient is noted to have acute kidney injury (AKI) and nephrology is consulted. Based on the patient’s diagnosis of CHF, physical findings and labs, is the patient exhibiting pre-renal, intra-renal or post renal failure? (1point). Explain your decision (3 points)

11) Oliguria occurs in AKI whether the cause is pre-renal or intrarenal. What are three mechanisms which account for the decrease in urine output? ( 3 points)

12) Describe the key differences in the pathophysiology between pre-renal and intrarenal failure.(4 points) As the nurse, what would you look for on your assessment of the patient who is in pre-renal failure? (2 points)

13) Comorbidities such as hypertension and diabetes can affect kidney function over and above this patient’s diagnosis of CHF. List five teaching points and expected outcomes on her diagnoses at discharge to prevent a reoccurrence and readmission ? (5 points)

APA 1 point Scholarly Work 1 point Total points 20

Urinary Tract Infection Glomerular Disease

NUR 41500

Chapter 30

Urinary Tract Infection

A urinary tract infection (UTI) is an inflammation of the urinary epithelium usually caused by bacteria from gut flora.

A UTI can occur anywhere along the urinary tract

Acute Cystitis

Acute cystitis is an inflammation of the bladder and is the most common site of UTI.

The morphologic appearance of the bladder through cystoscopy describes different types of cystitis:

Mild inflammation- the mucosa is hyperemic (red)

Hemorrhagic cystitis- diffuse hemorrhage

Suppurative cystitis- pus formation, or suppurative exudates on the epithelial surface of the bladder

Ulcerative cystitis- prolonged infection, sloughing of the bladder mucosa with ulcer formation

Gangrenous cystitis- necrosis of the bladder wall

Cystitis cont

The most common infecting microorganisms are uropathic strains of Escherichia coli and the second most common is Staphylococcus saprophyticus.

Less common microorganisms include Klebsiella, Proteus, Pseudomonas, fungi, viruses, parasites, or tubercular bacilli.

Schistosomiasis is the most common cause of parasitic invasion -strong association with bladder cancer.35

Cystitis, cont

Bacterial contamination is by retrograde movement of gram-negative bacteria

These bacteria resist flushing by normal micturition

Hematogenous causes are uncommon and usually occur in septicemia

Clinical Manifestations of cystitis

Related to the inflammatory response

Usually include frequency, urgency, dysuria (painful urination), and suprapubic and low back pain

10% of individuals with bacteriuria have no symptoms

30% of individuals with symptoms are abacteriuric

Clinical Manifestations of cystitis

Elderly persons with cystitis may be asymptomatic

May demonstrate confusion or vague abdominal discomfort.

The elderly with recurrent UTIs and other concurrent illness have a higher risk of mortality.

Evaluation and treatment

Urine dipstick testing that is positive for leukocyte esterase or nitrite reductase can be used for the diagnosis of uncomplicated UTI without a culture

Individuals are diagnosed by urine culture of specific microorganisms with counts of 10,000/ml or more from freshly voided midstream urine.

Microorganism-specific antibiotics used

3-7 days uncomplicated; 7-14 days complicated

Acute Pyelonephritis

An infection of one or both upper urinary tracts

Urinary obstruction and reflux of urine from the bladder are the most common underlying risk factors

One or both kidneys may be involved

Most cases occur in women

Acute Pyelonephritis

  1. coli, Proteus, or Pseudomonas most common organisms

Urethral instrumentation or urinary tract surgery are commonly associated

Infection is usually ascending pathogens up the ureters

May be spread through the blood stream

Acute Pyelonephritis

Inflammation affects pelvis, calyces and medulla

Result is renal inflammation, renal edema,

and purulent urine

Severe infection may result in abscess formation and extend to the cortex

Rarely causes renal failure

Acute Pyelonephritis

Uncomplicated acute pyelonephritis responds well to 2 to 3 weeks of microorganism-specific antibiotic therapy.

Complicated pyelonephritis requires blood cultures and urinary tract imaging

Follow-up urine cultures are obtained at 1 and 4 weeks after treatment if symptoms recur.

Glomerular Disorders

Disorders affecting the glomerulus

Includes

Acute glomerulonephritis

Rapidly progressing glomerulonephritis

Chronic Glomerulonephritis

Nephrotic Syndrome

Acute GN

Inflammation of the glomerulus from:

Immunologic abnormalities –think post streptococcal!

Drugs or toxins

Vascular disorders

Systemic diseases

Viral causes

Most common of the glomerular diseases

Mechanism of injury

Deposition of circulating soluble antigen-antibody complexes, often with complement fragments

Antibodies to the glomerular basement membrane are formed

Causes an increase in glomerular capillary permeability and loss of negative ionic charge barrier

This results in gaping holes in the basement membrane, allowing large plasma proteins and RBCs to escape into the urine

The loss of plasma proteins causes a drop in albumin and subsequent leakage of fluid into the interstitial spaces edema

Chronic GN

Encompasses many glomerular diseases

Associated with hypercholesterolemia and proteinuria

Diabetes and Lupus are secondary causes

Inflammation and damage again caused by damage to the glomerular basement membrane

Rapidly Progressive GN

Develops over days to weeks

Usually affects adults in 50’s and 60’s

Hematuria is a common sx along with proteinuria

Goodpasture’s Syndrome is a form of RPGN and involves both the basement membrane of the lung and the glomerulous

Nephrotic Syndrome

Excretion of more than 3.5 grams of protein in a 24 hour period in glomerular injury

Manifested by hypoalbuminemia, edema, hyperlipidemia and lipiduria

Assessment in Glomerular Diseases

Usually periorbital and extremity edema

Can develop anasarca (generalized edema) if albumin gets too low to hold fluid in the vascular space

Albumin and total protein always low

Proteinuria measured on a 24 hour urine. Can be in excess of 5 grams!!!

BUN and Creatinine not affected because filtering is still taking place

Biopsy gives definitive diagnosis

 

Last Updated on May 29, 2022

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