Medical Surgical Nursing:Geniro Urinary Tract Disorder.

Debre Brehan University Debre Brehan University School of Health ScienceSchool of Health Science

Program of Nursing Program of Nursing Medical-Surgical Nursing Medical-Surgical Nursing

IIII

GENTO - URINARY SYSTEM DISORDERPrepared by Tesfa D.(B.Sc. in Nursing)

Anatomy and physiology Anatomy and physiology ofof

gento-urinary systemgento-urinary systemThe main parts of the urinary system are as follow.

1. Two Kidneys-These organs extract waste from the blood and balance body fluid, these are also the organs of excretion that form urine.

2. Two ureters-These tubes conduct urine from the kidneys to the urinary bladder.

2

Lecture note for regular second year Nursing student, February

2003/2011.

Cont…dCont…d

3. A single urinary bladder-this reservoir receive and stores the urine brought to it by the two ureters.

4. A single urethra - This tube conducts urine from the bladder to the out side of the body for elimination.

3

Lecture note for regular second year Nursing student, February 2003/2011.

Cont…dCont…d

Lecture note for regular second year Nursing student, February 2003/2011. 4

The kidneysThe kidneysLOCATION OF THE KIDNEYSThe kidneys are a pair of brownish-

red structures located retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of the abdomen from the 11th (Left) and12th (Right) thoracic vertebra to the 3rd lumbar vertebra in the adult.

The two kidneys lie against the muscle of the back in the upper abdomen.

Each kidney is enclosed in a membranous capsule that is made of fibrous connective tissue.

5


Cont…dCont…dBlood supply to the kidneys

Kidney get blood supply from renal artery and it takes 20-25% of the total CO.

After entering the kidney the renal artery sub divided in to smaller and smaller branches, which eventually make contact with the functional unit of the kidney called nephyron.

6


Cont…dCont…dBlood leaves the kidney by vessel

that finally merges to from the renal vein. The renal vein carries blood into the inferior vena-cave for return to the heart.


Cont…dCont…d


Representation of a Representation of a nephron.nephron.


Function of the kidneysFunction of the kidneys1. Regulation of:

body fluid osmolarity and volume electrolyte balance acid-base balance blood pressure

2. Excretion of; metabolic products foreign substances (pesticides, chemicals etc.) excess substance (water, etc)

3. Secretion of; erythropoitin 1,25-dihydroxy vitamin D3 (vitamin D activation) renin prostaglandin

4. Urine formation.5. Renal clearance.

10


THE URETERS THE URETERS The two ureters are long slander muscular tube that originate at the lower portion of the renal pelvis and terminate in the trigone of the bladder wall.Their length naturally varies with the size of the individual (approximately from 25 cm - 33 cm long).The left ureter is slightly shorter than the right. (why?)Function:-Transmit urine from renal pelvis in to the bladder.

11


The urinary bladderThe urinary bladderThe urinary bladder is a muscular, hollow sac located just behind the pubic bone.

Adult bladder capacity is about 300 to 600 ml of urine.

In infancy, the bladder is found within the abdomen.

12


Cont…dCont…dCharacteristic of the bladder

When it is empty, the urinary bladder is located below the partial peritoneum and behind the pubic joint.

When it is filled it pushes the peritoneum up ward and may extend well in to the abdominal cavity.

The urinary bladder is a temporary reservoir for urine.


The urethraThe urethraAt a neck of the bladder that the

urethra leave, there is bundles of involuntary smooth muscle that form a portion of the urethral sphincter known as the internal sphincter control by autonomic nervous system (involuntary control).

14


Cont…dCont…dThe portion of the sphincteric

mechanism that is under voluntary control is the external urinary sphincter at the anterior urethra, the segment most distal from the bladder.

The length of urethra varies with sex;Female urethra-7.5 cm (3 inches).Male urethra-15 to 25 cm (6 to 10

inches).Lecture note for regular second year Nursing student, February 2003/2011. 15

Assessment of urinary Assessment of urinary systemsystem

Subjective data (The History)This section discusses the data

related to assessment of urinary system that a nurse should elicit from a client to obtains a health history.

16


1. Chief Compliant1. Chief CompliantPain; Usually flank/loin region-

obstruction, infection. dull persistent-tumor.

Pain radiate to the iliac fossa, the testicle or the labia- ureteric stone obstruction.

Suprapubic region and perineum-cystitis or urethritis.

N.B. Glomerulonephritis is usually painless.


Cont…dCont…dHaematuria; can be;Continuous Painless parenchymal renal

disease microscopic e.g. glomerulonephritis (occasionally macroscopic).

intermittent painful renal tumours macroscopic.


Cont…dCont…dOliguria/anuria;Oliguria:-passage of <500mL

urine per day. Prerenal oliguria: decrease in renal blood

Renal oliguria: intrinsic renal disease

Postrenal oliguria: renal obostruction

Anuria:-complete absence of urine flow.


Cont…dCont…d

Polyuria;psychogenic polydipsiabeer drinkingdiabetes mellituschronic renal failure diuretic usenephrogenic diabetes insipidus


Cont…dCont…d

Frequency;o excessive fluid intakeo reduced functional bladder capacity (prostatic hypertrophy and bladder outlet obstruction).

o Cystitiso multiple sclerosis (neurologic disease)


Cont…dCont…dNocturia; Implies the need to empty the

bladder during the hours of sleep.

Often associated with:reduction of functional bladder

capacityDiuretics use

Dysuria;pain immediately before,

during or after micturition.Lecture note for regular second year Nursing student, February 2003/2011. 22

Cont…dCont…dUrgency; is the loss of the normal ability

to postpone micturition beyond the time when the desire to pass urine is initially perceived.

Incontinence; is the involuntary passage of

urine. Enuresis; is usually used to describe

noctural enuresis, or bed-wetting.


Cont…dCont…dSlow stream, hesitancy and

terminal dribbling;triad of symptoms is most

frequently seen in elderly men with prostatic hypertrophy (BPH).

Urethral discharge;urethritissexually transmitted infectionEdema;facial ( periorbital ), ankle,

ascites, anasarca, etc.Lecture note for regular second year Nursing student, February 2003/2011. 24

Cont…dCont…dOther constitutional symptomfatigue, headache, blurred vision,increased B/P, lack of appetite,nausea, itching, thirsts,chills etc...


2. History of Present 2. History of Present IllnessIllness

Full elaboration of all presenting sign and symptoms in terms of;DurationLocationQuality QuantityAggravating factorsRelieving factorsAssociated manifestationE.t.c.


Cont…dCont…dN.B. when reviewing a health

history, it is important to be sure that the patient understand the question being asked.

In discussing problem involving the genitalia, the pt may deny symptoms b/c of anxiety. There fore, encourage the client to talk about it.

27


Cont…dCont…d2. Past medical history The client should be questioned about

the existence or history of the following disease which have known to be related to renal problem;hypertension, diabetes mellitus, gout, connective tissue disease, cystitis, kidney infection, renal calculi, infections disease etc....

28


Cont…dCont…dThe client should also be questioned

about any hospitalization related to the above disease.

The client should questioned if he/she has ever been catheterized or has had diagnostic study involving instrumentation of the urinary tract.

An assessment of the client’s current and past use of medications is very important.


Cont…dCont…d3. Family history

The presence of certain renal or urological problems in a family history accessed the likelihood of similar problems occurring in a family member.The specific disease related to renal problems to ask the client is about congenital urinary tract abnormalities, polycystic kidney disease, urinary tract infection, urinary calculi, hypertension, gout, connective tissue disorder, etc…

30


Cont…dCont…d

4. Social and personal historyAreas of importance to be

considered in this category include back ground information and life style. Background information e.g.

combination of carbon tetrachloride & alcohol cause tubular necrosis.

Life Style e.g. high mineral content and some foods cause renal calculi.

31


11 functional pattern 11 functional pattern assessmentassessment

Fill by your self!!!


Cont…dCont…d Objective data (The physical

Exam)A. Inspection

Skin (pallor, yellowish, changes in turgor, bruises, crystals, etc...).

Mouth (Stomatitis and urinous breath odor).

Face (facial edema). Abdomen and extremities

(generalized edema).Weight gain secondary to edema.General state of health (fatigue,

lethargy, diminished alertness, e.t.c…).

