Genito-urinary disorders
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Genito-urinary disorders, Medical surgical Nursing

Genito-urinary disorders, Medical surgical Nursing

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  • 1. Genito-Urinary disorders By Ashagre Molla (BScN. MScN.) ashagremolla@yahoo.com
  • 2. Anatomic and Physiologic Overview • The urinary system comprises the kidneys, ureters, bladder, and urethra. 10/17/2013 2
  • 3. Kidneys • The kidneys are a pair of brownish-red structures located retroperitoneally • The kidney consists of two distinct regions, the renal parenchyma and the renal pelvis. • The renal parenchyma is divided into the cortex and the medulla. • The cortex contains the glomeruli, proximal and distal tubules, and cortical collecting ducts and their adjacent peritubular capillaries. 10/17/2013 3
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  • 5. Kidneys • The afferent arteriole branches to form the glomerulus, which is the capillary bed responsible for glomerular filtration. • Blood leaves the glomerulus through the efferent arteriole and flows back to the inferior vena cava. • Each kidney contains about 1 million nephrons, the functional units of the kidney. • Each kidney is capable of providing adequate renal function if the opposite kidney is damaged or becomes nonfunctional. 10/17/2013 5
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  • 7. Glomerulus • The glomerulus is composed of three filtering layers: the capillary endothelium, the basement membrane, and the epithelium. • The glomerular membrane normally allows filtration of fluid and small molecules yet limits passage of larger molecules, such as blood cells and albumin. • Kidney function begins to decrease at a rate of approximately 1% each year beginning at approximately age 30. 10/17/2013 7
  • 8. 10/17/2013 8
  • 9. Urine Formation • Urine is formed in the nephrons through a complex three-step process: glomerular filtration, tubular reabsorption, and tubular secretion. • The various substances normally filtered by the glomerulus, reabsorbed by the tubules, and excreted in the urine include sodium, chloride, bicarbonate, potassium, glucose, urea, creatinine, and uric acid. • Within the tubule, some of these substances are selectively reabsorbed into the blood. • Some substances, such as glucose, are completely reabsorbed in 10/17/2013 the tubule and normally do not appear in the urine. 9
  • 10. Urine Formation • Amino acids and glucose are usually filtered at the level of the glomerulus and reabsorbed so that neither is excreted in the urine. • Glucose, however, appears in the urine (glycosuria) if the amount of glucose in the blood and glomerular filtrate exceeds the amount that the tubules are able to reabsorb. 10/17/2013 10
  • 11. Urine Formation • Normally, glucose is completely reabsorbed when the blood glucose level is less than 200 mg/dL (11 mmol/L). • In diabetes, when the blood glucose level exceeds the kidneys’ reabsorption capacity, glucose appears in the urine. • Glycosuria is also common in pregnancy. • Protein molecules are also generally not found in the urine; 10/17/2013 11
  • 12. Urine Formation • however, low-molecular-weight proteins (globulins and albumin) may periodically be excreted in small amounts. • Transient proteinuria in amounts less than 150 mg/dL is considered normal and does not require further evaluation. • Persistent proteinuria usually signifies damage to the glomeruli. 10/17/2013 12
  • 13. 10/17/2013 13
  • 14. Glomerular filtration: • The normal blood flow through the kidneys is about 1,200 mL/min. • As blood flows into the glomerulus from an afferent arteriole, filtration occurs. • The filtered fluid, also known as filtrate or ultrafiltrate, then enters the renal tubules. • Under normal conditions, about 20% of the blood passing through the glomeruli is filtered into the nephron, amounting to about 180 L/day of filtrate. 10/17/2013 14
