Genito-urinary disorder.pdf

Genitourinary disorders
By;- Tiwabwork T(AHN)
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By:- Tiwabwork T(AHN)
5/14/2023

Outline
• Anatomic and physiologic overview of GUS
• Assessment of GUS
• Common sign and symptoms of GUD
• Diagnostic modalities of GUD
• Genitourinary disorders
• Sexually transmitted infections
5/14/2023 By:- Tiwabwork T(AHN) 2

Objectives
At the end of this chapter you are expected to;-
• Mention the structure and function of genitourinary system
• Describe assessment of GUD
• Apply physical examination techniques
• Identify common diagnostic modalities of GUD
• List common sign/symptoms of GUD
• Differentiate each GUD
• Differentiate normal findings from the abnormal one
• Apply nursing process for patients with GUD

Anatomy & Physiology
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Figure: The Position of the Kidneys
Figure 26.2a, b

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Kidneys
Two bean-shaped- retro peritoneally
Each weighs 248.8 gm.
Size:
4 to 5 inches long
2 to 3 inches wide
1 inch thick
Receive 20-25% of the total cardiac output.
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Parts of kidney
Cortex
Outer layer of the kidney
most of the nephron
main site for filtration, reabsorption and secretion
Medulla
Inner core of the kidney
Used for salt, water and urea absorption

Nephron
Physiological unit of the kidney
Made up of two basic components:
The glomerulus and the attached tubule
Glomerulus
The site for blood filtration
Will remove both useful and non-useful material
(nonspecific filter)

Proximal convoluted tubule (PCT)
Reabsorbs most of the useful substances of the filtrate:
Sodium (65%)
Water (65%)
Bicarbonate (90%)
Chloride (50%)
Glucose (nearly 100%)
The primary site for elimination of drugs, waste and
hydrogen ions

Descending Limb of the Loop of Henle
Freely permeable to water and relatively
impermeable to solutes (salt particles)
“Saves water and passes the salt”
Ascending Limb of the Loop of Henle
Impermeable to water and actively transports
(reabsorbs) salt (NaCl) to the interstitial fluid
“Saves salt and passes the water.”

Distal Convoluted Tubule (DCT)
Sodium is reabsorbed and potassium is secreted.
Water and chloride follow the sodium.
Collecting Duct
The last segment to save water for the body
Peritubular Capillaries
Transport reabsorbed materials from the PCT and
DCT into kidney veins general circulation
Help complete the conservation process (reabsorption)
that takes place in the kidney

Function of the kidney
Urine formation
Excretion of waste products
Regulation of electrolytes
Regulation of acid–base balance
Control of water balance
Control of blood pressure
Hormonal secretion
Renine
Erythropoietin
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Summery

Assessment and
diagnostic evaluation
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Health History
Problems associated with changes in voiding
Frequency - voiding more than every 3 hours
Obstruction of the lower urinary tract
Anxiety
Drug
Disease- BPH, urethral stricture, DN , infection
Polyuria
DM, DI, Drugs

Oliguria – diminished quantity, <400ml/24 hours
Acute or chronic renal failure
Anuria- urine out put less than 50ml/day
Acute or chronic renal failure and complete
obstruction

Health…
Urgency- strong desire to void
Infection; chronic prostatitis, urethritis
Obstruction of the lower urinary tract
Anxiety
Diuretics
BPH
Urethral Stricture
Diabetic Neuropathy

Health…
Hesitancy- delay, difficulty in initiating voiding
BPH
Compression of urethra
Outlet obstruction
Neurogenic bladder

Health…
Nocturia
Decreased renal
concentrating ability
heart failure
DM
nephritic syndrome
cirrhosis with ascites
Dysuria
acute cystitis
Prostatitis
urethritis

Health…
Hematuria
Cancer of genitourinary tract
Acute glomerulonephritis
Renal stones
Renal tuberculosis
Trauma

Health…
Difficulty of controlling urine (Incontinence)
True incontinence- loss of urine without warning
Urgency incontinence- sudden loss, as with acute
cystitis
Stress incontinence- loss of urine with physical
strain due to weakness of sphincters
History of renal disease, renal stones, flank pain,
urinary tract infections, and prostate trouble

Physical Examination
Landmarks
The costovertebral angle
The rectus abdominis muscles-
longitudinal muscles extending
from the pubis to the ribs
on either side of the midline.
The symphysis

Inspection
General appearance and mental status.
Edema of face and dependent parts of the body
Hydration status and skin color
The costovertebral angles and flanks
Color
Symmetry
Masses

Auscultation
The renal arteries are auscultated for bruits

Percussion
Helps to assess pain or tenderness.
Pain elicited by blunt percussion of the back, flanks,
and costovertebral angle
Pyelonephritis
Calculi

Assessing Kidney Tenderness
Costo-vertebral angle(CVA) tenderness.
• Assist the client to a sitting position, and stand behind
the client.
For indirect percussion
• Place the palm of your non dominant hand over the
costovertebral angle
• Strike this area with the ulnar surface of your dominant
hand, curled into a fist
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Kidney Tenderness..
• Repeat the technique for the other kidney.
• You should do percussion of the kidneys with only
enough force so the client feels a gentle strike.
• Percussion is usually done at the end of the assessment.
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Assessing Kidney Tenderness…
Costovertebral angle
12th rib
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Percussion…
Urinary bladder
To check for residual urine
Begins at the midline just above the umbilicus
and proceeds downward.
The sound changes from tympanic to dullness
when percussing over the bladder

Kidneys palpation
• Kidneys are usually not palpable in adults unless
quite enlarged
• Kidneys are deep in the flank and move down with
inspiration.
To Palpate for masses :
• Use deep pressure with the palmar aspect of your
fingers, with a rolling motion.
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Kidneys…
• To palpate the right kidney
• Rest your left hand at the 12 ribs and your right hand
gently in the right upper quadrant lateral and parallel to
the rectus muscle.
• Ask the patient to breath deep and at the peak of
inspiration press your right hand firmly and deeply
in to the right upper quadrant just below the costal
margin and try to capture the kidney
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Kidneys…
• Ask the patient to breath out and then stop breathing briefly.
• Slowly release the pressure of your upper hand feeling at
the same time for the kidney to slide back in to the
respiratory position.
• To palpate the left kidney be on the left side & do similarly
• The left kidney sits 1cm higher than the right kidney and is
not palpable normally.
• The right kidney is palpable more often than the left.
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Palpation of the Right Kidney
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Palpation of Kidneys
Right kidney (take a deep
breath, capture kidney,
exhale, slowly release kidney
Left kidney (take a deep breath,
capture kidney, exhale, slowly
release kidney)
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The Bladder
• Should be distended above the symphysis pubis.
• On palpation, the dome of the distended bladder feels
smooth and round. Check for tenderness.
• Bladder percussion is unnecessary unless there is a
suspicion of urinary retention
• Use percussion to check for dullness and to determine how
high the bladder rises above the symphysis pubis.
Abnormal
• Bladder distention from outlet indicates obstruction due to
urethral stricture, prostatic hyperplasia
• Suprapubic tenderness in bladder infection
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Digital rectal examination(DRE)
 Recommended
mainly > 40 yrs
 Annually
 Prostate gland
 Size, shape and
consistency

Diagnostic Evaluation
Urinalysis:
Color and appearance
PH
Specific gravity
Protein
Glucose
RBCs
WBCs
Casts
Crystals
Renal Concentration Tests
Specific gravity and urine osmolality

Cytology
Gram stain and culture
Renal function test
BUN
Creatinine clearance (CrCl) - a measure of GFR
Normal value 70±14 ml/min/m2 for men &
60±10ml/min/m2 for women
Diagnostic …

• X-rays(Kidney, Ureter, Bladder)
• Computed tomography (CT scan)
• Ultra Sound
• Cystoscopy
• Magnetic Resonance Imaging
• Intravenous Urography
• Biopsy
• ECG
Diagnostic …

Fluid imbalance
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Objectives
• At the end of this session, the you will be able to:
• Describe the pathophysiology of fluid imbalance
• Describe common types of fluid imbalance
• Identify the symptoms of fluid imbalance
• Apply the nursing management for patients with fluid
imbalance
• Apply nursing process for patients with fluid
imbalance

Fluid balance
• Approximately 60% of the weight of a typical adult
consists of fluid.
• Factors that influence the amount of body fluid are age,
gender and body fat.
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Fluid …
• The ECF compartment is divided into the intravascular,
interstitial, and transcellular fluid spaces.
• The intravascular space contains plasma
• Approximately 3L of the average 6L of blood volume is
made up of plasma.
• The remaining 3L is made up of erythrocytes, leukocytes,
and thrombocytes.
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Fluid Volume Disturbances:
Hypovolemia(FVD)
• Occurs when loss of ECF volume exceeds the intake of
fluid.
• It occurs when water and electrolytes are lost in the same
proportion as they exist in normal body fluids.
• The ratio of serum electrolytes to water remains the same.
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Hypovolemia…
• Should not be confused with the term dehydration, which
refers to loss of water alone, with increased serum sodium
levels.
• It may occur alone or in combination with other
imbalances.
• FVD results from loss of body fluids and occurs more
rapidly when coupled with decreased fluid intake. 49
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Etiology
• Vomiting & diarrhea
• GI suctioning
• Sweating
• Inability to gain access
to fluids,
• Diabetes insipidus
• Adrenal insufficiency
• Osmotic diuresis
• Hemorrhage
• Movement of fluid from
the vascular system to
other body spaces
• Edema in burns, ascites

