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Genito-urinary system disorders-1.pptx

The document provides an overview of the nursing management of patients with genito-urinary system disorders, detailing urinary system functions, anatomy, and disorders such as glomerulonephritis and nephrotic syndrome. It discusses assessment techniques, clinical features, diagnostic evaluations, management strategies, and complications associated with these disorders. The focus is on promoting renal function and managing symptoms through both pharmacological and non-pharmacological approaches.

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Nursing management of patient with Genito-urinary system disorders Mr. Sushil Sudarshan Humane MSN, RN
Review of urinary system
Functions of urinary system • Filter. fluid from the bloodstream. • Waste processing. filtrate, allowing wastes and excess ions to leave the body, returning needed substances to the blood in just the right proportions. • Elimination. eliminating nitrogenous wastes, toxins, and drugs from the body. • Regulation. the proper balance between water and salts and between acids and bases is maintained. • Other regulatory functions. By producing the enzyme renin, they help regulate blood pressure, and their hormone erythropoietin stimulates red blood cell production in the bone marrow. • Conversion. Kidney cells also convert vitamin D to its active form.
Renin-angiotensin mechanism
Review of urinary system • Location. These small, dark red, kidney-bean shape, retroperitoneal position (beneath the parietal peritoneum) in the superior lumbar region, T12 to the L3 vertebra. • Positioning. right kidney is positioned slightly lower than the left. • Size. 12 cm (5 inches) long, 6 cm (2.5 inches) wide, and 3 cm (1 inch) thick, • Adrenal gland. • Fibrous capsule. glistening appearance. • Perirenal fat capsule. acts to cushion • Renal fascia. outermost capsule, anchors the kidney, hold it in place • Renal cortex. The outer region, light in color • Renal medulla. Deep, darker, reddish-brown area • Renal pyramids. triangular regions with a striped appearance, the renal, or medullary pyramid • Renal columns. The pyramids are separated by extensions of cortex-like tissue
Nephron • Nephrons. million tiny structures called nephrons • Glomerulus. a glomerulus is a knot of capillaries. • Renal tubule. • Bowman’s capsule. cup-shaped, the glomerulus,Podocytes- octopus-like cells- foot processes that intertwine with one another and cling to the glomerulus. • Collecting duct. • Proximal convoluted tubule. • Loop of Henle.- hairpin loop following the proximal convoluted tubule. • Afferent arteriole. is the “feeder vessel”. • Efferent arteriole. • Peritubular capillaries.
Ureters • Size.- 25 to 30 cm (10 to 12 inches) long and 6 mm (1/4 inch) in diameter. • Location. Each ureter runs behind the peritoneum from the renal hilum to the posterior aspect of the bladder, which it enters at a slight angle. • Function. carry urine from the kidneys to the bladder, peristalsis, valve-like folds of bladder mucosa that flap over the ureter openings.
Urinary bladder A smooth, collapsible, muscular sac that stores urine temporarily. • Location. retroperitoneally in the pelvis just posterior to the symphysis pubis. • Function. The detrusor muscles and the transitional epithelium both make the bladder uniquely suited for its function of urine storage. • Trigone. The smooth triangular region of the bladder base outlined by these three openings is called the trigone, where infections tend to persist. • Detrusor muscles. The bladder wall contains three layers of smooth muscle, collectively called the detrusor muscle, and its mucosa is a special type of epithelium, transitional epithelium.
Urethra • Internal urethral sphincter. At the bladder-urethral junction,an involuntary sphincter • External urethral sphincter. the external urethral sphincter, skeletal muscle, voluntarily controlled. • Female urethra. 3 to 4 cm (1 1/2 inches) long, and its external orifice, or opening, lies anteriorly to the vaginal opening. • Male urethra. 20 cm (8 inches) long and has three named regions: the prostatic, membranous, and spongy (penile) urethrae; it opens at the tip of the penis after traveling down its length.
Characteristics of urine • In 24 hours, 150 to 180 liters of blood plasma filters • Daily volume. In 24 hours, 1.0 to 1.8 liters of urine are produced. • Components. Urine contains nitrogenous wastes and unneeded substances. • Color. clear and pale to deep yellow. • Odor. sterile and slightly aromatic, but if allowed to stand, it takes on an ammonia odor caused by the action of bacteria on the urine solutes. • pH. slightly acidic (around 6), • Specific gravity. ranges from 1.001 to 1.035. • Solutes. sodium and potassium ions, urea, uric acid, creatinine, ammonia, bicarbonate ions, and various other ions.
Nursing assessment History, and physical examination • During physical examination for genitourinary dysfunction areas of emphasis include the abdomen, suprapubic region, genitalia and lower back, and lower extremities. • Direct palpation of the kidneys may help determine their size and mobility • The right kidney is easier to feel because it is somewhat lower than the left one
Nursing assessment History, and physical examination • Renal dysfunction may produce tenderness over the costovertebral angle, which is the angle formed by the lower border of the 12th, or bottom, rib and the spine. • The abdomen is auscultated to assess for bruits (low- pitched murmurs that indicate renal artery stenosis or an aortic aneurysm). • The abdomen is also assessed for the presence of peritoneal fluid, which may occur with kidney dysfunction.
Nursing assessment • The bladder should be percussed after the patient voids to check for residual urine • Percussion of the bladder begins at the midline just above the umbilicus and proceeds downward. • The sound changes from tympanic to dull when percussing over the bladder. • The bladder, which can be palpated only if it is moderately distended, feels like a smooth, firm, round mass rising out of the abdomen, usually at midline • Dullness to percussion of the bladder following voiding indicates incomplete bladder emptying.
Nursing assessment • The prostate gland is palpated by digital rectal examination (DRE) • Blood is drawn for PSA before the DRE because manipulation of the prostate can cause the PSA level to rise temporarily. • The inguinal area is examined for enlarged nodes, an inguinal or femoral hernia, or varicocele (varicose veins of the spermatic cord)
Nursing assessment • In female, the vulva, urethral meatus, and vagina are examined • The patient is assessed for edema and changes in body weight. • Edema may be observed, particularly in the face and dependent parts of the body, such as the ankles and sacral areas • An increase in body weight commonly accompanies edema. A 1-kg weight gain equals approximately 1,000 mL of fluid.
Disorders of kidney Mr. Sushil S. Humane MSN, RN
Disorders of kidney Glomerulonephritis Acute Nephritic Syndrome • Definition – Acute glomerulonephritis refers to a group of kidney diseases in which there is an inflammatory reaction in the glomeruli. • It is not an infection of the kidney, but rather the result of the immune mechanisms of the body.
Disorders of kidney Glomerulonephritis Risk factors • Group A beta- hemolytic streptococcal infection of the throat • Impetigo (infection of the skin) • Acute viral infections- upper respiratory tract infections, mumps, varicella zoster virus, Epstein- Barr virus, hepatitis B, and human immunodeficiency virus [HIV] infection). • Antigens outside the body (eg, medications, foreign serum) • In other patients, the kidney tissue itself serves as the inciting antigen.
