Genitourinary System

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Genitourinary System

  1. 1. GENITOURINARY SYSTEM Ma. Victoria Recinto, RN, USRN
  2. 2. OVERVIEW <ul><li>Fluid, e+ & acid-base balance </li></ul><ul><li>Excretion of the nitrogenous waste products, bacterial toxins, water-soluble drugs & drug metabolites </li></ul><ul><li>Secrete renin & erythropoetin (role in parathyroid hormones & Vit D) </li></ul>
  3. 3. OVERVIEW: KIDNEYS <ul><li>A pair of bean-shaped organs located retroperitoneally at the back of peritoneum at either side of the vertebral column </li></ul><ul><li>Parts: medulla, cortex & renal pelvis </li></ul>
  4. 4. OVERVIEW: NEPHRON <ul><li>Basic functional unit </li></ul><ul><li>Composed of glomerulus (network of capillaries that filters blood) & tubules (proximal, distal & loop of Henle) </li></ul><ul><li>Urine flows from the pelvis of the kidney through ureters & empties into bladder </li></ul>
  5. 5. OVERVIEW <ul><li>Kidney Function </li></ul><ul><ul><ul><li>Urine formation </li></ul></ul></ul><ul><ul><ul><ul><li>Stages </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Filtration: GFR: 125 ml/min </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Tubular reabsorption: 124 ml reabsorbed </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Tubular secretion: 1 ml excreted </li></ul></ul></ul></ul></ul>
  6. 6. OVERVIEW <ul><li>Ureters </li></ul><ul><ul><li>25 cm long, prevent reflux of urine back to the kidneys </li></ul></ul><ul><li>Bladder </li></ul><ul><ul><li>Behind symphysis pubis, elastic & muscular tissue that makes it distensible </li></ul></ul><ul><ul><li>Can hold up to 1.2-1.8 L urine </li></ul></ul><ul><ul><li>250-500 cc of urine can trigger micturition </li></ul></ul>
  7. 7. OVERVIEW <ul><li>Prostate gland </li></ul><ul><ul><li>Surrounds the male urethra </li></ul></ul><ul><ul><li>Contains a duct that opens into the prostatic portion of the urethra & secretes the alkaline portion of seminal fluid </li></ul></ul>
  8. 8. OVERVIEW <ul><li>Urethra- extends to the exterior surface of the body </li></ul><ul><ul><li>F: 2-5 cm/ 1-1.5 in </li></ul></ul><ul><ul><li>M: 20 cm/ 8 in </li></ul></ul><ul><ul><li>Catheter: Pedia: 8-10F, Adult F 12-14F, Adult M 14-16 F </li></ul></ul>
  9. 9. CYSTITIS (UTI) <ul><li>Inflammation of the bladder r/t microbial invasion or urethral obstruction </li></ul>
  10. 10. CYSTITIS (UTI) <ul><li>Predisposing Factors </li></ul><ul><ul><li>Microbial invasion (80%- E. coli, Enterobacter, Pseudomonas & Serratia) </li></ul></ul><ul><ul><li>Urinary obstruction & stagnation </li></ul></ul><ul><ul><li>F>M (shorter urethra that is close to the rectum) </li></ul></ul><ul><ul><li> estrogen levels (affecting vaginal flora) </li></ul></ul><ul><ul><li>Sexually active & pregnant woman </li></ul></ul>
  11. 11. CYSTITIS (UTI): Causes <ul><li>Allergens/irritants: soaps, sprays, bubble bath, perfumed sanitary napkins </li></ul><ul><li>Bladder distention, renal stones </li></ul><ul><li>Indwelling urethral cath </li></ul><ul><li>Urinary stasis </li></ul>
  12. 12. CYSTITIS (UTI): Causes <ul><li>Invasive UT procedures </li></ul><ul><li>Poor-fitting diaphragms, spermicides </li></ul><ul><li>Sexual intercourse </li></ul><ul><li>Synthetic underwear & pantyhose </li></ul><ul><li>Wet bathing suits </li></ul>