33


Cont…dCont…dB. Palpation The kidney are posterior organs

protected by the a abdominal organ, ribs and the heavy back muscles.

May be the right kidney is palpable. To palpate the right kidney the examiner’s left hand is placed behind and supporting the right side b/n the rib cage and the iliac crest.

Some disease can be suggestive (e.g. hydronephrosis, neoplasm or polycystic kidney problem etc…).

The bladder is palpable if it is distended otherwise not palpable.

34


Right kidney palpationRight kidney palpation


Left kidney palpationLeft kidney palpation


Palpation of the Palpation of the bladderbladder


Cont…dCont…d

C. Percussion Tenderness of the flank area. Percussion of the bladder begins at

the midline just above the umbilicus and proceeds downward.

Normally a bladder is not a percussable unit.

If the bladder is full dullness will be heard above the public symphysis.

38


Cont…dCont…d

Location of costovertabral angle


Cont…dCont…d

D/ Auscultation ◦Auscultation is not generally used

in the assessment of the urinary system.

40


Diagnostic studies of Diagnostic studies of urinary systemurinary system

Diagnostic studies are important in locating and understanding problems of the urinary system.The accuracy at the finding at these studies is influenced by:-

A-Adherence to the proper procedure related to the study.B- Cooperation of the client on restricting fluids, collection of urine specimen, lying quietly on the x-ray table, e.t.c…

41


1.Urinanalsis1.Urinanalsis General examination of urine to

establish baseline information or to provide data in establishing a tentative diagnosis & determine further studies to be ordered.

Findings give information about: Colour, Smell, protein, glucose, ketones, specific gravity, osmolality, PH, WBC, RBC, casts, culture for organisms, etc...

42


Cont…dCont…d Creatinine clearance - Creatinine is

waste product of protein (muscle) breakdown.

Normal value is 85 - 135 ml/min. Urine Culture: Confirm suspected

urinary tract infection and identity causative organisms.

Normally bladder is sterile, but urethra contains bacteria and a few WBC. If properly collected, stored and handle, it can helps to minimize false positivity.

Quantitative Test: A 12 or 24 hrs urine collection give a more accurate result of the amount of protein in urine (N.R 0-15 oms/ hr) consisting mainly of albumin.

43


2. Blood Chemistry2. Blood ChemistryBUN(Blood urea nitrogen ) most commonly used to diagnose renal problems. Concentration of urea in blood is determined by the rate at which kidney excrete urea ( NR:0-30 mg/dl).RFT (Renal Function Test) is used to evaluate the severity of kidney disease and to follow the patient's clinical progress. This test also give information concerning the kidneys effectiveness in caring out their execratory function this is serum creatinine (NR:0.5 - 1.5 mg/dl)

44


3. Radiological studies3. Radiological studiesA. KUB (kidney, ureter and bladder)

X-ray An x-ray study of the abdomen or

kidney, ureters, and bladder (KUB) may be performed to delineate the size, shape, and position of the kidneys and to reveal any abnormalities, such as calculi (stones) in the kidneys or urinary tract, hydronephrosis (distention of the pelvis of the kidney), cysts, tumors, or kidney displacement by abnormalities in surrounding tissues.

45


Cont…dCont…dB. IVP or excretory urogram.

It is x-ray that helps to visualize urinary tract after I.V injection or radio opaque dye (an organic iodine-containing contrast medium).

The bladder should be examined both pre- and postmicturition for abnormalities of contour and residual volume.

S/E of the contrast media;bronchospasm or urticaria (1%)cardiac arrhythmias & convulsions

(0.003%)Allergic reaction

46


Cont…dCont…dIt helps to note;

Any distortion of the smooth renal outline,

calyceal dilatation (e.g. due to obstruction),

filling defects in renal pelves (e.g. stones, tumour),

ureteric obstruction and displacement (e.g. retroperitoneal fibrosis).


Cont…dCont…d

C. Nephro-tomogram X-ray taken with rotating tubes,

to delineate segments of the kidney at different levels/degree.

I.V injection of radio opaque dye is performed before the procedure.


Cont…dCont…dD. Retrograde Pyelogram

In retrograde pyelography, catheters are advanced through the ureters into the renal pelvis by means of cystoscopy.

A contrast agent is then injected.Retrograde pyelography is usually

performed if intravenous urography provides inadequate visualization of the collecting systems.

49


Cont…d Cont…d Retrograde pyelography is mainly used; to investigate lesions of the ureter to define the lower level of ureteral obstruction shown on excretion urography or ultrasound plus antegrade studies.

It is invasive, commonly requires a general anaesthetic, and may result in the introduction of infection.


Cont…dCont…dCystoscope and urethral catheter

are insert through it in to renal pelvis and dye is injected through catheter .

E. Renal arteriogram (angiogram)

Injecting radiopaque dye in to artery, to visualize the renal blood vessel.


Cont…dCont…dF. Computed tomography (CT)CT is used; to characterize renal masses which are

indeterminate at ultrasonography. to stage renal tumours to detect 'lucent' calculi; low-density calculi

which are lucent on plain films (e.g. uric acid stones).

to evaluate the retroperitoneum for tumours, retroperitoneal fibrosis (periaortitis) and other causes of ureteric obstruction.

to assess severe renal trauma. to visualize the renal arteries and veins. to stage bladder and prostate tumours.


Cont…..dCont…..dG. Magnetic resonance imaging

(MRI)MRI is used:to characterize renal masses as an

alternative to CT.to stage renal, prostate and bladder

cancer.To demonstrate the renal arteries.what is the difference b/n CT

scan and MRI?Lecture note for regular second year Nursing student, February 2003/2011. 53

4. Endoscopy 4. Endoscopy A. Cystoscopy

Cystoscopy (cystourethroscopy) is a diagnostic procedure that uses an endoscope especially designed for urological use to examine the bladder, lower urinary tract, and prostate gland.

The cystoscope, which is inserted through the urethra into the bladder, has a self-contained optical lens system that provides a magnified, illuminated view of the bladder.

The cystoscope is manipulated to allow complete visualization of the urethra and bladder as well as the ureteral orifices and prostatic urethra.

It can also be used to collect urine samples, perform biopsies, and remove small stones.

A cystoscopy typically lasts from 10 to 40 minutes.

54


Cont…dCont…d


Purpose◦Cystoscopy is performed by urologists to examine the entire bladder lining and take biopsies of any questionable areas.


Cont…dCont…dIndication:

◦ Blood in the urine (hematuria).◦ Inability to control urination (incontinence).◦ Urinary tract infection.◦ Signs of congenital abnormalities in the

urinary tract.◦ Suspected tumors in the bladder.◦ Bladder or kidney stones.◦ Signs or symptoms of an enlarged prostate.◦ Pain or difficulty urinating (dysuria).◦ Disorders of or injuries to the urinary tract.◦ Symptoms of interstitial cystitis.


Cont…dCont…dPreparation Cystoscopy can be performed in a

hospital, doctor's office, or outpatient surgical facility.

Spinal or general anesthesia may be used for the procedure.

Distension of the bladder with fluid is particularly painful, and if it needs to be done, as in the case of evaluating interstitial cystitis, general anesthesia is required.

Cystoscopy is typically performed on an outpatient basis, but up to three days of recovery in the hospital is sometimes required. Lecture note for regular second

year Nursing student, February 2003/2011. 58

Cont…dCont…dAftercarePatients who have undergone a

cystoscopy are instructed to:◦ take warm baths to relieve pain.◦ rest and refrain from driving for

several days, especially if general anesthesia was needed

◦ expect any blood in the urine to clear up in one to two days.

◦ avoid strenuous exercise during recovery.

◦ postpone sexual relations until the urologist determines that healing is complete.


Cont…dCont…d

ComplicationsProfuse bleedingUrethral damage.Perforated bladder.Urinary tract infection.Injured penis.


5. Other test5. Other testKidney Biopsy

Biopsy of the kidney is used in diagnosing and evaluating the extent of kidney disease.Indications for biopsy include unexplained acute renal failure, persistent proteinuria or hematuria, transplant rejection, and glomerulopathies. A small section of renal cortex is obtained either percutaneously (needle biopsy) or by open biopsy through a small flank incision.Before the biopsy is carried out, coagulation studies are conducted to identify any risk for post biopsy bleeding. Contraindications to a kidney biopsy include bleeding tendencies, uncontrolled hypertension, and a solitary kidney.