Disorders of kidney Glomerulonephritis Categories – • Primary: Disease is mainly in glomeruli • Secondary: Glomerular diseases that are the consequence of systemic disease • Idiopathic: Cause is unknown • Acute: Occurs over days or weeks • Chronic: Occurs over months or years • Rapidly progressing: Constant loss of renal function with minimal chance of recovery
Disorders of kidney Glomerulonephritis Categories – • Diffuse: Involves all glomeruli • Focal: Involves some glomeruli • Segmental: Involves portions of individual glomeruli • Membranous: Evidence of thickened glomerular capillary walls • Proliferative: Number of glomerular cells involved
Disorders of kidney Glomerulonephritis Clinical features- • Hematuria - The urine may appear cola-colored because of red blood cells (RBCs) and protein plugs or casts; RBC casts indicate glomerular injury. • Edema and hypertension • Oliguria • Anemia from loss of RBCs into the urine
Pathophysiology
Clinical features- • In the more severe form of the disease, patients also complain of headache, malaise, and flank pain. • Elderly patients may experience circulatory overload with dyspnea, engorged neck veins, cardiomegaly, and pulmonary edema. • Atypical symptoms include confusion, somnolence, and seizures, which are often confused with the symptoms of a primary neurologic disorder Disorders of kidney Glomerulonephritis
Diagnostic evaluation- History • On examination- kidney is large, tender, edematous and congested • Urinanalysis- protienuria, hematuria , oliguria • Blood studies- • Serum creatinine, BUN increased • Hypoalbuminemia, hyperlipidemia • Elevated serum IgA level • Antistreptolysin O titers are usually elevated in post streptococcal glomerulonephritis • Electron microscopy and immunofluorescent analysis help identify the nature of the lesion • Kidney biopsy may be needed for definitive diagnosis. Disorders of kidney Glomerulonephritis
Complications- • Hypertensive Encephalopathy • Heart Failure • Pulmonary Edema • ESRD Disorders of kidney Glomerulonephritis
Management- Goal • To conserve renal function • To treat complication adequately • Types of management- • Non pharmacological management • Dietary management • Pharmacological management • Nursing management Disorders of kidney Glomerulonephritis
Non-pharmacological management- • Complete bed rest – As excessive activity may increase the proteinuria and hematuria. It should be encouraged until the urine clears and BUN, creatinine and BP return to normal. • Strict intake output charting • Fluid restrictions • Plasmapheresis to decrease the serum anti body level • Dialysis if, uremic symptoms are severe. Disorders of kidney Glomerulonephritis
Dietary management- • Protein restricted diet as the level of BUN and creatinine is high in blood • Low fat diet due to hyperlipidemia • Sodium restriction if hypertension, edema or congestive heart failure are present. • Increased carbohydrate diet to provide energy and to prevent the catabolism of protein. Disorders of kidney Glomerulonephritis
Pharmacological management- • Residual streptococcal infection is suspected, penicillin is the agent of choice. • Diuretics and antihypertensive agents may be given to control hypertension. • Corticosteroids and cytotoxic agents are used to reduce the inflammation. • H2 blockers (to prevent stress ulcers) • Phosphate binding agents (to reduce phosphate and elevate calcium). Disorders of kidney Glomerulonephritis
Nursing management- • Monitor vital signs, intake and output, and maintain dietary restrictions during acute phase. • Encourage rest during the acute phase as directed until the urine clears and BUN, creatinine, and blood pressure normalize. (Rest also facilitates diuresis.) • Administer medications as ordered, and evaluate patient's response to antihypertensives, diuretics, H2 blockers, phosphate-binding agents, and antibiotics (if indicated). Disorders of kidney Glomerulonephritis
Nursing management- • Carefully monitor fluid balance • Replace fluids according to the patient's fluid losses (urine, respiration, feces) • Daily body weight as prescribed. • Monitor pulmonary artery pressure and CVP, if indicated. • Monitor for signs and symptoms of heart failure: distended neck veins, tachycardia, gallop rhythm, enlarged and tender liver, crackles at bases of lungs. Observe for hypertensive encephalopathy, any evidence of seizure activity. Disorders of kidney Glomerulonephritis
Nursing management- • Regular monitoring of blood pressure, urinary protein, and BUN concentrations to determine if there is exacerbation of disease activity. • Encourage patient to treat any infection promptly. • Tell patient to report any signs of decreasing renal function and to obtain treatment immediately. Disorders of kidney Glomerulonephritis
Mr Sushil S. Humane MSN, RN
Nephrotic syndrome • Definition- Nephrotic syndrome is a clinical disorder characterized by marked increase of protein in the urine (proteinuria), decrease in albumin in the blood (hypoalbuminemia), edema, and excess lipids in the blood (hyperlipidemia). • These occur because of increased permeability of the glomerular capillary membrane.
Nephrotic syndrome Classification of nephrotic syndrome- ETOLOGICAL CLASSIFICATION • Primary NEPHROTIC syndrome. Disease limited to kidney • Secondary NEPHROTIC syndrome. Other systems involved HISTOLOGICAL CLASISIFICATION • MCD (Minimal change disease ) • FSGN (Focal segmental glomerulosclerosis ) • MN (Membranous nephropathy) • MPGN (membranous proliferative glomerulonephrosclerosis)
Nephrotic syndrome Etiology- • Membranous nephropathy (MN) • Hepatitis B • Sjogren's syndrome • Systemic lupus erythematosus (SLE) • Diabetes mellitus • Sarcoidosis • Syphilis • Drugs • Malignancy (cancer)
Nephrotic syndrome Etiology- • Focal segmental glomerulosclerosis (FSGS) • Hypertensive Nephrosclerosis • Human immunodeficiency virus (HIV) • Diabetes mellitus • Obesity • Kidney loss • Minimal change disease (MCD) • Drugs • Malignancy, especially Hodgkin's lymphoma
Nephrotic syndrome Clinical features- • The major manifestation of nephrotic syndrome is edema. • It is usually soft and pitting and commonly occurs around the eyes (periorbital), in dependent areas (sacrum, ankles, and hands), and in the abdomen (ascites). • Patients may also exhibit irritability, headache, and malaise.
Nephrotic syndrome Diagnostic evaluation- • Urinalysis- marked proteinuria, microscopic hematuria, • 24-hour urine for protein (increased) and creatinine clearance (decreased) • Protein electrophoresis and immunoelectrophoresis of the urine to categorize the proteinuria • Needle biopsy of kidney for histologic examination of renal tissue to confirm diagnosis • Serum chemistry- decreased total protein and albumin, normal or increased creatinine, increased triglycerides,
Nephrotic syndrome 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)
Nephrotic syndrome Management- • Treatment of causative glomerular disease • Diuretics (used cautiously) and angiotensin converting enzyme inhibitors to control proteinuria • Corticosteroids or immunosuppressant agents to decrease proteinuria • General management of edema • Sodium and fluid restriction; liberal potassium • Infusion of salt-poor albumin • Dietary protein supplements • Low-saturated-fat diet
Nephrotic syndrome Nursing Management- • Monitor daily weight, intake and output, and urine specific gravity. • Monitor CVP (if indicated), vital signs, orthostatic blood pressure, and heart rate to detect hypovolemia. • Monitor serum BUN and creatinine to assess renal function. • Administer diuretics or immunosuppressants as prescribed, and evaluate patient's response. • Infuse I.V. albumin as ordered. • Encourage bed rest for a few days to help mobilize edema; however, some ambulation is necessary to reduce risk of thromboembolic complications.