Clinical Manifestations
Acute weight loss
Decreased skin turgor
Oliguria
Postural hypotension
A weak rapid heart rate
Flattened neck veins
Cool, moist skin
Thirst, anorexia
nausea;
Muscle weakness and
cramps
Decreased central
venous pressure
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Diagnosis
• Health history and P/E.
• BUN
• Can be elevated because of dehydration or decreased
renal perfusion and function.
• Hematocrit level
• Greater than normal
• Potassium & sodium levels can be reduced or elevated;
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Medical Management
• Provide isotonic electrolyte solutions (e.g., lactated
Ringer's, 0.9% sodium chloride)
• Asses level of consciousness, breath sounds, and skin
color
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Nursing Management
• Monitors and measures fluid I & O at least every 8
hours, and sometimes hourly.
• Daily body weights are monitored
• Vital signs are closely monitored.
• Observes for a weak, rapid pulse and postural
hypotension.
• Skin turgor is monitored on a regular basis.
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Hypervolemia (FVE)
• Isotonic expansion of the ECF caused by the abnormal
retention of water and sodium in approximately the same
proportions in which they normally exist in the ECF.
• Related to diminished function of the homeostatic
mechanisms responsible for regulating fluid balance.
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Contributing factors
• Heart failure
• Renal failure
• Cirrhosis of the liver.
• Consumption of excessive amounts of salt.
• Excessive administration of sodium-containing fluids.
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• Edema
• Distended neck veins, and crackles.
• Tachycardia
• Increased blood pressure, weight
• Increased pulse pressure
• Increased urine output
• Shortness of breath and wheezing. 57
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Clinical …
• Azotemia can occur when urea and creatinine are not
excreted due to decreased perfusion by the kidneys and
decreased excretion of wastes.
• High uric acid levels occur due to increased
reabsorption and decreased excretion of uric acid by the
kidneys.

Diagnosis
• Decreased BUN and hematocrit levels
• Sodium level are decreased due to excessive retention of
water.
• Chest x-rays to r/o pulmonary congestion.
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Medical Management
• Cause management
• Symptomatic treatment consists of administering diuretics
and restricting fluids and sodium.
• Thiazide diuretics / Loop diuretics, like furosemide
• Hypokalemia
• Dialysis- if kidney function impaired
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Nursing Management
• Dietary restriction of sodium
• Measures I & O
• Weight monitoring
• Monitors the degree of edema
• Promoting bed rest
• Monitoring parenteral fluid therapy
• Administering appropriate medications.
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Electrolyte Imbalances
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Objectives
• Describe the pathophysiology of electrolyte Imbalances
• Describe common electrolyte Imbalances
• Identify the symptoms of common electrolyte Imbalances
• Differentiate each types of electrolyte Imbalances
• Apply the nursing management for patients with common
electrolyte Imbalances
• Apply nursing process for patients with electrolyte
Imbalances

Electrolytes
Active chemicals (cations and anions).
• Cations; sodium, potassium, calcium, magnesium, and
hydrogen ions.
• Anions; chloride, bicarbonate, phosphate, sulfate, and
proteinate ions.
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Major electrolyte content in body fluid
Extracellular Fluid (Plasma) in mEq/L
Cations
• Sodium (Na)......... 142
• Potassium (K)........... 5
• Calcium (Ca++)......... 5
• Magnesium (Mg++)… 2
• Total….154
Anions
• Chloride (Cl-)………
103
• Bicarbonate (HCO3-
)….6
• Phosphate (HPO4-)-2
• Sulfate (SO4-)…….1
• Organic acids……5
• Proteinate….. 17
• Total ….. 154
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Major electrolyte …
Intracellular Fluid
Cations
Potassium (K+)……50
Magnesium (Mg++)…40
Sodium (Na+)……….10
Total ….200
Anions
• Phosphates and
sulfates…….150
• Bicarbonate (HCO3-
)…10
• Proteinate……40
• Total ……..200
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Sodium Imbalances
• Sodium concentration ranges from 135 to 145 mEq/L.
• Role in controlling water distribution.
• Sodium is regulated by ADH, thirst, and the renin–
angiotensin–aldosterone system.
• It is the primary regulator of ECF volume.
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Hyponatremia
 A serum sodium level that is below <135 mEq/L.
Sodium may be lost by way of vomiting, diarrhea, or
sweating, deficiency of aldosterone & low-salt diet.
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• Poor skin turgor
• Dry mucosa
• Headache
• Decreased saliva production,
• Orthostatic fall in blood pressure
• Nausea and abdominal cramping
• If cellular swelling and cerebral edema
• Altered mental status, status epilepticus, and coma
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• Signs of increasing intracranial pressure
• Such as lethargy, confusion, muscle twitching, focal
weakness, hemiparesis, papilledema, and seizures.
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Clinical…