61


Cont…dCont…d

Ultrasound/Ultrasonography It is an instrument with small

external ultrasound probe and conductive attached to the patient.

Computer interprets tissue density based on sound wave & displays it in picture form.

What is the name of liquid that is polished on the probe?

62


Cont…dCont…dIn renal diagnosis it is the method of

choice for:renal measurement and for renal biopsy

or other interventional procedures.checking for pelvicalyceal dilatation as

an indication of renal obstruction when chronic renal obstruction is suspected.

characterizing renal masses as cystic or solid

diagnosing polycystic kidney disease.detecting intrarenal and/or perinephric

fluid (e.g. pus, blood).demonstrating renal arterial perfusion

or detecting renal vein thrombosis.


Cont…dCont…d

Disadvantages; It does not show detailed pelvicalyceal anatomy.

It does not fully visualize the normal adult ureter.

It may miss small renal calculi and does not detect the majority of ureteric calculi.

It is operator-dependent.Lecture note for regular second year Nursing student, February 2003/2011. 64

Disease of the kidneyDisease of the kidney1. Acute glomerulonephritis Acute glomerulonephritis refers to a group of

kidney disease in which there is an inflammatory reaction in the glomeruli (glomerular capillaries).

It is not an infection of the kidney but rather the result of unwanted side effect of the defense mechanism of the body.

Acute glomerulonephritis is primarily a disease of children older than 2 years of age, but it can occur at nearly any age.

As a result of antigen antibody reaction, aggregate of molecules ( complexes ) are formed and circulates throughout the body.

Some of these complexes lodge in the glomeruli filtering bed of the kidney and induce an inflammatory response.

65


Cont…dCont…d

Causes Group A beta hemolytic streptococcal

infection. (Most common following 2-3 wks infection of throat).

Impetigo (infection of the skin). Acute viral infections (upper

respiratory tract infections, mumps, varicella zoster virus, Epstein-Barr virus, hepatitis B, and HIV infection).

Antigens outside the body (eg, medications, foreign serum).

Kidney tissue itself.


Cont…dCont…d

Pathophysiology


Cont…dCont…d


Cont…dCont…dClinical manifestation

Generalized edema, Smokey urine (cola-colored), Gross heamaturia,Protienuria, Headache, Malaise, Flank pain (mild or sever),Hypertension, CVA tenderness, Some times and asymptomatic and

rarely renal failure.

69


Cont…dCont…d

DiagnosisDiagnostic History.Physical examination.Urinalysis.Serum IgA level.Antistreptolysin-O level. CBC.Renal biopsy.

70


Cont…dCont…dMedical Management Therapeutic bed rest until the sign of

glemerular inflammation (heamaturia, proteinuria, ) relived.

Restricting sodium and high fluid to treat edema.

Loop diuretic. Anti-hypertensive drug. Low protein diet to reduce nitrogenous

waste ( E.g. elevated BUN ). Antibiotics (Penicillin or erythromycin). Corticosteroids. Immunosuppressant medications.


Cont…dCont…dNursing intervention Heath promotion and maintenance

(E.g. early diagnosis and treatment of sore threat and skin lesion).

Appropriate antimicrobial drug (usually penicillin) is administration is essential. (If streptococcus is found in the culture).

Pt education concerning diet, rest, regular follow up etc...

Carbohydrates are given liberally to provide energy and reduce the catabolism of protein.

Intake and output are carefully measured and recorded.

72


Cont…dCont…d

ComplicationsHypertensive encephalopathy.

Congestive heart failure.Pulmonary edema.


2. Chronic 2. Chronic glomerulonephritisglomerulonephritis

Chronic glomerulonephritis is a syndrome that reflects the end stage of glemerular inflammatory disease.

CauseRepeated episodes of acute

glomerulonephritis.Hypertensive nephrosclerosis.Hyperlipidemia.Chronic tubulointerstitial injury.Hemodynamically mediated

glomerular sclerosis.

74


Cont…dCont…dPathophysiology

Antigen-antibody reaction occur repeatedly

kidneys are reduced to as little as one-fifth their normal size (consisting largely of fibrous tissue). The cortex shrinks to a layer 1 to 2 mm thick or less. Bands of scar tissue distort the remaining cortex, making the surface of the kidney rough and irregular. Numerous glomeruli and their tubules become scarred, and the branches of the renal artery are thickened. The result is severe glomerular damage that results in ESRD.


Cont…dCont…d

DiagnosisHx.P/E.Urinalysis.Chest x-rays.Electrocardiogram.

76


Cont…dCont…dClinical Manifestation The symptom of chronic glomerulonephritis are variable

some of them with sever grades of this disease have no symptom at all for a long time.Edema (periorbital and peripheral (dependent)).Massive protienuria.Hyperabuminureia. Elevated B/P.Headache.Dizziness.Anemia. Ascites. Hydrothorax (Fluid in the chest).Pericarditis with effusion. Prognosis: Poor (majority fail progressively and die 1or 2 yrs.

A few patients will improve & they may enjoy fair health for many years.


Cont…dCont…dManagement1. Medical interventionTreatment of patient with chronic

glomerulonephritis is entirely, non-specific and symptomatic, depends on the situation.

The goal of treatment is to:-Relieve edema.Cure or control the primary

disease. Treat hypertension.Treat the renal infection.

78


Cont…dCont…d If the patient has hypertension, the blood

pressure is reduced with; Sodium and water restriction, Antihypertensive agents, or both.

If fluid overload;Diuretic medications are prescribed.Weight is monitored daily.

Proteins of high biologic value (dairy products, eggs, meats) are provided to promote good nutritional status.

Adequate calories are also important to spare protein for tissue growth and repair.

UTIs must be treated promptly to prevent further renal damage.

Anti-inflammatory agent (Prednisolone).Lecture note for regular second year Nursing student, February 2003/2011. 79

Cont…dCont…d2. Nursing intervention

Daily weight control.Accurate record of intake and out.Observation of edema ( facial,

extremities, abdomen etc), cardiac and neurologic status, fluid and electrolyte status.

High protein diet (frequent small meal), protect from infection.

Psychological treatment.Complication

Cardiovascular disorder.Respiratory disorder.Metabolic disorder.

80


3. Nephrotic Syndrome3. Nephrotic SyndromeNephritic syndrome is primary

glomerular disease characterized by:◦Marked protienuria.◦Hypoalbuminemia.◦Edema.◦Hypercholesterolemia/lipidemia.

The syndrome is apparent in any condition that seriously damages the glomerular capillary membrane and results in increased glomerular permeability. Lecture note for regular second


Cont…dCont…d Nephrotic syndrome can occur

with almost any intrinsic renal disease or systemic disease that affects the glomerulus.

Although generally considered a disorder of childhood, nephrotic syndrome does occur in adults, including the elderly.


Cont…dCont…d

Causes◦Chronic glomerulonephritis, ◦Diabetes mellitus with intercapillary glomerulosclerosis,

◦Amyloidosis of the kidney, ◦Systemic lupus erythematosus,◦Multiple myeloma, and ◦Renal vein thrombosis.


Cont…dCont…d

PathophysiologyThe nephrotic syndrome occurs in

response to a group of diseases in which inflammation of the glomerulus (glomerulonephritis) is predominant.


Cont…dCont…d


Cont…dCont…dClinical manifestations

◦ Localized and generalized edema(eyes (periorbital), in dependent areas (sacrum, ankles, and hands)).

◦ Ascites.◦ Hydrothorax.◦ Protienuria.◦ Hypoproteinemia.◦ Less urine output. ◦ Headache.◦ Irritability.◦ Usually pale. ◦ Fatigue/Malaise.◦ Anorexia.


Cont…dCont…d

DiagnosisHx.P/E.U/A.CBC.


Cont…dCont…dManagement1. Medical

The objective of management is to preserve renal function.Usually it is nonspecific, depends on the cause.It includes;

Medication;Diuretics.Angiotensin-converting enzyme (ACE) inhibitors.Antineoplastic agents (cyclophosphamide [Cytoxan]).Immunosuppressant medications (azathioprine [Imuran], chlorambucil [Leukeran], or cyclosporine).Corticosteroids (prednisolone) if relapse occurs. Lecture note for regular second


Cont…dCont…dDiet;

Low-sodium, liberal-potassium diet.High biologic proteins (dairy products, eggs, meats). (Protein intake should be about 0.8 g/kg/day).Low saturated fat diet.

