genito urinary disorders medical surgical ii

1. Mar-19 1
By
Mr.A.Sanjaikumar M.Sc Nursing, PhD Fellow
Medical Surgical Nursing
Critical Care Department
Associate Professor
School of Health Sciences
Madda Walabu University
Bale Goba.

2. Anatomy and physiology review of GUT
Assessment of pt with GUT problem
Acid-base imbalance
Acid-base balance (continued)
Fluid and electrolyte imbalance
Infections of the urinary tracts
Diseases of the Kidney and interventions for
clients
Obstruction of urinary system
Mar-19 2

3. Mar-19 3

4. 1, Anatomic and Physiologic Overview of GUT
The urinary system comprises
The kidneys
Ureters
Bladder
Urethra
system is necessary for assessing individuals with
acute or chronic urinary dysfunction .
Mar-19 4

5. Mar-19 5

6.  Are a pair of brownish-red structures located retro
Peritoneally
 It is on the12th thoracic vertebra to the 3rd lumbar
vertebra in the adult
 an adult kidney weighs 120 to 170 g and is 12 cm
long, 6 cm wide, and 2.5 cm thick.
 The kidneys are well protected by the ribs, muscles,
fascia, perirenal fat, and the renal capsule, which
surround each kidney.
 It has two distinct regions, the renal parenchyma and
the renal pelvis.
 The renal parenchyma is divided into the cortex and
the medulla.
Mar-19 6

7. Each kidney contains approximately 8 to 18
renal pyramids.
The pyramids drain into 4 to 13 minor calices
that drain into 2 to 3 major calices that open
directly into the renal pelvis.
Each kidney contains about 1 million
nephrons, the functional units of the kidney.
Mar-19 7

8. The urinary system helps maintain homeostasis by
regulating water balance and by removing harmful
substances from the blood.
The blood is filtered by two kidneys, which produce
urine, a fluid containing toxic substances and waste
products.
Each kidney, the urine flows through a tube, the ureter,
to the urinary bladder, where it is stored until it is expelled
from the body through another tube, the urethra.
Mar-19 8

9. Inside the kidney, three major regions
The renal cortex borders the convex side
The renal sinus is a cavity that lies adjacent to the renal
medulla.
The renal medulla lies adjacent to the renal cortex.
It consists of striated
Cone-shaped regions called renal pyramids
(medullar pyramids)
Renal papillae, face inward.
Renal columns unstriated regions between the
Renal pyramids
Mar-19 9

10. Blood and nerve supply
Blood supply is delivered by the large renal Arteries.
The renal artery for each kidney enters the rena hilus
and successively branches into segmenta
Arteries and then into interlobar arteries, which Pass
between the renal pyramids toward the Renal cortex.
Autonomic nerves from the renal plexus follow the
Renal artery into the kidney through the renal hilus.
The nerve fibers follow the branching pattern of the
renal artery and serve as vasomotor fibers that regulate
blood volume.
Mar-19 10

11. Are narrow, muscular tubes, each 24 to 30 cm long
It originate at the lower portion of the renal pelvis and
terminate in the trigone of the bladder wall. There are
three narrowed areas of each Ureter:
-the ureteropelvic junction
-The ureteral segment near the sacroiliac junction,
-the ureterovesical junction.
The movement of urine from the renal pelves through
the ureters into the bladder.
Mar-19 11

12. Is a muscular, hollow sac located just behind the pubic
bone.
Is about 300 to 600 ml of urine in adult. In infancy, the
Bladder is found within the abdomen.
Is characterized by its central, hollow area called the
vesicle, which has two inlets
The bladder neck contains bundles of involuntary the
urethral sphincter known as the internal sphincter.
The portion of the sphincteric under voluntary control is
The external urinary sphincter at the anterior urethra, the
segment most distal from the bladder
Mar-19 12

13. The urethra arises from the base of the bladder:
In the male it passes through the penis
in the female, it opens just anterior to the
vagina.
In the male, the prostate gland, which lies
just below the bladder neck,surrounds
the urethra posteriorly and laterally.
Mar-19 13

14. The urinary system performs various roles that are
essential for normal
bodily homeostasis . These functions include
Urine formation
Excretion of waste products
Regulation of electrolyte, acid
Water excretion
Auto regulation of blood pressure
Mar-19 14

15. Mar-19 15

16. Assessments of GUT
• Radiographic Procedures of the Genitourinary
System
Types of Radiologic examination of the renal system
• Plain abdominal x-ray (KUB )
Kidney,
Ureter,
Bladder
Mar-19 16

17. It is x-ray of the abdomen.
• Involves no contrast media.
• Posses no risk to the person.
• Demonstrates the size, shape, & location
(position) of the KUB.
• Reveal any abnormalities: calculi in the
kidney/urinary tract, hydronephrosis,
cysts, tumors etc…
Mar-19 17

18. Examination of the renal system following the IV
injection of a radio-opaque dye filtered by the kidney &
excreted through the urinary tract.
Helps to identify the absence/presence, location, size,
&configuration of the kidneys, ureters, & bladder.
Helps to determine filling of the renal calices & pelvis.
Visualize different layers of the kidney &the diffuse
structure within each layer.
Visualize partial obstruction, Renovascular
hypertention, tumor, cyst, &congenital abnormalities.
Mar-19 18

19. Nursing responsibilities in patient
preparations
• Check for any allergies &notify for the physician
&the radiologist.
• A laxative may be prescribed the night before
examination to eliminate faces &gas from the
intestinal tract.
• Liquids may be restricted 8 to 10 hours before the test
to promote concentrated urine
• Describe the procedure &the sensations of warmth
&flushing of the face to the patient.
• Prepare the emergency drugs (epinephrine,
corticosteroids, and vasopressors) as well as oxygen,
tracheostmy, & other equipment, ready for immediate
therapy in case anaphylactic reaction occurs.
Mar-19 19

20. Contraindications of intravenous
urogram
– Poor renal function – can further compromise
function of the renal system because of
dehydrating effect & nephrotoxicity of IVP dye.
– Multiple myeloma – IVP dye may precipitate of
myeloma protein in kidney.
– Pregnancy – abdominal radiation should be
avoided.
– CHF – IVP dye has an acute osmotic effect that can
further compromise heart failure.
– Diabetes mellitus – Rapid deterioration of renal
function is common.Mar-19 20

21. URINALYSIS AND URINE
CULTURE
Urine color
Urine clarity and odor
Urine pH and specific gravity
Tests to detect protein, glucose, and ketone bodies
in the urine (proteinuria, glycosuria, and
ketonuria, respectively)
Microscopic examination of the urine sediment
after centrifuging to detect RBCs (hematuria),
white blood cells, casts (cylindruria), crystals
(crystalluria), pus (pyuria), and bacteria
(bacteriuria)
Mar-19 21

22. Mar-19 22

23. • The optimal PH of various body fluids differs but not
very much.
• The normal PH value is:
– 7.4 for arterial blood
– 7.35 for venous blood and intestinal fluid, and
– 7.0 for intercellular fluid.
Mar-19 23

