The urinary system eliminates waste products from the body and helps regulate the body’s water and chemical balance. The organs of the urinary system include two oval-shaped kidneys, each with a long, slender tube, called the ureter, that connects to the bladder. Another tubular vessel, the urethra, extends from the bladder to an opening out of the body.
An average adult produces about 1.5 liters (3 pt) of urine each day, and the body needs, at a minimum, to excrete about 0.5 liter (1 pint) of urine daily to get rid of its waste products. Excessive or inadequate production of urine may indicate illness and doctors often use urinalysis (examination of a patient’s urine) as part of diagnosing disease.
A sudden and almost complete loss of kidney function (decreased GRF) over a period of hours to days.
generally characterized by oliguria (decreased urine production, quantified as less than 400 mL per day in adults, less than 0.5 mL/kg/h in children or less than 1 mL/kg/h in infants); body water and body fluids disturbances; and electrolyte derangement.
UREMIA INTRODUCTION Uremia is a clinical syndrome associated with fluid, electrolyte, and hormone imbalances and metabolic abnormalities, which develop in parallel with deterioration of renal function. CONTINUE
ETIOLOGY Uremia may also be caused by specific lifestyle choices and certain types of trauma. A high protein diet or drug use, for example, can cause uremia. In addition, an increase in protein breakdown may occur from an infection, surgery, cancer , or trauma. This can also lead to uremia, as can gastrointestinal bleeding. Each of these potential causes of uremia makes the liver produce excessive amounts of urea, which may present in the blood stream. Uremia can also develop because urea is not eliminated from the body quickly enough. This can be caused by a blockage preventing urine from exiting the body. It may also be the result of decreased blood flow in the kidneys, which may be brought on by cardiac failure or hypotension . CONTINUE
Normally, the kidney is the site of hormone production and secretion, acid-base homeostasis, fluid and electrolyte regulation, and waste-product elimination. In the presence of renal failure, these functions are not performed adequately and metabolic abnormalities, such as anemia, acidemia, hyperkalemia, hyperparathyroidism, malnutrition, and hypertension, can occur. Uremia usually develops only after the creatinine clearance falls to less than 10 mL/min, although some patients may be symptomatic at higher clearance levels, especially if renal failure acutely develops. The syndrome may be heralded by the clinical onset of nausea, vomiting, fatigue, anorexia, weight loss, muscle cramps, pruritus, and change in mental status. PATHOPHYSIOLOGY CONTINUE
ASSESSMENT SKIN The classic skin finding in persons with uremia is uremic frost. The skin may have a velvety appearance and feel, particularly in patients who are pigmented. Patients who are uremic also may have a sallow coloration of the skin. Patients may become hyperpigmented as uremia worsens (melanosis). Neurologic system: Uremic encephalopathy symptoms include fatigue, muscle weakness, malaise, headache, restless legs, asterixis, polyneuritis, mental status changes, muscle cramps, seizures, stupor, and coma. Amyloid deposits may result in medial nerve neuropathy, carpal tunnel syndrome, or other nerve entrapment syndromes. CONTINUE
Head, ears, eyes, nose, and throat: Sclera may become slightly icteric. The oral pharynx may be dry. Stomatitis may be present. Calcium deposition in the sclera can cause "red eye." Cardiovascular system: Uremic pericarditis can be associated with a pericardial rub or a pericardial effusion. Increased fluid retention may result in pulmonary edema, peripheral edema, and severe hypertension. CONTI N UE
PERITONEAL DIALYSIS Introduction Peritoneal dialysis (PD) is based on the same filtering process as hemodialysis. But instead of using an artificial kidney as the filter, the peritoneal membrane is used. The peritoneal membrane — also called the peritoneum — is a thin membrane that lines the abdominal cavity. A catheter, or flexible hollow tube, is surgically placed in the lower abdomen. It’s about a foot long, but only four or five inches of it lies outside the body. Catheter insertion is done in an operating room, often with local anesthesia. CONTINUE
With CAPD, the patient manually performs his or her exchanges. Exchanges, which take approximately 30 minutes, are performed four times during the day by placing a bag of dialysate fluid on an IV pole or coat rack. Gravity then makes the filling and draining process possible. This form of PD can even be performed while the patient is at work, as long as he or she has a sterile environment to perform the exchanges.