Bed rest.Antimicrobial drugs for infection.


Cont…dCont…d2. Nursing Intervention Observation of edema by controlling

weight. Skin care and trauma should be

avoided. Monitoring the effectiveness of

diuretics. Accurate record of intake and output. Protect the patient from infection. Psychological support (severe

edema). Health education.


4. Pyelonephritis4. PyelonephritisPyelonephritis is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys.

Pyelonephritis is frequently secondary to ureterovesical reflux, in which an incompetent ureterovesical valve allows the urine to back up (reflux) into the ureters.


Cont…dCont…dMore common in female children that male, in pregnant women when there is failure to empty the bladder on time.

It can be;1. Acute.2. Chronic.


4.1. Acute 4.1. Acute PyelonephritisPyelonephritis

Causes Urinary tract obstruction. Bladder tumors. Strictures. Benign prostatic hyperplasia. Urinary stones.

Common bacteria responsible are different types of bacteria as a colon bacillus (E.coli) and rarely staphylococci.


Cont…dCont…dClinical Manifestations Acutely ill (Sudden onset). Chills. Fever. Leukocytosis. Bacteriuria. Pyuria. Flank pain. CVA tenderness. Dysuria. Frequent urination. Headache. Nausea & vomiting. Epithelial cells, in the urine.


Cont…dCont…dAssessment and Diagnostic

FindingsUltrasound study.CT scan.Urine culture and sensitivity tests.


Cont…dCont…dMedical Management

Patients with acute uncomplicated pyelonephritis are usually treated as outpatients if they are not dehydrated, not experiencing nausea or vomiting, and not showing signs or symptoms of sepsis.Other patients, including all pregnant women, may be hospitalized for at least 2 or 3 days of parenteral therapy.Oral agents may be substituted once the patient is afebrile and showing clinical improvement.


Cont…dCont…dPharmacologic therapy For outpatients, a 2-week course of antibiotics

is recommended because renal parenchymal disease is more difficult to eradicate than mucosal bladder infections.

Commonly prescribed agents;Ciprofloxacin, Gentamicin with or without ampicillin.Third-generation cephalosporin.

After the initial antibiotic regimen, the patient may need antibiotic therapy for up to 6 weeks if evidence of a relapse is seen.

A follow-up urine culture is done 2 weeks after completion of antibiotic therapy to document clearing of the infection.


4. 2. Chronic pyelonephritis4. 2. Chronic pyelonephritis

Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis.

Clinical Manifestations◦fatigue, ◦headache, ◦poor appetite,◦polyuria, ◦excessive thirst, and ◦weight loss.


Cont…dCont…dPathophysiologyThere are areas of inflammation in the

kidney with interstitial infiltrations of inflammatory cells which in time may produce tubular destruction & abscess formation.

Low grade interstitial inflammation may result in atrophy and destruction of tubules and in hyalinization of the glomeruli.

Eventually when pyelonephritis become chronic, the kidneys become scarred, contracted and of little functional value.



Findings

Intravenous urogram.Measurements of creatinine clearance.

BUN.


0

Cont…dCont…dMedical ManagementMedication (e.g. Nitrofurantoin, Oral

antimicrobial drugs (e.g. Sulfonamide, Ampicillin, e.t.c.)).

Fluid intake 300 ml/day.Light dite.Bed rest – of severe complete

(hospitalization).Follow-up urine cultures and other

discharges.Requires surgery, e.g. Nephrotomy,

nephrectomy or pyolotomy.Lecture note for regular second year Nursing student, February 2003/2011. 10

1

Cont…dCont…dNursing Management Measure and record fluid intake and output are

carefully. Unless contraindicated, fluids are encouraged

(3 to 4 L/day) to dilute the urine, decrease burning on urination, and prevent dehydration.

The nurse assesses the patient’s temperature every 4 hours and administers antipyretic and antibiotic agents as prescribed.

Bed rest during the acute phase of the illness. Protection from infection (URI). Patient teaching. (about medication, urine –

culture follow-up, identification of reoccurrence of infection).


2

Cont…dCont…d

ComplicationsESRD.Hypertension.Formation of kidney stone.


3

5. Renal Failure5. Renal FailureThe term is used to primarily to

denote failure of the excretory function of the kidneys, leading to retention of nitrogenous waste products of metabolism.

Various other aspects of renal function may fail at the same time, including the regulation of fluid and electrolyte status, endocrine function, metabolic function, and regulation of acid-base balance.


4

Cont…dCont…dRenal failure is a systemic disease

and is a final common pathway of many different kidney and urinary tract diseases.

A wide range of clinical manifestations may occur.

The most fundamental categorization of renal failure is;1. Acute Renal failure.2. Chronic Renal failure.


5

5.1. Acute renal failure5.1. Acute renal failure Acute renal failure is a sudden and almost

complete loss of kidney function(decreased GFR), usually reversible caused by failure of the renal circulation or by glemerular or tubular damage over a period of hours to days/weeks.

Oliguria (less than 400 ml/day of urine) is the most common clinical situation seen in ARF. Anuria (less than 50 ml/day of urine) and normal urine output are not as common.

Regardless of the volume of urine excreted, the patient with ARF experiences rising serum creatinine and BUN levels and retention of other metabolic waste products (azotemia) normally excreted by the kidneys.


6

Cont…dCont…dCauses of Acute Renal FailureI. Pre-renal Failure:- occurs as a result of

impaired blood flow that lead to hypo perfusion of the kidney.

Volume depletion resulting from: Hemorrhage. Renal losses (diuretics, osmotic diuresis). Gastrointestinal losses (vomiting, diarrhea, nasogastric

suction). Impaired cardiac efficiency resulting from:

Myocardial infarction. Heart failure. Dysrhythmias. Cardiogenic shock.

Vasodilation resulting from: Sepsis. Anaphylaxis. Antihypertensive medications or other medications that cause

vasodilation.


7

Cont…dCont…dII. Intra-renal Failure:- is the result of actual

parenchymal damage. Prolonged renal ischemia resulting from:

Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures).

Myoglobinuria (trauma, crush injuries, burns). Hemoglobinuria (transfusion reaction, hemolytic anemia).

Nephrotoxic agents such as: Aminoglycoside antibiotics (gentamicin, tobramycin) Radiopaque contrast agents. Heavy metals (lead, mercury). Solvents and chemicals (ethylene glycol, carbon

tetrachloride, arsenic). Nonsteroidal anti-inflammatory drugs (NSAIDs) Angiotensin-converting enzyme inhibitors (ACE

inhibitors). Infectious processes such as:

Acute pyelonephritis. Acute glomerulonephritis.


8

Cont…dCont…dIII. Post-renal Failure:-are

usually the result of an obstruction some where distal to the kidney, ureter, urethra.

Urinary tract obstruction, including:

Calculi (stones). Tumors. Benign prostatic hyperplasia. Strictures. Blood clots.


9

Cont…dCont…dPHASES OF ACUTE RENAL FAILUREThere are four clinical phases of

ARF:1. Initiation.2. Oliguria. 3. Diuresis.4. Recovery.


0

Cont…dCont…d1. Initiation:-The initiation period begins with

the initial insult and ends when oliguria develops.

2. Oliguria:-The oliguria period is accompanied by a rise in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). In this phase uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop. This phase lasts approximately 10 days.


1

Cont…dCont…d3. Diuresis:-In the diuresis period,

the patient experiences gradually increasing urine output, which signals that glomerular filtration has started to recover.

4. Recovery:-The recovery period signals the improvement of renal function and may take 3 to 12 months. Laboratory values return to the patient’s normal level. Although a permanent 1% to 3% reduction in the GFR is common, it is not clinically significant.


2

Cont…dCont…dClinical Manifestations

◦The patient may appear critically ill and lethargic.

◦Persistent nausea, vomiting, and diarrhea.

◦The skin and mucous membranes are dry from dehydration.

◦The breath may have the odor of urine(uremic fetor).