  • 15. GFR • The filtrate normally consists of water, electrolytes, and other small molecules, because water and small molecules are allowed to pass, whereas larger molecules stay in the bloodstream. • Efficient filtration depends on adequate blood flow maintaining a consistent pressure through the glomerulus. • Many factors can alter this blood flow and pressure – hypotension, decreased oncotic pressure in the blood, and increased pressure in the renal tubules from an obstruction. 10/17/2013 15
  • 16. Tubular reabsorption and tubular secretion • In tubular reabsorption, a substance moves from the filtrate back into the peritubular capillaries. • In tubular secretion, a substance moves from the peritubular capillaries into tubular filtrate. • Of the 180 L of filtrate that the kidneys produce each day, 99% is reabsorbed into the bloodstream, resulting in 1,000 to 1,500 mL of urine each day. 10/17/2013 16
  • 17. Cont’d • Although most reabsorption occurs in the proximal tubule, reabsorption occurs along the entire tubule. • Filtrate becomes concentrated under the influence of antidiuretic hormone (ADH) and becomes urine 10/17/2013 17
  • 18. 10/17/2013 18
  • 19. GFR • The normal adult GFR is about 100 to 120 mL/min . • Creatinine clearance is an excellent measure of renal function; as renal function declines, creatinine clearance decreases. • The average person voids 1,200 to 1,500 mL of urine in 24 hours • This amount varies depending on fluid intake, sweating, environmental temperature, vomiting, or diarrhea. 10/17/2013 19
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  • 23. Reading assignment • What are the types of diagnostic tests used to identify genito-urinary problems? 10/17/2013 23
  • 24. Urinary tract infections • Caused by pathogenic microorganisms in the urinary tract • UTIs are generally classified as infections involving the upper or lower urinary tract • Lower UTIs include bacterial cystitis, bacterial prostatitis and bacterial urethritis 10/17/2013 24
  • 25. Urinary tract infections • There can be acute or chronic nonbacterial causes of inflammation in any of these areas that can be misdiagnosed as bacterial infections. • Upper UTIs are much less common and include acute or chronic pyelonephritis, interstitial nephritis, and renal abscesses. 10/17/2013 25
  • 26. Findings on Exam in UTI • Physical Exam: – CVA tenderness (pyelonephritis) – Urethral discharge (urethritis) – Tender prostate on DRE (prostatitis) • Labs: Urinalysis – + leukocyte esterase – + nitrites • More likely gram-negative rods – + WBCs – + RBCs 10/17/2013 26
  • 27. Culture in UTI • Positive Urine Culture = >105 CFU/mL • Most common pathogen for cystitis, prostatitis, pyelonephritis: – Escherichia coli – Staphylococcus saprophyticus – Proteus mirabilis – Klebsiella – Enterococcus • Most common pathogen for urethritis • Chlamydia trachomatis • Neisseria Gonorrhea 10/17/2013 27
  • 28. Lower Urinary Tract Infection - Cystitis • Uncomplicated (Simple) cystitis – In healthy woman, with no signs of systemic disease • Complicated cystitis – In men, or woman with comorbid medical problems. • Recurrent cystitis 10/17/2013 28
  • 29. Uncomplicated (simple) Cystitis • Definition – Healthy adult woman (over age 12) – Non-pregnant – No fever, nausea, vomiting, flank pain • Diagnosis – Dipstick urinalysis (no culture or lab tests needed) • Treatment – Trimethroprim/Sulfamethoxazole for 3 days – May use fluoroquinolone (ciprofoxacin or levofloxacin) • Risk factors: – Sexual intercourse • May recommend post-coital voiding 10/17/2013 29
