RNSG 1443 MODULE 2 TEST BLUEPRINT

Anatomy and Physiology of the kidneys:

Located retroperitoneally (behind and outside the peritoneal cavity) on the
posterior wall of the abdomen. The hilum is the concave portion of the
kidney through which the renal artery enters the ureters and renal vein exit.
The kidneys receive 20%-25% of the cardiac output. This means that all of
the body’s blood circulates through the kidneys 12 times per hour. The renal
artery divides into smaller and smaller vessels eventually forming the
afferent arterioles. Each afferent arteriole branch to form glomerulus (part of
the nephron). Filtration occurs within the glomeruli. Blood exits the glomeruli
through the efferent arteriole and flows back into to the inferior vena cava
through network of capillaries and veins.
Nephrons: Each kidney has 1 million nephrons. Nephrons are responsible
for forming waste that will be excreted through urine. If 20% of nephrons
become damaged, renal replacement should be considered.
Functions of the Kidney:
 Urine formation
 Excretion of waste products
 Regulation of electrolytes
 Regulation of acid base balance
 Control of fluid balance
 Control of blood pressure
 Renal clearance
 Regulation of red blood cell production
 Synthesis of Vitamin D to active form
 Secretions of prostaglandins

Renal Failure:
Acute kidney injury: a rapid loss of kidney function due to damage. Damage
and reversal depend on the duration and severity of AKI. Treatment is aimed
at replacing renal function temporarily to minimize potential deadly
complications. Some factors of AKI may be reversible if treated promptly.
Hypovolemia, hypotension, decreased cardiac output/heart failure,
obstruction of the kidney or lower UTI via tumor/clot/stone, and bilateral
obstruction of the renal arteries or veins. Real stones are not a common
cause of AKI, but they place the patient at a higher risk of incidence.
 R(isk) Cr: GFR: >25% UOP:
Classification of AKI: 1.5xbaseline 0.5mL/kg/hr

I(njury Cr: 2xbaseline GFR: >50% UOP:

0.5mL/kg/hr
)

F(ailur Cr: 3xbaseline GFR: >75% UOP:

<0.3mL/kg/hr
e)
L(oss) Persistent AKI; complete loss of function. >24
hours.

E(SKD) >3 months.

Types of AKI: Prerenal, Intrarenal, and Postrenal.

Prerenal: Responsible for 60%-70% of AKI cases. This is the result of
impaired blood flow leading to hypo perfusion of the kidney.
Common causes:
 Volume depletion: burns, hemorrhage, GI losses.
 Hypotension: Sepsis, shock, renal artery stenosis- this leads to
decreased GFR.
In the instance of Prerenal Kidney Failure, TREAT THE CAUSE. Get H&H, Stool
sample, or administer beta blocker (they increase CO).
Intrarenal: MEDS MEDS MEDS. Damage to the glomeruli or kidney tubule.
 Acute Tubular necrosis is the most common type. ATN.
 intratubular obstruction
 tubular back leak
 Rhabdomyolysis/myoglobinuria (trauma, crush injuries, burns)
 Nephrotoxic meds (Vanc, Gent, tobramycin, ACE inhibitors, NSAIDs,
radiopaque contrast agents, solvents and chemicals.
 Infection processes: glomerulonephritis, acute pyelonephritis.
Postrenal: Urinary Tract Obstruction
 BPH
 Blood clot
 Calculi
 Structures
 tumors

Phases of AKI: Initiation, Oliguria, Diuresis, and Recovery.

Initiation: Begins when the initial insult occurs and ends when oliguria
develops.
Oliguria: Accompanied by the increase in serum concentration of substances
usually excreted by the kidneys. The minimum amount of urine needed to rid
the body of normal metabolic excretions is 400mL in 24 hours, or
0.5mL/kg/hr. In this phase, uremic symptoms first appear and life-
threatening conditions such as hyperkalemia develop.
Diuresis: the period is marked by gradual increase in urine output, which
signals that glomerular filtration has started to recover. Lab values begin to
stabilize and eventually decrease. Although, just because urine output
reaches normal, or increased amount, renal function may still be abnormal.
Observe the patient closely for dehydration. If dehydration occurs, uremic
symptoms are likely to increase.
Recovery: Signals the improvement of renal function and may take 3-12
months. Lab values return to the patient’s normal level. A permanent 1%-3%
reduction in GFR may occur. It is not clinically significant.