◦Central nervous system signs and symptoms include drowsiness, headache, muscle twitching, and seizures.


3

Cont…dCont…d

Assessment and Diagnostic Findings

Hx.P/E.U/A.UltrasonographyE.t.c.


4

Cont…dCont…dMedical ManagementThe objectives of treatment of ARF

are to restore normal chemical balance and prevent complications until repair of renal tissue and restoration of renal function can take place.◦Any possible cause of damage is

identified, treated, and eliminated.◦maintaining fluid balance, ◦avoiding fluid excesses, ◦performing dialysis.


5

Cont…dCont…dPharmacologic therapy

Cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema.

Sorbitol is often administered in combination with Kayexalate to induce a diarrhea-type effect (it induces water loss in the GI tract).

Low-dose dopamine (1 to 3 g/kg) is often used to dilate the renal arteries through stimulation of dopaminergic receptors.

Diuretic agents.Lecture note for regular second year Nursing student, February 2003/2011. 11

6

Cont…dCont…d

Nursing interventionMonitoring fluid and electrolyte balance.

Reduce metabolic rate.Promoting pulmonary function.Prevention of infection.Providing skin care.Providing support.


7

5.2. CHRONIC RENAL FAILURE5.2. CHRONIC RENAL FAILURE(END-STAGE RENAL DISEASE)(END-STAGE RENAL DISEASE)

Chronic renal failure, or ESRD, is a progressive, irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia (retention of urea and other nitrogenous wastes in the blood).


8

Cont…dCont…dCauses Systemic diseases, such as diabetes

mellitus (leading cause). Hypertension. Chronic glomerulonephritis. Pyelonephritis. Obstruction of the urinary tract. Hereditary lesions, as in polycystic kidney

disease. Vascular disorders. Infections. Medications. Environmental and occupational toxic

agents (lead, cadmium, mercury, and chromium). Lecture note for regular second


9

Cont…dCont…d

Stages of Chronic Renal DiseaseStage 1:-Reduced renal reserve

Characterized by a 40% to 75% loss of nephron function. The patient usually does not have symptoms because the remaining nephrons are able to carry out the normal functions of the kidney.

It is mild.


0

Cont…dCont…d

Stage 2:-Renal insufficiencyOccurs when 75% to 90% of nephron function is lost.

At this point, the serum creatinine and blood urea nitrogen rise, the kidney loses its ability to concentrate urine and anemia develops.

The patient may report polyuria and nocturia.

It is moderate.Lecture note for regular second year Nursing student, February 2003/2011. 12

1

Cont…dCont…dStage 3:-End-stage renal disease

(ESRD)The final stage of chronic renal failure,

occurs when there is less than 10% nephron function remaining.

All of the normal regulatory, excretory, and hormonal functions of the kidney are severely impaired.

ESRD is evidenced by elevated creatinine and blood urea nitrogen levels as well as electrolyte imbalances.


2

Cont…dCont…dClinical ManifestationsNeurologic:- Weakness and

fatigue, confusion, inability to concentrate, disorientation, tremors, seizures, asterixis, restlessness of legs, burning of soles of feet, behavior changes.

Integumentary:- Gray-bronze skin color, dry and flaky skin, pruritus, ecchymosis, purpura, thin, brittle nails, coarse and thinning of hair. Lecture note for regular second


3

Cont…dCont…d Cardiovascular:- Hypertension;

pitting edema (feet, hands, sacrum); periorbital edema; pericardial friction rub; engorged neck veins; pericarditis; pericardial effusion; pericardial tamponade; hyperkalemia; cardiac arrhythymia, hyperlipidemia.

Pulmonary:- Crackles; thick, tenacious sputum; depressed cough reflex; pleuritic pain; shortness of breath; tachypnea; Kussmaul-type respirations; uremic pneumonitis; “uremic lung”.


4

Cont…dCont…dGastrointestinal:- Ammonia odor to breath (“uremic fetor”); metallic taste; mouth ulcerations and bleeding; anorexia, nausea, and vomiting; hiccups; constipation or diarrhea; bleeding from gastrointestinal tract.

Hematologic:- Anemia; thrombocytopenia.


5

Cont…dCont…dReproductive:- Amenorrhea; testicular atrophy; infertility; decreased libido.

Musculoskeletal:- Muscle cramps; loss of muscle strength; renal osteodystrophy; bone pain; bone fractures; foot drop.


6


7


Findings Hx. P/E. U/A. CV examination. Respiratory examination. E.t.c.


8

Cont…dCont…d

Complications◦Hyperkalemia. ◦Pericarditis, pericardial effusion, and pericardial tamponade.

◦Hypertension. ◦Anemia.◦Bone disease and metastatic calcifications.


9

Cont…dCont…dMedical Management Both Ca and P binding antacids

(aluminum-based antacids) with food to be effective or calcium carbonate.

Antihypertensive and Cardiovascular Agents.

Antiseizure Agents. Erythropoietin (recombinant human

erythropoietin (Epogen)). Nutritional therapy. Dialysis.


0

6. Renal 6. Renal hypertensionhypertensionDefn

- Renal hypertension is increment of blood pressure in the renal system.

Cause:-rennin juxtaglamerular cell tumors, nephroblastomas.

131


Cont…dCont…dPathophysiology Any condition which reduce the blood flow through

the kidneys or destroy renal function tissue cause hypertension. Such condition are sclerotic changes or stenosis of a renal artery (nephritis and polycystic kidney disease).

The ischemic kidney reacts by secreting a proteolytic enzyme called rennin.

In the blood stream, rennin acts up on a plasma protein to reduce angiotensin I which is converted to angiotensin II cause wide spread vasoconstriction of the arterioles & increased peripheral resistance leading to an elevation of arterial blood pressure.

Angiotensin II is also alleged to increase the secretion of aldosterone by the adrenal glands which as previously ceiled increase the blood pressure through its influence on sodium and water retention.

132


Cont…dCont…d

Clinical Manifestation◦Decrease overall activity of the kidney.

◦Acute and chronic glomerulonephritis.

◦Polycystic kidney disease.◦Chronic pyelonephritis.◦Renal artery stenosis.

133


Cont…dCont…d

Mx ◦Depends up on the cause.◦ E.g. Ant hypertensive medication for HTN and dialysis treatment for renal failure e.t.c….


4

7. Neoplasm of the 7. Neoplasm of the kidneykidney

Renal tumor may arise from renal capsule parenchyma (renal cell carcinoma), connective tissue (sarcomas) or fatty tissue or they may be neurologic or vascular.

Almost 90% of tumors are renal adenocarcinomas, these tumors occur more frequently in males & may metastasize early to the lungs, bone, liver, brain and contra lateral kidneys.

135


Cont…dCont…dRisk Factors for Renal Cancer

Gender: Affects men more than women.Tobacco use.Occupational exposure to industrial chemicals, such as petroleum products, heavy metals, and asbestos.Obesity.Unopposed estrogen therapy.Polycystic kidney disease.


6

Cont…dCont…d

Clinical Manifestation Gross painless Heamaturia. Wt loss. Weakness (generalized). Anemia. Flank pain (Colicky pains occur if a

clot or mass of tumor cells passes down the ureter).

Some times palpable mass. Anorexia.

137


Cont…dCont…dMethod of diagnosis Radiological;

IV or retrograde pyelogram (catheters are advanced through the ureters into the renal pelvis by means of cystoscopy. A contrast agent is then injected) to determine location of neoplasm’s changes in the renal outline (invasion of the renal pelvis calcification) etc...

Cystocopy. Renal angiogram (The femoral (or axillary)

artery is pierced with a needle, and a catheter is threaded up through the femoral and iliac arteries into the aorta or renal artery. A contrast agent is injected to opacify the renal arterial supply) may be done to asses the expect of blood vessels involvement.

Ultrasound. 138


Cont…dCont…dManagement If disease is localized to one kidney a

radical nephrectomy is performed, followed by radiation and chemotherapy.

If renal pelvis is involved the ureters is removed along with the kidney, nephrouerelectomy will be done.

If the tumor is inoperetable, radiation therapy is used as a palliative therapy.

Diet:- a normal diet may be given to these patients as soon as peristaltic activity is present.

139


Cont…dCont…d

Nursing interventionPre operative nursing care.Post operative nursing care.