24. • Acid-base balance is situation in which the PH of the
blood is maintained between 7.35 and 7.45.
• Imbalances occur in the form of:
– Alkalosis- arterial blood PH rises above 7.45
– Acidosis- A drop in arterial Ph to below 7.35
Mar-19 24

25. • Chemical Acid-Base Control /buffer system
–Bicarbonate
– phosphate
–Proteins
• Respiratory Acid Base Control
–Carbon dioxide
• Renal Acid Base Control
–Bicarbonate, acids, ammonium
Mar-19 25

26. Chemical Mechanisms (Buffers)
• Buffers are the first line of defense against
changes in H+ concentration. By acting as ‘H+
sponges’; buffers can bind H+ when the
concentration is too high or release H+ when
concentration is too low.
• Fluid buffers are composed of chemicals (e.g.
bicarbonate, phosphate) & proteins (e.g.
albumin, globulins, hemoglobin).
Mar-19 27

27. Mar-19 28

28. • This system is an effective buffer in urine and
intracellular fluid (ICF)
• Works much like the bicarbonate system
• System involves:
– Sodium Monohydrogen phosphate (Na2HPO4
2-)
 H+ + HPO4
2-  H2PO4
-
Mar-19 29

29. • Plasma and intracellular proteins are the body’s
most plentiful and powerful buffers
• Some amino acids of proteins have:
– Free organic acid groups (weak acids)
– Groups that act as weak bases (e.g., amino
groups)
Mar-19 30

30. Respiratory Mechanism
• When chemical buffers alone can not prevent
changes in body fluid PH, the respiratory
system is the second line of defense against
changes.
Mar-19 31

31. Fig:- Neural regulation of respiration and H+ concentration.
Hypoventilation ( ed rate&
depth of respiration
 ed PaCo2
 ed H+
Inhibition of control
chemoreceptor
Stimulation of central
chemoreceptor
 ed Pa Co2
 ed H+
 ed rate & depth of
respiration
(hyperventilation)
Mar-19 32

32. • The kidneys regulate extracellular fluid pH by:
– secreting H+,
– reabsorbing HCO3-, and
– producing new HCO3
-
• During alkalosis, excess HCO3
- is not bound by H+,
and is excreted, effectively increasing H+ in the
circulation and reversing the alkalosis.
• In acidosis, the kidneys reabsorb all the bicarbonate
and produce additional bicarbonate which is all added
back to the circulation to reverse the acidosis.
Mar-19 33

33. Mar-19 35

34. • Is characterized by PH below 7.35 & HCO-
3 level below 22m
E/L.
Over production of H+
– Excessive oxidation of fatty acids
– Hyper metabolism which result in deficiency of 02
– Excessive ingestion of acids
Under eliminations of H+
Under production of HCO3
-
Over elimination of HCO3
-
Mar-19 36

35. • Anorexia, nausea, vomiting
• Head ache, lethargy, confusion
• Kussmaul respiration
• Peripheral vasodilatation & ed cardiac out put
• Cold & clammy skin.
• Lab. (PH<7.35, HCO3
-<22mEq/L, PaCO2
(compansatory by the lungs), Hypercalemia
Mar-19 37

36. Mar-19 38

37. • Treatment is aimed at reversing the underlying disorder
– DKA, infections & diarrhea if present, renal failure
• NaHCO3 is administered IV to neutralize blood acidity
• Dialysis
• Fluids (NaCl solution) as required
• Adjusting potassium
– Monitor serum K+
– Rapid acting insulin to reverse drive K+ back in
to the cells
Mar-19 39

38. Metabolic Alkalosis
Mar-19 40

39. • Metabolic alkalosis is characterized by a blood PH
above 7.45 and an HCO3
- level above 26m E/L.
• the underlying mechanisms include a loss of H+
ions(acid), a gain in HCO3
- , or both.
Causes
Increase of base component
– Oral ingestion of bases (antacids, milk alkali
syndrome)
– Parentral base administration
– Excessive retention of HCO-
3
Mar-19 41

40. Decrease of acid component
– Prolonged vomiting, NG suctioning
– pyloric stenosis b/c only gastric fluid is lost in this
disorder
Potassium deficit
– Cushing’s syndrome
– Thiazide diuretics
Mar-19 42

41. Clinical manifestations
Symptoms of hypocalcemia are more prominent
Confusion, muscle twitching, apathy, paresthesia,
Weakness,
 Anorexia, nausea, vomiting
Hypoventilation
tachy cardia
• Lab.
– PH ed (>7.45)
– HCO-
3 ed (>26m mEq/L) (primary)
– PCO2 ed (compensatory)
Mar-19 43

42. Mar-19 44

43. Management
• Management usually directed to wards correcting the
cause of the condition
– Sufficient chloride supplementation for the kidney
to absorb sodium with chloride (allowing the
excretion of HCO-
3).
– Restoring normal fluid volume by administering
NaCl solution (because continued volume
depletion serves to maintain alkalosis).
Mar-19 45

44. – KCl in patients with hypokalemia to replace both
K+ &Na+ losses.
– Thiazide diuretics & NG suctioning are
discontinued.
– Antiemetics may be administered to treat
underlying nausea &Vomiting
Mar-19 46

45. Respiratory Acidosis (H2CO3 excess)
Mar-19 47

46. Respiratory Acidosis (H2CO3 excess)
• Respiratory acidosis is a clinical disorder in which
the
– PH is less than 7.35 and
– the PaC02 is greater than 42mmHg.
• It is always due to inadequate excretion(removal)
of C02 with inadequate ventilation, resulting in
elevated plasma CO2 levels and thus elevated
H2CO3 level & usually causes ed PaO2 (due to
hypoventilation).
Mar-19 48

47. Causes
Respiratory depression
Drugs (especially opoids- NSAID)
Trauma - Cerebral edema
- Spinal cord injury
Neurologic disorders
 Gullian- Barre syndrome
 Myasthenia gravis
Muscle weakness (inadequate chest expansion)
Mar-19 49

48. • Alveolar-capillary block
– Thrombus or embolus
– Pneumonia
– Pulmonary edema
– Atelectasis
– COPD
– Acute respiratory distress syndrome (ARDS)
• Breathing air with high CO2 content
Mar-19 50

49. Clinical manifestations
• Headache, confusion, depression, hallucination,
dizziness, stupor & coma, tremors
• HR, BP, ICP, Hyperkalemia
• Cyanosis & tachypnea
• Warm & flushed skin
• Lab
– PH < 7.35
– PaCO2 > 42mmHg (primary)
– HCO3
- ed (compensatory)
– Low PaO2
Mar-19 51

50. Mar-19 52

51. Management
• Directed towards improving ventilation
• Pharmacologic Mgt include:
– Bronchodilators
– Antibiotics (for respiratory infection)
– Thrombolytics (Anticoagulants for pulmonary
emboli)
• Air way clearance
• Adequate hydration
• Mechanical ventilation (in sever cases).
Mar-19 53

52. Respiratory Alkalosis (H2CO3 deficit)
• Respiratory alkalosis is a clinical condition in
which:
• the PH is >7.45
• PaCO2 is <38 mmHg.
• Because respiratory alkalosis can occur suddenly,
compensatory decrease in HCO3
- level may not occur
before respiratory correction has been accomplished.
Mar-19 54