Diagnosis
• The serum sodium level is less than 135 mEq/L
• Serum osmolality is also decreased, except in azotemia
• The specific gravity is low
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Medical Management
Sodium Replacement
• By mouth, nasogastric tube, or a parenteral route.
Water Restriction
• Restricting fluid to a total of 800 mL in 24 hours.
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Hypernatremia
• Serum sodium level > 145 mEq/L.
• Caused by a gain of sodium in excess of water or by a loss of
water in excess of sodium.
• Occur in patients with normal fluid volume or FVD or FVE.
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Hypernatremia…
Cause
Administration of hypertonic enteral feedings without
adequate water supplements, watery diarrhea and greatly
increased insensible water loss (eg, hyperventilation, burns).
Diabetes insipidus
Deficiency of ADH
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• Cellular dehydration
• Thirst
• Restlessness and weakness
• Disorientation
• Delusions
• Hallucination
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Diagnosis
• Serum electrolyte level
• In hypernatremia >145 mEq/L and the serum osmolality >300
mOsm/kg (300 mmol/L).
• U/A
• The urine specific gravity and urine osmolality are increased as
the kidneys attempt to conserve water.
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Medical Management
• Infusion of a hypotonic electrolyte solution (eg, 0.3%
sodium chloride) or an isotonic non saline solution (eg,
dextrose 5% in water.
• D5W is indicated when water needs to be replaced
without sodium.
• Desmopressin acetate- synthetic ADH
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Potassium Imbalances
• Potassium is the major intracellular electrolyte
• Potassium influences both:
• skeletal and
• Cardiac muscle activity.
• The normal serum potassium concentration ranges from
3.5 to 5.0 mEq/L (3.5 to 5 mmol/L).
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Etiology
• Potassium imbalances are commonly associated with
various diseases, injuries, medications (e.g., NSAIDs
and ACE inhibitors), and acid–base imbalances.
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Hypokalemia
• Hypokalemia (<3.5 mEq/L) usually indicates a deficit in
total potassium stores.
• However, it may occur in patients with normal potassium
stores:
• When alkalosis is present, a temporary shift of serum
potassium into the cells occurs.
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Cause
• Potassium-losing diuretics,
• Medications include corticosteroids, sodium penicillin,
carbenicillin, and amphotericin B.
• GI loss of potassium, Diarrhea
• Prolonged intestinal suctioning
• Alterations in acid–base balance
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• Clinical signs rarely develop before the serum potassium
level has decreased to less than 3 mEq/L (3 mmol/L)
• Fatigue, anorexia, nausea, vomiting,
• Leg cramps, decreased bowel motility, paresthesias
(numbness and tingling), and dysrhythmias.
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Clinical ...
• Potassium depletion suppresses the release of insulin
and results in glucose intolerance.
• Decreased muscle strength
• Cardiac or respiratory arrest
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Diagnostic findings
• The serum potassium concentration is less than the lower
limit of normal.
• Hypokalemia increases sensitivity to digitalis(its toxicity)
• Metabolic alkalosis is commonly associated with
hypokalemia.
• A 24-hour urinary potassium excretion test can be performed
to distinguish between renal and extra-renal loss.
• Urinary potassium excretion exceeding 20 mEq/day with
hypokalemia suggests that renal potassium loss is the cause.
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Medical Management
• Administration of 40 to 80 mEq/day of potassium
• Foods high in potassium include most fruits and
vegetables, legumes, whole grains, milk, and meat.
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Nursing management
• Hypokalemia can be life-threatening, the nurse needs
to monitor.
• Careful monitoring of clinical manifestation
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Potassium excess (hyperkalemia)
• Hyperkalemia (>5.0 mEq/L) seldom occurs in patients
with normal renal function.
• Often caused by iatrogenic (treatment-induced) causes.
• Less common than hypokalemia
• Usually more dangerous, (cardiac arrest)
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Causes
• The three major causes of hyperkalemia are:
• Decreased renal excretion of potassium
• Rapid administration of potassium, and
• Movement of potassium from the ICF compartment
to the ECF compartment.
• Extensive tissue trauma has occurred, as in burns,
crushing injuries, or severe infections.
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• The most important consequence of hyperkalemia is its effect
on the myocardium.
• Peaked, narrow T waves; ST-segment depression; and a
shortened QT interval.
• If continues to increase, the PR interval becomes prolonged
and is followed by disappearance of the P waves.
• Widening of the QRS complex
• Ventricular dysrhythmias
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Clinical ….
• Severe hyperkalemia causes
Skeletal muscle weakness and even paralysis.
Rapidly ascending muscular weakness leading to
flaccid quadriplegia.
Paralysis of respiratory and speech muscles.
GI manifestations, such as nausea, intermittent
intestinal colic, and diarrhea.
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Diagnosis
• Serum potassium levels and ECG
• Arterial blood gas analysis - acidosis
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Medical Management
• Administer IV calcium gluconate
• Monitoring the blood pressure is essential to detect
hypotension,
• Which may result from the rapid IV administration of
calcium gluconate.
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Nursing Management
• Patients at risk for potassium excess (e.g., those with
renal failure) need to be identified and closely monitored
for signs of hyperkalemia.
• Observes for signs of muscle weakness and dysrhythmias
and the presence of paresthesias.
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HYPOCALCEMIA
• Hypocalcemia (< 8.5 mg/dL)
• A patient may have a total body calcium deficit (as in
osteoporosis) but a normal serum calcium level.
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Causes
• Hypoparathyroidism
• Massive administration of citrated blood (i.e., massive
hemorrhage and shock),
• Because citrate can combine with ionized calcium and
temporarily remove it from the circulation.
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Causes…
• Hypocalcemia is common in patients with renal failure,
• Because these patients frequently have elevated serum
phosphate levels.
• Hyperphosphatemia usually causes a reciprocal drop in
the serum calcium level.
• Inadequate vitamin D consumption, magnesium
deficiency, medullary thyroid carcinoma, low serum
albumin levels, alkalosis, and alcohol abuse.
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• Tetany
• Sensations of tingling in the tips of the fingers, around the
mouth, and, less commonly, in the feet.
• Spasms of the muscles of the extremities and face-Pain
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Clinical…
• Trousseau’s sign can be elicited by inflating a blood pressure
cuff on the upper arm to about 20 mm Hg above systolic
pressure; within 2 to 5 minutes, carpal spasm (an adducted
thumb, flexed wrist and metacarpophalangeal joints, extended
interphalangeal joints with fingers together) will occur as
ischemia of the ulnar nerve develops.
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Clinical…
• Chvostek’s sign consists of twitching of muscles enervated by
the facial nerve when the region that is about 2 cm anterior to
the earlobe.
• If hypocalcemia increases- seizures
• Mental changes such as depression, impaired memory,
confusion, delirium.
• Loss of bone mass- porous and brittle - susceptible to fracture.
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Diagnosis
• Clinical manifestation
• Evaluating serum calcium levels
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Medical Management
• IV administration of a calcium salt.
• Parenteral calcium salts include calcium gluconate,
calcium chloride, and calcium gluceptate.
• Too-rapid IV administration of calcium can cause cardiac
arrest, preceded by bradycardia.
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Medical…
• IV administration of calcium is particularly dangerous in
patients receiving digitalis-derived medications.
• Therefore, calcium should be diluted in D5W and
administered as a slow IV bolus or a slow IV infusion
• A 0.9% sodium chloride solution should not be used with
calcium because it increases renal calcium loss.
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Medical…
• Vitamin D therapy may be instituted to increase calcium
absorption from the GI tract
• Increasing the dietary intake of calcium to at least 1000
to 1500 mg/day in the adult is recommended.
• Calcium-containing foods include milk products; green
leafy vegetables.
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Nursing Management
• Safety precautions are taken, as indicated, if confusion is
present.
• It is important to teach the patient what foods are rich in
calcium.
• Consider calcium supplements if sufficient calcium is not
consumed in the diet.
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Nursing…
• Alcohol and caffeine in high doses inhibit calcium
absorption
• Moderate cigarette smoking increases urinary calcium
excretion.
• Avoid the overuse of laxatives and antacids that contain
phosphorus, because their use decreases calcium
absorption.
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Hypercalcemia
• Hypercalcemia(>10.5mg/dL) is a dangerous imbalance
• Hypercalcemic crisis has a mortality rate as high as
50% if not treated promptly
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Causes
• Malignancies and hyperparathyroidism.
• Prolonged immobilization
• Vitamin D intoxication, as well as chronic lithium use
and theophylline toxicity, can cause calcium excess.
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• Anorexia, nausea, vomiting, and constipation
• Severe thirst
• Confusion, impaired memory, slurred speech, lethargy
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Clinical …
• Hypercalcemic crisis
refers to an acute rise to 17 mg/dL or higher.
Severe thirst and polyuria
Muscle weakness, intractable nausea, abdominal
cramps, severe constipation, diarrhea, peptic ulcer
symptoms, and bone pain.
This condition is dangerous and may result in cardiac
arrest.
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Assessment and diagnostic findings
• The serum calcium level is greater than 10.5 mg/dL
• Variety of dysrhythmias (i.e., heart blocks) and
shortening of the QT interval and ST segment.
• The PR interval is sometimes prolonged.
• X-rays may reveal bone changes
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Medical Management
• Treating the underlying cause (e.g., chemotherapy for a
malignancy, partial parathyroidectomy for
hyperparathyroidism)
• Mobilizing the patient
• Restricting dietary calcium intake
• Pharmacologic Therapy:
Administering fluids to dilute serum calcium and
promote its excretion by the kidneys
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Medical…
Administering IV phosphate can cause a reciprocal drop
in serum calcium.
Furosemide (Lasix) is often used in conjunction with
administration of a saline solution
 Also increases calcium excretion.
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Medical…
• Calcitonin reduces bone resorption, increases the
deposition of calcium and phosphorus in the bones, and
increases urinary excretion of calcium and phosphorus .
• For patients with cancer, treatment is directed at
controlling the condition by surgery, chemotherapy, or
radiation therapy.
113
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Nursing Management
• Increasing patient mobility and encouraging fluids
• Early ambulation in hospitalized patients
• Those who are outpatients and receive home care are
instructed about the importance of frequent ambulation.
114
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Acid - base
Disturbances

Objectives
• Describe the pathophysiology of acid base imbalance
• Identify the symptoms of acid base imbalance
• Differentiate each types of acid base imbalance
• Apply the nursing management for patients with acid
base imbalance
• Apply nursing process for patients with acid base
imbalance

Acid - base Disturbances
• Plasma pH is an indicator of hydrogen ion (H+)
concentration
• H+ is a proton
• Range is from 0 - 14
117
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118
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Acid – base…
• Homeostatic mechanisms keep pH within a normal range
(7.35 to 7.45).
• These mechanisms consist of buffer systems, the
kidneys, and the lungs.
119
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Acid – base…
• Buffer systems prevent major changes in the pH of body
fluids by removing or releasing H+.
• The major EC buffer system is the bicarbonate–
carbonic acid buffer system.
• CO2 is a potential acid; when dissolved in water, it
becomes carbonic acid (CO2 + H2O = H2CO3).
• Therefore, when CO2 is increased, the carbonic acid
content is also increased, and vice versa.
120
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Acid – base…
• Even a slight variance outside of normal can be life-
threatening.
121
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• Causes depression of the CNS through ↓ in synaptic
transmission.
• Generalized weakness
• If severe - disorientation, coma and death
122
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Acidosis

• Causes over excitability of the central and PNS
• Numbness
• Lightheadedness
• Nervousness
• Muscle spasms or tetany
• Convulsions
• Loss of consciousness
• Death
123
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Alkalosis

Types of acid - base imbalances
• There are four types of acid - base imbalances:
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
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Metabolic Acidosis
• Base Bicarbonate Deficit
• It is a clinical disturbance characterized by a low pH
(increased H+ concentration) and a low plasma
bicarbonate concentration.
• It can be produced by a gain of hydrogen ion or a loss of
bicarbonate.
125
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• Vary with the severity of the acidosis.
• Headache
• Confusion
• Drowsiness
• Hyperventilation
• Increased respiratory rate and depth,
• Nausea and vomiting
126
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Clinical…
• Peripheral vasodilation
• Decreased cardiac output -when the PH < 7.
• Decreased blood pressure
• Cold and clammy skin
• Dysrhythmias and shock.