Renal failure Mr Sushil S. Humane MSN, RN
Renal failure • Definition- Acute renal failure is a sudden and almost complete loss of kidney function caused by failure of renal circulation or by glomerular or tubular dysfunction.
Renal failure Etiology- • Pre – renal (hypoperfusion of kidney) • Intra – renal (actual damage to the kidney tissue) • Post – renal (obstruction to urine flow)
Renal failure
Renal failure
Renal failure
Renal failure RISK FACTORS • Advanced age • Blockages in the blood vessels in your arms or legs • Diabetes • High blood pressure • Heart failure • Kidney diseases • Liver disease
Renal failure PHASES OF ARF • Initiating phase • Oliguric phase • Diuretic phase • Recovery phase
Renal failure PHASES OF ARF • Initiating phase Begins with the initial insult and ends when oliguria develops • Oliguric phase Urine output less than 400 ml/day • Diuretic phase Urine output become normal but nitrogenous waste products still remain elevated in blood • Recovery phase It signifies the improvement of renal function It takes 3-12 months to return normal
Renal failure Clinical features- • 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 • Haematuria. • Pressure, or difficulty urinating. • Itching.
Renal failure Clinical features- • Bone damage. • Non-union in broken bones. • Muscle cramps (caused by low levels of calcium which can cause hypocalcaemia) • Abnormal heart rhythms. • Muscle paralysis. • 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.
Renal failure Clinical features- • Memory problems. • Difficulty concentrating. • Dizziness. • Low blood pressure. • Anorexia • Pruritus • Seizures (if blood urea nitrogen level is very high)
Renal failure Diagnostic evaluation- • History regarding the etiological factors and risk factors. • Physical symptoms • Urine output – scanty, bloody, and low specific gravity • Increased BUN and creatinine level in blood • Hyperkalemia • Metabolic acidosis • Hyperphoshatemia • Hypocalcemia • Anemia
Renal failure Prevention- • Provide adequate hydration to patient at high risk for dehydration • Prevent and treat shock with blood and fluid replacement therapy • Manage hypotension • Monitor critically ill patient for central venous and arterial pressures and hourly urine output to detect the onset of renal failure as early as possible. • Continuously assess the renal function
Renal failure Prevention- • Prevent and treat infections • Cautiously administer the blood • Closely monitor the all medications that metabolized and excreted by the kidney for dosage and blood levels for the toxic effects. • Pay special attention to wound, burns and other precursors of sepsis.
Renal failure COMPLICATIONS ARF can affect the entire body in the form of – • Infection • Hyperkalaemia, Hyperphosphataemia, Hyponatraemia • Water overload • Pericarditis • Pulmonary oedema. • Reduced level of consciousness. • Immune deficiency
Renal failure Management- • To correct fluid and electrolyte balance. • To correct dehydration. • To Keep other body systems working properly
Renal calculi Mr Sushil S Humane MSN, RN
Renal calculi • Urolithiasis refers to stones (calculi) in the urinary tract. • Stones are formed in the urinary tract when urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increase. • This is referred to as supersaturation and is depen- dent on the amount of the substance, ionic strength, and pH of the urine.
Renal calculi Incidence- • The occurrence of urinary stones occurs predomi- nantly in the third to fifth decades of life and • Affects men more than women. • About half of patients with a single renal stone have another episode within 5 years. • Most stones contain calcium or magnesium in combination with phosphorus or oxalate. • Most stones are radiopaque and can be detected by x-ray studies
Renal calculi Types of stone- • Calcium stone • Oxalate stone • Cystiene stone • Struvite stone
Renal calculi Types of stone- • Calcium stone • Most stones (75%) are composed mainly of calcium oxalate crystals. • Increased calcium concentrations in blood and urine promote precipitation of calcium and formation of stones. • Causes of hypercalcemia (high serum calcium) and hypercalciuria (high urine calcium) include the following:
Renal calculi Types of stone- • Calcium stone • Hyperparathyroidism • Renal tubular acidosis • Cancers • Granulomatous diseases (sarcoidosis, tuberculosis), which may cause increased vitamin D production by the granulomatous tissue • Excessive intake of vitamin D • Excessive intake of milk and alkali • Myeloproliferative diseases (leukemia, polycythemia vera, multiple myeloma), which produce an unusual proliferation of blood cells from the bone marrow
Renal calculi Types of stone- • Uric acid stones • 5% to 10% of all stones • gout • myeloproliferative disorders • Diet high in purines and abnormal purine metabolism
Renal calculi Types of stone- • Struvite stones • 15% of urinary calculi • form in persistently alkaline, ammonia-rich urine • caused by the presence of urease splitting bacteria such as Proteus, Pseudomonas, Klebsiella, Staphy- lococcus, or Mycoplasma species. • Predisposing factors for struvite stones (commonly called infection stones) include neurogenic bladder, foreign bodies, and recurrent UTIs
Renal calculi Types of stone- • Cystine stones • 1% to 2% of all stones occur in patients with a rare inherited defect in renal absorption of cystine (an amino acid).
Renal calculi Causes and predisposing factors: • Chronic dehydration, poor fluid intake, and immobility • Living in mountainous, desert, or tropical areas • Infection, urinary stasis, and periods of immobility • Inflammatory bowel disease and in patients with an ileostomy or bowel resection because these patients absorb more oxalate. • Medications- antacids, acetazolamide (Diamox), vitamin D, laxatives, and high doses of aspirin
Renal calculi Location of stones- • Kidney • Ureter • Bladder • Urethra
Renal calculi Clinical features- • Pain • Heamturia • Dysuria • Oedema • Pyuria Associated symptoms- • Nausea, vomiting, diarrhea, abdominal discomfort • Chills and fever (may)
Renal calculi Clinical features- Pain- • Stones in the renal pelvis may be associated with an intense, deep ache in the costovertebral region • Pain originating in the renal area radiates anteriorly and downward toward the bladder in the female and toward the testis in the male. • If the pain suddenly becomes acute, with tenderness over the costovertebral area, and nausea and vomiting appear termed as renal colic
Renal calculi Clinical features- • Pain- • Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia • It is called ureteral colic • Colic is mediated by prostaglandin E, a substance that increases ureteral contractility and renal blood flow and that leads to increased intraureteral pressure and pain • If the stone present in the bladder and obstruct he urine flow, produces the pain at suprapubic region along with bladder distension
Renal calculi Clinical features- • Hematuria- Hematuria is often present because of the abrasive action of the stone. • Dysuria- Painful micturition is termed as dysuria. • Obstruction in urine flow tend to cause the dysuria.
Renal calculi Clinical features- • Oedema- When the stones block the flow of urine, obstruction develops, producing an increase in hydrostatic pressure and distending the renal pelvis and proximal ureter. • Thereby GFR decreases leads to sodium and water retetion and gives rise to oedema. • Pyuria- Obstruction in urine flow, urinary retention and urinary stasis may cause the UTI and featured as pyuria.
Renal calculi Clinical features- • Associated symptoms- Nausea, vomiting, diarrhea, abdominal discomfort due to renointestinal reflexes and shared nerve supply (celiac ganglion) between the ureters and intestineand the anatomic proximity of the kidneys to the stomach, pancreas, and large intestine. • Features of infection- Due to UTI. These features may be chill, high grade fever dysuria etc.