53. Causes
– Any condition that increases respiratory rate &
depth like anxiety,
– Hyperventilation
– Hypocapnia
– Conditions that affect brain’s respiratory control
center
– Acute hypoxia secondary to high altitude,
pulmonary disease, severe anemia, pulmonary
embolus & hypotension
Mar-19 55

54. Clinical manifestations
– Dizziness, light headiness
– Tetany
– Numbness & tingling of figures & toes
– Seizures
– Inability to concentrate
Mar-19 56

55. – Hyperventilation
– Tachycardia, dysrthmia
– Lab.
• PH > 7.45
• PaC02 < 35 mm Hg
• HCO-3 normal
• Serum electrolytes
– Hypokalemia
– ed CO2+
Mar-19 57

56. Mar-19 58

57. Management
• Treatment depends on the underlying cause of
respiratory alkalosis.
Mar-19 59

58. Mar-19 61

59. Mar-19 62

60. Fundamental concepts
Mar-19
• The human body functions when certain conditions are kept
with in a narrow range of normal value. These conditions
include:-
– Body temperature
– Electrolytes
– Blood PH
– Blood volume
Body fluid contains:
– water
– Electrolytes
– Non electrolytes (glucose, urine), and
– other substances
63

61. Body fluid compartments
Mar-19
• Approximately 55-60%of a typical adult’s weight
consists of fluids. These fluids are distributed in to
different compartments:
1. Intracellular fluid(ICF) compartment
– Is fluid with in the cells
– Located mainly (primarily) in skeletal muscle mass
– Contains approximately 2/3 (28L)of the total body
fluid
– Constitute 45% of body weight
64

62. Body fluid…
Mar-19
2. Extra cellular fluid(ECF) compartment
– Is fluid outside cells
– Contains approximately 1/3(15L) of body fluid
3. further divided in to
– Intravascular space
– Interstitial space
– Trans-cellular space
65

63. Factors that influence the amount of
body fluid include:
Mar-19
• Age
• Gender
• Body fat
68

64. FLUILD SHIFT
Mar-19
• Is the term used to classify the distribution of
water. This is of three types:
First space fluid shift
– normal distribution of fluid
Second spacing
– Is an excess accumulation of interstitial fluid
Third spacing
– Is losing of ECF in to spaces that do not have
contribution in the equilibrium of ICF and ECF.
69

65. Mar-19
• Third spacing occurs in:
Ascites
Burns
Peritonitis
Bowl obstruction
Massive bleeding in to joint or body cavities
70

66. Mar-19
S/S of third spacing
ed urine out put
ed heart rate
ed BP
Edema
ed CVP
ed Body weight
Imbalances in fluid intake and out put
71

67. Functions of fluid
Mar-19
• Water provides about 90-93% of the volume in the
extra cellular compartment. Its functions include:
– Providing form for body structures
– Acts as transport vehicle
– Aids in the hydrolysis of food
– Acts as medium and reactant for chemical
reactions
– Acts as a lubricant
– Cushions and acts as shock absorber
72

68. Gains and losses of body fluid (water)
Mar-19
The sources of fluid gains
Absorption from GIT
Parenterally administered fluids
Metabolic oxidation of foods
Bathing in fresh water
73

69. Mar-19
• Routs of fluid losses
Kidney (1ml/kg/hr in all age groups
Insensible loss
»Skin
»Lungs
Stool (GIT)
74

70. Mar-19
Average in take and out put of fluids in adults
• Intake Out put
Oral intake Urine----------1500ml
– As liquid -------------1300ml Stool------------200ml
– In food ---------------1000ml Insensible
Metabolic oxidation ------300ml Lung-------300ml
Skin--------600ml
• Total gain-----------------2600ml Total lose-----2600ml
75

71. Regulation of body fluids
Mar-19
• physiologic mechanisms assist in the regulation of
body fluids include:
i. Thirst level-primarily regulates intake occurs when an
increase in the extra cellular osmolality causes
osmoreceptors (nerve cells in hypothalamus) to
shrink.
76

72. Regulation…
Mar-19
ii. Renal concentrating mechanisms
• The kidney controls the concentration of most of the
constitutes in body fluid, including water and
electrolytes. Mediated by the function of
 Osmo receptors
 Baro receptors
 Adrenal functions-Renin- angiotensin- aldesterone
system
 Release of atrial natriuretic peptide
77

73. Organs involved in the homeostasis of
body fluid include:
Mar-19
• Kidneys
• Heart and blood vessels
• Lungs
• Posterior pituitary gland-store and release ADH
• Adrenal gland(cortex)-secretes aldostrone which
increases sodium retention and potassium loss
• Parathyroid gland-PTH(parathyroid hormone)
regulates calcium and phosphorus balance
78

74. Normal laboratory values used in evaluating fluid and
electrolyte status in adults
Mar-19
Serum test
Cations Reference range
• Sodium (Na+) ------------------------------------135-145mEq/l
• Potassium (K+)-------------------------------------3.5-5.5mEq/l
• Calcium (Ca2+)-------------------------------------8.6-10mEq/l
• Magnesium (Mg2+)-------------------------------1.3-2.5mEq/l
79

75. Normal laboratory values…
Mar-19
Anions
• Chloride (Cl-)------------------------------------97-107mEq/l
• Bicarbonate (HCO3
-)---------------------------20-30mEq/l
• Phosphate (PO4
3-)-------------------------------2.8-4.5mEq/l
• Osmolality-------------------------------------280-300mEq/l
• Blood urea nitrogen (BUN)--------------------5-20mg/dl
80

76. Normal laboratory values…
Mar-19
• Creatinine--------------------------------------F: 0.5-1.1mg/dl
M: 0.6-1.2mg/dl
• BUN to creatinine ratio---------------------10:1-15:1
• Hematocrite-----------------------------------F: 35-47%
M: 42-52%
• Glucose----------------------------------------70-105mg/dl
• Albumin-----------------------------------------3.5-5.0g/dl
81

77. Normal laboratory values…
Mar-19
Urine tests
• Sodium(Na+)--------------------------------------------------75-220mEq/l
• Potassium(K+)-------------------------------------------------25-123mEq/l
• Chloride(Cl-)--------------------------------------------------110-250mEq/l
• Specific gravity------------------------------------------------1.016-1.022
• Osmolality-----------------------------------------------------250-
900mOsml/kg H2O
• PH---------------------------------------------------------------Random: 4.5-8.0
Typical urine: <5-6
82

78. Fluid volume disturbances
Mar-19 83

79. Mar-19
• occurs when water and electrolytes are lost in
the same proportion as they exist in normal
body fluids, so that the ratio of serum
electrolytes to water remains the same.
• should not be confused with dehydration
84

80. Mar-19
Inadequate fluid intake
Unconsciousness/coma or inability to
express thirst
Oral trauma or inability to swallow
Impaired thirst mechanism
Withholding of fluid for therapeutic reason
85

81. Mar-19
Excessive fluid losses
• GI losses
Vomiting
Diarrhea
GI suctioning
Fistula drainage
• Urine losses
Diuretic therapy
Osmotic diuresis (hyperglycemia)
Salt wasting renal disease
86