  • 30. Complicated Cystitis – Females with comorbid medical conditions – All male patients – Indwelling foley catheters – Urosepsis/hospitalization • Diagnosis – Urinalysis, Urine culture – Further labs, if appropriate. • Treatment – Fluoroquinolone (or other broad spectrum antibiotic) – 7-14 days of treatment (depending on severity) – May treat even longer (2-4 weeks) in males with UTI 10/17/2013 30
  • 31. Recurrent Cystitis • Want to make sure urine culture and sensitivity obtained. • May consider urologic work-up to evaluate for anatomical abnormality. • Treat for 7-14 days. 10/17/2013 31
  • 32. Pyelonephritis • Infection of the kidney • Associated with constitutional symptoms – fever, nausea, vomiting, headache • Diagnosis: • Urinalysis, urine culture, CBC, Chemistry • Treatment: • 2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone • Complications: – Perinephric/Renal abscess: • Diagnosis: CT with contrast, renal ultrasound • May need surgical drainage. – Nephrolithiasis with UTI • Suspect in patient with severe flank pain • Need urology consult for treatment of kidney stone 10/17/2013 32
  • 33. Prostatitis • Symptoms: – Pain in the perineum, lower abdomen, testicles, penis, and with ejaculation, bladder irritation, bladder outlet obstruction, and sometimes blood in the semen • Diagnosis: – Typical clinical history (fevers, chills, dysuria, malaise, myalgias, pelvic/perineal pain, cloudy urine) – The finding of an edematous and tender prostate on physical examination – Will have an increased PSA – Urinalysis, urine culture • Treatment: – Trimethoprim/sulfamethoxazole, fluroquinolone – 4-6 weeks of treatment • Risk Factors: – Trauma , Dehydration 10/17/2013 33
  • 34. Urethritis • Chlamydia trachomatis – Frequently asymptomatic in females, but can present with dysuria, discharge or pelvic inflammatory disease. – Send UA, Urine culture (if pyuria seen, but no bacteria, suspect Chlamydia) – Pelvic exam – send discharge from cervical or urethral or for chlamydia PCR – Chlamydia screening is now recommended for all females ≤ 25 years – Treatment: • Azithromycin – 1 g po x 1 • Doxycycline – 100 mg po BID x 7 days • Neisseria gonorrhoeae – May present with dysuria, discharge, PID – Send UA, urine culture – Pelvic exam – send discharge samples for gram stain, culture – Treatment: • Ceftriaxone – 125 mg IM x 1 • Cipro – 500 mg po x 1 • Levofloxacin – 250 mg po x 1 10/17/2013 • Ofloxacin – 400 mg po x 1 34
  • 35. Nephrotic syndrome Nephrotic syndrome (NS) results from increased permeability of Glomeulrar basement membrane (GBM) to plasma protein. It is clinical and laboratory syndrome characterized by massive proteinuria, which lead to hypoproteinemia ( hypoalbuminemia), hyperlipidemia and pitting edema. 10/17/2013 35
  • 36. Nephrotic Criteria:*Massive proteinuria: 3+ or 4+, *Hypo-proteinemia : total plasma proteins < 5.5g/dl and serum albumin : < 2.5g/dl. *Hyperlipidemia: serum cholesterol : > 5.7mmol/L *Edema: pitting edema in different degree 10/17/2013 36
  • 37. Nephritic Criteria • -Hematuria: RBC in urine (gross hematuria) • -Hypertension: • ≥130/90 mmHg in school-age children • ≥120/80 mmHg in preschool-age children • ≥110/70 mmHg in infant and toddler’s children • -Azotemia(renal insufficiency): Increased level of serum BUN 、Cr • -Hypo-complementemia: 10/17/2013 Decreased level of serum c3 37
  • 38. Classification: • Primary Idiopathic NS (INS): majority The cause is still unclear up to now. Recent 10 years ,increasing evidence has suggested that INS may result from a primary disorder of T– cell function. • Secondary NS: NS resulted from systemic diseases, such as anaphylactoid purpura , systemic lupus erythematosus, HBV infection. • Congenital NS: rare *1st 3month of life ,only treatment renal transplantation 10/17/2013 38