Renal calculi Diagnostic evaluation- • History • Physical examination • Urinanalysis • Blood studies • Stone chemistry • Radiographic studies
Renal calculi Diagnostic evaluation • History - • Diet • Water • Occupation • medication • Past and recent medical history • Collect the informations regarding the reasons for seeking health care services
Renal calculi Diagnostic evaluation • Physical examination - Locate, nature and characteristics of pain • Assess the level of pain ,tenderness etc. • Observe for the associated symptoms.
Renal calculi Diagnostic evaluation • Urinanalysis- hematuria and pyuria • pH < 5.5 indicates uric acid stone • pH > 7.5 indicates struvite stone • urine culture and drug sensitivity studies to detect infection. • 24-hour urine test for measurement of calcium, uric acid, creatinine, sodium,citrate and oxalate
Renal calculi Diagnostic evaluation Blood studies- • Hyperuracemia • Hypercalcemia • Neutrophilia • Elevated serum parathyroid hormone
Renal calculi Diagnostic evaluation • Stone chemistry- • Collection of stone through a strainer is useful. • Analyze the stone chemically to find out the composition which helps in therapeutic management.
Renal calculi Diagnostic evaluation • Radiographic studies- • Kidney, ureters, and bladder radiography may show stone. • Intra venous urogram (intravenous pyelogram) to determine site and evaluate degree of obstruction • Retrograde pyelography • Ultrasound • Helical or axial CAT Scan
Renal calculi Management General Principles • If small stone (< 4 mm) and able to treat as outpatient, 80% will pass stone spontaneously with hydration, pain control, and reassurance. • Hospitalized for intractable pain, persistent vomiting, high-grade fever, obstruction with infection, and solitary kidney with obstruction. • Medical management • Surgical management • Nursing management
Renal calculi Management • Medical management Goal- Immediate goal- • To relieve the pain until its causes can be eliminated. Long term goal (basic goal)- To eradicate the stone • To determine the stone type • To prevent nephron destruction • To control infection • To relieve any obstruction
Renal calculi Management • Medical management • Opioid analgesics or NSAIDs are administered to prevent shock and syncope that may result from the excruciating pain. • NSAIDs provide specific pain relief because they inhibit the synthesis of prostaglandin E. • Hot baths or moist heat to the flank areas may also be useful.
Renal calculi Management • Medical management • Fluids are encouraged. This increases the hydrostatic pressure behind the stone, assisting it in its downward passage. • A high, around-the-clock fluid intake reduces the concentration of urinary crystalloids, dilutes the urine, and ensures a high urine output.
Renal calculi Management • Medical management • Fluids are encouraged. This increases the hydrostatic pressure behind the stone, assisting it in its downward passage. • A high, around-the-clock fluid intake reduces the concentration of urinary crystalloids, dilutes the urine, and ensures a high urine output.
Renal calculi Management • Medical management Calcium stone- Cellulose sodium phosphate (Calcibind) may be effective in preventing calcium stones. It binds calcium from food in the intestinal tract, reducing the amount of calcium absorbed into the circulation. • restrict calcium in diet • Therapy with thiazide diuretics may be beneficial in reducing the calcium loss in the urine and lowering the elevated paratharmone levels. • The urine may be acidified by use of medications such as ammonium chloride or acetohydroxamic acid • Sodium and protein restriction diet
Renal calculi Management • Medical management Uric acid stone- • low-purine diet such as shellfish, anchovies, asparagus, mushrooms, and organ meats are avoided • Allopurinol may be prescribed to reduce serum uric acid levels and urinary uric acid excretion. • Proteins may be limited in diet
Renal calculi Management • Medical management Cystine stone - • Low-protein diet • Penicillamine is administered to reduce the amount of cystine in the urine • urine is alkalinized.
Renal calculi Management • Medical management Oxalate stone - • Encourage the increased fluid intake • Avoid the food contains oxalate such as- spinach, strawberries, tea, peanuts, wheat bran
Renal calculi Management Non surgical management- • Ureteroscopy • ESWL (Extra Corporeal Shock wave lithotripsy) • Endoscopic procedures • Electrohydrolic lithotripsy • Chemolysis
Renal calculi Management • Non surgical management- Ureteroscopy • Ureteroscopy involves visualizing the stone and then destroying it. • Access to the stone is accomplished by inserting a ureteroscope into the ureter and then inserting a laser, electrohydraulic lithotriptor, or ultrasound device through the ureteroscope to fragment and remove the stones. • A stent may be inserted and left in place for 48 hours or more after the procedure to keep the ureter patent
Renal calculi Management • Non surgical management- ESWL- ESWL is a noninvasive procedure used to break up stones in the calyx of the kidney • In ESWL, a high-energy amplitude of pressure, or shock wave, is generated by the abrupt release of energy and transmitted through water and soft tissues. • When the shock wave encounters a substance of different intensity (a renal stone), a compression wave causes the surface of the stone to fragment. • Repeated shock waves focused on the stone eventually reduce it to many small pieces. These small pieces are excreted in the urine, usually without difficulty.
Renal calculi Management • Non-surgical management- ESWL
Renal calculi Management • Non surgical management- • Endoscopic procedures- • A percutaneous nephrostomy or a percutaneous nephrolithotomy may be performed, and a nephroscope is introduced through the dilated percutaneous tract into the renal parenchyma. • Depending on its size, the stone may be extracted with forceps or by a stone retrieval basket. Alternatively, an ultrasound probe may be introduced through the nephrostomy tube.
Renal calculi Management-Non surgical management- • Electrohydraulic lithotripsy- • an electrical discharge is used to create a hydraulic shock wave to break up the stone. • A probe is passed through the cystoscope, and the tip of the lithotriptor is placed near the stone • This procedure is performed under topical anesthesia.
Renal calculi Management • Non-surgical management- • Chemolysis- Chemolysis, stone dissolution using infusions of chemical solutions (eg, alkylating agents, acidifying agents) • A percutaneous nephrostomy is performed, and the warm irrigating solution is allowed to flow continuously onto the stone.
Renal calculi Management • Surgical management- Nephrolithotomy - Incision into the kidney with removal of the stone • Nephrectomy – removal of kidney • Pyelolithotomy - removal of stone from renal pelvis • Ureterolithotomy - removal of stone from ureter • Cystostomy – removal of stone from bladder • Cystolitholapaxy - an instrument is inserted through the urethra into the bladder, and the stone is crushed in the jaws of this instrument
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Genito-urinary system disorders-1.pptx

  • 1.
    Nursing management of patientwith Genito-urinary system disorders Mr. Sushil Sudarshan Humane MSN, RN
  • 2.
  • 3.
    Functions of urinarysystem • Filter. fluid from the bloodstream. • Waste processing. filtrate, allowing wastes and excess ions to leave the body, returning needed substances to the blood in just the right proportions. • Elimination. eliminating nitrogenous wastes, toxins, and drugs from the body. • Regulation. the proper balance between water and salts and between acids and bases is maintained. • Other regulatory functions. By producing the enzyme renin, they help regulate blood pressure, and their hormone erythropoietin stimulates red blood cell production in the bone marrow. • Conversion. Kidney cells also convert vitamin D to its active form.