82. Causes…
Mar-19
• Skin losses (salt water)
Fever
Exposure to hot environment
Burs and wounds that remove skin
• Third space losses
Intestinal obstruction
Edema, ascites, burns (for the firs
several days)
• Other risk factors
Diabetic incipidus
Hemorrhage
87

83. Mar-19
Acute weight loss (% body weight)
–Mild FVD: 2% loss
–Moderate FVD: 2-5%loss
–Severe FVD: 6% or more loss
Thirst, anorexia, nausea
Urine out put(oliguria)
Urine osmolality
Specific gravity
88

84. Mar-19
Serum osmolality
Hematocrite
BUN
Vascular volume
Tachycardia, weak thready pulse
Postural hypotention
Vein filling and vein refill time
Hypotention and shock
Volume in extra cellular space
Depressed fontanel
Sunken eyes and soft eyeballs
89

85. Mar-19
Loss of ICF
Dry skin (skin turgor) and mucous membrane
Cracked and fissured tongue
Salivation and lacrimation
Neuromuscular weakness and cramps
Fatigue
Increased body temperature
Cool clammy skin related to peripheral
vasoconstriction
90

86. Diagnosis
Mar-19
Hx
Physical exam
ed BUN
ed BUN to creatnine ratio(>20:1)
ed hematocrite
Electrolyte changes may occur
Urine osmolality
ed as kidney attempt to conserve water
ed with DI
91

87. Mar-19
• Isotonic fluid replacement
 0.9%nacl solution, ringer’s lactate
• After the patient becomes normotensive, a
hypotonic solution
 0.45%nacl solution often used
 provide both electrolytes and water
facilitates renal excretion of metabolic wastes
• Determine the presence of renal tubular damage due
to FVD
92

88. Mar-19
• Monitoring intake and out put at least every 8 hours
and sometimes every hour.
• Monitoring daily body weight (at the same time of
day)
• Monitoring vital signs
Pulse-weak and rapid
Bp-postural hypotension
Temperature
Respiration-rapid shallow
93

89. Mar-19
• Avoid orthostatic hypotension or possible syncope.
Do not allow the patient to sit or standup quickly
as long as circulation is compromised
• Monitoring skin and tongue turgor
– Mouth care every 4 hours
• central venous pressure
• level of consciousness
• breath sounds
• skin color
94

90. Mar-19 95

91. Prevention
Mar-19
• Identifying at risk and taking measures to minimize
fluid loss
96

92. Fluid Volume Excess (FVE)/ HYPERVOLEMIA
Mar-19
• Refers to an isotonic expansion of the ECF
caused by the abnormal retention of water and
sodium in approximately the same proportion
in which they exist in the total body fluid.
97

93. Causes/ contributing factors
Mar-19
• Excessive sodium and water in take
Dietary intake
Ingestion of medications containing g sodium
• Inadequate renal losses
Renal disease (renal failure)
Increased corticosteroid level
• Congestive heart failure
98

94. Clinical manifestations
Mar-19
Acute weight gain (in excess of 5%)
Pitting edema of the extremities
Puffy eyelids
Pulmonary edema
Shortness of breathing (dyspnea)
Rales, wheezing
 Cough
99

95. Clinical…
Mar-19
Tachycardia-full and bounding pulse
ed BP and CVP
Distended neck veins
ed Urinary out put
100

96. Diagnosis
Mar-19
Hx
Physical exam
ed BUN
Hematocrite may be ed
ed Urine specific gravity (because of urine
sodium level)
ed Serum osmolality
Chest X-ray reveals pulmonary congestion
101

97. Medical management
Mar-19
Management is directed towards the causes
If related to excessive administration,
discontinuing the infusion
Diuretics (thiazides/ loop diuretics)
Restricting fluid and sodium intake
Hemodialysis/peritoneal dialysis, if pharmacologic
and dietary management cannot act effectively
102

98. Nursing management
Mar-19
Monitoring
Daily input and out put
Daily body weight
Degree of edema in most dependent body parts
–Feet and ankles in ambulatory patients
–Sacral area in bed reddened patients
103

99. Nursing…
Mar-19
Promoting rest (bed rest favors diuresis of
edema fluid)
Restricting sodium intake
Regular positioning (to prevent skin break
down)
Teaching the patient about the edema
Ex. raising extremities.
104

100. Mar-19 105

101. Mar-19 107

102. 1. Pyelonephritis
• It is an inflammation of the kidneys &its
pelvis, beginning in the interstitium &rapidly
extending to involve the tubules, glomeruli
&blood vessels.
Classification: Acute, & Chronic pyelonephritis
Mar-19 108

103. • It is sudden onset &self-limited bacterial
disease of the kidneys
• Bacteria: E-coli (80%), Proteus, Pseudomonas,
S. aures, Strep. faecalis (entrococcus)
• Procedures: Catheterization, Cystoscopy,
Urologic surgery
• Other causes: Urinary obstruction, Neurogenic
bladder (vesicouretral reflux)
Mar-19 109

104. Increased with age
Increased in sexually active women
Increase in obstructive disease of LUT
Pregnancy
Neurogenic bladder
Frequent catheterization
Glucoseuria (Diabetes Mellitus)
Mar-19 110

105. Flank pain
Urinary urgency & frequency
Burning during urination
Costovertebral angle tenderness
Dysuria (Painful or difficulty of urination)
Nocturia, Hematuria, Cloudy urine
Shaking Chills, Generalized fatigue, Anorexia
Mar-19 111

106. • history taking, & Phy/exam
• Urinalysis: - Proteinuria, Glucoseuria, Rarely
ketonuria
- Leucocytes, Few red blood cells
- Casts, Decreased urine specific
gravity
• Urine culture reveals the causative organism
• CBC – Elevated WBC (40,000mm3) – Elevated
Neutrophils.
• Erythrocyte sedimentation rate will be elevated
Mar-19 112

107. Secondary arteriosclerosis
Calculi formation, Renal damage
Renal abscess (Metastasing to the other
organs)
Septic shock
Chronic pyelonephritis
Chronic renal failure
Mar-19 113

108. Medical Management
• Cotrimoxazole
• Ampicillin or Amoxicillin, Penicillin G
• Cephalosporin drugs
• Gentamycin, or Tobaramycin
Mar-19 114

109. Nursing intervention
– Administer antipyretic
– Fluids to empty the bladder of contaminated urine
& prevent calculus formation
– Catheterize with strict sterile technique
– Instruct the patient to perform appropriate perineal
care
– Teach proper technique for collecting a clean catch
urine specimen
– Instruct to complete the prescribed drug
– Advice routine checkups for patient with history of
UTIs
Mar-19 115

110. B. Chronic pyelonephritis
• It is a persistent inflammation of kidneys.
Etiology: Bacteria, Urinary obstruction,
Vesicoureteral reflux
Clinical manifestations
• Usually have no symptoms of infection
• Noticeable signs – Fatigue, headache, poor
appetite
- Polyuria /Low specific gravity of urine/
- Excessive thirst, Weight loss
- Flank pain
Mar-19 116