  • 39. Secondary NS • Drug,Toxic,Allegy: mercury, snake venom, vaccine, pellicillamine, Heroin, gold, NSAID, captopril, probenecid, volatile hydrocarbons • Infection: APSGN, HBV, HIV, shunt nephropathy, reflux nephropathy, leprosy, syphilis, Schistosomiasis, hydatid disease • Autoimmune or collagen-vascular diseases: SLE, Hashimoto’s thyroiditis,, HSP, Vasculitis • Metabolic disease: Diabetes mellitus • Neoplasma: carcinoma ( renal cell, lung, neuroblastoma, breast, and etc) • Genetic Disease: Alport syn, Sickle cell disease, Amyloidosis, Congenital nephropathy • Others: Chronic transplant rejection, congenital nephrosclerosis 10/17/2013 39
  • 40. Idiopathic NS (INS): • Minimal Change Nephropathy (MCN): <80% The glomeruli appear normal basically Under Light microscopy, and Under Immunofluorescence *under Electron microscopy – fusion of the foot processes of the podocytes • (2) Non—MCN: <20% *Mesangial proliferative glomerulonephritis (MsPGN): about 10% *Focal segmental glomerulosclerosis (FSGS): 5% *Membranous Nephropathy (MN) : 2% *Membrane proliferative glomerulonephritis • (MPGN) : 1% – *Others: rare,Cresent glomerulonephritis 10/17/2013 40
  • 41. Pathogenesis of Proteinuria • Increase glomerular permeability for proteins due to loss of negative charged glycoprotein Degree of protineuria:• Mild less than 0.5g/m2/day • Moderate 0.5 – 2g/m2/day • Sever more than 2g/m2/day Type of proteinuria:• A-Selective proteinuria: where proteins of low molecular weight such as albumin, are excreted more readily than protein of HMW • B-Non selective : • LMW+HMW are lost in urine 10/17/2013 41
  • 42. Pathogenesis of hypoalbuminemia *Due to hyperproteinuria----- Loss of plasma protein in urine mainly the albumin. *Increased catabolism of protein during acute phase. 10/17/2013 42
  • 43. Pathogenesis of hyperlipidemia *Response to Hypoalbuminemia → reflex to liver --→ synthesis of generalize protein ( including lipoprotein ) and lipid in the liver ,the lipoprotein high molecular weight no loss in urine → hyperlipidemia *Diminished catabolism of lipoprotein 10/17/2013 43
  • 44. Pathogenesis of edema • *Reduction plasma colloid osmotic pressure↓ secondary to hypoalbuminemia Edema and hypovolemia • *Intravascular volume↓ antidiuretic hormone (ADH ) and aldosterone(ALD)  water and sodium retention Edema • *Intravascular volume↓ glomerular filtration rate (GFR)↓ water and sodium retention  Edema 10/17/2013 44
  • 45. How many pathological types causes nephrotic syndrome? 10/17/2013 45
  • 46. Clinical Manifestation 1.Main manifestations: Edema (varying degrees) is the common symptom Local edema: edema in face , around eyes( Periorbital swelling) , in lower extremities. Generalized edema (anasarca), edema in penis and scrotum. 2-Non-specific symptoms: Fatigue and lethargy loss of appetite, nausea and vomiting ,abdominal pain , diarrhea body weight increase, urine output decrease pleural effusion (respiratory distress) 10/17/2013 46
  • 47. 10/17/2013 47
  • 48. Investigations 1-Urine analysis:- A-Proteinuria : 3-4 + SELECTIVE. b-24 urine collection for protein >40mg/m2/hr for children c- volume: oliguria (during stage of edema formation) d-Microscopically:microscopic hematuria 20%, large number of hyaline cast 10/17/2013 48
  • 49. Investigations .. . .. 2-Blood: • A-serum protein: decrease >5.5gm/dL , Albumin levels are low (< 2.5gm/dL). • B-Serum cholesterol and triglycerides: Cholesterol >5.7mmol/L (220mg/dl). • C-- ESR↑>100mm/hr during activity phase 3. Renal function • . 10/17/2013 49
  • 50. Kidney Biopsy:• Considered in: • 1-Secondary N.S • 2-Frequent relapsing N.S • 3-Steroid resistant N.S • 4- Hematuria • 5-Hypertension • 6- Low GFR 10/17/2013 50
  • 51. Differential Diagnosis of NS: D.D of generalized edema:1-Protein –losing enteropathy 2-Hepatic Failure. 3-HF 4-Protein energy malnutrition 5-Acute and chronic GN 10/17/2013 51