Diagnosis
• Arterial blood gas analysis
• Low bicarbonate level (< 22 mEq/L) and a low pH
(<7.35).
• ECG to detect dysrhythmia
128
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Medical Management
• Treatment is directed at correcting the metabolic defect .
• Bicarbonate is administered if the pH is less than 7.1 and
the serum bicarbonate level is less than 10 mEq/L.
• The serum potassium level is monitored closely
129
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Metabolic Alkalosis
• Base bicarbonate Excess
• Characterized by a high pH (decreased H+ concentration)
and a high plasma bicarbonate concentration.
• Caused by
• Vomiting or gastric suction with loss of hydrogen and
chloride ions.
• loss of potassium, such as diuretic therapy
130
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• Tingling of the fingers and toes
• Dizziness
• Hypertonic muscles
• Respirations are depressed as a compensatory Mzm
• Tachycardia
• PH increases to > 7.6 and hypokalemia develops
• Decreased motility and paralytic ileus.
131
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Assessment and Diagnostic Findings
• Arterial blood gases
• pH greater than 7.45 and a serum bicarbonate
concentration greater than 26 mEq/L.
• Urine chloride levels help identify the cause of
metabolic alkalosis.
132
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Assessment….
• In patients with vomiting, those receiving diuretic
therapy, and hypovolemia produce urine chloride
concentrations lower than 25 mEq/L.
• Urine chloride concentration exceeds 40 mEq/L in
patients with mineralocorticoid excess.
• The urine chloride concentration should be less than 15
mEq/L when decreased chloride levels.
133
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Medical Management
• Aimed at correcting the underlying cause .
• The patient's fluid I & O must be monitored carefully.
• Sufficient chloride must be supplied for the kidney to
absorb sodium with chloride (allowing the excretion of
excess bicarbonate).
• Restoring normal fluid volume by administering sodium
chloride fluids.
134
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Medical …
• In patients with hypokalemia, potassium is administered
as KCl to replace both K+ and Cl- losses.
• H2 receptor antagonists, such as cimetidine, reduce the
production of gastric HCl, thereby decreasing the
metabolic alkalosis associated with gastric suction.
135
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Respiratory Acidosis (Carbonic Acid Excess)
• A clinical disorder in which the pH is less than 7.35 and
the PaCO2 is greater than 42 mmHg.
• Occurs due to inadequate excretion of CO2 with
inadequate ventilation, resulting in elevated plasma CO2
concentrations and, consequently, increased levels of
carbonic acid.
• In addition hypoventilation usually causes a decrease in
PaO2.
136
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Respiratory Acidosis…
• Acute pulmonary edema
• Aspiration of a foreign object,
• Atelectasis
• Pneumothorax
• Overdose of sedatives
137
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• Sleep apnea syndrome
• Severe pneumonia, and
• Acute respiratory distress
syndrome
Acute respiratory acidosis occurs in emergency situations,
such as

• Sudden hypercapnia (elevated PaCO2) can cause
• Increased pulse and respiratory rate, increased blood
pressure
• Mental cloudiness, and a feeling of fullness in the head.
• Cerebrovascular vasodilation
138
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Clinical…
• Hyperkalemia may result as the hydrogen concentration
overwhelms the compensatory mechanisms and H+
moves into cells, causing a shift of potassium out of the
cell.
• If the PaCO2 increases rapidly, cerebral vasodilation will
increase the intracranial pressure, and cyanosis and
tachypnea will develop.
139
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• Arterial blood gas analysis
• pH lower than 7.35, a PaCO2 greater than 42 mm
Hg
• Serum electrolyte levels,
• Chest x-ray for determining any respiratory disease,
• Drug screen if an overdose is suspected.
• An ECG to identify any cardiac involvement
140
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Medical Management
• Treatment is directed at improving ventilation.
• Bronchodilators help reduce bronchial spasm
• Antibiotics are used for respiratory infections
• Thrombolytics or anticoagulants for pulmonary emboli.
• Adequate hydration (2 to 3 L/day)
• Supplemental oxygen is administered as necessary.
141
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Medical…
• Mechanical ventilation
• Placing the patient in a semi-Fowler's position facilitates
expansion of the chest wall.
142
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Respiratory Alkalosis (Carbonic Acid Deficit)
• A clinical condition in which the arterial pH is greater
than 7.45 and the PaCO2 is less than 38 mm Hg.
• Caused by hyperventilation, which causes excessive
“blowing off” of CO2 and, hence, a decrease in the
plasma carbonic acid concentration.
143
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Causes
• Extreme anxiety
• Hypoxemia due to salicylate intoxication
• Inappropriate ventilator settings that do not match the
patient's requirements.
144
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• Lightheadedness due to vasoconstriction and decreased
cerebral blood flow.
• Inability to concentrate
• Numbness and tingling
• Tinnitus and sometimes loss of consciousness.
• Tachycardia and ventricular and atrial dysrhythmias.
145
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• Analysis of arterial blood gases
• A toxicology screen to rule out salicylate intoxication.
146
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Medical Management
• Treatment depends on the underlying cause
• If the cause is anxiety, the patient is instructed to breathe
more slowly to allow CO2 to accumulate or to breathe
into a closed system (such as a paper bag).
• A sedative may be required to relieve hyperventilation in
very anxious patients.
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Objectives
• Describe the pathophysiology of UTI
• Describe the types of UTI
• Identify the pertinent symptoms of each types of UTI
• Apply the nursing management for patients with UTI
• Apply nursing process for patients with UTI
• List common preventive measures of UTI

Urinary tract infection
 Invasion of the urinary tract by bacteria
 Normally, the urinary tract is sterile above the urethra
 Recurrent

Pathophysiology
Pathogens which have colonized urethra, vagina, or
perineal area enter urinary tract by ascending
mucous membranes of perineal area into lower
urinary tract
Bacteria can ascend from bladder to infect the
kidneys

Risk Factors
Aging
 Gender
 Females: short urethra, use of contraceptives that alter
normal bacteria flora of vagina and perineal tissues;
Males: prostatic hypertrophy, prostatitis
Urinary tract obstruction: tumor or calculi, strictures
Impaired bladder innervation

Classifications of infections
 Upper urinary tract infection: pyelonephritis
(inflammation of kidney and renal pelvis) and ureteritis
Lower urinary tract infections: urethritis, prostatitis,
cystitis
They can also be classified as uncomplicated or
complicated UTI

UTI…
 Uncomplicated Lower or Upper UTIs
 Community-acquired infection; common in young
women and not usually recurrent
 Complicated Lower or Upper UTIs
 Nosocomial - related to catheterization;
 Occur in patients with urologic abnormalities,
 Pregnancy
 Immunosuppression, diabetes mellitus, and obstructions

Upper urinary tract infections
 Pyelonephritis - a bacterial infection of the renal
pelvis, tubules, and interstitial tissue of one or both
kidneys.
 Pathogenic bacteria from a bladder infection can ascend
into the kidney, resulting in pyelonephritis.

Risk factors
Obstruction
Congenital malformation
Vesicouretral reflex

Pathophysiology
 Usually begins with colonization and infection of the lower
urinary tract by means of the ascending urethral route.
 Involve either the upward spread of bacteria from the
bladder or
 Spread from systemic sources reaching the kidney via the
bloodstream.
 Acute or chronic

Acute pyelonephritis
 Usually manifested by enlarged kidneys with
interstitial infiltrations of inflammatory cells.
 Abscesses may be noted on or within the renal capsule
and at the corticomedullary junction.

Clinical presentations
Acutely ill – had chills, fever, leukocytosis, bacteriuria,
and pyuria.
Low back pain, flank pain, nausea and vomiting,
headache, malaise, and painful urination.
Pain and tenderness in the cost vertebral angle
Symptoms of lower urinary tract involvement, such as
urgency and frequency

Diagnostic Findings
Ultrasound study
CT scan
IV pyelogram
U/A
Culture and sensitivity tests

Medical Management
• Patients with acute uncomplicated 2-week course of
antibiotics is recommended.
• Pregnant women may be hospitalized for 2 or 3 days
of parenteral antibiotic therapy.

Chronic pyelonephritis
Repeated bouts of acute pyelonephritis may lead to
chronic pyelonephritis.

Clinical manifestations
• Has no symptoms of infection unless an acute
exacerbation occurs.
• Noticeable signs and symptoms may include fatigue,
• Headache
• Poor appetite
• Polyuria
• Excessive thirst, and
• Weight loss.

Clinical…
• Persistent and recurring infection may produce
• Progressive scarring of the kidney, then
• Renal failure.

Diagnostic Findings
Intravenous Urogram (IVP)
Creatinine, blood urea nitrogen,
Urine analysis

Medical Management
• Long-term use of prophylactic antimicrobial therapy
may help limit recurrence of infections and renal
scarring.
• Administers antipyretic and antibiotic agents as
prescribed.

Nursing management
• Fluid intake and output measured & record
• Fluids per day is encouraged to
• Dilute the urine
• Decrease burning on urination, and
• Prevent dehydration.
• The patient’s temperature measured every 4 hours

Nursing management
• Patient teaching focuses on prevention of further
infection
• By consuming adequate fluids, emptying the
bladder regularly,
• Performing recommended perineal hygiene.

Lower Urinary Tract Infections
• Infection with in the bladder, urethra and prostate
• Bacteria must gain access to the bladder, attach to and
colonize

Cystitis
Inflammation of urinary bladder
C/Manifestation
• Frequency, small volumes, dysuria, urgency, Urine has
foul odor, hematuria, fever & incontinence
• Suprapubic pain and tenderness

Clinical…
Older clients may present with different
manifestations
 Nocturia, incontinence
 Confusion
 Behavioral changes
 Lethargy
 Anorexia
 Fever or hypothermia

Diagnosis
• Urinalysis
• No culture or lab tests needed

Uncomplicated (simple) Cystitis
oTreatment
Trimethroprim/ Sulfamethoxazole for 3 days
May use fluoroquinolone

Complicated Cystitis
Clients with comorbid medical conditions
 Indwelling Foley catheters
 Hospitalization
Diagnosis
 Urinalysis, Urine culture
 Further labs, if appropriate.

Complicated Cystitis…
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.

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.