111. Diagnosis
 History taking & Physical examination
• Laboratory investigations
– Urinalysis- Proteinuria (Albuminuria)
• Intermittent bacteruria
• Leukocytes in urine
• Low specific gravity of urine
– Urine culture to identify the pathogen
– Blood
- Decreased Hgb
- Measuring BUN & creatinine
• Decrease HCI
• Radiologic IV Urogram
Mar-19 117

112. Complications:
Hypertension, Chronic renal failure, Kidney
stone
Management:
• Same as acute pyelonephritis
• Monitor HPN
• Monitor intake and out put
Mar-19 118

113. 2. Urinary Tract Infections
• Bladder – cystitis
• Urethra – Urethritis
• Prostrate – Prostatitis
• Kidneys – Pyelonephritis
Mar-19 119

114. 2. Urinary Tract Infections
• Urinary tract infection is an infection of the
urinary tract caused by the presence of
pathogenic microorganism in the urinary tract
with or without signs & symptoms.
The most common site of infection:
• Bladder – cystitis
• Urethra – Urethritis
• Prostrate – Prostatitis
• Kidneys – Pyelonephritis
Mar-19 120

115. Etiology:
1. Ascending infections [Enter via Urinary
meatus]
2. Obstructive abnormalities [strictures, prostatic
tumors or hyperplasia]
3. Upper Urinary track disease may occasionally
cause recurrent bladder infections.
Mar-19 121

116. Sign and symptoms:
Dysuria, frequency, urgency and a nocturnal
Suprapubic pain and discomfort
Gross hematuria.
Mar-19 122

117. Diagnosis:
1. Urine dipstick: may react positively for blood
WBC and titrates indicate infection.
2. Urine microscopy: Shows RBC and many
WBC per field with or epithelial cells.
3. Urine culture: It is used to detect presence of
bacteria & for antimicrobial sensitivity test
Mar-19 123

118. Management:
1. Relieve discomfort and provide rest.
(Catheterization if needed)
2. Antibiotic
3. Follow up culture to prove treatment
effectiveness.
4. Increase fluid intake.
5. Avoid irritants - Coffee, tea, alcohol, cola drinks.
6. Promote Urinary output
Complication: Pyelonephritis, Sepsis
Mar-19 124

120. 1.Nephrolithiasis Refers to the presence of stones,
or calculi in the renal pelivis, &
2. Urolithiasis refers to their presence in the urinary
system.
• Stones are formed by crystallization of urinary
solutes (calcium oxalate, uric acid, calcium
phosphate, struvite & cystine)
• In 80% of pts with urolithiasis, gravel stones pass
spontaneously
• Men are affected more frequently than women,
& recurrences are possible
Mar-19 126

121. DEFINITION
Abnormal collection are formed
in the excretory passages of the
kidney, composed primarily of
calcium oxalates and phosphates; -
also called kidney stone, nephrolithsis,
and nephritic calculus

122. Causes & Predisposing factors
• Hypocalcaemia& hypercalciuria 2o to
hyperparathyroidism
• Renal tubular acidosis
• Multiple myeloma
• Excessive intake of Vit D milk & alkali
• Poor fluid intake& prolonged immobility
• Abnormal purine metabolism (hyperuricemia &
govt )
• Chronic infection with urea splitting bacteria
Mar-19 128

123. • Chronic obstruction by foreign bodies in the
UT
• Excessive oxalate absorption in inflammatory
bowel disease Complications obstruction
Infection,& Impaired renal function
Mar-19 129

124. The five major categories of stone are
1. calcium phosphate
2. calcium oxalate
3. uric acid
4. Cystine
5. striuvite (magnesium ammonium phosphate)
Mar-19 130

126. Clinical manifestations:
• Pain pattern (referred to as colic) depends on
site of obstruction
• Chills, fever, dysuria, frequency & hematuria –
Secondary to infection
• N/V diarrhea general abdominal discomfort
Mar-19 132

127. Diagnostic Evaluation:
 History collection
 Physical examination
 Urinalysis -hematuria, pyuria
 Urine culture
 IVP,
 Retrograde pyelogram,
 Ultrasound
 Cystoscopy
 BUN, Serum calcium, phosphate,sodium, pottassium,
Creatine levels
 Serum RFT
Mar-19 133

128. Management:
• Conservative therapy for small stones
• Hydration, Straining of Urine & observation,
Pain mgt
• Hospitalization for intractable pain, persistent
Vomiting high grade fever, Obstruction &
infection
• Extracorporeal shock wave lithotripsy (ESWL)
• A percutaneous nephrostomy or a percutaneous
nephrolithotomy (which are similar procedures)
Mar-19 134

129. Surgery:
• Nephrolithotomy: is an incision into the
kidney to remove stone.
• Pyelolithotomy: is an incision into the renal
pelvis to remove stone.
• Ureterolithotomy: is an incision into the
ureter to remove stone.
• Cystotomy: indicated for the bladder calculi.
Mar-19 135

132. Mar-19 138

133. • The enlargement of the prostate causes
narrowing of the urethra and upward pressure
on the lower border of the bladder.
• Urinary retention may develop, as the body
has a harder time emptying the bladder.
• Hydronephrosis and dilation of the renal
pelvis and ureter are complications of the
urinary retention due to overgrowth of the
prostate.
Mar-19 139

134. • Exact causes is unknown
• Aging.
• Family history.
• Ethnic background.
• Diabetes and heart disease.
• Lifestyle.
Mar-19 140

135. • Urinary hesitancy—difficulty initiating stream
of urine due to pressure on urethra and bladder
neck
• Urinary frequency—need to urinate frequently
due to pressure on bladder
• Urinary urgency—need to get to bathroom
quickly to urinate due to pressure on bladde
Mar-19 141

136. • Nocturia—need to get up at night to urinate
due to pressure on bladder
• Decrease in force of urinary stream
• Intermittent stream of urination
• Hematuria
Mar-19 142

137. Diagnostic evaluation
• Urography shows high volume of post-void
residual urine.
• PSA (prostate-specific antigen) may be mildly
elevated.
• Prostate ultrasound shows hypertrophy.
• Digital rectal exam reveals fullness of prostate and
loss).
• Urinalysis may show microscopic hematuria.
• BUN and creatinine levels may elevate, if renal
function is impaired
Mar-19 143

138. TREATMENT
• Administer alpha1-blockers for symptom relief:
• doxazosin
• tamsulosin
• terazosin
• Monitor blood pressure; hypotension may be
side effect of some alpha1-
blockers.
Mar-19 144

139. • Administer finasteride to relieve symptoms by
shrinking prostate gland.
• Monitor PSA levels periodically.
• Monitor renal function.
• Surgical removal of prostate tissue to relieve
pressure.
• Continuous bladder irrigation postoperatively.
•Administer antispasmodics for patients
experiencing bladder spasms.
Mar-19 145

140. Surgical management
• Transurethral resection of the prostate
(TURP)
• Transurethral incision of the prostate (TUIP)
• Transurethral microwave thermotherapy
(TUMT)
• Transurethral needle ablation (TUNA)
Mar-19 146