  • 52. Complications of NS 1-Infections: Nephrotic pt are liable to infection because : A-loss of immunoglobins in urine. B-the edema fluid act as a culture medium. C-use immunosuppressive agents. D- malnutrition The common infection : URI, peritonitis, cellulitis and UTI Organisms: encapsulated (Pneumococci, H.influenzae), Gram negative (e.g E.coli) 10/17/2013 52
  • 53. Complication….. 2-Hypercoagulability (Thrombosis) • Hypercoagulability of the blood leading to venous or arterial thrombosis: • Hypercoagulability in Nephrotic syndrome caused by: – 1-Higher concentration of I,II, V,VII,VIII,X and fibrinogen – 2- Lower level of anticoagulant substance: antithrombin III – 3-decrease fibrinolysis. – 4-Higher blood viscosity – 5- Increased platelet aggregation – 6- Overaggressive diuresis 10/17/2013 53
  • 54. Complication….. 3-ARF: pre-renal and renal 4- cardiovascular disease :-Hyperlipidemia, may be a risk factor for cardiovascular disease. 5-Hypovolemic shock 6-Others: growth retardation, malnutrition, . … 10/17/2013 54
  • 55. Management of NS: • General (non-specific ) • *Corticosteroid therapy 10/17/2013 55
  • 56. General therapy • Hospitalization:- for initial work-up and evaluation of treatment. • Activity: usually no restriction , except massive edema, sever hypertension and infection. • Diet Hypertension and edema: Low salt diet (<2gNa/ day) only during period of edema or salt-free diet. Severe edema: Restricting fluid intake • Avoiding infection: very important. • Diuresis: Hydrochlorothiazide (HCT) :2mg/kg.d • Antisterone : 2~4mg/kg.d • Dextran : 10~15ml/kg , after 30~60m, • followed by Furosemide (Lasix) at 2mg/kg . 10/17/2013 56
  • 57. Corticosteroid—prednisone therapy • Prednisone tablets at a dose of 60 mg/day (maximum daily dose, 80 mg divided into 2-3 doses) for at least 4 consecutive weeks. • After complete absence of proteinuria, prednisone dose should be tapered to 40 mg/day given every other day as a single morning dose. • The alternate-day dose is then slowly tapered and discontinued over the next 2-3 months. 10/17/2013 57
  • 58. Treatment of relapse in NS: • Many children with nephrotic syndrome will experience at least 1 relapse (3-4+proteinuria plus edema). • daily divided-dose prednisone at the doses noted earlier (where he has the relapse) until the child enters remission (urine trace or negative for protein for 3 consecutive days). • The pred-nisone dose is then changed to alternate-day dosing and tapered over 1-2 mo. 10/17/2013 58
  • 59. According to response to prednisone therapy: *Remission: no edema, urine is protein free for 5 consecutive days. * Relapse: edema, or first morning urine sample contains > 2 + protein for 7 consecutive days. *Frequent relapsing: > 2 relapses within 6 months (> 4/year). *Steroid resistant: failure to achieve remission with prednisolone given daily for 28 days. 10/17/2013 59
  • 60. Side Effects With Long Term Use of Steroids “Steroid toxicity” -Stunted growth • hyperglycemia Cataracts • myopathy - Pseudotumor cerebri • peptic ulcer • poor healing of wound. -Psycosis -Osteoporosis • Hirsutism • Thromboembolism - Cushingoid features -Adrenal gland suppression 10/17/2013 60
  • 61. Alternative agent • When can be used: • Steroid-dependent patients, frequent relapsers, and steroidresistant patients. – Cyclophosphamide Pulse steroids – Cyclosporin A – Tacrolimus – Microphenolate 10/17/2013 61
  • 62. Renal Failure Acute and Chronic
  • 63. Acute Renal Failure • Sudden interruption of kidney function resulting from obstruction, reduced circulation, or disease of the renal tissue • Results in retention of toxins, fluids, and end products of metabolism • Usually reversible with medical treatment • May progress to end stage renal disease, uremic syndrome, and death without treatment 10/17/2013 63
  • 64. Acute Renal Failure • Persons at Risks – Major surgery – Major trauma – Receiving nephrotoxic medications – Elderly 10/17/2013 64
