Chapter 37
Nursing Care of Patients With Disorders of the Urinary System
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retention enema; it exchanges sodium for potassium in the gastrointestinal (GI) tract to then be eliminated in the stool. Since it is associated with serious risks of intestinal isch- emia or thrombosis and GI ulcers and perforation it is not as commonly used as before. Patiromer (Veltassa) given orally exchanges sodium for potassium in the GI tract to then be eliminated in the stool. SZC an oral medication binds with potassium in the GI tract for elimination in the stool. Calcium levels decrease because the kidneys are unable to produce the hormone that activates vitamin D, the vitamin needed for calcium absorption. Hypocalcemia exists when the calcium level falls below 8.5 mg/dL. Hyperphosphatemia (greater than 5 mg/dL) is associated with a low calcium level. These imbalances cause the bones to release calcium, increas- ing the risk of fractures. Regular ambulation is important to prevent further calcium loss from the bone. Many patients who are on dialysis develop hypercalcemia due to second- ary hyperparathyroidism (excess release of parathyroid hor- mone). Medication may be prescribed to reduce excess levels of parathyroid hormone, which then reduces calcium levels. Phosphates are found in many foods. Medication to bind phosphates (phosphate binders) is taken by patients with high phosphate levels. Patients must take these medications with each meal so they can bind with the phosphates in the food and be eliminated in the stool. High phosphorus levels may cause severe itching, and then produce open sores from the scratching, creating the risk of infection. Patients also may have muscle cramps and aches. Disturbance of Removal of Waste Products With azotemia (rapid accumulation of toxic wastes in the blood), patients may show signs of weakness and fatigue, confusion, seizures, twitching movements of extremities (asterixis), nausea, vomiting, and lack of appetite. They may report a metallic or bad taste in the mouth, and there may be the odor of urine on the patient’s breath. The patient may have yellowish skin and report itching due to urea crystals on the skin. Dialysis to remove excessive waste products in the blood is the only treatment for the underlying causes of these symptoms. Disturbance in Maintaining Acid–Base Balance Hydrogen ion excretion is affected, causing a disturbance in the acid–base balance that results in metabolic acidosis. Patients may report headache, fatigue, weakness, nausea, vomiting, and lack of appetite. As metabolic acidosis pro- gresses, the patient displays lethargy, stupor, and coma. Respirations become fast and deep as the lungs attempt to blow off carbon dioxide to correct the acidosis (Kussmaul respirations). See Chapter 6 for a detailed discussion of acid– base balance. Disturbance in Hematologic Function Anemia is seen mainly in CKD, which causes disturbances in blood cells over time. Damaged kidneys do not produce adequate erythropoietin, the hormone that stimulates RBC
Oral cavity Stomatitis Bad taste in mouth
Neurological system Fatigue Depression
Headache Confusion Seizures Coma
Cardiovascular system Hypertension Heart failure Arrhythmias
Respiratory system Pulmonary edema Pulmonary effusion Dyspnea Renal system Anemia Oliguria/anuria
Gastrointestinal system Anorexia Nausea Vomiting Gastrointestinal bleeding Ulcers Reproductive system Sexual dysfunction Infertility Musculoskeletal system Prone to fractures
Skin
Pruritis (itching) Ecchymosis Uremic frost Dry skin Yellowish skin
Fluid volume Edema
FIGURE 37.6 Symptoms of chronic kidney disease.
A high potassium level in the patient with CKD may be caused by a diet high in potassium-rich foods, medications, injuries (releasing potassium from the cells), or blood trans- fusions. Monitor daily patient laboratory values and report abnormalities. Providing dietary education on foods to avoid that are high in potassium and evaluation of the patient’s medications is extremely important (Box 37.1). The emer- gency and definitive treatment for hyperkalemia is hemo- dialysis. IV insulin with glucose (to prevent hypoglycemia from the insulin) may be used as a temporary measure to drive excess potassium quickly into the cells. For maintenance therapy to reduce potassium, sodium polystyrene sulfonate (Kayexalate), patiromer (Veltassa), or sodium zirconium cyclosilicate (SZC; Lokelma) can be used. Sodium polystyrene sulfonate is given either orally or as a Box 37.1 Foods High in Potassium • Beans: Kidney, lentils, lima, navy, northern, pinto, refried, soy • Chocolate • Dairy products: Cheese, ice cream, milk, yogurt • Dried fruit: Apricots, dates, figs, prunes, raisins • Fruit: Avocado, banana, kiwi, mango, melons (cantaloupe, honeydew), nectarine, oranges, orange juice, papaya, pumpkin, tomato paste • Juice: Carrot, prune, tomato, vegetable • Nuts • Salt substitutes • Seeds • Vegetables: Beet greens, potatoes (chips, sweet, white, yams), spinach, squash
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