Chronic Kidney Disease: When a patient has sustained enough kidney

damage to require renal replacement therapy on permanent basis. The
patient is in the 5th stage of CKD, also known as ESKD.
Patho: As renal function declines, the end products of protein metabolism
accumulate in the blood. Uremia develops and adversely affects every
system in the body. The greater the buildup of waste products the more
pronounced the symptoms. The rate of failure increases in patients with
significant amounts of protein or have elevated BP.
Clinical Manifestations:
Virtually every body system is effected by ESKD. The patient will present
with various symptoms. Symptoms depend on the severity of kidney
impairment, and other comorbidities. Cardiovascular disease is the
predominant cause of death in patients with ESKD. The leading causes of
ESKD are diabetes and hypertension.
 Peripheral neuropathy
 Complaints of severe pain and discomfort
 Restless leg syndrome
 Burning feet can present in the early stage of uremic peripheral
neuropathy
It is thought that the accumulation of the uremic waste product is the cause.

Assessing the Body Systems for ESKD: Be alert to the following signs
and symptoms.
Neruo:
 Asterixis
  Behavior changes
 Burning of soles of feet
 Confusion/disorientation/inability to concentrate
 RLS
 Seizures
 Tremors
 Weakness/fatigue
Skin:
 Course, thinning hair
 Dry, flaky skin
 Ecchymosis
 Grey-bronze skin color
 Pruritus
 Purpura
 Thin, brittle nails
Cardiovascular:
 JVD
 Hyperkalemia
 Hyperlipidemia
 Hypertension
 Pericardial effusion
 Pericardial friction rub
 Pericardial tamponade
 Pericarditis
 Periorbital edema
 Pitting edema (feet, hands, sacrum)
Pulmonary:
 Crackles, SOB, tachypnea
 Depressed cough reflex
 Kussmaul respirations
 Pleuritic pain
 Thick tenacious sputum
 Uremic pneumonitis
GI:
 Uremic odor to the breath
 Anorexia/N/V
 GI bleeding
 Constipation/diarrhea
 Hiccups
 Metallic taste
  Mouth ulcerations and bleeding
Hematologic:
 Anemia
 Thrombocytopenia
Reproductive:
 Amenorrhea
 Decreased libido
 Infertility
 Testicular atrophy
Musculoskeletal:
 Fractures, bone pain
 Footdrop
 Loss of muscle strength/muscle cramps
 Renal osteodystrophy

Complications of ESKD: there are a number of complications of ESKD that

require collaborative approach to care.
 Anemia due to decreased erythropoietin production, decreased RBC
lifespan, bleeding in the GI tract from irritating toxins and ulcer
formation and blood loss during hemodialysis.
 Bone disease and metastatic and vascular calcification due to retention
of phosphorus, low serum calcium levels, abnormal vitamin D
metabolism, and elevated aluminum levels.
 Hyperkalemia due to decreased excretion, metabolic acidosis,
catabolism, and excessive intake.
 Hypertension due to sodium and water retention and malfunction of
the renin-angiotensin-aldosterone system.
 Pericarditis, pericardial effusion, and pericardial tamponade due to
retention of uremic waste products and inadequate dialysis.