141. NURSING INTERVENTIONS
• Maintain the 3-port catheter postop. One port is
for irrigation, another is for drainage, and the
third to inflate a balloon that holds the catheter
in position.
• Monitor intake and output.
• Monitor vital signs for changes.
• Monitor postoperative patient’s bladder
irrigation: Monitor the amount of fluid instilled
and the amount of fluid returned an
Mar-19 147

142. • Document color of urinary output
postoperatively; the greatest risk of
hemorrhage is the first day after the operation.
• Monitor for bladder spasms which may
indicate blocked catheter drainage
postoperatively.
• Teach patient:
• Avoid caffeine, alcohol, decongestants,
anticholinergics which may increase
Mar-19 148

143. 5. Renal Cell Carcinoma
• It is the most common malignant renal tumor,
occurring twice as frequently in men as in
women.
• adenocarcinoma in the renal parenchyma &
develop with few if any symptoms.
• No known cause, but may be associated with
cigarette smoking.
• They are aggressive metastasize rapidly to
adjacent organs
Mar-19 149

144. Clinical manifestation:
• Commonly asymptomatic
• May be found as palpable abdominal
mass
• Intermittent ,painless hematuria may
occur
• Fatigue, anemia, anorexia, Wt- loss
• Class triad of symptoms: hematuria ,
flank pain,& palpable mass in flank
Mar-19 150

145. • Diagnostic Evaluation : Renal,
Ultrasonography
• Management: Chemotherapy, Radiation, &
surgery
Mar-19 151

146. 6. Orchitis
• Orchitis is inflammation of the testis (testicular
congestion).
• The S/S of orchitis usually have an abrupt onset,
including
• Testicular swelling on one or both sides
• Pain – mild to severe; Tenderness in one or both
testicles
• N/V, Fever
• Discharge from penis
• Prostate enlargement and tenderness
Mar-19 152

147. Causes - A number of bacterial & viral
organisms can lead to orchitis.
Bacterial orchitis – Most often resulted from
epididymitis, an inflammation of the coiled
tube (epididymis) that connects the vas
deferens and the testicle. Often the cause of the
infection is an STD, particularly gonorrhea or
Chlamydia.
Mar-19 153

148. Viral orchitis - Most cases are the result of
mumps. The mumps virus can spread from the
salivary glands to other parts of the body,
including the testicles.
Physical trauma – particularly in individuals
with hazardous occupation
Thermal – (radiation) decrease testicular
secretion & can cause atrophy of the testis.
Mar-19 154

149. Risk factors
• Not being immunized against mumps; Being
older than 45; Recurring UTI
• Surgery that involves the genitals or urinary
tract, b/s of the risk of infection
• Malformations in the urinary tract present at
birth (congenital)
• High-risk sexual behaviors that can lead to
STDs
Mar-19 155

150. Complications
• Orchitis may cause the affected testicle to
shrink (atrophy).
• Scrotal abscess
• Rarely it can impair fertility
Mar-19 156

151. Treatment
– Symptomatic Rx for viral orchitis: analgesics,
bed rest, elevating the scrotum and applying
cold packs.
– Antibiotic for bacterial orchitis
– Protection of STIs & Sexual partner
management if the cause is an STI
– Immunization against mumps
Mar-19 157

152. 7. Phimosis
• It is a condition in which the foreskin is
constricted so that it can not be retracted over
the glans penis.
• Cause – congenitally or inflammation
• Treatment - instruction to clean the preputial
area.
- Circumcision is the only management
Mar-19 158

153. 8. Paraphimosis
• It is a condition in which the foreskin is
retracted behind the glans penis & because of
narrowing and subsequent edema can not be
reduced back to its position.
• Treatment – manual reduction but
circumcision is the best management.
Mar-19 159

154. Phimosis is a tight prepuce that cannot be
retracted over the glans
Paraphimosis is a tight prepuce that, once retracted,
cannot be returned.
Mar-19 160

155. Mar-19 161

156. 1. Renal Failure
• Results when the kidneys cannot remove the
body’s metabolic wastes or perform their
regulatory functions.
Acute renal failure (ARF):
• ARF is a sudden and almost complete loss of
kidney function (decreased GFR) over a period
of hours to days.
Mar-19 162

157. ARF manifests with:
• Oliguria (<400 ml/day) ⇒ Most common
• Anuria (<50 ml/day)
• Normal urine volume Not common
• Rising serum cretinine & BUN levels
• Retention of other waste products (azotemia)
Mar-19 163

158. Cause:
• Prerenal (hypoperfusion of kidney)
• Volume depletion resulting from:
– Hemorrhage
– Renal loses (diuretics)
– GI losses (vomiting, diarrhea)
• Impaired cardiac efficiency resulting from:
– Myocardial infarction
– Heart failure
– Dysrhythmias
• Cardiogenic shock
Mar-19 164

159. • Vasodilation
• Intrarenal (actual damage to kidney tissues)
– Prolonged renal ischemia resulting from:
• Myoglobinuria (trauma, crush injuries,
burns)
• Hemoglobinuria (Transfusion reaction,
hemolytic anemia)
– Nephrotoxic agents such as:
• Heavy metals
• Solvents & chemicals
• Non-steroidal anti inflammatory drugs
Mar-19 165

160. • Post renal (obstruction to urine flow)
• Urinary tract obstruction, including:
–Calculi (stones)
–Tumors
–BPH
–Strictures
• Blood clots
Mar-19 166

161. ETIOLOGY
PRE RENAL
• Volume depletion
• Impaired cardiac efficiency
• vasodilatation
INTRA RENAL
• Prolonged renal ischemia
• Nephrotoxic agents
• Infectious process
POST RENAL
• Urinary tract obstructions
• Calculi
• strictures

162. Phases of ARF
Mar-19 168
Initiating phase
Oliguric phase
Diuretic phase
Recovery phase

163. Clinical Manifestation
– Almost every system of the body is affected
– The patient may appear critically ill & lethargic .
– The breath may have the odor of urine (uremic
fetor)
– CNS sign and symptoms
• Drowsiness
• Headache
• Muscle twitching
• seizures
Mar-19 169

164. Vomiting and/or diarrhea, which may lead
to dehydration.
Nausea.
Weight loss.
Nocturnal urination.
pale urine.
Less frequent urination, or in smaller amounts than
usual, with dark coloured urine

165. Haematuria.
Pressure, or difficulty urinating.
Itching.
Bone damage.
Non-union in broken bones.
Muscle cramps (caused by low levels of calcium which
can cause hypocalcaemia).:
Abnormal heart rhythms.
Muscle paralysis.

166. Swelling of the legs, ankles, feet, face and/or hands.
Shortness of breath due to extra fluid on the lungs
Pain in the back or side
Feeling tired and/or weak.
Memory problems.
Difficulty concentrating.
Dizziness.
Low blood pressure.