  13. 13. CYSTITIS (UTI): S/Sx <ul><li>Flank pain & tenderness </li></ul><ul><li>Urinary frequency & urgency (incomplete bladder emptying) </li></ul><ul><li>Dysuria (painful urination), bladder spasms </li></ul><ul><li>Burning sensation upon urination </li></ul><ul><li>Cloudy, dark, foul-smelling urine, Hematuria </li></ul><ul><li>Fever, chills, A/N/V, malaise </li></ul>
  14. 14. CYSTITIS (UTI): Diagnostic Procedure <ul><li>Urine C/S: determines the causative agent </li></ul>
  15. 15. CYSTITIS (UTI): Nursing Interventions <ul><li>Force fluids </li></ul><ul><li>Heat on abdomen, Sitz bath as ordered </li></ul><ul><li>Monitor for the color, odor, blood in urine </li></ul><ul><li>Strict asepsis in foley cath. insertion, maintain close system </li></ul><ul><li>Meticulous perineal care </li></ul><ul><li>Avoid caffeine & alcohol </li></ul>
  16. 16. CYSTITIS (UTI): Nursing Interventions <ul><li>Administer meds as ordered </li></ul><ul><ul><li>Systemic Antibiotics (Cephalosporin, Tetracycline, Ampicillin) </li></ul></ul><ul><ul><li>Sulfonamides (Cotrimoxazole: Bactrim, Gantricin): can cause crystals in concentrated urine </li></ul></ul><ul><ul><li>Urinary analgesic: Pyridium </li></ul></ul><ul><ul><li>Antispasmodics </li></ul></ul>
  17. 17. CYSTITIS (UTI): Nursing Interventions <ul><li>Acid ash diet (maintaining urine pH of 5.5) </li></ul><ul><ul><li>Bread, cereals, whole grains </li></ul></ul><ul><ul><li>Cheese, eggs </li></ul></ul><ul><ul><li>Corns, legumes </li></ul></ul><ul><ul><li>Cranberries, prunes, plums, tomatoes </li></ul></ul><ul><ul><li>Meat, fish, oysters, poultry </li></ul></ul><ul><ul><li>Pastries </li></ul></ul><ul><li>Prevent Cx: Pyelonephritis </li></ul>
  18. 18. Health Teaching: CYSTITIS (UTI) Prevention <ul><li>Good perineal care (wipe from front to back) </li></ul><ul><li>Avoid bubble baths, tub baths, vaginal deodorants/sprays </li></ul><ul><li>Void q 2-3 hrs (esp. for pregnant women) </li></ul><ul><li>Void & drink a glass of water after intercourse </li></ul>
  19. 19. Health Teaching: CYSTITIS (UTI) Prevention <ul><li>Wear cotton pants, avoid tight clothes or pantyhose with slacks </li></ul><ul><li>Avoid sitting in a wet bathing suit for prolonged periods of time </li></ul><ul><li>Use estrogen vaginal creams to restore pH, use water-soluble lubricants for coitus (esp. for menopausal women) </li></ul>
  20. 20. BENIGN PROSTATIC HYPERTROPHY <ul><li>Slow enlargement of the prostate gland  urethral narrowing & obstruction </li></ul><ul><li>Predisposing factors </li></ul><ul><ul><li>Male >40-50 y/o r/t hormonal influences </li></ul></ul>
  21. 21. BENIGN PROSTATIC HYPERTROPHY <ul><li>S/Sx </li></ul><ul><ul><li>Urinary frequency, hesitancy, urgency,  urinary stream </li></ul></ul><ul><ul><li>Terminal dribbling </li></ul></ul><ul><ul><li>Backache </li></ul></ul><ul><ul><li>Hematuria </li></ul></ul><ul><ul><li>Dysuria, nocturia </li></ul></ul><ul><ul><li>Burning sensation upon urination </li></ul></ul><ul><ul><li>Urinary stasis, UTI </li></ul></ul>
  22. 22. BENIGN PROSTATIC HYPERTROPHY <ul><li>Diagnostic Procedures </li></ul><ul><ul><li>Digital rectal exam: enlarged prostate gland </li></ul></ul><ul><ul><li>Cystoscopy: urinary obstruction </li></ul></ul><ul><ul><li>KUB- enlarged prostate gland </li></ul></ul><ul><ul><li>U/A-  WBC,  RBC </li></ul></ul>