Prostatitis
Inflammation of the prostate gland
Symptoms:
Pain in the perineum , lower abdomen, testicles, penis,
Pain while ejaculation
Blood in the semen
Fevers, chills, dysuria, malaise, cloudy urine
By:- Tiwabwork T(AHN) 176
5/14/2023

Risk Factors
Trauma
 Sexual abstinence
 Dehydration

Diagnosis:
Clinical history
The finding of an edematous and tender prostate
Will have an increased PSA
 Urinalysis, urine culture

Prostatitis…
Treatment:
 Trimethoprim/ sulfamethoxazole, fluroquinolone or
other broad spectrum antibiotic
4-6 weeks of treatment

Urethritis
 Asymptomatic, but can present with dysuria, discharge or PID
 Send UA, Urine culture (if pyuria seen, but no bacteria, suspect
Chlamydia)
 Pelvic exam – send discharge from cervical or urethral os for
chlamydia
 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

Glomerular disease
Nephrotic syndrome
Glomerulonephritis
5/14/2023 181

Objectives
• Describe the pathophysiology of glomerular disease
• Identify the pertinent symptoms of glomerular disease
• Differentiate each glomerular disease
• Apply the nursing management for patients with
glomerular disease
• Apply nursing process for patients with glomerular
disease

NEPHROTIC SYNDROME
Type of renal failure characterized by increased
glomerular permeability and is manifested by massive
proteinuria
5/14/2023 183

5/14/2023 184
Pathophysiology

Clinical manifestation
Proteinuria exceeding 3.5 g/day
Hypoalbuminemia
Diffuse edema
High serum cholesterol
Low-density lipoproteins (hyperlipidemia)
5/14/2023 185

Clinical….
Edema - soft and pitting around the eyes
(periorbital), sacrum, ankles, and hands), and
abdomen.
Irritability
 Headache
Malaise
5/14/2023 186

Nephrotic syndrome
5/14/2023 187

Diagnosis
Urine analysis
A needle biopsy
5/14/2023 188

Complications
 Infection(due to a deficient immune response)
Thromboembolism (especially of the renal vein)
Pulmonary emboli
ARF (due to hypovolemia)
Accelerated atherosclerosis (due to hyperlipidemia).
5/14/2023 189

Medical Management
Diuretics for edema
ACE inhibitors to reduce proteinuria and
Lipid lowering agents for hyperlipidemia.
5/14/2023 190

Nursing management
Provide meticulous skin care to combat the edema
Encourage activity and exercise
Frequently check the patient’s urine for protein,
indicated by frothy appearance.
Monitor weight
Monitor intake and output hourly.
5/14/2023 191

GLOMERULONEPHRITIS
5/14/2023 192

Acute glomerulonephritis
Inflammation of the glomeruli which causes the kidneys to
malfunction
So called Acute Nephritis, Glomerulonephritis and
Post-Streptococcal Glomerulonephritis
Predominantly affects children from ages 2 to 12
Other glomerulnephritis could be subacute or chronic.
5/14/2023 193

Etiology
• Immunological abnormalities
• Toxins
• Vascular disorders
• Systemic diseases
• Streptococcus pyogenes
5/14/2023 194

Clinical presentation
Foamy(soapy) urine
Hematuria: dark brown or smoky urine
Oliguria
Edema: starts in the eye lids and face then the lower
and upper limbs then becomes generalized; may be
migratory
Hypertension: usually mild to moderate
5/14/2023 195

General symptoms
 Fever
 Headache
 Malaise
 Anorexia
 Nausea and vomiting
 High blood pressure
5/14/2023 196
 Pallor due to edema
and/or anemia
 Confusion
 Lethargy
 Loss of muscle tissue
 Enlargement of the liver

Diagnostic Tests
Urinalysis
Kidney ultrasound
X-ray
Biopsy
Scarring of the glomeruli
5/14/2023 197

Management
• Most cases resolve spontaneously
• Sodium and fluid restrictions
• Diuretics
• Antihypertensive drugs
• Antibiotics for streptococcal infection
• If fluid overload is severe, dialysis may be done
5/14/2023 198

Nursing Management
Vital signs are monitoring
Fluid and sodium intake restrictions.
Protein intake may be limited
Antibiotics for diagnosed streptococcal throat infections
should be taken for prevention
5/14/2023 199

Nursing…
 Bed rest helps in maintaining adequate blood flow to
the kidney.
 Decreased sodium and protein intake
 Recording of the patient's weight, fluid intake and
urinary output
 Helps to estimate kidney function.
5/14/2023 200

Objectives
• List the common etiologies of urolithiasis
• List common manifestations
• Apply the nursing managements for patients with
calculi
• Apply nursing process for patients with urolithiasis

Urolithiasis
• The presence of stone /Calculi/ in the urinary tract.
• Calculi may be found anywhere from the kidney to the
bladder
• If the stone formation is in the kidney is called
Nephrolithiasis, and if in the ureter = uretrolithiasis.
5/14/2023

Sites of calculi formation
5/14/2023

5/14/2023

Calculi…
Cause
Calcium oxalate, calcium phosphate, and uric acid
increase
Absorption of excessive amount calcium through GI
tract/hypercalcimia
Dehydration/increase super saturation of calcium.
5/14/2023

Calculi…
• 75% of stones contain calcium - Calcium oxalate
(alkaline) or Calcium phosphate.
• Others : Uric acid (8%), and cystine (3%).
• It can also occur when there is deficiency of substances
that normally prevent crystallization in the urine such as
Citrate.
5/14/2023

Calculi…
Hypercalcimia can be primary or secondary.
• Primary: absorptive (intestinal calcium absorption) and or
renal( decrease renal excretion of calcium).
• Secondary: hyperthyroidism, vitamin D intoxication,
immobilization, renal tubular acidosis.
5/14/2023

Calculi…
Factors which affect the
rate of stone formation
include:
• PH of the urine
• Urinary stasis
• immobilization
• Fluid volume status of
individuals (stones tend
to occur more often in
dehydrated states).
• Urinary retention,
• Infection
5/14/2023

Calculi…
Incidence:
• About 12% of adults will have at least one episode of
renal stone formation.
• Recurrence rate vary depending on the type of
treatment.
5/14/2023

• Clinical manifestations of stones in the urinary tract
depends on the presence of obstruction, infection &
edema.
• When the stones block the flow of urine
• Obstruction develop = increase in hydrostatic
pressure ; distending the renal pelvis & proximal
ureter and infection.
5/14/2023

Clinical…
Stones in the renal pelvis may be associated with:
• Sever pain commonly called renal colic (major c/ms) :
Intense deep ache in the costovertebral region.
• Flank pain suggests stone in the kidney or ureter.
• If it radiate to scrotum, testes, or vulva suggests stone
in ureter and bladder.
5/14/2023

Clinical…
Others
• Nausea/Vomiting/pallor
• Hematuria
• Pyuria
• Frequency and dysuria
• Oliguria/anuria:
suggests obstruction
• Diarrhea & abdominal
discomfort due to reno
intestinal reflexes and
anatomic proximity of
kidney to stomach,
pancreases and large
intestine
5/14/2023

Diagnostic Evaluation
• KUB/kidney, ureter, bladder/ ultra sound studies.
• Radiography (stones are seen in KUB)
• Blood chemistry (increased serum calcium, phosphate
or uric acid).
• Urine analysis (hematuria, WBC, bacteria)
5/14/2023

Management /Non surgical/
The immediate objective of renal or ureteral colic is to
relieve the pain until its cause can be eliminated.
• Strong analegesic
• Meperidine is administered to prevent shock
and syncope that may result from the
excruciating/sever pain.
• Apply hot baths or Moist heat to the flank areas.
5/14/2023

Management…
• Encourage fluid taking (2-3 liters/day) to dilute stone
forming crystals, prevent dehydration, promote urine flow.
• Encourage walking.
• Vitamin "D" enriched foods should be avoided
• Table salt & high sodium foods should be reduced.
5/14/2023

Management…
• Reduction of dietary calcium & phosphorus content
may help to prevent further stone formation
5/14/2023

Management…
• Acidification or alkalization of urine depends on the
cause.
• E.g. uric acid containing stones : alkalinize the urine by
using drugs such as potassium citrate, sodium citrate,
sodium bicarbonate(normal urine pH on average 5-6)
5/14/2023

Management…
• For oxalate stones, a dilute urine is maintained and
the intake of oxalate is limited.
• Treatment of infection and prevention of obstruction
5/14/2023

Management…
• If the stone is not passed spontaneously or if
complications occur treatment modalities may include.
• Non invasive procedure used to break up stones in the
calyx of the kidney.
• End urologic methods of stone removal
 Extra-corporeal Shock Wave Lithotripsy
Ureteroscopy
5/14/2023

Extracorporeal Shock Wave Lithotripsy
5/14/2023

Management…
• Surgical Removal- surgical intervention is indicated
• if the stone doesn't respond to the other form of
treatment
• To correct any anatomic abnormalities
• To improve urinary drainage
5/14/2023

Management…
Surgical
• Nephrolithetomy /Incision into the kidney with
removal of stone/
• Nephrectomy
• Pyelolithotomy /into the kidney pelvis/
• Ureterolithotomy /in to the ureter
• Cystotomy /in to the bladder
5/14/2023

Objectives
• List the common etiologies of BPH
• Identify the clinical manifestations of BPH
• Apply the nursing management for patients with
BPH
• Apply nursing process for patients with BPH

Benign prostatic hyperplasia
• Obstruction to urinary flow from the bladder to the
urethral meatus due to hyperplasia of the prostate
• Affects
• ∼50% of men age 50–60
• >80% of men age>80.
5/14/2023 224