  • 65. Acute Renal Failure • Causes – Prerenal • Hypovolemia, shock, blood loss, embolism, pooling of fluid d/t ascites or burns, cardiovascular disorders, sepsis – Intrarenal • Nephrotoxic agents, infections, ischemia and blockages, polycystic kidney disease – Postrenal • Stones, blood clots, BPH, urethral edema from invasive procedures 10/17/2013 65
  • 66. Acute Renal Failure • Stages – Onset – 1-3 days with ^ BUN and creatinine and possible decreased UOP – Oliguric – UOP < 400/d, ^BUN, Phos, K, may last up to 14 d – Diuretic – UOP ^ to as much as 4000 mL/d but no waste products, at end of this stage may begin to see improvement – Recovery – things go back to normal or may remain insufficient and become chronic 10/17/2013 66
  • 67. Acute Renal Failure • Subjective symptoms – Nausea – Loss of appetite – Headache – Lethargy – Tingling in extremities 10/17/2013 67
  • 68. Acute Renal Failure • Objective symptoms – Oliguric phase – • • • • • • • • 10/17/2013 vomiting disorientation, edema, ^K+ decrease Na ^ BUN and creatinine Acidosis uremic breath (fishy odor) • CHF and pulmonary edema • hypertension • sudden drop in UOP • convulsions, coma • changes in bowels 68
  • 69. Acute Renal Failure • Objective symptoms – Diuretic phase • • • • • • 10/17/2013 Increased UOP Gradual decline in BUN and creatinine Hypokalemia Hyponaturmia Tachycardia Improved LOC 69
  • 70. Acute Renal Failure • Diagnostic tests – H&P – BUN, creatinine, sodium, potassium. pH, bicarb. Hgb and Hct – Urine studies – US of kidneys – ABD and renal CT/MRI 10/17/2013 70
  • 71. Acute Renal Failure • Medical treatment – Fluid and dietary restrictions ( e.g. k+) – Maintain E-lytes – D/C or change cause – May need dialysis to jump start renal function – May need to stimulate production of urine with IV fluids, Dopomine, diuretics, etc. 10/17/2013 71
  • 72. Acute Renal Failure • Medical treatment – Hemodialysis – Peritoneal dialysis – Continous renal replacement therapy (CRRT) • Can be done continuously • Does not require dialysate 10/17/2013 72
  • 73. Acute Renal Failure • Nursing interventions – Monitor I/O, including all body fluids – Monitor lab results – Watch hyperkalemia symptoms: malaise, anorexia, parenthesia, or muscle weakness, EKG changes – watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions 10/17/2013 – – – – – Maintain nutrition Safety measures Mouth care Daily weights Assess for signs of heart failure – Skin integrity problems 73
  • 74. Chronic Renal Failure • Results form gradual, progressive loss of renal function • Occasionally results from rapid progression of acute renal failure • Symptoms occur when 75% of function is lost but considered chronic if 90-95% loss of function • Dialysis is necessary D/T accumulation or uremic toxins, which produce changes in major organs 10/17/2013 74
  • 75. Chronic Renal Failure • Subjective symptoms are relatively same as acute • Objective symptoms – Renal • Hyponaturmia • Dry mouth • Poor skin turgor • Confusion, salt overload, accumulation of K with muscle weakness • Fluid overload and metabolic acidosis • Proteinuria, glycosuria • Urine = RBC’s, WBC’s, and casts 10/17/2013 75
  • 76. Chronic Renal Failure • Objective symptoms – Cardiovascular • Hypertension • Arrythmias • Pericardial effusion • CHF • Peripheral edema 10/17/2013 – Neurological • Burning, pain, and itching, parestnesia • Motor nerve dysfunction • Muscle cramping • Shortened memory span • Apathy • Drowsy, confused, seizures, coma, EEG changes 76
  • 77. Chronic Renal Failure • Objective symptoms – GI • Stomatitis • Ulcers • Pancreatitis • Uremic fetor • Vomiting • consitpation 10/17/2013 – Respiratory • ^ chance of infection • Pulmonary edema • Pleural friction rub and effusion • Dyspnea • Kussmaul’s respirations from acidosis 77