Automated peritoneal dialysis (APD)
Automated peritoneal dialysis (APD), commonly referred to as continuous cycling peritoneal dialysis (CCPD), requires a cycler machine to automate the filling and draining process. Most patients choose this form of PD because it allows most of their dialysis to be performed while they sleep, freeing up the day for other activities. Many patients can have all their dialysis done while they sleep. Some patients will carry dialysis fluid in their abdomen during the day, and some will need to perform a manual fluid exchange during the day. Every patient is different, and doctors and PD nurses will help patients decide which peritoneal dialysis (PD) treatment regimen is best for them
Peritoneal dialysis is often done to manage kidney failure until a kidney transplant is possible. Kidney failure itself usually results from a long-term (chronic) disease that causes kidney damage over a number of years. Common causes of kidney failure include:
A nephrectomy is the surgical removal of a kidney, the organ that filters waste from the blood and produces urine. There are two kidneys, right and left. Each is about 4 inches to 5 inches long. They are located at the back of the abdomen, just below the diaphragm, behind the liver on the right, and the spleen on the left. A portion of each kidney is protected by the lowest one or two ribs and by the muscles that cover the back and side of the body. Depending on the reason for a nephrectomy, all or part of one kidney or both kidneys will be removed:
Partial nephrectomy � Part of one kidney is removed.
Simple nephrectomy � All of one kidney is removed.
Radical nephrectomy � All of one kidney is removed together with the neighboring adrenal gland (the adrenaline-producing gland that sits on top of the kidney) and neighboring lymph nodes.
Several factors have been associated with increased risk of RCC.
Obesity and cigarette smoking are the most consistently established causal risk factors, accounting for more than 30% and 20% of renal cell cancers, respectively.1
Hypertension as an independent factor is associated with increased risk of RCC.1
Analgesic use was once considered to be a more significant etiology than recent reports have indicated.1
A family history of RCC is associated with a 2- to 3-fold increased risk of RCC. However, a familial predisposition is identified in less than 2% of RCC cases.1 The identification of families with a predisposition to the development of renal neoplasms, including von Hippel-Lindau (VHL), hereditary papillary renal carcinoma (HPRC), Birt-Hogg-Dubé (BHD), and hereditary leiomyomatosis and renal cell cancer (HLRCC), has enabled the identification of the different genes for these cancers.2
Watch for any manifestation of bleeding or hemorrhage.
Monitor for complication by assessing for sudden shortness of breath or loss of breath sounds on the affected side.
Administer pain medication if indicated
Monitor for fluid and electrolyte imbalances
Assess patient for deep breathing exercise
Encourage patient for early ambulation
Intraoperative complications include injury to any gastrointestinal organs (eg, liver, spleen, pancreas) or to any major blood vessels (eg, aorta, inferior vena cava). Pleural injuries can result in pneumothorax. Postoperative complications include secondary hemorrhage from the renal pedicle or any unrecognized injury, atelectasis, ileus, both superficial and deep wound infections, temporary or permanent renal failure, and incisional hernia. Systemic complications include myocardial infarction, congestive heart failure, pulmonary embolism, cerebrovascular accident, pneumonia, and thrombophlebitis. Complication CONTINUE
Is a bladder dysfunction that results from a lesion of the nervous system. It may be caused by spinal cord injury, spinal tumor, herniated vertebral disc, multiple sclerosis, congenital anomalies (spinal bifida or myelomenignocele ) infection or diabetes mellitus. Neurogenic Bladder
The uninhibited neurogenic bladder produces “infantile” or uninhibited voiding. The urge to void causes urine to flow. The primary cause is a lesion in the corticoregulatory tracts, as from a stroke or multiple scloresis
Transection of the spintal cord above the sacral segments causes a reflex neurogenic bladder. There is no sensation, and the bladder contracts reflexively but does not empty completely.