Etiology
• Increased androgen effects (dihydrotestosterone and
its metabolites), or oestrogens.
• Castration post-onset gives a 30% reduction in size
only.
5/14/2023 225

Urinary retention
Frequency and urgency symptoms.
 Per rectum examination reveals a smoothly
enlarged prostate
Dribbling of urine
5/14/2023 226

Diagnosis
• History or physical examination
• Bladder scan
• Serum prostate specific antigen (PSA)
5/14/2023 227

Management
• α-blockers such as doxazosin
• Finasteride is a 5 alpha reductase inhibitor
• Inhibits the conversion of testosterone to
dihydrotestosterone.
• Transurethral resection of the prostate (TURP)
5/14/2023 228

Renal failure

Objectives
• List the common risk factors of renal failure
• Identify the pertinent symptoms of RF
• Differentiate the types of RF
• Apply the nursing and other management of RF
• State the indication of dialysis
• Apply nursing process for patients with RF

Renal failure
Renal failure, is diagnosed when the kidneys are no
longer functioning adequately to maintain normal
body processes.
This results in dysfunction in almost all other parts
of the body
Renal failure can be acute or chronic
5/14/2023 231

Types of RF
•Acute and chronic renal failure
5/14/2023 232

Acute Renal Failure
 Sudden (hours to days) loss of the kidneys’
ability to clear waste products and regulate fluid
and electrolyte balance.
 Results in azotemia
 Reversible if treated immediately
 urine output of less than 30 mL/hr or 400
mL/day.
5/14/2023 233

5/14/2023 234

Risk groups
• Major surgery
• Trauma
• Receiving nephrotoxic medications
• Elderly
5/14/2023 235

Stages/phases of acute renal failure
There are four clinical phases of acute renal failure:
1. The initiation/onset period
2. The period of oligouria/anuric
3. Period of diuresis and
4. Period of recovery
5/14/2023

Stages/phases….
1. The initiation period - begins with the initial insult and
ends when oligouria develops.
• is characterized by:
 Urine output at 30 ml (or less) per hour
 Urine sodium excretion greater than 40 mEq/L.
 Renal flow at 25% of normal
 Oxygenation to the tissue at 25% of normal
5/14/2023

Stages/phases…
2. The period of oligouria/anuric –
• urinary volume less than 400ml/24 hrs/
• Further damage to the renal tubular wall & membranes
• Great reduction in the glomerular filtration rate (GFR)
• Increased blood BUN/Creatinine level
• Electrolyte abnormalities (hyperkalemia,
hyperphosphatemia and hypocalcaemia)
• Metabolic acidosis
5/14/2023

Stages/phases…
3. Period of diuresis
• The patient experiences a gradually increasing urine
output, which signals that glomerular filtration has
started to recover.
• The volume of urinary output may reach normal to
elevated levels.
• Renal function may be still abnormal.
5/14/2023

Stages/phases…
4. Period of recovery
• Signals the improvement of renal function and may be
taking from 3 to 12 months.
• Laboratory values will return to a normal level
• Permanent 1-3% reduction of GFR may occur but it is
not clinically significant.
• Elderly clients recover normal function less frequently
than younger clients
5/14/2023

 Nausea, vomiting
 Loss of appetite
 Headache, Lethargy
 Disorientation
 Edema(body)
  K+ ,  BUN and
creatinine
 Acidosis
5/14/2023 241
 CHF manifestation
 Pulmonary edema
 Convulsions, coma
 Changes in bowels
 Tingling of extremities
decrease Na
Uremic breath

Diagnosis
• Laboratory Evaluation:
• Serum creatinine
• BUN(can be elevated due to hypovolemia)
• BUN/Cr helpful in classifying cause of ARF
• ratio> 20:1 suggests prerenal cause
• ratio 10-15:1 suggests intrinsic renal cause

Management
The objective of treatment of acute renal failure
is:
• To restore normal chemical balance
• To prevent complications so that repair of renal tissue
occurs and
• Restoration of renal functions can take place
5/14/2023

Management ….
• Mannitol, Furosemide with 20% of glucose IV solution may be
prescribed to;
• Initiate a diuresis ,
• prevent or minimize subsequent renal failure,
• To prevent tubular necrosis and treat shock
• Adequate renal blood flow in patients with prerenal causes of ARF
may be restored by IV ﬂuids or transfusions of blood products.
• The elevated potassium levels may be reduced by administering
cation exchange resins (sodium polystyrene sulfonate [Kayexalate])
orally or by retention enema.
5/14/2023

Management …
• Antimicrobial drugs to treat infection
• Diet – restriction of protein in order to limit sources of
nitrogen.
• Foods and fluids containing potassium and phosphorus
/bananas, citrus fruits & juices, coffee/ are restricted.
• Sodium is usually restricted to 2gm/day.
• Bed rest
• Fluid: Limit excessive water intake.
5/14/2023

Nursing interventions
Monitor input and out put
Watch hyperkalemia symptoms
Malaise, anorexia, or muscle weakness, EKG
changes
Watch for hyperglycemia or hypoglycemia if
receiving TPN or insulin infusions
5/14/2023 246

Chronic Renal Failure(CKD)
A kidney damage or a decrease in the glomerular
filtration rate (GFR) for 3 or more months.
If untreated can result in end-stage renal disease
 Results form gradual, progressive loss of renal
function
 Symptoms occur when 75% of function is lost
 Chronic if 90-95% loss of function
5/14/2023 247

Risk factors
Cardiovascular disease
Diabetes
Obesity
5/14/2023 248

 Elevated serum
creatinine levels
 Anemia
 Metabolic acidosis
 Fluid retention
 Abnormalities in
electrolytes
5/14/2023 249
Dry mouth
Poor skin turgor
Confusion
Muscle weakness
Proteinuria, glycosuria

Clinical presentation…
Cardiovascular
Hypertension
Arrhythmias
Pericardial
effusion
CHF
Peripheral edema
Neurological
Burning, pain, and itching,
paresthesia
Motor nerve dysfunction
Muscle cramping
Shortened memory span
Apathy
Drowsy, confused, seizures, coma,
EEG changes
5/14/2023 250

Stages of Chronic Kidney Disease
• Based on the glomerular filtration rate (GFR).
• The normal GFR is 125 mL/min/1.73 m2.
Stage 1
• GFR 90 mL/min/1.73 m2
• Kidney damage with normal or increased GFR
Stage 2
• GFR 60–89 mL/min/1.73 m2, Mild decrease in GFR
5/14/2023 251

Stages of Chronic Kidney Disease
Stage 3
• GFR 30–59 mL/min/1.73 m2 (Moderate decrease)
Stage 4
• GFR 15–29 mL/min/1.73 m2
• Severe decrease in GFR
Stage 5
• GFR 15 mL/min/1.73 m2 (Kidney failure)
5/14/2023 252

Causes
 Systemic disease such as
• Diabetes mellitus
• Chronic
glomerulonephritis
• Pyelonephritis
• Uncontrolled HTN
• Obstruction of urinary
tract
• Vascular disorders
• Infections
• medications
• Toxic agents
5/14/2023

Lab findings
BUN – Normal is 10-20mg/dL. When reaches 70 –
needs dialysis
Serum creatinine – Normal is 0.5-1.5 mg/dL.
When reaches 10 x normal, it is time for dialysis
Creatinine clearance
 Need 12-24 hour urine collection.
Normal is > 100 ml/min
5/14/2023 254

Management
• Before ESRD medical management is aimed at slowing
the progression of CRF and avoiding complications.
• Diabetes and hypertension should be aggressively
treated
• Volume depletion, infection & nephrotoxic agents must
be avoided to prevent further deterioration of renal
function.
5/14/2023

Protein restriction: decreasing protein intake.
Salt restriction: Limit to 2.4 grams/day
Fluid intake: Limit excessive water intake
Potassium restriction: Decrease K+ intake.
 Phosphorus restriction: Decreasing phosphorus intake.
Management…

Management…
 Once the patient reaches ESRD, management is aimed
at; alleviating uremic symptoms & providing dialysis.
• Renal transplantation
5/14/2023

Dialysis Indications
• Refractory hyperkalemia
• Metabolic acidosis
• Volume overload
• Mental status changes

Dialysis
5/14/2023

• Abdominal lining filters blood
260
Peritoneal Dialysis
5/14/2023

• Rx usually occurs 3
times a week
• Takes 3-4 hours per
Rx
• Machine filters
blood and
returns it to
body.
261
Hemomodialysis
5/14/2023

Medical Management
 Treatment of the underlying causes.
 Regular clinical and laboratory assessment is
important to keep the blood pressure (BP) below
130/80 mm Hg.
 Early referral for initiation of renal replacement
therapies
5/14/2023 262

Sexually transmitted
infections

At the end of this session, the you will be able to:
􀂃 List the common sexually transmitted infections
􀂃 Identify the diagnostic symptoms of STIs
􀂃 Identify STIs that are transmitted through vertical
route.
􀂃 Apply the syndromic management of STIs
􀂃 State the preventive and control measures for them
Learning Objectives

Introduction
• STIs are infectious diseases caused by one or more
microorganisms that are mainly transmitted from one
infected person to another during unprotected sexual
intercourse.
• STIs are caused by more than 30 different pathogens
including bacteria, viruses, protozoa, fungus and
ectoparasites

Introduction…
• STIs can be broadly recognized as ulcerative or
non-ulcerative, and can be classified as curable or
non-curable.