  • 78. Chronic Renal Failure • Objective symptoms – Endocrine • Stunted growth in children • Amenorrhea • Male impotence • ^ aldosterone secretion • Impaired glucose levels R/T impaired CHO metabolism • Thyroid and parathyroid 10/17/2013 abnormalities – Hemopoietic • Anemia • Decrease in RBC survival time • Blood loss from dialysis and GI bleed • Platelet deficits • Bleeding and clotting disorders – purpura and hemorrhage from body orifices , ecchymoses 78
  • 79. Chronic Renal Failure • Objective symptoms – Skeletal • Muscle and bone pain • Bone demineralization • Pathological fractures • Blood vessel calcifications in myocardium, joints, eyes, and brain 10/17/2013 – Skin • Yellow-bronze skin with pallor • Puritus • Purpura • Uremic frost • Thin, brittle nails • Dry, brittle hair, and may have color changes and alopecia 79
  • 80. Chronic Renal Failure • Lab findings – BUN – indicator of GFR and is affected by the breakdown of protein. Normal is 10-20mg/dL. When reaches 70 = dialysis – Serum creatinine – waste product of skeletal muscle breakdown and is a better indicator of kidney function. Normal is 0.5-1.5 mg/dL. When reaches 10 x normal, it is time for dialysis – Creatinine clearance is best determent of kidney function. – Must be a 12-24 hour urine collection. Normal is > 100 ml/min 10/17/2013 80
  • 81. Chronic Renal Failure • K+ – The kidneys are means which K+ is excreted. – Normal is 3.5-5.0 ,mEq/L. maintains muscle contraction and is essential for cardiac function. – Both elevated and decreased can cause problems with cardiac rhythm – Hyperkalemia is treated with IV glucose and Na Bicarb which pushes K+ back into the cell – Kayexalate is also used 10/17/2013 81
  • 82. Chronic Renal Failure • Ca – With disease in the kidney, the enzyme for utilization of Vit D is absent – Ca absorption depends upon Vit D – Body moves Ca out of the bone to compensate and with that Ca comes phosphate bound to it. – Normal Ca level is 4.5-5.5 mEq/L – Hypocalcemia = tetany • Treat with calcium with Vit D and phosphate • Avoid antacids with magnesium 10/17/2013 82
  • 83. Chronic Renal Failure • Other abnormal findings – Metabolic acidosis – Fluid imbalance – Insulin resistance – Anemia – Immunoligical problems 10/17/2013 83
  • 84. Chronic Renal Failure Medical treatment • IV glucose and insulin • Na bicarb, Ca, Vit D, phosphate binders • Fluid restriction, diuretics • Iron supplements, blood, erythropoietin • High carbs, low protein • Dialysis - After all other methods have failed 10/17/2013 84
  • 85. Chronic Renal Failure • Hemodialysis – Vascular access • Temporary – subclavian or femoral • Permanent – shunt, in arm – Care post insertion – Can be done rapidly – Takes about 1 to 4 hours – Done 3 x a week 10/17/2013 85
  • 86. Chronic Renal Failure • Peritoneal dialysis – Semipermeable membrane – Catheter inserted through abdominal wall into peritoneal cavity – Cost less – Fewer restrictions – Can be done at home – Risk of peritonitis – 3 phases – inflow, dwell and outflow 10/17/2013 • Automated peritoneal dialysis – Done at home at night – Maybe 6-7 times /week • CAPD – Continous ambulatory peritoneal dialysis – Done as outpatient – Usually 4 X/d 86
  • 87. Chronic Renal Failure • Nursing care – Frequent monitoring – Hydration and output – Cardiovascular function – Respiratory status – E-lytes – Nutrition – Mental status – Emotional well being – Ensure proper medication regimen – Skin care – Bleeding problems – Care of the shunt – Education to client and family 10/17/2013 87
  • 88. Chronic Renal Failure • Nursing diagnosis – Excess fluid volume – Imbalanced nutrition – Ineffective coping – Risk for infection – Risk for injury 10/17/2013 88
  • 89. Chronic Renal Failure • Transplant – Must find donor – Waiting period long – Good survival rate – 1 year 95-97% – Must take immunosuppressant’s for life – Rejection • Watch for fever, elevated B/P, and pain over site of new kidney 10/17/2013 89