  23. 23. BENIGN PROSTATIC HYPERTROPHY: Nursing Interventions <ul><li>Force fluids unless contraindicated </li></ul><ul><li>Bladder drainage via urinary cath as ordered </li></ul><ul><li>Prostatic massage </li></ul><ul><li>Administer as ordered </li></ul><ul><ul><li>Terazosin- relaxes urinary sphincters </li></ul></ul><ul><ul><li>Finasteride (Proscar)- promotes atrophy of BPH </li></ul></ul><ul><ul><li>Avoid meds that can cause urinary retention (anticholinergics, antihistamines, decongestants) </li></ul></ul>
  24. 24. BENIGN PROSTATIC HYPERTROPHY: Nursing Interventions <ul><li>Assist in surgery </li></ul><ul><ul><li>Prostatectomy (perineal, retropubic & suprapubic) </li></ul></ul><ul><ul><li>Transurethral Resection of the Prostate (TURP) </li></ul></ul><ul><ul><ul><li>Cystoclysis: continuous bladder irrigation </li></ul></ul></ul><ul><ul><ul><ul><li>Irrigate the tube with pNSS to flush the clots </li></ul></ul></ul></ul><ul><ul><ul><ul><li>WOF bleeding, hemorrhage </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Strict asepsis </li></ul></ul></ul></ul>
  25. 25. PROSTATE CA: TURP <ul><li>Insertion of a scope into the urethra to excise prostatic tissue </li></ul><ul><li>Bleeding is common post-op, WOF hemorrhage </li></ul><ul><li>Continuous bladder irrigation (CBI) post-op to maintain the urine at a pink color </li></ul>
  26. 26. PROSTATE CA: TURP <ul><li>Bladder spasms are common post-op, give antispasmodics as ordered </li></ul><ul><li>WOF dribbling & incontinence </li></ul><ul><li>Sterility may or may not occur post-op </li></ul>
  27. 27. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal Technique Via abdominal & bladder incision Via low abdominal incision without opening the bladder Via incision bet. scrotum & anus Hemorrhage Yes No No Bladder spasms Yes Yes but less Urinary incontinence common
  28. 28. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal CBI Yes Yes - Sterility Yes Yes Yes Remarks Abdominal dressing soaked frequently with urine, Longer healing time than TURP Minimal abdominal drainage WOF infection, (No rectal tubes, rectal temp. taking & enema) Teach perineal exercises
  29. 29. Nursing Interventions: s/p TURP <ul><li>Monitor VS, U.O., hematuria & </li></ul><ul><li>clots, Hgb & Hct levels </li></ul><ul><li>Force fluids </li></ul><ul><li>Expect red to light pink urine for 24 hrs, turning to amber in 3 days (then encourage ambulation) </li></ul><ul><li>WOF arterial bleeding (bright red urine with clots):  CBI & notify MD </li></ul>
  30. 30. Nursing Interventions: s/p TURP <ul><li>WOF venous bleeding (burgundy- </li></ul><ul><li>colored urine): notify MD who will apply traction on the catheter </li></ul><ul><li>Continuous urge to void is N but not encouraged to prevent bladder spasms </li></ul><ul><li>Antibiotics, analgesics, stool softeners & antispasmodics as ordered </li></ul>
  31. 31. Nursing Interventions: s/p TURP <ul><li>Monitor 3-way foley catheter (for the balloon (30-45 cc), inflow & outflow) </li></ul><ul><li>Use pNSS only to prevent water intoxication or hypoNa (  LOC,  HR,  BP) </li></ul>
  32. 32. Nursing Interventions: s/p TURP <ul><li>Maintain infusion rate as ordered, if (+) clots:  rate </li></ul><ul><li>For obstructed catheter: turn off CBI, irrigate with 30-50 ml pNSS, notify MD if it does not resolve </li></ul><ul><li>CBI is d/c usually after 1-2 days, WOF continence & urinary retention </li></ul>
  33. 33. Discharge Health Teaching: s/p TURP <ul><li>Avoid heavy lifting, stressful exercise, driving, Valsalva maneuver & sexual intercourse for 2-6 wks </li></ul><ul><li>Drink 2.4-3L fluids/day before 8 pm </li></ul>