167. Assessment & diagnostic findings:
– Changes in urine
– Increased BUN & creatinine levels (Azotemia)
– Hyperkalemia
– Metabolic acidosis
– Anemia
Mar-19 173

168. Medical management
 Identify, treat, and eliminate any possible cause of
damage
 correcting fluid and electrolyte balance.
 Correct dehydration.
 Keeps other body systems working properly
 Furosemide, Torsemide, ethacrynic acid
 calcium gluconate and Sodium bicarbonate
 dialysis
Mar-19 174

169. Nursing management:
• Monitoring fluid & electrolyte balance
• Reducing metabolic rate
• Promoting pulmonary function
• Preventing infection
• Providing skin care
• Providing support
Mar-19 175

170. NUTRITIONAL THERAPY
Provide protein diet.
Calorie requirements are met with high carbo-
hydrate meals (carbo-hydrates have a protein-sparing
effect.
Foods and fluid containing potassium or
phosphorous (banana, coffee) are restricted.
Patient may require parenteral nutrition.

171. Prevention
A careful history (nephrotoxic antibiotic agent
aminoglycosides, gentamicin, tobramicine, etc.)
blood tests and urinalysis
Drink enough fluids
Difficulties urinating or blood in the urine should
prompt a visit
Treat hypotension promptly.
Prevent and treat infections promptly.
Pay special attention to wound, burns and other
precursors of sepsis.

172. B . Chronic Renal Failure (CRF)
CRF is a progressive, irreversible deterioration
in renal function in which the body’s ability to
maintain metabolic & fluid & electrolyte
balance fails, resulting in uremia or azotemia
(retention of urea & other nitrogenous wastes
blood).
Mar-19 178

173. ETIOLOGY• CHRONIC GLOMERULO
NEPHRITIS
• ACUTE RENAL FAILURE
• POLYCYSTIC KIDNEY DISEASE
• OBSTRUCTION
• REPEATED EPISODES OF
PYELONEPHIRITIS
• NEPHROTOXINES
• SYSTEMIC DISEASES LIKE,
 DIABETES MELLITUS
 HYPERTENSION
 LUPUS ERYTHEMATOSIS
 POLY ARTERITIS
 SICKLE CELL DISEASE
 AMYLOIDOSIS

174. DUE TO ETIOLOGICAL FACTORS
DECREASED GFR
HYPERTROPHY OF REMAINING NEPHRONS
INABILITY TO CONCENTRATE URINE
FURTHER LOSS OF NEPHRON FUNCTION
LOSS OF NON-EXCRETORY AND EXCRETORY FUNCTION

175. STAGES OF CRF
1) Reduced Renal reserve
- BUN is high or normal
- Client has no C/M
- 40 to 75 % loss of nephron
function
2) Renal Insufficiency
- 75 to 90 % loss of nephron
function
- Impaired urine
concentration
- Nocturia, mild anemia,
increased Creatinine and
BUN

176. Renal failure
- Severe azotemia
- Impaired urine dilution
- Severe anemia
-Electrolyte Imbalances
Hypernatremia
Hyperkalemia
Hyperphosphatemia
4) End Stage Renal Disease
-10 percentage nephrons
functioning
-Multisystem dysfunction

177. CLINICAL MANIFESTATIONS
• REDUCED RENAL RESERVE
• RENAL INSUFFICIENCY
• RENAL FAILURE
• ESRD

178. DIAGNOSTIC EVALUATION
• HISTORY AND PHYSICAL EXAMINATION
• CREATININE CLEARANCE TEST
• RENAL FUNCTION TEST
• SERUM ELECTROLYTES
• BLOOD ROUTINE
• URINE ANALYSIS

179. DIALYSIS

180. DIALYSIS
PRINCIPLES
• ULTRAFILTRATION
• DIFFUSION

181. PERITONEAL DIALYSIS

182. PERITONEAL DIALYSIS

183. TYPES OF PERITONEAL DIALYSIS
• continuous ambulatory peritoneal
dialysis
• automated peritoneal dialysis
• continuous cyclic peritoneal dialysis
• intermittent peritoneal dialysis
• nightly intermittent peritoneal
dialysis

184. HEMODIALYSIS

185. ARTERIOVENOUS FISTULA

186. HEMODIALYSIS

187. MEDICAL MANAGEMENT
• DIET
• MEDICATIONS
 VITAMINE SUPPLEMENTS
 CALCIUM SUPPLIMENT
 STOOL SOFTNERS
 ANTIHYPERTENSIVES
 EPOETIN ALPHA

188. Medications
* Hyperkalemia
- Insulin administration – I/V
- Sodium bicarbonate
- Calcium Gluconate – I/V
- Sodium polystrene suffocate(Kayexalate)

189. Hypertension
• Sodium and fluid restriction
• Anti hypertensive drugs
• Diuretics
• Beta adrenergic blockers
• Ca channel blockers
• ACE inhibitors

190. Renal osteodystrophy
- Regulation of calcium, phosphorus
and acidosis
- Treatment of hyperparathyroidism
- Calciferol
- Paricalcitol (Vitamin D analog)
- Calcium based phosphate binders
Calcium acetate
Calcium carbonate

191. Anaemia
- Erythropoietin – I/V
subcutaneously
- Epogen ( Epoetin alfa)
- Parental iron
- Folic Acid 1 mg daily
* Diuretics
- Given early to stimulate excretion
of water

192. Vitamins
Supplemental water soluble
vitamins
• Diet
Protein restriction
0.6 to 0.75 gm/kg of ideal body
weight/day(1.2 to 1.3 gm/kg of ideal
body
weight/day once the patient starts
dialysis)
Phosphate restriction
- 1000 mg/day
Potassium restriction
2 to 4 gm/day
Sodium restriction
- 2 to 4 gm/day

193. Water restriction
Patient not receiving dialysis – 600ml + an
amount equal to the previous days urine out
put
Patients on dialysis – fluid intake is adjusted so
that weight gains are not more than 1 to 3 kg
between dialysis

194. SURGICAL MANAGEMENT
• RENAL TRANSPLANTATION

197. NURSING MANAGEMENT
• Educate regarding ESRD, treatment options, potential
complications
• Emotional support
• Evaluate level of anxiety
• Involve family in the assessment to determine their ability to
cope with disease
• Assess the patency of venous access site,graft for thrill or
vibrating sensation

198. Clinical manifestations:
• Cardiovascular manifestations
– Hypertension
– Heart failure
– Pulmonary edema
– Pericarditis
• Dermatologic symptoms
– Severe itching (pruritus) is common
– Uremic frost (the deposit of urea crystals on the skin.
Mar-19 204

199. • Other systemic manifestations
• Anorexia
• Vomiting
• Hiccups
• Alterd level of conciousness
• Inability to concentrate
• Muscle twitching
• Seizures
Mar-19 205

200. 2. Nephrotic syndrome
• It is a clinical disorder of unknown cause
characterized by proteinuria,
hypoalbuminemia, edema, & hyperlipidemia.
These conditions result from excessive leakage
plasma proteins in to the urine b/s of
impairment of the glomerular capillary
membrane.
• Categorized as congenital, primary
(idiopathic), & secondary
Mar-19 206

201. • Secondary to URTIs, Immunization, Chronic
glomerulonephritis, DM, Systemic Lupus
Erythematous, Renal vein thrombosis, &
Malignancy
• The loss of proteins, particularly albumin,
reduces oncotic pressure & causes edema.
Mar-19 207

202. Clinical manifestation:
• Insidious onset of pitting edema, periorbital
edema, Ascites, Pleural effusions
• Decreased Urine output
• Irritability, fatique, Anorexia, N/V
• Profound Wt gain (Child may double wt)
• Wasting of skeletal muscles
Mar-19 208