0

8. 8. Nephrolithiasis/UrolithiasisNephrolithiasis/Urolithiasis Nephrolithiasis/Urolithiasis is

the presence of stones in the kidney and in the urinary tract respectively.

The term calculi is refers to the stone and lithiasis to stone formation.

There are many factors involved in the incidence and type of stone formation.


1

Cont…dCont…d Factors in the development of urinary

tract calculi;

Dietary;Large intake of dietary proteins increasing uric acid excretion.

Excessive amount of tea or fruit juices elevating the urinary oxalate level.

Large intake of calcium and oxalate. Excessive intake of vitamin D.Excessive intake of milk and alkali.


2

Cont…dCont…dGenetic;

Family hx of stone formation, cystinuria, gout or renal tubular acidosis.

Life style;Sedentary occupation, client on bed rest (affects 320,000 hospitalized patient).

Climate;High atmospheric temperature resulting in increased fluid loss, low urine volume, and increased solute concentration in the urine.

Medications (antacids, acetazolamide (Diamox), vitamin D, laxatives, and high doses of aspirin.

Medical disorder (hyperparathyroidism).


3

Cont…dCont…dInfection (the presence of urease splitting bacteria such as Proteus, Pseudomonas, Klebsiella, Staphylococcus, or Mycoplasma species).

Inflammatory bowel disease (it increase the absorption of oxalate).


4

Cont…dCont…dDifferent types of stones are formed in the urinary tract by the deposit of different crystalline substances. Such as calcium phosphate/oxalate (75% of all cases), uric acid (5% to 10% of all stones), cystine stone (1% to 2% of all stones) & struvite (15% of urinary calculi) which are excreted in the urine.

145


Cont…dCont…d


6

Cont…dCont…dClinical Manifestations The manifestation of renal calculus

depend upon the size of the stone of the stone, obstruction, infection, and edema, and whether it remains stationary.

It may remain latent over a long period, producing no symptoms.

Small gravel-like stones may be passed without any disturbance.


7

Cont…dCont…d◦ Increase in hydrostatic pressure.◦ Infection (pyelonephritis and cystitis

with chills, fever, and dysuria). ◦An intense, deep ache in the

costovertebral region (Stones in the renal pelvis) that radiates anteriorly and downward toward the bladder in the female and toward the testis in the male).

◦Hematuria.◦Pyuria.


8

Cont…dCont…dUreteral colic symptom

(Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia. Often, the patient has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone.


9


FindingsHx.P/E.X-ray films of the kidneys, ureter,

and bladder (KUB) Ultrasonography.Intravenous urography. Retrograde pyelography. Blood chemistries. A 24-hour urine test.


0

Cont…dCont…dMedical ManagementThe basic goals of management are;

to eradicate the stone. to determine the stone type. to prevent nephron destruction.

to control infection,to relieve any obstruction. to relieve the pain.


1

Cont…dCont…dIt includes;Opoid analgesics.NSAIDs. Hot baths or moist heat to the

flank areas. Encourage fluids intake.Nutritional therapy.


2

Cont…dCont…dDietary Recommendations for Prevention of

Kidney Stones; Restricting protein to 60 g/day is

recommended to decrease urinary excretion of calcium and uric acid.

A sodium restriction of 3–4 g/day is recommended. Table salt and high-sodium foods should be reduced because sodium competes with calcium for reabsorption in the kidneys.

Low-calcium diets are not generally recommended, except for true absorptive hypercalciuria.

Restricting oxalate-containing foods (spinach, strawberries, tea, peanuts, wheat bran).


3

9. Nephrosclerosis9. Nephrosclerosis It is hardening, or sclerosis, of the arteries

of the kidney due to prolonged hypertension. Pathophysiology There are two forms of nephrosclerosis:

Malignant (accelerated); Often associated with malignant hypertension

(diastolic blood pressure higher than 130 mm Hg).

It usually occurs in young adults, and men are affected twice as often as women.

The disease process progresses rapidly. Without dialysis, more than half of patients die from uremia in a few years.

Benign;It is usually found in older adults and is

often associated with atherosclerosis and hypertension.


4

Cont…dCont…dAssessment and Diagnostic Findings

◦Hx.◦P/E.◦U/A. ◦E.t.c.

Medical Management◦Aggressive antihypertensive

therapy.◦ACE inhibitor, alone or in

combination with other antihypertensive medications.Lecture note for regular second


5

10. Hydronephrosis10. Hydronephrosis It is dilation of the renal pelvis and

calyces of one or both kidneys due to an obstruction.

CauseObstruction to the normal flow of urine due

to;Renal stone. Tumor.Kinking.Odd angle of the ureter (altered anatomical position of kidney).

Pregnancy.BPH. Lecture note for regular second


6

Cont…dCont…dPathophysiology Obstruction to the normal flow of urine causes

the urine to back up, resulting in increased pressure in the kidney.

If the obstruction is in the urethra or the bladder, the back pressure affects both kidneys, but if the obstruction is in one of the ureters only one kidney is damaged.

Whatever the cause, as the urine accumulates in the renal pelvis, it distends the pelvis and its calyces. In time, atrophy of the kidney results.

As one kidney undergoes gradual destruction, the other kidney gradually enlarges (compensatory hypertrophy).

Ultimately, renal function is impaired.


7

Cont…dCont…dClinical Manifestations Aching in the flank and back

(acute obstruction). Dysuria, chills, fever, tenderness, and pyuria (If infection is present).

Hematuria and pyuria. Signs and symptoms of chronic renal failure (If both kidneys are affected).


8

Cont…dCont…dMedical ManagementThe goals of management are;

◦ to identify and correct the cause of the obstruction.

◦ to treat infection.◦ to restore and conserve renal

function. It includes;

◦ Nephrostomy or another type of diversion.

◦ Antibiotic agents.◦ Surgical removal of obstructive

lesions.◦ Nephrectomy. Lecture note for regular second


9

11. Renal TB11. Renal TB It is the involvement of renal system by

tuberculosis infection. PathophysiologyTuberculosis of the urinary tract is caused

by the organism Mycobacterium tuberculosis.

The organism usually travels from the lungs by means of the bloodstream (hematogneous spread) to the kidneys.

On arrival in the kidney, the microorganism may lie dormant for years. After the organism reaches the kidney, a low-grade inflammation and the characteristic tubercles are seen.


0

Cont…dCont…dIf the organism continues to

multiply, the tubercles enlarge to form cavities, with eventual destruction of parenchymal tissue.

The organism spreads down the urinary tract into the bladder and may also infect the prostate, epididymis, and testicles in men.


1

Cont…dCont…d

Clinical Manifestations◦Slight afternoon fever.◦Weight loss. ◦Night sweats.◦Loss of appetite.◦general malaise. ◦Hematuria (microscopic or gross)

and ◦Pyuria.◦Pain, dysuria, and urinary frequency

(due to bladder involvement). Lecture note for regular second year Nursing student, February 2003/2011. 16

2


FindingsUrine culture.ESR.PCR (polymerase chain reaction) (PCR).

Intravenous urography.Biopsy.


3

Cont…dCont…dMedical Management The goal of treatment is to eradicate the offending

organism. Combinations of ethambutol, isoniazid, and

rifampin are used to delay the emergence of resistant organisms.

Shorter-course chemotherapy (4 months) has been effective in eradicating the organism and in penetrating renal tissue.

Surgical intervention may be necessary to treat obstruction and to remove an extensively diseased kidney.

Proper nutrition, adequate rest, and good hygiene practices.

A scrotal support may be used by male patients with genital swelling.


4

Cont…dCont…dNursing ManagementPatient education to promote

effective self-care at home.Instructions are provided about taking

prescribed medications properly, recognizing adverse effects, and understanding the importance of completing the course of therapy.

Instructions are also given regarding the nature of tuberculosis; its cause, spread, and treatment; and necessary follow-up care.


5

Cont…dCont…dMen are instructed to use

condoms during sexual intercourse to prevent spread of the organisms; those with penile or urethral tuberculosis are instructed to abstain from intercourse during treatment.

The patient is encouraged to maintain a healthy lifestyle with a well-balanced diet, adequate intake of fluids, and exercise.


6

Cont…dCont…dThe patient is counseled about the

need for follow-up examinations (urine cultures, intravenous urograms), usually for 1 year.