  34. 34. Discharge Health Teaching: s/p TURP <ul><li>Avoid alcohol, caffeine & spicy foods to prevent overstimulation of the bladder </li></ul><ul><li>Pt may pass small clots & tissue debris for several days </li></ul><ul><li>If urine becomes less in amount & bloody, rest & force fluids, notify MD if persistent </li></ul>
  35. 35. Nursing Interventions: s/p Suprapubic Prostatectomy <ul><li>Monitor foley catheter & suprapubic catheter drainage </li></ul><ul><li>As ordered, clamp the suprapubic cath after foley cath is removed (2-4 days post-op) & instruct the pt to void, measure residual urine by unclamping the cath & measuring the U.O. </li></ul>
  36. 36. Nursing Interventions: s/p Suprapubic Prostatectomy <ul><li>Prepare for removal of suprapubic cath if pt consistently empties bladder & residual urine is <75 ml </li></ul>
  37. 37. UROLITHIASIS AND NEPHROLITHIASIS <ul><li>Formation of stones elsewhere in the urinary tract (esp. in the kidneys)  obstruction  dilation (Hydroureter, Hydronephrosis)  RF </li></ul><ul><li>Common type: Ca, oxalate, uric acid </li></ul>
  38. 38. UROLITHIASIS AND NEPHROLITHIASIS <ul><li>Predisposing Factors </li></ul><ul><ul><li>Diet:  Ca, Vit. D, milk, oxalate (chocolates), protein, purines or alkali </li></ul></ul><ul><ul><li>Obstruction & urinary stasis, UTI, prolonged urinary catheterization </li></ul></ul><ul><ul><li>Use of diuretics, Dehydration </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Sedentary lifestyle, Prolonged immobility </li></ul></ul><ul><ul><li>Hyperparathyroidism (HyperCa), Gout </li></ul></ul><ul><ul><li>Family hx </li></ul></ul>
  39. 39. UROLITHIASIS AND NEPHROLITHIASIS: S/Sx <ul><li>Problems: pain, obstruction, tissue trauma, hemorrhage & infection </li></ul><ul><li>Renal colic (dull, aching or sudden sharp severe pain) from lumbar region radiating to the testicles (M) & bladder (F) </li></ul><ul><li>Ureteral colic radiating to the genitalia & thigh </li></ul><ul><li>N/V, pallor, diaphoresis, cool, moist skin </li></ul><ul><li>Alternating urinary frequency & retention </li></ul><ul><li>S/Sx of UTI </li></ul>
  40. 40. UROLITHIASIS/NEPHROLITHIASIS: Diagnostic Procedures <ul><li>KUB film, CT scan, renal UTZ- locates stones </li></ul><ul><li>IV Pyelogram- location & composition of stones </li></ul><ul><li>Cystoscopy: urinary obstruction </li></ul><ul><li>U/A:  WBC,  RBC, bacteria </li></ul><ul><li>Stone analysis: type, no. & composition </li></ul>
  41. 41. UROLITHIASIS/NEPHROLITHIASIS: Nursing Interventions <ul><li>Monitor VS, I/O, S/Sx of infection </li></ul><ul><li>Force fluids </li></ul><ul><li>Strain all urine with gauze, WOF presence of stones, send to lab for analysis </li></ul><ul><li>Warm sitz bath, warm compress on flank area </li></ul><ul><li>Turn immobilized pt q2h </li></ul><ul><li>Administer Narcotic analgesics, Antibiotics, Allopurinol as ordered </li></ul>
  42. 42. UROLITHIASIS/NEPHROLITHIASIS: Nursing Interventions (DIET) <ul><li>Acid ash diet (maintaining urine pH of 5.5) </li></ul><ul><ul><li>Cranberries, prunes, plums, tomatoes </li></ul></ul><ul><ul><li>Bread, cereals, whole grains </li></ul></ul><ul><ul><li>Cheese, eggs </li></ul></ul><ul><ul><li>Corns, legumes </li></ul></ul><ul><ul><li>Meat, fish, oysters, poultry </li></ul></ul><ul><ul><li>Pastries </li></ul></ul><ul><li>Alkaline ash diet </li></ul><ul><ul><li>Fruits except cranberries, prunes, plums, tomatoes </li></ul></ul><ul><ul><li>Milk </li></ul></ul><ul><ul><li>Most vegetables </li></ul></ul><ul><ul><li>Rhubarb </li></ul></ul><ul><ul><li>Beef, halibut, veal, trout & salmon </li></ul></ul>