Hemodialysis Dialysis:
Indications:
1. Acute/chronic renal failure
2. Dialyze medications= i.e. drug overdose
3. Hyperkalemia.
The procedure involves:
a. Diverting toxin laden blood from the person into a filter known as a
dialyzer or artificial kidney.
b. Returning the clean blood to the patient.
 c. While blood is within the dialyzer, the dialysis fluid is delivered by a
mechanical proportioning pump to flow on the other side of the
membrane.
The dialyzer has two compartments separated by a membrane that is
semipermeable- only particles of certain size can pass through it.
A specially prepared electrolyte solution called Dialysate circulates on one
side of the membrane, and blood flows through the other side.
There are three processes that occur in dialysis:
1. Diffusion 2. Osmosis 3. Ultrafiltration
Four goals of dialysis therapy:
 Remove accumulated metabolic wastes
 Controls levels of electrolytes
 Maintains and restores pH
 Eliminates excess water from the circulatory system.
Access to Patient circulation:
 Most common is AV fistula and graft.
o AV fistula: the preferred method of permanent access.
o Artery and vein are surgically anastomosed together.
o Allows to dilate enough for large needles. Patient needs to
exercise hand by squeezing tennis balls.
 Takes 2-3 months to mature.
 Long term use of access.
 AV Graft: Used for patients with inadequate vasculature for fistula. (DM
or compromised CV system).
o Artery and vein are connected by a synthetic tube.
o Preferred over cannula or shunt due to a decreased chance of
hemorrhage or clot.
Care of the Access: Site must mature before using.
 Prevent clotting.
o Do not use access arm for BP, IV, or venipuncture.
 Hang signs in patient’s room
 Avoid tight fitting clothing, and sleeping on side for long
period of time
 Auscultate for bruit, palpate for thrill. “hear the bruit, feel the thrill”
o Lack of bruit can indicate clot.
o Teach patient to check for thrill every day.
o Teach to monitor for bleeding, swelling, redness and drainage.
Nursing considerations:
o Protect vascular access: Post sign in room
 o Watch IV therapy closely: Can’t excrete fluids, so watch for
fluid overload, and pulmonary edema
o Monitor for uremia: Monitor patients on corticosteroids, TPN,
infection or bleeding disorders closely.
o Monitor for cardiac/respiratory complications: Should be
noticed by nurse.
o Monitor electrolyte levels and diet
o Manage pain and discomfort: neuropathy, pruritis
o Monitor BP: most patients have hypertension and take
hypertensives. Hold BP med prior to dialysis d/t risk of BP drop.
o Prevent Infection: watch WBC, RBC, and platelet function.
o Catheter Care: Daily to prevent HAI
o Monitor meds: check dosages, and prevent further damage
caused by nephrotoxic agents.
o Provide psychological support: allow patient to express their
feelings
Nursing Management:
 Prior to Dialysis do a baseline vital check: weight, edema, lung/heart
sounds, condition of access, skin temp/condition.
 During dialysis: VS Q30-60 Minutes.
Medications often get filtered out during dialysis. Hold medications until after
dialysis. (cardiac glycosides, antibiotics, antihypertensives, water soluble
vitamins (B&C), folic acid.)
 Protein bound medications will not filter out.
Complications of Dialysis:
 Blood loss/decrease in BP or vision loss.
o Rinse blood back, monitor heparinization, apply pressure on
access site.
o Could worsen anemia by loss of blood in dialysis.
 Disequilibrium syndrome: Caused by fluid shift. Seen in patients with
BUN >150 with severe azotemia.
o More rapid removal of urea from blood vs the brain.
 Causes cerebral edema, and increased ICP.
o Can also happen with wastes, electrolytes, and fluids are
removed from blood faster than from cells.
o S/S: HA, N/V, confusion/restlessness.
 Twitching, jerking seizures, and decreased BP can lead to
coma, cardiac arrest, and death is untreated.
 o Treatment of DDS: prevention is key. If occurs: PRIORITY is to
slow the rate of dialysis, or d/c dialysis treatment.
 Administer hypertonic solution, albumin, mannitol (pulls
fluid off the brain)
 Administer oxygen at 2L NC and raise HOB 45
 Minimize light/noise. (decreases seizures)
 Most patients recover with volume restoration.
 May need mannitol, anticonvulsants, or barbiturates.
 If patient is prone to DDS, increase weekly treatments, for
less time.
 Hypotension: due to hypovolemia, or administration of
antihypertensives.
o Place patient in Trendelenburg position, use LR/albumin/NS.
o Nursing Interventions: decreased the volume removed, infuse
100-300mL NS, elevate feet.
o Hold BP meds before treatment
o Monitor weight/VS
o Safety: orthostatic hypotension.
 Muscle cramping/spasms: due to sodium shift. Very painful.
o Treatment with massage, standing, or warm compresses.
o Decrease ultrafiltration pressure, decrease rate, and infuse
hypertonic or NS.
 Sepsis: maintain aseptic technique.
o Monitor for fever, drop in BP, and increase in WBC.
Nursing Diagnosis:

Peritoneal Dialysis: Repeated cycles of instilling dialysate into the

peritoneal cavity for a period of time and then draining the fluid.
Goal: to remove toxic substances and metabolic wastes and reestablish
normal fluid and electrolyte imbalance.
 The peritoneal membranes serve as the semi permeable membrane.
 Sterile dialysate is placed into the peritoneal cavity through an
abdominal catheter.
 Diffusion and osmosis occur.
Candidates for PD:
 Young children: vessels are too small for HD.
 Patients who want to stay home
  Elderly/fragile patients with cardiovascular disease who can’t handle
fluid shifts from HD. Patient’s with no peripheral sites available for
access placement.
Advantages:
 Independence and mobility
 Minimizes symptoms of HD d/t lack of rapid fluid shifts
 Simple process and no heparin
 Can be done intermittently, several times a week, or continuous. Gives
flexibility to the patient.
Disadvantages:
 Time: requires longer time commitment and cannot be used in an
emergency.
o Takes 6-8 hours per session.
 Less effective in catabolic patients.
To prevent Infection: Teach aseptic technique for connecting and
disconnecting tubing. If items fall on the floor, replace them.

3 Phases of PD: Good hand hygiene, turn off fan, or air. No pets/children in
room. Put on mask and sterile cap on peritoneal catheter.
 Inflow (fill): Prescribed amount of solution (2L) is infused over 10
minutes.
o Warm solution (prevents cramping) NO microwave.
 Dwell (equilibrium): Diffusion and osmosis occur. Dwell time can range
from 20 minutes to over 8 hours. (depends on type cont. is 6-8 hours)
 Drain: Fluid is removed from the peritoneal cavity. Takes 15-30
minutes.
o Should be more than what you put in
o Turn from side to side if nothing comes out.
Ambulatory PD: At least 4 exchanges/day
 Disconnect tubing between cath and bag during dwell time.
 Drain by gravity- massage abd. Gently or turn from side to side to
facilitate drainage.
 The patient can do PD overnight with a machine- 8-9 hours.
Complications of PD:
 Peritonitis: Most common, and most serious.
o FIRST sign is cloudy dialysate drainage.
 S/S: increase in WBC(over 100 increase in neutrophils), abd
pain/distention, N/V, hyperactive BS. (GI s/s occur later)
o Results in large protein losses (this leads to acute malnutrition
and delayed healing)
 o If untreated patient can go septic (drop in BP, and increased HR)
 Prevention: Aseptic technique at home. (no kids/pets, no air/fan on,
wear mask, wash hands, stay in a confined area, if equipment falls to
the ground, replace it.
 Treatment: treated with antibiotic therapy after C&S for 10-14 days.
Leakage: usually immediately after insertion of catheter. Resolves with no
rest (no dialysis for a few days)
 Decrease factors that delay healing- abdominal muscle activity, BM
straining
 Avoid by using small volumes and increasing slowly.
Bleeding: Usually occurs during menstruation in women or after new
catheter insertion. Typically requires no intervention.
Long term complications:
 Hypertriglyceridemia, and hernia. (d/t the increased abdominal
pressure.
Nursing Diagnosis:

Renal Transplant: Treatment of choice because it provides normalcy for

the patient. It is also cost effective. In order to be a match, the donor must
match ABO and leukocyte antigens. (rare, so family would be the best
chance).
Patient Teaching:

Pre-op teaching:
 Warn the patient that the kidney function may not return immediately,
therefore dialysis may be necessary.
 Teach patient preoperatively about the lifestyle change that will be
needed to maintain function of donated kidney.
o Meds: immunosuppressants will be needed and infection
prevention measures will need to be reviewed.
 Avoid large crowds, good hand hygiene, healthy lifestyle.
 Pulmonary hygiene, pain management, dietary restriction
teaching.
 Explain to the patient what can be expected. (NG tube,
drain)
Post-op teaching: Hourly I&O
 Fluid and electrolyte balance.
 Fluid replacement
 Prevent dehydration bc it can cause more stress to the kidneys.
  Delayed kidney function. (the sooner the kidneys function, the better
the prognosis.)
Contraindication for transplant:
 Cancer: Active diagnosis
 Active or chronic infection
 Severe cardiac or lung disease
 Severe PVD
 Active autoimmune disease (HIV, HEP)
 Morbid obesity
 Substance abuse
 H/O non-compliance. If they aren’t compliant to begin with, they won’t
be with an even more strenuous protocol.
Kidney Transplant Process:
Pre-op:
 Patient should be in optimal health
 Patient should be educated about placement of donated kidney. The
non-functioning kidney is left in place and the donated kidney is placed
in the iliac crest.
Post-op:
 Recognize rejection symptoms (malaise, fever or pain)
 Medications:
o Immunosuppression can impair healing and increase risk of
infection
 Monitor visitors closely, encourage hand hygiene, sterile
dressings and catheter care mandatory.
 Prevent infection: Hand hygiene, no large crowds, flu shot.
 Monitor urine output: report a decrease.
o Report if <100mL/hr
o A sudden decrease in UO may indicate a clot at the renal artery
anastomosis site.
Signs and Symptoms of Rejection: Can occur within 24 hours.
 Oliguria
 Edema
 Fever
 Increase in BP
 Weight gain
 Swelling/tenderness of kidney
Medications such as Cyclosporine can mask rejection signs- monitor
creatinine levels CLOSELY.
Hyperacute Rejection S/S:
  Onset within 48 hours
 Malaise, high fever
 Graft tenderness
 Only treatment is removal of the kidney.
Acute Rejection S/S: 1 week – 2 years.
 Oliguria/anuria
 Increased temp
 Increased BP
 Flank tenderness
 Lethargy
 Increased BUN, K, Creatinine
 Fluid retention
Chronic Rejection S/S:
 Gradual- over months to years
 Increase in BUN, creatinine
 Imbalances in proteinuria and electrolytes
 Fatigue

Immunosuppressive Therapy: Goal is to prevent rejection, while

maintaining immunity to also prevent increased risk of infection.
 Side effects: Increased risk of infection, malignancies, or GI issues.
Complications:
 CV Disease: leading cause of death after kidney transplant.
o Immunosuppressants worsen the HTN and hyperlipidemia
o Heart disease damages new kidney
 Malignancies: Small number develop cancer. (100x greater in a
transplant pt)
o Due to immunosuppression.
 Recurrence of renal disease: damage to transplant’s function.
 Corticosteroid related complications:
o Joint necrosis
o PUD
o Increased blood glucose/ DM
o Cataracts
o Hyperlipidemia
o Infection
o Cancer

Acute Nephrotic Syndrome:

Kidney disease with glomerular inflammation. Inflammation of the glomerular
capillaries that can occur in acute/chronic forms. Often a result of a strep
infection in the throat.
 Also follows impetigo, acute viral infection (upper resp infection),
mumps, varicella zoster, Epstein-Barr virus, Hep B, and HIV.
Signs and Symptoms: hematuria, diffuse edema, azotemia, increased
protein in urine (HALLMARK).
 Increased cholesterol and LDL: loss of plasma protein, stimulates the
synthesis of lipoproteins causing hyperlipidemia, anemia, HA, malaise,
circulatory overload, cardiomegaly, pulmonary edema, and HTN.
Assessment:
 Recent strep infection
 Mild to moderate hypertension
 Dark colored urine (hematuria)
 Slight to moderate proteinuria
 Elevated antistreptolysin (ASO) titer, elevated BUN & creatinine.
Treatment:
Treat the underlying disease and symptoms.
 Treat hypertension, treat complications
 Corticosteroids
 Restrict protein AND sodium.
Monitor for signs of CHF and renal failure.
Monitor for seizures (hypertensive encephalopathy)