  • 4.
  • 5.
    Review of urinarysystem • Location. These small, dark red, kidney-bean shape, retroperitoneal position (beneath the parietal peritoneum) in the superior lumbar region, T12 to the L3 vertebra. • Positioning. right kidney is positioned slightly lower than the left. • Size. 12 cm (5 inches) long, 6 cm (2.5 inches) wide, and 3 cm (1 inch) thick, • Adrenal gland. • Fibrous capsule. glistening appearance. • Perirenal fat capsule. acts to cushion • Renal fascia. outermost capsule, anchors the kidney, hold it in place • Renal cortex. The outer region, light in color • Renal medulla. Deep, darker, reddish-brown area • Renal pyramids. triangular regions with a striped appearance, the renal, or medullary pyramid • Renal columns. The pyramids are separated by extensions of cortex-like tissue
  • 7.
    Nephron • Nephrons. milliontiny structures called nephrons • Glomerulus. a glomerulus is a knot of capillaries. • Renal tubule. • Bowman’s capsule. cup-shaped, the glomerulus,Podocytes- octopus-like cells- foot processes that intertwine with one another and cling to the glomerulus. • Collecting duct. • Proximal convoluted tubule. • Loop of Henle.- hairpin loop following the proximal convoluted tubule. • Afferent arteriole. is the “feeder vessel”. • Efferent arteriole. • Peritubular capillaries.
  • 8.
    Ureters • Size.- 25to 30 cm (10 to 12 inches) long and 6 mm (1/4 inch) in diameter. • Location. Each ureter runs behind the peritoneum from the renal hilum to the posterior aspect of the bladder, which it enters at a slight angle. • Function. carry urine from the kidneys to the bladder, peristalsis, valve-like folds of bladder mucosa that flap over the ureter openings.
  • 9.
    Urinary bladder A smooth,collapsible, muscular sac that stores urine temporarily. • Location. retroperitoneally in the pelvis just posterior to the symphysis pubis. • Function. The detrusor muscles and the transitional epithelium both make the bladder uniquely suited for its function of urine storage. • Trigone. The smooth triangular region of the bladder base outlined by these three openings is called the trigone, where infections tend to persist. • Detrusor muscles. The bladder wall contains three layers of smooth muscle, collectively called the detrusor muscle, and its mucosa is a special type of epithelium, transitional epithelium.
  • 10.
    Urethra • Internal urethralsphincter. At the bladder-urethral junction,an involuntary sphincter • External urethral sphincter. the external urethral sphincter, skeletal muscle, voluntarily controlled. • Female urethra. 3 to 4 cm (1 1/2 inches) long, and its external orifice, or opening, lies anteriorly to the vaginal opening. • Male urethra. 20 cm (8 inches) long and has three named regions: the prostatic, membranous, and spongy (penile) urethrae; it opens at the tip of the penis after traveling down its length.
  • 13.
    Characteristics of urine •In 24 hours, 150 to 180 liters of blood plasma filters • Daily volume. In 24 hours, 1.0 to 1.8 liters of urine are produced. • Components. Urine contains nitrogenous wastes and unneeded substances. • Color. clear and pale to deep yellow. • Odor. sterile and slightly aromatic, but if allowed to stand, it takes on an ammonia odor caused by the action of bacteria on the urine solutes. • pH. slightly acidic (around 6), • Specific gravity. ranges from 1.001 to 1.035. • Solutes. sodium and potassium ions, urea, uric acid, creatinine, ammonia, bicarbonate ions, and various other ions.
  • 14.
    Nursing assessment History, and physicalexamination • During physical examination for genitourinary dysfunction areas of emphasis include the abdomen, suprapubic region, genitalia and lower back, and lower extremities. • Direct palpation of the kidneys may help determine their size and mobility • The right kidney is easier to feel because it is somewhat lower than the left one
  • 15.
    Nursing assessment History, andphysical examination • Renal dysfunction may produce tenderness over the costovertebral angle, which is the angle formed by the lower border of the 12th, or bottom, rib and the spine. • The abdomen is auscultated to assess for bruits (low- pitched murmurs that indicate renal artery stenosis or an aortic aneurysm). • The abdomen is also assessed for the presence of peritoneal fluid, which may occur with kidney dysfunction.
  • 16.
    Nursing assessment • Thebladder should be percussed after the patient voids to check for residual urine • Percussion of the bladder begins at the midline just above the umbilicus and proceeds downward. • The sound changes from tympanic to dull when percussing over the bladder. • The bladder, which can be palpated only if it is moderately distended, feels like a smooth, firm, round mass rising out of the abdomen, usually at midline • Dullness to percussion of the bladder following voiding indicates incomplete bladder emptying.
  • 17.
    Nursing assessment • Theprostate gland is palpated by digital rectal examination (DRE) • Blood is drawn for PSA before the DRE because manipulation of the prostate can cause the PSA level to rise temporarily. • The inguinal area is examined for enlarged nodes, an inguinal or femoral hernia, or varicocele (varicose veins of the spermatic cord)
  • 18.
    Nursing assessment • Infemale, the vulva, urethral meatus, and vagina are examined • The patient is assessed for edema and changes in body weight. • Edema may be observed, particularly in the face and dependent parts of the body, such as the ankles and sacral areas • An increase in body weight commonly accompanies edema. A 1-kg weight gain equals approximately 1,000 mL of fluid.
  • 19.
    Disorders of kidney Mr.Sushil S. Humane MSN, RN
  • 20.
    Disorders of kidney Glomerulonephritis AcuteNephritic Syndrome • Definition – Acute glomerulonephritis refers to a group of kidney diseases in which there is an inflammatory reaction in the glomeruli. • It is not an infection of the kidney, but rather the result of the immune mechanisms of the body.
  • 21.
    Disorders of kidney Glomerulonephritis Riskfactors • Group A beta- hemolytic streptococcal infection of the throat • Impetigo (infection of the skin) • Acute viral infections- upper respiratory tract infections, mumps, varicella zoster virus, Epstein- Barr virus, hepatitis B, and human immunodeficiency virus [HIV] infection). • Antigens outside the body (eg, medications, foreign serum) • In other patients, the kidney tissue itself serves as the inciting antigen.
  • 22.
    Disorders of kidney Glomerulonephritis Categories– • Primary: Disease is mainly in glomeruli • Secondary: Glomerular diseases that are the consequence of systemic disease • Idiopathic: Cause is unknown • Acute: Occurs over days or weeks • Chronic: Occurs over months or years • Rapidly progressing: Constant loss of renal function with minimal chance of recovery
  • 23.
    Disorders of kidney Glomerulonephritis Categories– • Diffuse: Involves all glomeruli • Focal: Involves some glomeruli • Segmental: Involves portions of individual glomeruli • Membranous: Evidence of thickened glomerular capillary walls • Proliferative: Number of glomerular cells involved
  • 24.
    Disorders of kidney Glomerulonephritis Clinicalfeatures- • Hematuria - The urine may appear cola-colored because of red blood cells (RBCs) and protein plugs or casts; RBC casts indicate glomerular injury. • Edema and hypertension • Oliguria • Anemia from loss of RBCs into the urine
  • 25.
  • 26.