Risk factors
• Age
• Many partner
• Change of partners
• Not using condoms
• Substance use
• Unprotected sex

Etiology
A. Bacterial
• Neisseria gonorrhea (causing gonorrhoea)
• Chlamydia trachomatis (chlamydial infection)
• Treponema pallidum (syphilis)
• Haemophilus ducreyi (chancroid)
• Clamatato bacterium granulomatis
• Gardnella vaginalis

Etiology…
B. Viral
• Herpes simplex type I and II
• Human papillomavirus (genital warts)
• Hepatitis B virus
• Cytomegalovirus
• HIV

Etiology…
C. Others
• Trichomonal virginals (Trichomoniasis)
• Candida albicans
• Genital scabies

Common symptoms
• Urethral discharge
• Vaginal discharge
• Genital ulcer
• Lower abdominal pain
• Scrotal swelling
• Inguinal Bubo
• Neonatal conjunctivitis

Assessment patient with STI
• Privacy & confidentiality
• Proper/detailed history taking and physical
examination.

Assessment…
P/Examination should proceed as follows:
• General examination- inspect all over the body
• Examination of the oral cavity
• Examination of the scrotum and testes for swelling
and/or pain
• Examination of the inguinal and femoral lymph nodes
• Examination of the vulva
• Speculum examination

Common STIs
• Gonorrhea
• Chancroid
• Chlamydia
• Syphilis
• Lymphogranuloma venereum(LGV)
• Candidasis
• Hepatitis B

Syphilis (Hard chancre)
• A disease characterized by a primary lesion, a later
secondary eruption on the skin and mucus
membranes, then
• Long period of latency finally
• Late lesions of skin, bones, viscera, CNS and
cardiovascular systems.
• Caused by Treponema pallidum.

Clinical Manifestation
Divided into three groups
• a) Primary syphilis – consists of hard chancre together
with regional lymphadenitis.
• The hard chancre is a single, painless ulcer on the
genitalia or elsewhere (lips, tongue, breasts)
• Heals spontaneously in a few weeks without treatment.
• The lymph glands are bilaterally enlarged and not painful.
• There will not be suppuration.

Clinical…
Secondary syphilis
 After 4 – 6 weeks of the primary infection
A generalized secondary eruption appears,
Accompanied by mild constitutional symptoms.
Infective symmetrical rash, quickly passing, and do
not itch.

Clinical…
Tertiary syphilis
• Characterized by destructive, non-infectious lesions
of the skin, bones, viscera, and mucosal surfaces.
• Other manifestations occur in the cardiovascular
system (aortic incompetence, aneurysms) or central
nervous system (dementia paralytica).

Diagnosis
• Serological test – will be positive 6 to 8 weeks after
infection
• Dark field microscopy of smears from primary
lesion (hard chancre) or
• From skin lesions in the early secondary stage will
show the spirochaetes.

Mode of transmission
• Direct contact with lesion mainly during sexual
intercourse.
• Accidentally by touching infective tissues.
• Blood transfusion
• Congenitally, which may occur before birth

Treatment
Primary and secondary syphilis
• Benzathin penicillin 2.4 M IU Im stat or
• Tetracycline or Erythromycin 500mg PO Qid for 2
weeks for penicillin sensitive people
Tertiary syphilis
• Benzathin penicillin 2.4 M IU Im single dose every
week for 3 consecutive weeks or
• Tetracycline or Erythromycin for one month for
penicillin sensitive individuals.
Early congenital syphilis
• Crystalline penicillin 50,000 IU/ Kg per dose IV or Im
bid in the first 7 days of life and Tid then after for 10-
14 days.

Gonorrhea
• Bacterial infection of the urethra anus, or eyes.
• Caused by Neisseria gonorrhea.
• This infection can occur in the penis, vagina, anus, and
eye.
• The bacteria can also be found in body fluids such as
semen, pre-ejaculate, vaginal fluids, and anal fluids.

• Males- Usually involves the urethra resulting in
purulent discharge, dysurea and frequency.
• Females - Females are usually asymptomatic. Vaginal
discharge is common. Most common site of infection
is cervix, followed by urethra, anal canal and pharynx.
• Bartholinitis occurs unilaterally.

Clinical…
• Neonates borne to infected mothers develop a
purulent discharge which exudes from between
eyelids which are edematous and erythematous 2 -3
days postpartum.

Mode of Transmission
1. Sexual intercourse
2. Passage through birth canal of infected persons.
3. Use of shared towels or clothing from infected
person.

Diagnosis
• Gram stain of discharge (urethral, cervical,
conjuctival discharge)
• Culture on selective media

Chancroid (soft chancre)
• It is a curable sexually transmitted infection (STI)
caused by a germ negative bacterium called
Haemophilus ducreyi.
• The initial lesion is a papule with surrounding
erythema & in 2 to 3 days  pustule  spontaneously
ruptures  ulcers which are painful and bleed easily.

 Classic Chancroid ulcer begins as a tender papule that
ulcerates within 24 hours.
The ulcer is painful, irregular and sharply demarcated
from the nearby skin.

• By direct sexual contact with discharges from open
lesion and pus from buboes.
• Infected males don’t pass the infection farther
because of the painful ulcer.

Diagnosis
• Clinical, but always rule out syphilis
• Gram stain of smear from ulcer shows typical rods in
chain
• Culture.

Chlamydia
• Caused by the bacteria Chlamydia trachomatis.
• Chlamydia can be transmitted during vaginal, anal, or
oral sex, and also can be passed from an infected
mother to her baby during vaginal childbirth
• If left untreated, it can spread to the upper, internal
reproductive organs (ovaries and fallopian tubes) and
cause pelvic inflammatory disease.

Diagnosis
 Clinical presentation
 Culture

Chlamydia…
• The majority of individuals with chlamydial infection
are asymptomatic.
• The symptoms, will most likely show up between 2
and 6 weeks after sexual contact.
• The most common symptoms include:
• Penis discharge
• Eye swelling or abnormal discharge

Lymphogranuloma venereum
• A venereal disease caused by chlamydia
microorganisms,
• Most commonly manifested by acute inguinal
lymph adenitis.
• Caused by chlamydia trachomatis (ll l2 and l3)

• Direct contact with open lesions of
• Infected people, usually during sexual intercourse.

• Lymph adenopathy with non-specific symptoms of
fever, Chills, head ache, malaise, anorexia and
weight loss.
• Regional lymph nodes undergo suppuration
followed by
• Extension of inflammatory process to the adjacent
tissues.

Clinical…
• In the female, inguinal nodes are less frequently
affected but pelvic nodes with extension to the
rectum and recto vaginal septum, (esulting in
proctitis, stricture of the rectum and fistula).
• Elepthantiasis of genitalia, scrotum and vulva

Diagnosis
 Clinical presentation (i.e. presence of bubo.)
 Culture of bubo aspirate.

Candidiasis
• A mycosis usually confined to the superficial layers of
skin or mucus membranes, presenting clinically as oral
thrush or vulvovaginitis.
• Infectious agent
• Candida albicans (most common cause)
• Candida tropicalis (rare cause)

 Contact with secretions or excretions of mouth,
skin, vagina and feces, from patients or carriers.
Passage from mother to neonate during childbirth.

Severe vulvar pruritis (prominent feature)
 Vaginal discharge (scanty, whitish, yellow, thick to
form curds, non-offensive)
Sore vulva due to itching
Speculum examination – thick whitish plugs
attached to vaginal wall

Diagnosis
Based on clinical grounds
Microscopic demonstration of pseudohyphae or
yeast cells in infected tissue or body fluids (vaginal
discharge)
Culture (vaginal discharge)

Diagnosis and Management
approaches of STIs

Management…
• The following methods are used to diagnose
STI.
• Etiological Diagnosis
• Clinical diagnosis
• Syndromic approach

Diagnostic
Approaches
Advantages Challenges
Etiologic
This is done by
identifying the
causative agent(s)
using laboratory
tests and giving
treatment targeting
to the pathogen
identified.
• Avoids over
treatment.
Conforms to
traditional training.
• Satisfies patients
who feel not
properly attended
• Can be used to
screen
asymptomatic
patients
• Identifying the 30 or
more STI causative
agents requires
skilled personnel.
• Lab tests are
expensive, time
consuming.
• Delay in treatment of
patients to wait for
lab results.