Treatment is reinstituted if a relapse occurs and the tubercle bacilli again invade the genitourinary tract.

Monitored for these complications.


7

12. Renal cysts12. Renal cystsRenal cysts are abnormal, fluid-filled

sacs that arise from the kidney tissue. They may be genetic in origin,

acquired, or associated with a host of unrelated conditions.

Cysts of the kidney may be single or multiple (polycystic), involving one or both kidneys.

Polycystic disease of the adult is inherited as an autosomal dominant trait and affects men and women equally.


8

Autosomal dominant polycystic Autosomal dominant polycystic kidney diseasekidney disease

Autosomal dominant polycystic kidney disease is a common inherited condition, occurring in between 1 in 200 and 1 in 1,000 of the population.

Renal stone disease is also common, occurring in 20% of patients.

Polycystic renal disease is also associated with cystic diseases of other organs (liver, pancreas, spleen) and aneurysms of the cerebral arteries.


9

Cont…dCont…dIt has long been recognized that patients on long term dialysis (both hemodialysis and peritoneal dialysis) develop multiple cysts on their nonfunctioning kidneys.

Many of these cysts contain cancer cells.


0

Acquired cystic kidney diseaseAcquired cystic kidney disease

An acquired form of polycystic disease occurring as a result of ESRD associated with dialysis is called acquired cystic kidney disease.

Acquired cystic kidney disease has been associated with cyst infection, cyst hemorrhage, retroperitoneal hemorrhage, and spontaneous rupture of the kidney.


1

Cont…dCont…d

Clinical ManifestationsAbdominal or lumbar pain.Hematuria.Hypertension.Palpable renal masses.Recurrent UTIs. Renal insufficiency and failure.


2

Cont…dCont…d

Diagnostic method◦Intravenous urography.◦CT scan.◦Transabdominal ultrasound. ◦Urine cytology.


3

Cont…dCont…dManagement Patient care focuses on relief of pain,

symptoms, and complications. Hypertension and UTIs are treated

aggressively. Dialysis is initiated when signs and symptoms

of renal insufficiency and failure occur. Genetic counseling is part of management

with polycystic kidney disease that is genetic in origin.

The patient is advised to avoid sports and occupations that present a risk for trauma to the kidney.

Cyst drainage percutaneously for simple cyst. Rest and antibiotic treatment.


4

Diseases of ureters, Diseases of ureters, bladder and urethra bladder and urethra 1. Uretric disorder1. Uretric disorder

Primary disorder of the ureters occurs less frequently than disease of the other part of the urinary system.

A congenital anomaly or rarely a neoplasm may occur in ureters.

The most common anomaly is a defect at the opening of the ureters in to the bladder normally urine can only flow the ureters in to the bladder.

175


Cont…dCont…dThe ureters vesicle defect

permits a urinary reflux a background flow of urine in to the ureter from the bladder this predispose pyelonephritis.

Surgery is carried out to correct the defect primary neoplasm of the ureters is quite rare.

176


A. UreteritisA. UreteritisUreteritis is an inflammation of ureter.

CauseInfection (e.g. pyelonephritis).Renal stone.Neoplasm. e.t.c

Mgx Treatment of pyelonephritis. Surgery.


7

B. Ureteral constrictionB. Ureteral constrictionIt is narrowing of the ureters.

CauseInfection.Foreign body.Congenital anomaly.Tumors.

178


Cont…dCont…dClinical Manifestation

◦Patient shows all the sign and symptom of infection.

◦ E.g. Pain and other urinary compliants.

Mgx ◦Surgical intervention;

Uretroplasty. Anastomosis.

◦Analgesics.◦Antispasmodics.


9

2. 2. DisorderDisorder of the bladder of the bladderA. CystitisA. Cystitis

Cystitis is an acute or chronic inflammation of the urinary bladder characterized by frequency, urgency and dysuria and abnormal urinary constituents.

Incidence is common in female because of shorter urethra.

180


Cont…dCont…dCause

◦Ascending bacteria infection from the urethra.

◦Urethrovesicular reflux (flowing back of urine from the urethra in the bladder).

◦Organisms from rectal and vaginal discharge can enter easily.

◦Mechanical (use of catheters and other examination objects & administration of some drugs).

181


Cont…dCont…d◦Predisposing factors (e.g. in

infective cystitis are trauma of the tissue, stagnation of urine and distortion or compression of the bladder by outer large neighbor organs).

◦Congenital malformation (e.g. hypospadiasis).

◦In male prostatic hyperplasia or infection may cause cystitis.

182


Cont…dCont…d

Clinical Manifestation Altered urinary pattern (urgency, frequency and dysuria).

Suprapubic pain. Dysuria & Foul Smelling urine. In Some Individuals Haematuria. The Presence of Fever, Nausea, vomiting & flank tenderness usually indicate pyelonephritis.

183


Cont…dCont…d

Method of diagnosis ◦Hx.◦P/E.◦Urinalysis.◦Urine for culture and sensitivity.

◦Radiological examination.◦Cystoscopy.

184


Cont…dCont…dMgx

Analgesic (Antispasmodics).Sodium bicarbonate relives

bladder irritation.Increase fluid intake.Antimicrobial drugs for 10 -14 days. E.g. Sulfonamides and antibiotics.

Health education e.g. about use of fluid intake, regular emptying of bladder etc.

185


B. Bladder Stone B. Bladder Stone (Calculi)(Calculi)

It is the formation of stone in the bladder.

Cause◦Urinary stasis (in prostate

hypertrophy).◦Neurological disease or injury that

hat resulted in the loss of voluntary bladder control or interruption of the sacral reflex arc.

◦Bladder diverticula’s.

186


Cont…dCont…d◦Urethral stricture or prolonged immobility.

◦Dehydration ( increased urine concentration).

◦Indwelling catheter for a prolonged period of time.

◦Infection.

187


Cont…dCont…d

Clinical Manifestation◦Sudden cessation of urinary flow.◦Haematuria.◦Sever pain during micturation.

Methods of diagnosis Cystoscopy Radiological Examination;

IVP.

U/S.

188


Cont…dCont…d

MgxMechanical crushing of the stone by ultrasonic lithotripsy.

Surgery (cystolithotomy).Large amount of fluid to help wash of the bladder.

Cause should be treated (e.g. prostatic hypertrophy).

189


C. Trauma of the C. Trauma of the bladderbladder

It is a kick or blow in the lower abdomen when the bladder is full.

In accidental injury if urinary bladder causing perforation and ensuring extravasations of the urine (escape of urine from the bladder) is common.

It may occur when the pelvis is fractured.

If the bladder is full and distended at the time of accident it is more vulnerable.

190


Cont…dCont…dCause

◦Trauma.◦Accidental direct kick or blow.◦E.t.c...

Clinical ManifestationIntra peritonial rupture:-

peritonitis due to escape of urine in to the peritoneal cavity (necrosis).

Sever pain of abdomen.Tenderness of abdomen.Distended abdomen.

191


Cont…dCont…dShock.Extraperitonial rupture:- urine

escapes in to the surrounding tissue cause cellulites, infection and necrosis of tissue.

Abdominal and peritoneal fistula develops.

192


Cont…dCont…dMethod of Diagnosis

◦Urinalysis.◦Cystoscopy.

Mgx Shock and hemorrhage should be

treated with blood transfusion and IV infusion.

An indwelling catheter is inserted in to the bladder and prepare patient for abdominal surgery.

193


Cont…dCont…dSurgical intervention The site of injury is repaired and

temporary cystostomy (incision of the bladder and introduction of suprapubic catheter) done to establish urinary drainage & prevent the possibility of pressure on the repair suture line .

If the rupture was in intraperitonial the extravsated fluid should be aspirated before closure.

194


Cont…dCont…dStrict Observation for sign of shock (Infection).

An accurate fluid intake and out put should be done.

Antimicrobial drugs may be administered.

195


D. Tumor (neoplasm) of the bladder

Neoplasm in the bladder may develop at any age but have more frequently after the age of 50 years and have a high incidence in male than in female (3:1).

196


Cont…dCont…d

cause◦Cigarette smoking.◦Carcinogens in the work environment

such as dyes, rubber, leather ink or paint.