Upper motor neuron lesions occur above the sacral segments of the spinal cord. They produce bladders that are spastic or characterized by exaggerated reflexes (hyperreflexia).
Lower motor neuron lesions occur at or below the sacral vertebrae. They produce bladders that are lacking reflexes or atonic
A motor paralytic bladder is the most uncommon type and is caused by lesions in the motor outflow from vertebrae S2 to S4. Disease processes causing this dysfunction include poliomyelitis, tumor, trauma, spina bifida,and infection. This dysfunction may be temporarily if a bacterial or viral infection is the cause. Although there is full sensation of bladder filling, even to the point of pain, the client cannot initiate micturition.
A sensory paralytic bladder results from an interruption in the lateral spinal tracts, as occurs in tabes dorsalis, diabetic neuropathy, and pernicious anemia. Because of the sensory loss, the client cannot sense the bladder filling. This lack perception leads to atonic bladder, retention with possible overflow incontinence, and upper tract involvement.
Clients with an autonomous neurogenic bladder cannot perceive bladder fullness, or they cannot start and maintain urination without some type of exertional pressure. Retention and incontinence are common problems. The autonomous type of dysfunction occurs after destruction of all nerve connections between the bladder and the central nervous system at vertebra S2,S3 and S4 following trauma, inflammatory process, spinal anesthesia and malignancy.
Pathophysiology Lesions at the lower motor neuron level of the spinal cord often directly interfere with the reflex arc leading to inappropriate interpretation of efferent and afferent impulses. When the bladder fills, the message is transmitted through afferent fibers to the brain cortex. The injury keeps these impulses from being correctly interpreted, leading to the loss of the micturition reflex. A flaccid bladder with urinary retention is the result. With upper motor neuron lesions, impulses are not transmitted to or from the lower spinal areas to the cortex. When the bladder distends, no sensation is transmitted. Because the lower cord is intact, activity of the reflex arc can occur. The client would have reflex incontinence in result. When the damage is to the cortical area itself, as with a stroke or trauma, the client cannot correctly interpret the impulses that are being transmitted. Unless the client is evaluated and treated appropriately, serious UTIs, skin breakdown associated with incontinence, and even renal failure due to chronic overdistention of the bladder are more likely to develop.
Evaluation for neurogenic bladder involves measurement of fluid intake, urine output, and residaual urine volume;urinalysis; and assessment of sensory awareness of bladder fullness and degree of motor control. Comprehensive urodynamic studies and are also perfomed.
Hemodialysis is the most commonly used method of dialysis:It is used for patients who are acutely ill and require short-term dialysis and for ESRD who require long- term or permanent therapy. A dialyzer (artificial kidney) serves as a synthetic semipermeable membrane, replacing the renal glomeruli and tubules as the filter for the impaired kidneys.
The toxins and waste in the blood are removed by diffusion- that is, they move from an area of higher concentration in the dialsate.
Excess water is removed from the blood by osmosis, in which water moves from an area of higher solute concentration to an area of lower solute concentration
Defined as water moving under high pressure to an area of lower pressure. This process is much more efficient at water removal osmosis. Ultrafiltration is accomplished by applying negative pressure or a suctioning force to dialysis membrane.
The dialysis machine is about the size of a dishwasher. This machine has three main jobs:
pump blood and watch flow for safety
clean wastes from blood
watch your blood pressure and the rate of fluid removal from your body
The dialyzer is a large canister containing thousands of small fibers through which your blood is passed. Dialysis solution, the cleansing fluid, is pumped around these fibers. The fibers allow wastes and extra fluids to pass from your blood into the solution, which carries them away. The dialyzer is sometimes called an artificial kidney.
Dialysis solution, also known as dialysate, is the fluid in the dialyzer that helps remove wastes and extra fluid from your blood. It contains chemicals that make it act like a sponge. Your doctor will give you a specific dialysis solution for your treatments. This formula can be adjusted based on how well you handle the treatments and on your blood tests.