    Clinical features- • Inthe more severe form of the disease, patients also complain of headache, malaise, and flank pain. • Elderly patients may experience circulatory overload with dyspnea, engorged neck veins, cardiomegaly, and pulmonary edema. • Atypical symptoms include confusion, somnolence, and seizures, which are often confused with the symptoms of a primary neurologic disorder Disorders of kidney Glomerulonephritis
  • 27.
    Diagnostic evaluation- History •On examination- kidney is large, tender, edematous and congested • Urinanalysis- protienuria, hematuria , oliguria • Blood studies- • Serum creatinine, BUN increased • Hypoalbuminemia, hyperlipidemia • Elevated serum IgA level • Antistreptolysin O titers are usually elevated in post streptococcal glomerulonephritis • Electron microscopy and immunofluorescent analysis help identify the nature of the lesion • Kidney biopsy may be needed for definitive diagnosis. Disorders of kidney Glomerulonephritis
  • 28.
    Complications- • Hypertensive Encephalopathy •Heart Failure • Pulmonary Edema • ESRD Disorders of kidney Glomerulonephritis
  • 29.
    Management- Goal • Toconserve renal function • To treat complication adequately • Types of management- • Non pharmacological management • Dietary management • Pharmacological management • Nursing management Disorders of kidney Glomerulonephritis
  • 30.
    Non-pharmacological management- • Completebed rest – As excessive activity may increase the proteinuria and hematuria. It should be encouraged until the urine clears and BUN, creatinine and BP return to normal. • Strict intake output charting • Fluid restrictions • Plasmapheresis to decrease the serum anti body level • Dialysis if, uremic symptoms are severe. Disorders of kidney Glomerulonephritis
  • 31.
    Dietary management- • Proteinrestricted diet as the level of BUN and creatinine is high in blood • Low fat diet due to hyperlipidemia • Sodium restriction if hypertension, edema or congestive heart failure are present. • Increased carbohydrate diet to provide energy and to prevent the catabolism of protein. Disorders of kidney Glomerulonephritis
  • 32.
    Pharmacological management- • Residualstreptococcal infection is suspected, penicillin is the agent of choice. • Diuretics and antihypertensive agents may be given to control hypertension. • Corticosteroids and cytotoxic agents are used to reduce the inflammation. • H2 blockers (to prevent stress ulcers) • Phosphate binding agents (to reduce phosphate and elevate calcium). Disorders of kidney Glomerulonephritis
  • 33.
    Nursing management- • Monitorvital signs, intake and output, and maintain dietary restrictions during acute phase. • Encourage rest during the acute phase as directed until the urine clears and BUN, creatinine, and blood pressure normalize. (Rest also facilitates diuresis.) • Administer medications as ordered, and evaluate patient's response to antihypertensives, diuretics, H2 blockers, phosphate-binding agents, and antibiotics (if indicated). Disorders of kidney Glomerulonephritis
  • 34.
    Nursing management- • Carefullymonitor fluid balance • Replace fluids according to the patient's fluid losses (urine, respiration, feces) • Daily body weight as prescribed. • Monitor pulmonary artery pressure and CVP, if indicated. • Monitor for signs and symptoms of heart failure: distended neck veins, tachycardia, gallop rhythm, enlarged and tender liver, crackles at bases of lungs. Observe for hypertensive encephalopathy, any evidence of seizure activity. Disorders of kidney Glomerulonephritis
  • 35.
    Nursing management- • Regularmonitoring of blood pressure, urinary protein, and BUN concentrations to determine if there is exacerbation of disease activity. • Encourage patient to treat any infection promptly. • Tell patient to report any signs of decreasing renal function and to obtain treatment immediately. Disorders of kidney Glomerulonephritis
  • 36.
    Mr Sushil S.Humane MSN, RN
  • 37.
    Nephrotic syndrome • Definition-Nephrotic syndrome is a clinical disorder characterized by marked increase of protein in the urine (proteinuria), decrease in albumin in the blood (hypoalbuminemia), edema, and excess lipids in the blood (hyperlipidemia). • These occur because of increased permeability of the glomerular capillary membrane.
  • 38.
    Nephrotic syndrome Classification ofnephrotic syndrome- ETOLOGICAL CLASSIFICATION • Primary NEPHROTIC syndrome. Disease limited to kidney • Secondary NEPHROTIC syndrome. Other systems involved HISTOLOGICAL CLASISIFICATION • MCD (Minimal change disease ) • FSGN (Focal segmental glomerulosclerosis ) • MN (Membranous nephropathy) • MPGN (membranous proliferative glomerulonephrosclerosis)
  • 39.
    Nephrotic syndrome Etiology- • Membranousnephropathy (MN) • Hepatitis B • Sjogren's syndrome • Systemic lupus erythematosus (SLE) • Diabetes mellitus • Sarcoidosis • Syphilis • Drugs • Malignancy (cancer)
  • 40.
    Nephrotic syndrome Etiology- • Focalsegmental glomerulosclerosis (FSGS) • Hypertensive Nephrosclerosis • Human immunodeficiency virus (HIV) • Diabetes mellitus • Obesity • Kidney loss • Minimal change disease (MCD) • Drugs • Malignancy, especially Hodgkin's lymphoma
  • 42.
    Nephrotic syndrome Clinical features- •The major manifestation of nephrotic syndrome is edema. • It is usually soft and pitting and commonly occurs around the eyes (periorbital), in dependent areas (sacrum, ankles, and hands), and in the abdomen (ascites). • Patients may also exhibit irritability, headache, and malaise.
  • 43.
    Nephrotic syndrome Diagnostic evaluation- •Urinalysis- marked proteinuria, microscopic hematuria, • 24-hour urine for protein (increased) and creatinine clearance (decreased) • Protein electrophoresis and immunoelectrophoresis of the urine to categorize the proteinuria • Needle biopsy of kidney for histologic examination of renal tissue to confirm diagnosis • Serum chemistry- decreased total protein and albumin, normal or increased creatinine, increased triglycerides,
  • 44.
    Nephrotic syndrome 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)
  • 45.
    Nephrotic syndrome Management- • Treatmentof causative glomerular disease • Diuretics (used cautiously) and angiotensin converting enzyme inhibitors to control proteinuria • Corticosteroids or immunosuppressant agents to decrease proteinuria • General management of edema • Sodium and fluid restriction; liberal potassium • Infusion of salt-poor albumin • Dietary protein supplements • Low-saturated-fat diet
  • 46.
    Nephrotic syndrome Nursing Management- •Monitor daily weight, intake and output, and urine specific gravity. • Monitor CVP (if indicated), vital signs, orthostatic blood pressure, and heart rate to detect hypovolemia. • Monitor serum BUN and creatinine to assess renal function. • Administer diuretics or immunosuppressants as prescribed, and evaluate patient's response. • Infuse I.V. albumin as ordered. • Encourage bed rest for a few days to help mobilize edema; however, some ambulation is necessary to reduce risk of thromboembolic complications.
  • 47.
    Renal failure Mr SushilS. Humane MSN, RN
  • 48.
    Renal failure • Definition-Acute renal failure is a sudden and almost complete loss of kidney function caused by failure of renal circulation or by glomerular or tubular dysfunction.
  • 49.