Diagnostic
Approaches
Clinical
Uses clinical
experience to
identify
symptoms which
are typical for a
specific STI, then
giving treatment
targeted, to the
suspected
pathogen(s)
• Saves time for
patients
• Reduces lab
expenses
• Requires high
clinical skill
• Mixed infections
often overlooked
• Doesn’t identify
asymptomatic
STIs

Diagnostic
Approaches
Syndromic
Identification of
clinical syndrome and
giving treatment
targeting all the locally
known pathogens
which can cause the
syndrome
Complete STI care
offered at first visit
• Simple, rapid and
inexpensive
• Patients treated for
possible mixed
infections
• Accessible to a
broad range of health
workers
• Limits unnecessary
referral to hospitals
• Risk of over-
treatment
• Requires prior
research to
determine the
• common causes
of particular
syndromes
• Asymptomatic
infections are
missed

Management…
The commonly encountered STI syndromes are:
• Urethral discharge in men
• Genital ulcer
• Lower abdominal pain in women
• Inguinal bubo
• Scrotal swelling
• Neonatal conjunctivitis

URETHRAL DISCHARGE
• Urethral discharge is the presence of abnormal
secretions from the distal part of the urethra and it is
the characteristic manifestation of urethritis.
• Urethritis is usually due to sexually transmitted
infections although urinary tract infections may
produce similar symptoms.
• Urethral discharge is one of the commonest sexually
transmitted infections among men in our country

Urethral…
Etiologic agents:
• Neisseria. gonnorhea
• Chlamydia. Trachomitis
• Trichomonas. vaginalis

Clinical…

Clinical presentation
• Burning sensation on urination,
• Dysuria
• Urethral discharge
• Meatus excoriation

Treatment
• Ceftriaxone 250mg IM stat/ Spectinomycin 2gm IM
stat
Plus
• Azithromycin 1gm po stat/ Doxycycline 100 mg po
bid for 7 days/ Tetracycline 500 mg po qid for 7
days/Erythromycin 500 mg po qid for 7 days in cases
of contraindications for Tetracycline (children and
pregnancy)
• Note: The preferred regimen is Ceftriaxone 250mg IM
stat plus Azithromycin 1gm po stat

Vaginal discharge syndrome
• Physiologically women have vaginal discharge which
is white mucoid, odor less and nonirritant, thin or
thick based on menstrual cycle.
• Abnormal vaginal discharge which is STI related is
abnormal in color, odor and amount.
• In another word abnormal vaginal discharge is there
when a women notices a change in color, odor and
amount.

Etiology
The most common causes of vaginal discharge
syndrome are
• Neisseria gonorrhea
• Chlamydia trachomatis
• Trichomonas vaginalis
• Gardnerella vaginalis (Polymicrobial)
• Candida albicans

• The classical manifestation of vaginal discharge is
discharge from the vagina, the discharge can be
• Thin, regular whitish discharge with fishy odor
• Thick, plentiful, foul-smelling, yellow-green, frothy
itchy
• Purulent exudate from the cervical Os'
• White , thick and curd like discharge coating the walls
of the vagina

Clinical…
Risk assessment
• Multiple sexual partners in the last 3 month
• New sexual partner in the last 3 month
• Ever traded sex
• Age below 25 years
• The presences of one or more risk factor suggest
cervicitis.

Treatment
Treatment for vaginal discharge syndrome:
• If the risk assessment is negative, treat the patient with
Metronidazole plus Nystatin or Clotrimazole.
• In the presence of risk factors treat with Ciprofloxacin
500mg orally single dose Or

Treatment…
• Spectinomycin 2gm im single dose Or
• Ceftriaxone 250mg im single dose Or
• Norfloxcin 800mg orally single dose Plus Doxycycline
100gm orally twice daily for 7 - 14 days Or
• Tetracycline 500mg orally four times daily for 7 days

Genital Ulcers
• Genital ulcer is an open sore or a break in the
continuity of the skin or mucous membrane of the
genitalia as a result of sexually acquired infections.
• Commonly genital ulcer is caused by bacteria and
viruses.

Etiology
• Some of the common etiologies of genital ulcer
syndrome are:-
• Herpes simplex virus (HSV-1 and HSV-2)
• Treponema pallidum
• Haemophilius ducreyia
• Klebsiella granulomatis (donovanosis

Clinical…
• Recurrent painful vesicles and irritations
• Shallow and non-indurated tender ulcers
• Common sites in male are glance penis, prepuce and
penile shaft
• Common sites in women are vulva, perineum, vagina
and cervix and can cause occasionally severe vulvo-
vaginitis and necrotizing cervicitis
• Regional lymph adenopathy

Treatment
• Treat for Syphilis:
• Benzathine penicillin 2.4 million units i.m in single
dose.
• In the presence of penicillin allergy:
• Erythromycin 500mg orally four times daily for 15
days;
• Doxycycline 100mg orally two times daily for 15 days
Or

Treatment…
• Tetracycline 500mg orally four times daily for 15 days
Treat for chancroid,
days; Alternatively, Cotrimoxazole 2 tablets orally two
times daily for 7 days; Or
• Syectinomycin (Togomycin) 2gm i.m single dose can
be given.

Lower abdominal pain
• A clinical syndrome resulting from ascending
infection from the cervix and/or vagina.
• It consists of the upper female genital tract, including
any combination of endometritis, tubo-ovarian abscess
and pelvic peritonitis.
• It may spread to the liver, spleen or appendix.

PID…
• PID with or without pelvic abscess improves with
antibiotics alone and the fever usually subsides in less
than 72 hours.

Etiology
• C. trachomatis and N. gonorrhoea (common)
• Other causes
• Mycoplasma genitalium
• Bacteroides species
• E. coli
• H. influenza
• Streptococcus

• Lower abdominal pain
• Abnormal vaginal discharge
• Inter-menstrual or post coital bleeding
• Dysuria
• Backache
• Fever, nausea and vomiting
• Cervical excitation tenderness

Treatment
Treatment for lower abdominal pain syndrome in the
female:
• Treatment should cover gonococcal, chlamydial and
anaerobic bacterial infections.
• Ciprofloxacin 500mg orally single dose Or

Treatment…
• Norfloxacin 800mg orally single dose Or
• Spectinomycin 2gm i.m single dose Or
• Ceftriaxone 250mg i.m single dose Plus
Doxycycline 100mg orally twice daily for 14 days

Scrotal swelling syndrome
• Scrotal swelling can be caused by trauma, tumor, and
torsion of the testis or inflammation of the epididymis.
• Mostly the inflammation of the epididymis is caused by
sexually transmitted diseases.
• The cause of scrotal swelling can vary depending on the
age of the patient.
• Among patients who are younger than 35 years, the
swelling is likely to be caused by sexually transmitted
infections

Etiology
• N. gonorrhea
• C. trachomatis
• T. pallidum

• Scrotal swelling can manifest itself with different signs
and symptoms.
• Some of the signs and symptoms of scrotal swelling are:
• Pain and swelling of the scrotum
• Tender and hot scrotum on palpation
• Edema and erythema of the scrotum
• Dysuria
• Sometimes frequency and urethral discharge can be there

Treatment
• Treat the patient for gonococcal and Chlamydial
infection:
• Ciprofloxacin 500mg orally single dose Or
• Norfloxacin 800mg orally single dose Or
• Spectinomycin 2gm im single dose Or
• Ceftriaxone 250mg im single dose Plus Doxycycline
100mg orally twice daily for 14 days

Inguinal bubo syndrome
• Inguinal bubo is defined as swelling of inguinal lymph
nodes as a result of STIs.
• Regional enlargement of lymph nodes should not be
regarded as inguinal bubo

Etiology
• Klebsiella granulomatis
• Treponema pallidum
• Haemophilius ducreyia

• Constitutional symptoms of fever, headache and pain
• Tender unilateral or bilateral lymphadenopathy forms
the inguinal area
• Fluctuant abscess formation which forma coalesce
mass (bubo)
• Some time concurrently occur with genital ulcer

Treatment
• If inguinal bubo with genital ulcer, treat the patient
with:
• Benzathine penicillin G 2.4 million IU im single dose
Plus Erythromycin base 500mg orally four times daily
for 3 weeks Or
• Cotrimoxazole 2 tablets orally twice daily for 15 days
(480mg).

Treatment…
If inguinal bubo with no genital ulcer treat the patient
with:
• Tetracycline 500 mg orally four times daily for 14
days. Or
days.

Treatment…
• If the bubo become fluctuant pus should be aspirated
with a needle every third day until it is dry.
• The aspiration should be done through a normal skin.
• N.B: Direct incising and drainage should not be
attempted over the lymph node.
• Sexual contacts should get the same treatment.

Neonatal conjunctivitis
• Neonatal conjunctivitis is an ocular redness, swelling
and drainage which can be sometimes purulent due to
pathogenic agents or irritant chemicals occurring in
infants less than 4 weeks of age.
• In cases of neonatal conjunctivitis due to pathogenic
agents, the neonates get the infections from their
infected mothers.

Neonatal…
• Neonatal conjunctivitis can cause loss of sight if it
is not managed properly and promptly.
• Neonatal conjunctivitis due to sterile chemical
irritants can be resolved by itself within 48 hours
without any intervention

Etiology
Some of the common etiologic causes of neonatal
conjunctivitis are:
• N. gonorrhea
• C. trachomatis
• S. pneumoniae
• H. influenzae
• S. aureus

• The common clinical presentations of neonatal
conjunctivitis are:
• Red and edematous conjunctiva
• Edematous eye lead
• Discharge which may be purulent
• Orbital cellulitis in more serious case

THE END

Reference
1. Brunner and suddarth’s, text book of medical surgical
nursing 12th ed. volume, 2010.
2. Carol pathophysiology 8 th edition
3. Aghababian, R., et.al. (2006) Essentials of Emergency
Medicine, Jones and Bartlett Publisher, Inc., USA
4. Sue C. De Laune, Patricia K. Ladner, et al; Fundamentals
of Nursing: Standards & Practice, Second Edition
5. B. Bates, Guide physical examination and history
taking,10th edition

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