  43. 43. UROLITHIASIS/NEPHROLITHIASIS: Nursing Interventions (DIET) <ul><li>Calcium Phosphate Stones </li></ul><ul><ul><li>Acid ash,  Ca,  Phosphate,  Vit D </li></ul></ul><ul><li>Calcium Oxalate </li></ul><ul><ul><li>Acid ash,  Ca,  Oxalate (tea, almonds, cashews, chocolate, cocoa, beans, spinach & rhubarb) </li></ul></ul><ul><li>Struvite/ Triple Phosphate (Mg & NH3) </li></ul><ul><ul><li>Caused by urea splitting by bacteria </li></ul></ul><ul><ul><li>Acid ash,  Phosphate (dairy products, red & organ meats, whole grains) </li></ul></ul>
  44. 44. UROLITHIASIS/NEPHROLITHIASIS: Nursing Interventions (DIET) <ul><li>Uric acid </li></ul><ul><ul><li>Alkaline ash,  purines (organ meats, gravies, red wines, sardines) </li></ul></ul><ul><li>Cystine </li></ul><ul><ul><li>Alkaline ash,  methionine (AA that forms cystine): meat, milk, cheese, eggs </li></ul></ul>
  45. 45. UROLITHIASIS/NEPHROLITHIASIS: Nursing Interventions <ul><li>Assist in surgery </li></ul><ul><ul><li>Nephrectomy: removal of 1 kidney </li></ul></ul><ul><ul><li>Extracorporeal Shockwave Lithotripsy: if stones are recurrent </li></ul></ul><ul><li>Prevent Cx: ARF </li></ul>
  46. 46. UROLITHIASIS/NEPHROLITHIASIS: Cystoscopy <ul><li>For stones located in the bladder or lower ureter </li></ul><ul><li>No incision, 1 or 2 ureteral cath will be inserted & left X 24h, stones are manipulated & dislodged </li></ul><ul><li>With continuous chemical irrigation to dissolve the stones </li></ul>
  47. 47. UROLITHIASIS/NEPHROLITHIASIS: Cystoscopy
  48. 48. UROLITHIASIS/NEPHROLITHIASIS: Extracorporeal Shockwave Lithotripsy <ul><li>Non-invasive mechanical procedure for breaking up stones located in the kidney or upper ureter </li></ul><ul><li>No incision or drain </li></ul><ul><li>Fluoroscopy is used to visualize the stones </li></ul>
  49. 49. UROLITHIASIS/NEPHROLITHIASIS: Extracorporeal Shockwave Lithotripsy <ul><li>Ultrasonic waves are delivered through bath of warm water </li></ul><ul><li>Stones are passed in the urine within a few days </li></ul><ul><li>NPO 8 hrs pre-procedure </li></ul><ul><li>Force fluids & ambulation post-procedure </li></ul><ul><li>WOF bleeding, pain, S/ of urinary obstruction </li></ul>
  50. 50. UROLITHIASIS/NEPHROLITHIASIS: Percutaneous Lithotripsy <ul><li>Done via cystoscopy (no incision) or nephroscopy (with small flank incision) to break stones located in the KUB </li></ul><ul><li>Fluoroscopy is used to visualize the stones </li></ul>
  51. 51. UROLITHIASIS/NEPHROLITHIASIS: Percutaneous Lithotripsy <ul><li>Ultrasonic waves are aimed at the stone to break it into fragments </li></ul><ul><li>Stones are passed via indwelling cath or nephrostomy tube (for chemical irrigation) left X 1-5 days </li></ul><ul><li>Force fluids post-procedure </li></ul><ul><li>WOF bleeding, infection, extravasation of fluid in the peritoneal cavity </li></ul>
  52. 52. UROLITHIASIS/NEPHROLITHIASIS: Surgery <ul><li>Ureterolithotomy: incision through lower </li></ul><ul><li>abdominal or flank area </li></ul><ul><ul><li>With Penrose drain, ureteral stent & indwelling cath post-op </li></ul></ul><ul><li>Pyelolithotomy: via large flank incision </li></ul><ul><ul><li>With Penrose drain & indwelling cath post-op </li></ul></ul><ul><li>Nephrolithotomy: via large flank incision </li></ul><ul><ul><li>With nephrostomy tube & indwelling cath post-op </li></ul></ul>