    Renal failure Etiology- • Pre– renal (hypoperfusion of kidney) • Intra – renal (actual damage to the kidney tissue) • Post – renal (obstruction to urine flow)
  • 50.
  • 51.
  • 52.
  • 53.
    Renal failure RISK FACTORS •Advanced age • Blockages in the blood vessels in your arms or legs • Diabetes • High blood pressure • Heart failure • Kidney diseases • Liver disease
  • 54.
    Renal failure PHASES OFARF • Initiating phase • Oliguric phase • Diuretic phase • Recovery phase
  • 55.
    Renal failure PHASES OF ARF •Initiating phase Begins with the initial insult and ends when oliguria develops • Oliguric phase Urine output less than 400 ml/day • Diuretic phase Urine output become normal but nitrogenous waste products still remain elevated in blood • Recovery phase It signifies the improvement of renal function It takes 3-12 months to return normal
  • 56.
    Renal failure Clinical features- •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 • Haematuria. • Pressure, or difficulty urinating. • Itching.
  • 57.
    Renal failure Clinical features- • Bonedamage. • Non-union in broken bones. • Muscle cramps (caused by low levels of calcium which can cause hypocalcaemia) • Abnormal heart rhythms. • Muscle paralysis. • 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.
  • 58.
    Renal failure Clinical features- • Memoryproblems. • Difficulty concentrating. • Dizziness. • Low blood pressure. • Anorexia • Pruritus • Seizures (if blood urea nitrogen level is very high)
  • 59.
    Renal failure Diagnostic evaluation- • Historyregarding the etiological factors and risk factors. • Physical symptoms • Urine output – scanty, bloody, and low specific gravity • Increased BUN and creatinine level in blood • Hyperkalemia • Metabolic acidosis • Hyperphoshatemia • Hypocalcemia • Anemia
  • 60.
    Renal failure Prevention- • Provide adequatehydration to patient at high risk for dehydration • Prevent and treat shock with blood and fluid replacement therapy • Manage hypotension • Monitor critically ill patient for central venous and arterial pressures and hourly urine output to detect the onset of renal failure as early as possible. • Continuously assess the renal function
  • 61.
    Renal failure Prevention- • Prevent andtreat infections • Cautiously administer the blood • Closely monitor the all medications that metabolized and excreted by the kidney for dosage and blood levels for the toxic effects. • Pay special attention to wound, burns and other precursors of sepsis.
  • 62.
    Renal failure COMPLICATIONS ARF canaffect the entire body in the form of – • Infection • Hyperkalaemia, Hyperphosphataemia, Hyponatraemia • Water overload • Pericarditis • Pulmonary oedema. • Reduced level of consciousness. • Immune deficiency
  • 63.
    Renal failure Management- • To correctfluid and electrolyte balance. • To correct dehydration. • To Keep other body systems working properly
  • 64.
    Renal calculi Mr SushilS Humane MSN, RN
  • 65.
    Renal calculi • Urolithiasisrefers to stones (calculi) in the urinary tract. • Stones are formed in the urinary tract when urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increase. • This is referred to as supersaturation and is depen- dent on the amount of the substance, ionic strength, and pH of the urine.
  • 66.
    Renal calculi Incidence- • Theoccurrence of urinary stones occurs predomi- nantly in the third to fifth decades of life and • Affects men more than women. • About half of patients with a single renal stone have another episode within 5 years. • Most stones contain calcium or magnesium in combination with phosphorus or oxalate. • Most stones are radiopaque and can be detected by x-ray studies
  • 67.
    Renal calculi Types ofstone- • Calcium stone • Oxalate stone • Cystiene stone • Struvite stone
  • 68.
    Renal calculi Types ofstone- • Calcium stone • Most stones (75%) are composed mainly of calcium oxalate crystals. • Increased calcium concentrations in blood and urine promote precipitation of calcium and formation of stones. • Causes of hypercalcemia (high serum calcium) and hypercalciuria (high urine calcium) include the following:
  • 69.
    Renal calculi Types ofstone- • Calcium stone • Hyperparathyroidism • Renal tubular acidosis • Cancers • Granulomatous diseases (sarcoidosis, tuberculosis), which may cause increased vitamin D production by the granulomatous tissue • Excessive intake of vitamin D • Excessive intake of milk and alkali • Myeloproliferative diseases (leukemia, polycythemia vera, multiple myeloma), which produce an unusual proliferation of blood cells from the bone marrow
  • 70.
    Renal calculi Types ofstone- • Uric acid stones • 5% to 10% of all stones • gout • myeloproliferative disorders • Diet high in purines and abnormal purine metabolism
  • 71.
    Renal calculi Types ofstone- • Struvite stones • 15% of urinary calculi • form in persistently alkaline, ammonia-rich urine • caused by the presence of urease splitting bacteria such as Proteus, Pseudomonas, Klebsiella, Staphy- lococcus, or Mycoplasma species. • Predisposing factors for struvite stones (commonly called infection stones) include neurogenic bladder, foreign bodies, and recurrent UTIs
  • 72.
    Renal calculi Types ofstone- • Cystine stones • 1% to 2% of all stones occur in patients with a rare inherited defect in renal absorption of cystine (an amino acid).
  • 73.
    Renal calculi Causes andpredisposing factors: • Chronic dehydration, poor fluid intake, and immobility • Living in mountainous, desert, or tropical areas • Infection, urinary stasis, and periods of immobility • Inflammatory bowel disease and in patients with an ileostomy or bowel resection because these patients absorb more oxalate. • Medications- antacids, acetazolamide (Diamox), vitamin D, laxatives, and high doses of aspirin
  • 74.
    Renal calculi Location ofstones- • Kidney • Ureter • Bladder • Urethra
  • 75.
    Renal calculi Clinical features- •Pain • Heamturia • Dysuria • Oedema • Pyuria Associated symptoms- • Nausea, vomiting, diarrhea, abdominal discomfort • Chills and fever (may)
  • 76.
    Renal calculi Clinical features- Pain- •Stones in the renal pelvis may be associated with an intense, deep ache in the costovertebral region • Pain originating in the renal area radiates anteriorly and downward toward the bladder in the female and toward the testis in the male. • If the pain suddenly becomes acute, with tenderness over the costovertebral area, and nausea and vomiting appear termed as renal colic
  • 77.
    Renal calculi Clinical features- •Pain- • Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia • It is called ureteral colic • Colic is mediated by prostaglandin E, a substance that increases ureteral contractility and renal blood flow and that leads to increased intraureteral pressure and pain • If the stone present in the bladder and obstruct he urine flow, produces the pain at suprapubic region along with bladder distension
  • 78.
    Renal calculi Clinical features- •Hematuria- Hematuria is often present because of the abrasive action of the stone. • Dysuria- Painful micturition is termed as dysuria. • Obstruction in urine flow tend to cause the dysuria.
  • 79.
    Renal calculi Clinical features- •Oedema- When the stones block the flow of urine, obstruction develops, producing an increase in hydrostatic pressure and distending the renal pelvis and proximal ureter. • Thereby GFR decreases leads to sodium and water retetion and gives rise to oedema. • Pyuria- Obstruction in urine flow, urinary retention and urinary stasis may cause the UTI and featured as pyuria.
  • 80.