Chronic Glomerulonephritis: The result of repeated episodes of ANS,

hypertensive nephrosclerosis, hyperlipidemia, chronic tubulointerstitial injury
or hemodynamically mediated glomerular sclerosis. Kidneys are reduced to
1/5 of the normal size. Scar tissue distorts the shape of the kidney, the
tubules and renal artery become scarred and thickened.
 Kidneys reduced to 1/5 of normal size
 Patients may be asymptomatic or have generalized symptoms
 Review assessment and diagnostic findings
Assessment and diagnostic findings: A number of lab abnormalities occur. UA
reveals a fixed specific gravity of 1.010. Proteinuria, and urinary casts
(proteins secreted by damaged kidney tubules). As kidney disease
progresses and the GFR falls below 50mL/min the following changes occur:
 Hyperkalemia due to decreased potassium excretion, acidosis,
catabolism, and excessive potassium intake from food and
medications.
  Metabolic acidosis from decreased acid secretion by the kidney and
inability to regenerate bicarb.
 Anemia secondary to the decreased production of erythropoiesis
(production of RBC)
 Hypoalbuminemia with edema secondary to protein loss through the
damaged glomerular membrane
 Increased serum phosphorus level due to decreased renal excretion of
phosphorus
 Decreased serum calcium level (calcium bonds to phosphorus to
compensate for elevated phosphorus levels)
 Mental status change
 Impaired nerve conduction d/t electrolyte abnormalities and uremia.

Treatment of Chronic Glomerulonephritis:

 Treat symptoms
 Promote adequate nutrition
 Dialysis may be needed
Nursing considerations:
 Observe fluid and electrolyte imbalances
 Emotional support
 Encourage appropriate follow up
Chronic Glomerulonephritis treatment include treatment of symptoms:
 Hypertension is reduced by restricting sodium and fluids and a
hypertensive medication if indicated.
 Weight is monitored daily and a diuretic prescribed when needed for
fluid overload.
 Healthy protein intake is encouraged to promote good nutritional
status for tissue growth and repair.
 Dialysis may be necessary to prevent fluid and electrolyte imbalances
and minimize the risk of renal failure

Polycystic kidney disease:

 Genetic Disorder
 Autosomal dominant PKD
 Autosomal recessive PKD
 5th leading cause of kidney failure
Patho: PKD is a genetic disorder characterized by the growth of numerous
cysts in the kidneys. The autosomal dominant variety is most common and
usually identified in young adults. Autosomal recessive PKD is rare, and often
diagnosed in utero. The cysts fill with fluid, destroying the nephrons leading
to kidney failure. PKD can also cause problems in other organs and blood
vessels in the heart and brain.
Clinical Manifestations: hematuria, polyuria, hypertension, renal calculi, UTI,
proteinuria, abdominal pain, flank pain.
 Assessment includes palpation which will reveal an enlarged kidney.
 Diagnosis is made via ultrasound.
PKD has no cure, and is treatment is supportive.

Urinary Diversions:
Means of diverting the urine away from the bladder with the urine exiting the
body via an opening in the skin (stoma)
 Ureters may be implanted into the colon so that urine passes through
the rectum
 Openings into the kidney are established to drain urine directly from
the renal pelvis into an external collection system.
Reasons for diversion:
 Large invasive bladder tumor that requires removal of the bladder
 Management of pelvic malignancy
 Birth defects
 Strictures and trauma to ureters and urethra
 Neurogenic bladder
 Chronic infection causing ureteral and renal damage
 Intractable interstitial cystitis
Considerations in determining appropriate surgical procedure:
 Age of patient
 Condition of bladder
 Body build
 Degree of obesity (with a lot of fat tissue, the bag won’t adhere)
 Degree of ureteral dilation
 State of renal function
 Patient’s acceptance of results of the procedure
 Learning ability
Two categories of Urinary Diversions:
1. Cutaneous urinary diversions
a. A diversion in which urine drains through an opening created in
the abdominal wall and skin
2. Continent Urinary Diversions
 a. A portion of the intestine is used to create a reservoir for urine.
If the appliance is needed to collect urine, check for LATEX allergy.
Most common methods of urinary diversions:
Ileal Conduit: most common type of diversion
 Using a segment of the intestine as a conduit (passageway), this
procedure constructs a system so that urine is emptied through an
opening in the skin.
 Ureters are anastomosed to an isolated 4 to 6-inch segment of the
terminal ileum (least re-absorptive) near the proximal end.
 Continuity of the intestines reestablished, and distal end is brought
through the abdominal wall. A stoma is formed. A Drainage bag is used
to collect the urine.
Advantages: good urine flow with few physiological alterations. Little
absorption of electrolytes.
Disadvantages:
 External appliance required to continually drain urine
Complications (most common):
 Obstruction at the ureteroileal anastomosis
 UTI
 Stenosis anywhere along the system
 Calculi
 Skin irritation
 Stoma defects.
Special Considerations: ostomy appliance needed; drains only urine.