203. Diagnostic Evaluation:
– Urinalysis – Protein 2+ or greater
- Numerous casts
– Serum – Total protein & albumin reduced
- Cholesterol & triglycerides
elevated
- May be normal or increased
creatinine
– Needle biopsy of kidney may be necessary to
confirm diagnosis
Mar-19 209

204. Management:
– Treat causative glomerular disease
– Restriction of Na & fluids, Liberal intake of K
– Dietary protein supplements
– Paracentesis for severe ascites
– Low saturated fat diet
– Corticosteroid & Immunosuppressant to reduce
proteinuria
– Diuretics
– Infusion of salt-poor albumin to raise oncotic pressure
& shift fluid from interstitial to intravascular space.
Mar-19 210

205. Glomerulonephritis
Glomerulonephritis is an inflammation of
the glomerular capillaries.
(Brunner)
.

206. TYPES
Acute Glomerulonephritis.
Chronic Glomerulonephritis

207. ACUTE GLOMERULONEPHRITIS.
TYPES
• Post infectious Glomerulonephritis.
• Rapidly progressive Glomerulonephritis.
• Membrane proliferative Glomerulonephritis.
• Membranous Glomerulonephritis.

208. ETIOLOGY
Beta hemolytic streptococcal infection of the
throat.
Impetigo
Acute viral infections(upper resp.tract
infections,mumps , varicella zoster
virus,epstein barr virus,hepatitis B and HIV
infection.
Medications
Foreign serum.

209. Beta streptococcal infection impetigo
mumpsEpstein barr virus & it’s infection
ETIOLOGY

210. CLINICAL MANIFESTATIONS
PRIMARY PRESENTING FEATURES
Edema
azotemia
Cola colored urine (due to RBC protein plugs or casts)
Acute renal failure
Oliguria,proteinuria
hypertension
Hyperlipidemia
Hypoalbuminemia
Increased BUN and S.creatinine
Decreased urine output.
Hematuria

211. CLINICAL MANIFESTATIONS
Edema of face
Edema of hands
Engorged
neck veins

212. DIAGNOSTIC FINDINGS
Enlarged kidney
Immunofluroscent analysis
Electron microscopy
Kidney biopsy

213. COMPLICATIONS
Crescent shape
Crescent shaped cells in bowman's
capsule-microscopic view
Hematuria

214. MANAGEMENT
MEDICAL MANAGEMENT
Preserve kidney functions and treat complications
corticosteroids
Manage hypertension
Control proteinuria
Penicillin for streptococcal infection
Dietary protein for renal insufficiency and nitrogen
retention
Sodium restriction if patient has hypertension , edema
and heart failure.

215. NURSING MANAGEMENT
HOSPITAL CARE
• I/O chart carefully measured and recorded.
• Fluids based on the patient ‘s fluid losses and
daily bodyweight.
• Diuresis to decrease edema and blood pressure.
• Explain lab results and other diagnostic
procedures.

216. • It’s due to repeated episodes of acute nephritic
syndrome ,hypertensive nephrosclerosis,
hyperlipidemia ,chronic tubulointerstitial injury or
hemodynamically mediated glomerular sclerosis.

217. ETIOLOGY
amyloidosis nephritic syndrome
Good pasture's syndrome

218. CLINICAL MANIFESTATIONS
• Hypertension
• elevated BUN and S.creatinine
• Loss of weight and strength
• Increasing irritability
• Increased need to urinate at night
• Headache ,dizziness and digestive
disturbances.
• CKD and CRF develops.

219. • Poorly nourished patient with yellow grey
pigmentation of the skin.
• Peri orbital and peripheral edema
• Blood pressure normal or elevated
• Retinal findings :-hemorrhage, exudates,
narrowed tortuous arterioles and papilledema.
• anemia
• Cardiomegaly, gallop rhythm
• Distended neck veins
• Other symptoms of heart failure
• Crackles on the base of the lungs.

220. • Peripheral neuropathy with diminished
tendon reflexes.
• Neurosensory changes.
• patient is confused and limited attention
span.
• Later : pericarditis , pericardial friction rub
& pulsus paradoxus.

221. CLINICAL MANIFESTATIONS
Periorbital edema
Cardiomegaly
yellow grey pigmenta
of the skin

222. DIAGNOSTIC FINDINGS
URINE ANALYSIS:
Proteinuria
Urinary casts
GFR falls below 50ml/min
BLOOD ANALYSIS
Hyperkalemia due to decreased potassium
excretion
Metabolic acidosis due to the inability to
regenerate bicarbonate.
Anemia due to decreased erythropoiesis.

223. hypoalbunemia due to protein loss
Increased serum phosphorus due to decreased
renal excretion of phosphorous.
Decreased calcium level due to the binding of
calcium with the increased phosphorus.
Mental status changes
Impaired nerve conduction.
CHEST X-RAY
Cardiac enlargement
Pulmonary edema

224. ECG
Left ventricular hypertrophy associated with
hypertension.
Signs of electrolyte disturbances –tall T wave
due to hyperkalemia.
CT &MRI
Decrease in the size of renal cortex.

225. DIAGNOSTIC FINDINGS
Decreased renal
cortex size in MRI
tall T wave due to
hyperkalemia

226. Left ventricular hypertrophy

227. MANAGEMENT
MEDICAL MANAGEMENT.
Reduce BP with sodium and water restriction,
antihypertensives or both.
Daily weight monitoring
Diuretic medications to treat fluid overload.
Proteins of high biological value are
provided(dairy products, eggs and meats )

228. Adequate calories
Treat UTI.
Dialysis
–to prevent fluid and electrolyte imbalances.
_to minimize risk of complications

230. NURSING MANAGEMENT
Observe for the fluid and electrolyte imbalances.
Reduce anxiety of both the patient and family.
Give emotional support and Answer the
questions.
Vital signs every 4 hours; notify physician of
significant changes.
Weigh daily;
intake and output every 8 hour

231. Schedule fluids allowing 650 mL on day shift,
450 mL on evening shift, and 100 mL on night
shift.
•Arrange dietary consultation to plan a diet that
includes preferred foods as allowed.
•Provide small meals with high-carbohydrate
between-meal snacks.
Instruct in appropriate antibiotic use.

232. HOME AND CONTINUING CARE
Teach the prescribed treatment plan and risk
associated with non compliance.
Instruct for the follow up evaluations:-
Blood and urine analysis.
Dietary restrictions.
Teach how to observe for medication side effects. And
worsening signs( nausea , decreased urine output,etc)
If dialysis is initiated the patient and family require
considerable support in dealing with the long term
complications.

233. 10 Ways to Keep Kidneys Healthy
• Exercise regularly
• Don’t overuse over-the-counter painkillers or NSAIDs
• Control weight
• Get an annual physical
• Follow a healthful diet
• Know your family’s medical history
• Monitor blood pressure & cholesterol
• Learn about kidney disease
• Don’t smoke or abuse alcohol
• Talk to your doctor about getting tested if you’re at risk
for CKD
Mar-19 239

234. Mar-19 240