  53. 53. UROLITHIASIS/NEPHROLITHIASIS: Partial/Total Nephrectomy <ul><li>For extensive kidney damage, renal infection or severe obstruction & to prevent stone recurrence </li></ul><ul><li>Focus of care: maintain patency of tubes (but never irrigate unless ordered), prevent infection </li></ul><ul><li>Force fluids, monitor I/O </li></ul>
  54. 54. UROLITHIASIS/NEPHROLITHIASIS: Partial/Total Nephrectomy <ul><li>Determine stone composition, special diet as ordered </li></ul><ul><li>Long-term medication to prevent stone recurrence </li></ul><ul><ul><li>For Ca stones: Phosphates, Thiazide diurectics, Allopurinol (for oxalate & uric acid stones also) </li></ul></ul><ul><ul><li>For Oxalate stones: Pyridoxine or Mg oxide </li></ul></ul><ul><ul><li>For Struvite & Cystine stones: Antibiotics </li></ul></ul>
  55. 55. RENAL FAILURE <ul><li>Loss of kidney function </li></ul><ul><li>S/Sx r/t retention of waste & fluids & inability to regulate e+ </li></ul><ul><li>Causes </li></ul><ul><ul><li>Prerenal: DHN, hypovolemic shock,  C.O., vasodilation or vascular obstruction </li></ul></ul><ul><ul><li>Intrarenal: ATN, nephrotoxicity, altered renal blood flow </li></ul></ul><ul><ul><li>Postrenal: obstruction of urine flow </li></ul></ul>
  56. 56. ARF: Oliguric Phase <ul><li>Duration: 8-15 days (if longer, less chance of recovery </li></ul><ul><li>Sudden  U.O. (<400 ml/day) </li></ul><ul><li> GFR,  USG </li></ul><ul><li> K, N or  Na (Fluid overload):  LOC, S/Sx of CHF, pericarditis, dysrythmias, acidosis </li></ul><ul><li> BUN, crea </li></ul><ul><li>A/N/V, HTN </li></ul><ul><li>Pruritus, tingling extremities </li></ul>
  57. 57. ARF: Diuretic Phase <ul><li>Slow  U.O. then diuresis (4-5L/day) </li></ul><ul><li> GFR </li></ul><ul><li> K,  Na </li></ul><ul><li>Hypovolemia,  BP,  HR, LOC improves </li></ul><ul><li>Gradual  BUN, crea </li></ul>
  58. 58. ARF: Recovery (Convalescent) Phase <ul><li>Complete recovery: 1-2 yrs </li></ul><ul><li>N U.O. </li></ul><ul><li>Stable & N BUN </li></ul><ul><li>Pt may develop Chronic RF </li></ul>
  59. 59. CHRONIC RENAL FAILURE <ul><li>Stage 1: Diminished Renal Reserve </li></ul><ul><ul><li> renal function </li></ul></ul><ul><ul><li>(-) accumulation of metabolic wastes </li></ul></ul><ul><ul><li>Healthier kidney compensates </li></ul></ul><ul><ul><li>Nocturia & polyuria r/t  ability to concentrate urine </li></ul></ul>
  60. 60. CHRONIC RENAL FAILURE <ul><li>Stage 2: Renal Insufficiency </li></ul><ul><ul><li>Metabolic wastes begin to accumulate </li></ul></ul><ul><ul><li>Oliguria & edema r/t  responsiveness to diuretics </li></ul></ul><ul><li>Stage 3: End Stage (Uremia) </li></ul><ul><ul><li>Excessive accumulation of metabolic wastes </li></ul></ul><ul><ul><li>Kidneys unable to maintain homeostasis </li></ul></ul><ul><ul><li>Dialysis or other renal replacement tx required </li></ul></ul>
  61. 61. CHRONIC RENAL FAILURE: S/Sx <ul><li>A/N, HA, weakness & fatigue </li></ul><ul><li>HTN </li></ul><ul><li> LOC, sz, coma </li></ul><ul><li>Kussmaul’s respiration </li></ul><ul><li>Diarrhea or constipation </li></ul><ul><li>Muscle twitching, paresthesia </li></ul>
  62. 62. CHRONIC RENAL FAILURE: S/Sx <ul><li> U.O.  or fixed USG </li></ul><ul><li>Proteinuria, azotemia, anemia </li></ul><ul><li>Fluid overload, CHF </li></ul><ul><li>Uremic frost: urea crystals from evaporated perspiration on the face, eyebrows, axilla & groin (advanced uremic syndrome) </li></ul>