  • 90. 10/17/2013 90
  • 91. Chronic Renal Failure • Post op care – ICU – I/O – B/P – Weight changes – Electrolytes – May have fluid volume deficit – High risk for infection 10/17/2013 91
  • 92. Renal Calculi (Kidney Stones) • Made of crystals of calcium phosphate and uric acid • Gradually they get larger until they block ureters • First sym severe pain • Other sym nausea and vomiting, frequency, chills, fever, hematuria • Diagnosis by symptoms, ultrasound, or x-ray • Rx –increase fluids to flush out stone, medications, and if needed LITHOTRIPSY 10/17/2013 92
  • 93. Renal Calculi • Called nephrolithiasis or urolithiasis • Most commonly develop in the renal pelvis but can be anywhere in the urinary tract • Vary in size –from very large to tiny • Can be 1 stone or many stones • May stay in kidney or travel into the ureter • Can damage the urinary tract • May cause hydronephrosis 10/17/2013 93
  • 94. Renal Calculi • Predisposing factors – Dehydration – Prolonged immobilization – Infection – Obstruction – Anything which causes the urine to be alkaline – Metabolic factors • Excessive intake of calcium, calcium based antacids or Vit D • Hyperthyroidism • Elevated uric acid 10/17/2013 94
  • 95. Renal Calculi • Subjective symptoms – Sever pain in the flank area, suprapubic area, pelvis or external genitalia – If in ureter, may have spasms called “renal colic” – Urgency, frequency of urination – N/V – Chills 10/17/2013 95
  • 96. Renal Calculi • Objective symptoms – Increased temperature – Pallor – Hematuria – Abdominal distention – Pyuria – Anuria – May have UTI on urinalysis 10/17/2013 96
  • 97. Renal Calculi- Manifestations • Kidney/Pelvis – May be asymptomatic – Dull, aching flank pain • Ureter – Acute severe flank pain, may radiate – Nausea/vomiting – Pallor – Hematuria 10/17/2013 97
  • 98. Renal Calculi- Manifestations • Bladder – May be asymptomatic – Dull suprapubic pain – Hematuria 10/17/2013 98
  • 99. Renal Calculi • Diagnostic procedures – Urinalysis – 24 hour urine – Renal CT – Kidney ultrasound – Cystoscopy with retrograde pyleogram 10/17/2013 99
  • 100. Renal Calculi • Treatment – Most are passed without intervention – May need cysto with basket retrieval – Lithotripsy : Extracorporeal shock wave lithotripsy (ESWL) is the non-invasive treatment of kidney stones (urinary calculosis) and biliary calculi (stones in the gallbladder or in the liver) using an acoustic pulse. – Lasertripsy : – Lithotomy: is a surgical method for removal of calculi, stones formed inside certain hollow organs, such as the bladder and kidneys (urinary calculus) and gallbladder (gallstones), that cannot exit naturally through the urethra, ureter or biliary duct 10/17/2013 100
  • 101. Renal Calculi • Nursing interventions – Primary is to treat pain – usually with opioids – Ambulate – Force fluids, may have IV • Watch for fluid overload – Strain urine – send stone to lab if passed – Accurate I/O – Medicate N/V 10/17/2013 101
  • 102. Renal Calculi • Surgical removal – Routine pre and post op care – May return with catheter, drains, nephrostomy tube and ureteral stent – must maintain patency and may need to irrigate as ordered – Measure drainage from all tubes – need at least 30 cc/hr – Watch site for bleeding – May need frequent dressing changes due to fluid leakage, or may have collection bag 10/17/2013 102
  • 103. Renal Calculi • Discharge and prevention – Continue to force fluids post discharge – May need special diet • Stones are analyzed for calcium or other minerals • May need to watch products with calcium 10/17/2013 103
  • 104. Lithostripsy • Surgical procedure to remove kidney stones • Shock waves hit dense stones and break them up • Done on outpatient basis 10/17/2013 104
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