Ureterosigmoidostomy (continent urinary diversion):

Ureters excised from bladder and anastomosed into the sigmoid colon; urine
flows into the colon and empties via the rectum. The colon becomes the
reservoir.
 Requires competent anal sphincter, adequate renal function and active
renal peristalsis.
Advantages: No external drainage device, and urinary control via the
rectum.
Disadvantages: Patient’s need to urinate through the rectum, and the
colon can reabsorb the urine.
Major complications:
 Chronic pyelonephritis: reflux of the fecal material into the ureters and
kidney
 Hydronephrosis: collection of urine in the renal pelvis due to
obstructed outflow.
  Hyperchloremic acidosis: occurs when chronic infection and
hydronephrosis interfere with normal tubular function and thus inhibits
adequate excretion of chloride in the urine; because of its absorptive
properties, the sigmoid colon itself may absorb the chlorides present in
the urine.
Special considerations: frequent elimination needed to prevent F&E problems
and reflux. Enemas usually are contraindicated; flatus causes stress
incontinence; flatus needs to be expelled in toilet.
TEACH S/S of UTI: fever, flank pain, and frequency.

Cutaneous Ureterostomy: detaching the ureter from the bladder and bringing
it through the abdominal wall. Urine flows directly into the drainage device.
 Used in patients with ureteral obstruction or risky patients because it
requires less extensive surgery.
Advantages:
 Doesn’t require major surgery
 Can be used with patients who have has abdominal irradiation
Disadvantages:
 Requires external appliance d/t continuous urine drainage
 Stricture or stenosis of the small stoma may occur.
 Leakage and odor
Special Considerations:
Periodic catheterization may be required to maintain patency of the stomas.
Permanent appliance- elimination through the stoma is urine.

Continent ileal urinary diversion (Kock Pouch): Used for patients with a
neurogenic bladder.
 Segment of small intestine is surgically isolated from the intestine and
stores urine. Ureters are implanted into the new “bladder” and an
opening is made into the abdominal wall. Nipple valve is created to
prevent leakage of urine.
Advantage: The valve prevents leakage of urine and the drainage of urine
is under control of the patient.
Special Considerations:
 To drain the stored urine, a catheter is inserted through the nipple
valve and is drained.
 The pouch must be drained at regular intervals to prevent absorption
of metabolic waste products from the urine and reflux of urine to the
ureters.
  An absorptive pad or band-aid is placed over the stoma to collect the
mucus it secretes.
 Reservoir irrigations are performed at least once daily using a 50 to 60
cc catheter tip or bulb syringe to remove the mucus that has
accumulated in the reservoir.