  63. 63. SPECIAL PROBLEMS IN RENAL FAILURE <ul><li>Anemia </li></ul><ul><ul><li>Vit. B9/Folic acid instead of iron (not well absorbed by the GIT of pt with CRF), Epogen, BT as ordered </li></ul></ul><ul><li>GI bleeding (r/t ammonia irritation) </li></ul><ul><ul><li>Bleeding precautions </li></ul></ul><ul><li>HTN & Hypervolemia </li></ul><ul><ul><li>Propranolol (Inderal):  renin release, diuretics, fluid restriction,  Na diet as ordered </li></ul></ul>
  64. 64. SPECIAL PROBLEMS IN RENAL FAILURE <ul><li>Infection & injury </li></ul><ul><ul><li>Minimize urinary catheterization, strict hand washing, asepsis </li></ul></ul><ul><li>Insomnia & fatigue </li></ul><ul><ul><li>Adequate rest, mild CNS depressant as ordered </li></ul></ul>
  65. 65. SPECIAL PROBLEMS IN RENAL FAILURE <ul><li>HypoCa, Hyperphosphatemia, HyperK </li></ul><ul><ul><li>Diet, dialysis </li></ul></ul><ul><li>Metabolic acidosis </li></ul><ul><ul><li>NaHCO3 as ordered (pt with CRF adjusted to low HCO3 levels without getting acutely ill) </li></ul></ul><ul><li>Muscle cramps </li></ul><ul><ul><li>e+ replacement, heat & massage as ordered </li></ul></ul><ul><li>Pruritus (r/t uremic frost) </li></ul><ul><ul><li>Skin care, avoid soaps, antipruritics as ordered </li></ul></ul>
  66. 66. SPECIAL PROBLEMS IN RENAL FAILURE <ul><li>Neuro changes </li></ul><ul><ul><li>Monitor LOC, side rails up, calm & restful env’t, comfort measures & backrubs </li></ul></ul><ul><li>Occular irritation (r/t Ca deposits in conjunctiva) </li></ul><ul><ul><li>Ca & Phosphate binders, Eye drops as ordered </li></ul></ul><ul><li>Psychosocial problems </li></ul>
  67. 67. HEMODIALYSIS: FUNCTIONS <ul><li>Cleanses the blood with accumulated waste products (urea, crea & uric acid) </li></ul><ul><li>Removes excessive fluids </li></ul><ul><li>Restores buffer system & e+ levels of the body </li></ul>
  68. 68. HEMODIALYSIS: PRINCIPLES <ul><li>Semipermeable membrane: thin, porous cellophane (only water, urea, crea & uric acid can pass through) </li></ul><ul><li>Proteins, bacteria & some blood cells are too large to pass through </li></ul><ul><li>Blood flows into the dialyzer & into the dialysate </li></ul>
  69. 69. HEMODIALYSIS: PRINCIPLES <ul><li>Diffusion: mov’t of particles from greater to lesser concentration </li></ul><ul><li>Osmosis: mov’t of fluids across a semipermeable membrane from lesser to greater concentration </li></ul><ul><li>Ultrafiltration: mov’t of fluids across a semipermeable membrane due to artificial pressure gradient </li></ul>
  70. 70. HEMODIALYSIS: Nursing Interventions <ul><li>Monitor VS, lab values before, during & after HD </li></ul><ul><li>Weigh the pt before & after HD to determine fluid loss/overload </li></ul><ul><li>Hold antiHTN meds & other water soluble vit. & antibiotics before HD as ordered </li></ul>
  71. 71. HEMODIALYSIS: Nursing Interventions <ul><li>Provide adequate nutrition (pt may eat before HD) </li></ul><ul><li>WOF hypovolemic shock </li></ul><ul><li>Assess the patency of blood access device </li></ul>
  72. 72. HEMODIALYSIS: Blood Access <ul><li>Subclavian or femoral vein catheter </li></ul><ul><ul><li>For temporary use </li></ul></ul><ul><ul><li>Check site for hematoma, bleeding, dislodging & infection </li></ul></ul><ul><ul><li>Do not use for any other reason EXCEPT HD </li></ul></ul><ul><ul><li>Maintain sterile, occlusive dressing </li></ul></ul><ul><ul><li>Good for 6 weeks if complications do not occur </li></ul></ul>