    Renal calculi Clinical features- •Associated symptoms- Nausea, vomiting, diarrhea, abdominal discomfort due to renointestinal reflexes and shared nerve supply (celiac ganglion) between the ureters and intestineand the anatomic proximity of the kidneys to the stomach, pancreas, and large intestine. • Features of infection- Due to UTI. These features may be chill, high grade fever dysuria etc.
  • 81.
    Renal calculi Diagnostic evaluation- •History • Physical examination • Urinanalysis • Blood studies • Stone chemistry • Radiographic studies
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    Renal calculi Diagnostic evaluation •History - • Diet • Water • Occupation • medication • Past and recent medical history • Collect the informations regarding the reasons for seeking health care services
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    Renal calculi Diagnostic evaluation •Physical examination - Locate, nature and characteristics of pain • Assess the level of pain ,tenderness etc. • Observe for the associated symptoms.
  • 84.
    Renal calculi Diagnostic evaluation •Urinanalysis- hematuria and pyuria • pH < 5.5 indicates uric acid stone • pH > 7.5 indicates struvite stone • urine culture and drug sensitivity studies to detect infection. • 24-hour urine test for measurement of calcium, uric acid, creatinine, sodium,citrate and oxalate
  • 85.
    Renal calculi Diagnostic evaluation Bloodstudies- • Hyperuracemia • Hypercalcemia • Neutrophilia • Elevated serum parathyroid hormone
  • 86.
    Renal calculi Diagnostic evaluation •Stone chemistry- • Collection of stone through a strainer is useful. • Analyze the stone chemically to find out the composition which helps in therapeutic management.
  • 87.
    Renal calculi Diagnostic evaluation •Radiographic studies- • Kidney, ureters, and bladder radiography may show stone. • Intra venous urogram (intravenous pyelogram) to determine site and evaluate degree of obstruction • Retrograde pyelography • Ultrasound • Helical or axial CAT Scan
  • 88.
    Renal calculi Management GeneralPrinciples • If small stone (< 4 mm) and able to treat as outpatient, 80% will pass stone spontaneously with hydration, pain control, and reassurance. • Hospitalized for intractable pain, persistent vomiting, high-grade fever, obstruction with infection, and solitary kidney with obstruction. • Medical management • Surgical management • Nursing management
  • 89.
    Renal calculi Management • Medicalmanagement Goal- Immediate goal- • To relieve the pain until its causes can be eliminated. Long term goal (basic goal)- To eradicate the stone • To determine the stone type • To prevent nephron destruction • To control infection • To relieve any obstruction
  • 90.
    Renal calculi Management • Medicalmanagement • Opioid analgesics or NSAIDs are administered to prevent shock and syncope that may result from the excruciating pain. • NSAIDs provide specific pain relief because they inhibit the synthesis of prostaglandin E. • Hot baths or moist heat to the flank areas may also be useful.
  • 91.
    Renal calculi Management • Medicalmanagement • Fluids are encouraged. This increases the hydrostatic pressure behind the stone, assisting it in its downward passage. • A high, around-the-clock fluid intake reduces the concentration of urinary crystalloids, dilutes the urine, and ensures a high urine output.
  • 92.
    Renal calculi Management • Medicalmanagement • Fluids are encouraged. This increases the hydrostatic pressure behind the stone, assisting it in its downward passage. • A high, around-the-clock fluid intake reduces the concentration of urinary crystalloids, dilutes the urine, and ensures a high urine output.
  • 93.
    Renal calculi Management • Medicalmanagement Calcium stone- Cellulose sodium phosphate (Calcibind) may be effective in preventing calcium stones. It binds calcium from food in the intestinal tract, reducing the amount of calcium absorbed into the circulation. • restrict calcium in diet • Therapy with thiazide diuretics may be beneficial in reducing the calcium loss in the urine and lowering the elevated paratharmone levels. • The urine may be acidified by use of medications such as ammonium chloride or acetohydroxamic acid • Sodium and protein restriction diet
  • 94.
    Renal calculi Management • Medicalmanagement Uric acid stone- • low-purine diet such as shellfish, anchovies, asparagus, mushrooms, and organ meats are avoided • Allopurinol may be prescribed to reduce serum uric acid levels and urinary uric acid excretion. • Proteins may be limited in diet
  • 95.
    Renal calculi Management • Medicalmanagement Cystine stone - • Low-protein diet • Penicillamine is administered to reduce the amount of cystine in the urine • urine is alkalinized.
  • 96.
    Renal calculi Management • Medicalmanagement Oxalate stone - • Encourage the increased fluid intake • Avoid the food contains oxalate such as- spinach, strawberries, tea, peanuts, wheat bran
  • 97.
    Renal calculi Management Nonsurgical management- • Ureteroscopy • ESWL (Extra Corporeal Shock wave lithotripsy) • Endoscopic procedures • Electrohydrolic lithotripsy • Chemolysis
  • 98.
    Renal calculi Management • Nonsurgical management- Ureteroscopy • Ureteroscopy involves visualizing the stone and then destroying it. • Access to the stone is accomplished by inserting a ureteroscope into the ureter and then inserting a laser, electrohydraulic lithotriptor, or ultrasound device through the ureteroscope to fragment and remove the stones. • A stent may be inserted and left in place for 48 hours or more after the procedure to keep the ureter patent
  • 99.
    Renal calculi Management • Nonsurgical management- ESWL- ESWL is a noninvasive procedure used to break up stones in the calyx of the kidney • In ESWL, a high-energy amplitude of pressure, or shock wave, is generated by the abrupt release of energy and transmitted through water and soft tissues. • When the shock wave encounters a substance of different intensity (a renal stone), a compression wave causes the surface of the stone to fragment. • Repeated shock waves focused on the stone eventually reduce it to many small pieces. These small pieces are excreted in the urine, usually without difficulty.
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  • 101.
    Renal calculi Management • Nonsurgical management- • Endoscopic procedures- • A percutaneous nephrostomy or a percutaneous nephrolithotomy may be performed, and a nephroscope is introduced through the dilated percutaneous tract into the renal parenchyma. • Depending on its size, the stone may be extracted with forceps or by a stone retrieval basket. Alternatively, an ultrasound probe may be introduced through the nephrostomy tube.
  • 102.
    Renal calculi Management-Nonsurgical management- • Electrohydraulic lithotripsy- • an electrical discharge is used to create a hydraulic shock wave to break up the stone. • A probe is passed through the cystoscope, and the tip of the lithotriptor is placed near the stone • This procedure is performed under topical anesthesia.
  • 103.
    Renal calculi Management • Non-surgicalmanagement- • Chemolysis- Chemolysis, stone dissolution using infusions of chemical solutions (eg, alkylating agents, acidifying agents) • A percutaneous nephrostomy is performed, and the warm irrigating solution is allowed to flow continuously onto the stone.
  • 104.
    Renal calculi Management • Surgicalmanagement- Nephrolithotomy - Incision into the kidney with removal of the stone • Nephrectomy – removal of kidney • Pyelolithotomy - removal of stone from renal pelvis • Ureterolithotomy - removal of stone from ureter • Cystostomy – removal of stone from bladder • Cystolitholapaxy - an instrument is inserted through the urethra into the bladder, and the stone is crushed in the jaws of this instrument
  • 105.