Nursing Management:
 Pre-op:
o Visit with an ostomy visitor or nurse.
o Site selection: preoperative stoma site. RLQ/RUQ. Smooth skin
surface (free of scars, skin folds, and bony prominence) needed
surrounding the stoma.
 Site is measured and marked with the patient sitting,
standing, and lying in order to determine if the surrounding
surface is indeed smooth.
o Practice wearing the appliance with or without 100mL of water in
the appliance bag to stimulate the weight of urine.
o Teach patient about the type of diversion
o Intensive bowel prep is started 2-3 days prior to surgery.
 This is used for diversions where intestines have to be
utilized.
 Bowel is cleansed to minimize fecal stasis
 Decompress the bowel and minimize post-op ileus.
o Diet: LOW residue usually 2 days before surgery.
o Medications:
 IV fluids: provides adequate hydration to ensure urine flow
during surgery and prevents hypovolemia during operative
procedure.
 Antibiotics: To disinfect the bowel
 Nutrition: enteral or parenteral nutrition to promote healing
and improve response to treatment.
 Post-op:
o Skin care:
 Prevent urine from coming in contact with the skin.
 Change appliance- some appliances last 3-7 days before
leakage occurs.
 Make sure the appliance adheres well to the body.
  Empty the appliance about 1/3 full (about 100mL) or empty
Q2H. (weight of the urine will cause the appliance to pull
away from the skin)
 The stoma should be visualized through the appliance and
show no evidence of skin breakdown.
 Assess stoma: teach patient and family characteristics of a
normal stoma.
 Pink, red, and moist.
 Insensitive to pain because it has no nerve endings.
 Vascular, which means it may bleed when cleaned.
 Gray or black discoloration may indicate stoma
necrosis.
 Stoma adhesives protect the skin around the stoma.
o Urine output: QH. IV fluids
Complications may occur as detected by decreased urine output include:
 Stoma edema which may cause inadequate drainage
 Dehydration
 Compromised renal function
 Observe the color and nature of the urine
 Blood in the urine early post-op is expected, as long as it gradually
clears
 Mucous is normal discharge from the intestinal segment
 Mucous is normally secreted from an ileal conduit
Self-Care:
 Providing stoma and skin care
 Testing urine and caring for the ostomy
 Encouraging fluids and relieving anxiety
 Selecting the ostomy appliance
 Promoting home and community-based care
 Teaching patient’s self-care
 Changing the appliance
 Controlling odor
 Managing the ostomy appliance
 Cleaning and deodorizing the appliance
 Continuing care.

Patient Education:
Clothing:
  Avoid extra tight clothing. (interferes with urine flowing freely into the
appliance.)
Controlling odor:
 Avoid ingestion of certain foods (fish, eggs, asparagus, and spicy
foods)- they cause pungent urine odor.
 Most appliances contain odor barriers but can also add a few drops of
liquid deodorizer or diluted white vinegar to the pouch.
 Ascorbic acid by mouth helps acidify urine and suppress urine odor.
(vitamin C)
 Odor may also develop if the pouch is worn longer than recommended,
and not cared for properly. (no reusing appliances)
 Adequate fluid intake (2,000mL/day), dilutes urine, decreases odor,
and helps to prevent GU infection.
 Cranberry juice can help keep urine acidic. It assists in decreasing
problems with odor and bacteria growth.
 Never let an appliance get more than 1/3 full, the weight of the urine
can pull the appliance from the skin.
 Apply appliance while standing or reclining, not sitting. (sitting
wrinkles, the skin and causes leaks.)
 Use tissue, or similar item to absorb the flow of urine in between
appliance changes
 Bend over at waist before removing appliance. (expresses the urine
from the stoma minimizing dribbling.)
Skin and Stoma Care:
 Avoid bath oils (inhibits the appliance from adhering.
 Pat dry using soft gauze pad, old towel, or toilet tissues.
Patient education for complications:
 Injured or inflamed stomas
 Check tightness of appliance (could cause friction)
 Buildup of salts from urine (sand paper-like crust) remove crust from
appliance by soaking in dilute solution of vinegar and water.
 Allergic reaction to the material in the appliance (latex)
o Switch to disposable for a week or two and see if the reaction
clears up.
 Instruct the patient that occasional flecks of blood from the stoma is
normal, because the stoma is vascular, and the blood vessels lining the
stoma are delicate.
 Threads of mucous appearing in the urine is normal. Mucous is
secreted by glands in the intestine.
REPORT TO THE HCP:
  Sudden change in the size, length, or color of the stoma
 Sudden change in the quantity of urine that cannot be explained by
change in fluid intake
 Persistent foul odor of the urine, or abnormal cloudiness.
 Pain in the back where kidneys are located
 Pain in the stoma area.
 Symptoms of a UTI ^^^^
Nursing Diagnosis related to urinary diversions:
 Acute pain r/t surgery
 Disturbed body image r/t urinary diversion
 Potential of sexual dysfunction r/t structural/physiological dysfunction.
Pre-op:
 Anxiety r/t losses associated with procedure
 Imbalanced nutrition r/t inadequate intake
 Knowledge deficit r/t procedure/post-op care
 Risk for impaired skin integrity r/t problems in managing urine
collection appliance.