  73. 73. HEMODIALYSIS: Blood Access <ul><li>External AV shunt </li></ul><ul><ul><li>Surgical insertion of 2 Silastic cannulas into an artery & a vein (U-shaped) in the forearm or leg to form an external blood path </li></ul></ul><ul><ul><li>Can be used immediately after creation </li></ul></ul><ul><ul><li>No venipuncture is necessary for HD </li></ul></ul><ul><ul><li>Shunt may be disconnected or dislodged </li></ul></ul><ul><ul><li>WOF hemorrhage, infection, clotting (tingling or discomfort on the extremity) & skin erosion at the cath site </li></ul></ul>
  74. 74. HEMODIALYSIS: Blood Access
  75. 75. HEMODIALYSIS: Blood Access <ul><li>External AV shunt </li></ul><ul><ul><li>Keep the shunt dressing dry & intact </li></ul></ul><ul><ul><li>Prepare cannula clamps at bedside </li></ul></ul><ul><ul><li>No BP taking, blood extraction, injection & venipunctures in the shunt extremity </li></ul></ul><ul><ul><li>A patent shunt is warm to touch </li></ul></ul><ul><ul><li>Auscultate for bruit & palpate for thrill </li></ul></ul><ul><ul><li>WOF circulatory impairment in the shunt extremity </li></ul></ul>
  76. 76. HEMODIALYSIS: Blood Access <ul><li>Internal AV shunt </li></ul><ul><ul><li>For chronic dialysis pt </li></ul></ul><ul><ul><li>Can be used 1-2 wks after creation (subclavian/femoral cath, external AV shunt or PD can be used while the fistula is maturing) </li></ul></ul><ul><ul><li>Venipuncture is necessary for HD </li></ul></ul><ul><ul><li>Less risk of clotting, bleeding & infection </li></ul></ul><ul><ul><li>Fistula can be used indefinitely </li></ul></ul><ul><ul><li>No external dressing is required </li></ul></ul>
  77. 77. HEMODIALYSIS: Blood Access <ul><li>Internal AV shunt </li></ul><ul><ul><li>Infiltration of needles  hematoma </li></ul></ul><ul><ul><li>Aneurysm can form in the fistula </li></ul></ul><ul><ul><li>CHF can occur from  blood flow to the venous system </li></ul></ul><ul><ul><li>WOF arterial steal syndrome : compromised arterial perfusion r/t  blood diverted to the vein & refer to MD </li></ul></ul>
  78. 78. HEMODIALYSIS: Blood Access <ul><li>Internal AV graft </li></ul><ul><ul><li>For chronic dialysis pt who do not have adequate blood vessels for fistula creation </li></ul></ul><ul><ul><li>Artificial graft (Gore-Tex or bovine carotid artery) is used </li></ul></ul><ul><ul><li>Can be used 2 wks after creation </li></ul></ul><ul><ul><li>Dis/Advantages: same as in internal AV fistula </li></ul></ul>
  79. 79. HEMODIALYSIS: Complications <ul><li>Disequilibrium syndrome </li></ul><ul><li>Dialysis encephalopathy </li></ul><ul><li>Electrolyte changes </li></ul><ul><li>Muscle cramping </li></ul><ul><li>Blood loss, hypoTN & shock </li></ul><ul><li>Hepatitis </li></ul><ul><li>Sepsis </li></ul>
  80. 80. HEMODIALYSIS: Disequilibrium syndrome <ul><li>Solutes are removed from the blood faster than from the CSF & brain  cerebral edema </li></ul><ul><li>S/Sx: N/V, HA, HTN,  LOC, sz </li></ul><ul><li>Prepare to dialyze the pt for a shorter pd. at  blood flow rates </li></ul><ul><li> env’tal stimuli </li></ul><ul><li>Refer to MD </li></ul>
  81. 81. HEMODIALYSIS: Dialysis Encephalopathy <ul><li>Al toxicity r/t water source of the dialysate & ingestion of Al-containing antacids (phosphate binders) </li></ul><ul><li>S/Sx:  LOC, sz, speech disturbance, dementia, bone pain </li></ul><ul><li>Refer to MD </li></ul><ul><li>Al-chelating agents as ordered </li></ul>

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