◦Chronic parasitic infestations that irritates the bladder (E.g. schistosmasis).

◦Cancer arising from another place (prostate, colon and rectum in and from the lower gynecologic tract in female) may metastasize to the bladder.

197



◦Gross painless heamaturia. ◦Cystitis – frequency, urgency &

dysuria.◦Pelvic and for back pain may be

due to metastasis.◦Renal failure due to obstruction of

ureter cause hydronephrosis.◦Anemia may be develop as a result

the patient manifests weakness & loss of body weight.

198


Cont…dCont…d

Method of DiagnosisUrinalysis.Cystoscopy.CystogramBiopsy. CT scans.Ultrasound examination.

199


Cont…dCont…dMgx Treatment of bladder cancer depends on the

grade and growth of the tumor, the patients age, physical, mental & emotional status are considered in determining treatment modalities.

Surgical interventions = Cystostomy or partial cystectomy.

Radiation. Chemotherapy. Combination of surgery, radiation &

Chemotherapy. Encourage fluid intake. Seitz bath. Psychological and emotional support.

200


E. Diverticulum's of the E. Diverticulum's of the bladderbladder

A pouch or sac protruding from the wall of the bladder.

It results from long period of voiding against resistance obstruction at the bladder neck or in the urethra and inherent weakness of the musculature of the bladder.

201


Cont…dCont…dCommon in male due to the

hypertrophy of prostate.The condition is frequently

complicated by sepsis, stone formation and the occurrence of new tissue growth.

Mgx Treating the cause. Excision of the diverticulum.

202


3. Disorder of the 3. Disorder of the urethara A. Urethritisurethara A. Urethritis

It is an inflammation of the urethral mucosa usually an ascending.

There is gonorrheal and non gonorrheal urethritis.

Cause ◦Bacterial (gonococci streptococcal,

e.t.c..)◦Viral. ◦Protozoan (trichomonal).◦Fungal. ◦Trauma.

203


Cont…dCont…d

Clinical ManifestationDysuria, frequency.Burning sensation during micturatin.

Discharge (yellowish green could be scanty or profuse, thin or mucoids thick and purulent).

204


Cont…dCont…dMethod of DiagnosisUrinalysis.Urine culture (smear of discharge

(gram stain and wet smear).MgxAntimicrobial drugs depending on to

causative microorganisms.Analgesics if necessary.Perennial care after bowel

movement.Urinary antiseptics.Encourage to drink copious amount

of fluid.205


B. Urethral StrictureB. Urethral StrictureIt is a narrowing of the lumen of the

urethra due to scar tissue and contraction.

CausesInjury - insertion of surgical

instruments during transurethral surgery, indwelling catheter or cystoscopic procedure.

Straddle injuries.Automobile Accident.Untreated Gonorrhea.Congenital Abnormality.

206


Cont…dCont…d

Clinical Manifestations◦The force & size of urinary stream is

diminished and symptoms of urinary infection and retention occur.

◦Stricture cause urine to back up resulting in cystitis, prostatitis and pyelonephritis.

207


Cont…dCont…dMgx Dilatation of the narrowed area. Operation under direct vision- internal

urethrotomy (surgical removal of the stricture).

Hot sitz bath and non - narcotic analgesics are given to control pain.

Antimicrobial drugs are given for several days after dilatation to minimize infection.

Surgical excision or urethroplasty may be necessary for sever cases.

Rarely a temporary cystostomy is necessary, b/c of sever retention.

208


4. 4. Disorder of Male reproductive Disorder of Male reproductive systemsystem

A. Prostatitis A. Prostatitis Prostatitis is inflammation of prostate

gland caused by infections agent. Cause

◦ Infections agents – bacterial (E.coli, klebsiella), fungi & mycoplasma.

◦Urethral stricture.◦Hyperplasia of prostate (BPH).

Microorganisms usually are carried to the prostate from the urethra.

209



◦Perineal pain and discomfort.◦Urethrtitis-Urgency, frequency and

dysuria.◦Prastatodynia (pain in the

prostate) on voiding.◦Acute bacterial prostatitis may

produce a sudden on set of fever & chills.

◦Perineal, rectal, low back pain and dysuria.

210


Cont…dCont…dMethods to Diagnosis

◦ Careful history.◦ Culture of prostate fluid or tissue.◦ Urine culture. ◦ Digital examination.

MgxThe goal of treatment is to avoid the

complication of abscess formation and septicemia.

A broad spectrum antimicrobial drugs for 10 - 14 days, I.V administration of the drug may be necessary to achieve high serum and tissue level.

211


Cont…dCont…dBed rest, antispasmodics, laxatives

to soften stool and sitz bath.Patient education

◦ Foods and liquids that have diuretic action or that increase prostatic secretions, such as alcohol, coffee, tea, chocolate, cola, and spices, should be avoided.

◦ Avoidance of sexual intercourse during acute inflammation.

◦ Prolonged sitting also be avoided.◦ Medical follow up for at least 6

months to 1 year.

212


5. Benign prostatic 5. Benign prostatic hyperplasia hyperplasia

(hypertrophy)-BPH (hypertrophy)-BPH It is the most common problem of

the adult male reproductive system.

This problem occurs in about 50 percent of men over 50 years of age and 75% of men over 70 years.

The prostate gland enlarges extending up ward in to the bladder and obstructing the outflow of urine by encroaching on the vesicle orifice.

213


Cont…dCont…dCauseUncertain but evident suggests a hormonal (effect of androgen hormone) cause as initiating hyperplasia of the supporting stromal tissue and a glandular element in the prostate.

Other factors that cause over production of this responsible hormone, such as infection.

214


Cont…dCont…dClinical Manifestation Increasing potency of urination. Nocturia, hesitancy. In starting urination increasing of force of

urinary stream but a decrease and interruption of urinary stream will occur.

Sensation of incomplete emptying of the bladder.

Urine dribbles out after urination. An acute urinary retention (infection). Fatigue secondary to anorexia, nausea and

vomiting due to impaired renal function. Epigastric discomfort due to distended

bladder. Heamaturia, uremia at the later stage.

215


Cont…dCont…d

Diagnostic EvaluationRectal examination.Complete hematological investigation (CBC).

X-ray.Cystoscopy examination.RFT.

216


Cont…dCont…dMgxThe plan of treatment depends on the

cause, the severity of obstruction, the condition of the patient, age.

Catheterization to treat an acute urinary retention.

Some times a suprapubic cystostomy to give adequate drainage.

Water and electrolyte replacement in necessary.

Antimicrobial drugs may be necessary to treat UTI.

217


Cont…dCont…dAlpha-adrenergic receptor blockers

(e.g, terazosin [Hytrin]) relax the smooth muscle of the bladder neck and prostate.

5-alpha-reductase inhibitors such as finasteride have been effective in preventing the conversion of testosterone to dihydrotestosterone (DHT).

Prostatectomy:-surgery to remove the hyper plastic prostate tissue to provide permanent relief of the obstruction.

218


Cont…dCont…d1. Transurethral Resection.

Not require abdominal incision; it is a removal of prostatic tissue by instrument introduced through urethra.

2. Suprapubic Prostatectomy.Require open surgery, an opening made in

the bladder.3. Perineal prostatectomy.

Require open surgery-an incision made in the perineum.

4. Retro pubic Prostatectomy. Requires open surgery-a low abdominal

incision is made.

219


Cont…dCont…dPer-operative nursing care

◦Assessment of the pts general health status.

◦Adequate nutrition.◦Adequate rest to have best physical condition before surgery.

◦Appropriate antimicrobial drug to come back infection.

◦Foley catheter maybe inserted.◦Reduce Anxiety.

220


Cont…dCont…dPost-operative nursing care

◦ Frequent observation for symptoms of shock & hemorrhage.

◦ Frequent observation for infection & thrombosis.

◦ Urologist should change dressing on the first post operative day.

◦ Careful aseptic technique is practiced. ◦ Rectal temperature, rectal tubes and

enemas are to be avoided.◦ Pts undergoing prostatectomy (with

the exception of transurethral resection) have a high incidence of develop vein thrombosis.

221


Cont…dCont…d◦ Dressing should be changed frequently

for drainage and bleeding.◦ Encourage fluid in take. ◦ In take and out put should be

recorded.◦ If the pt is too old additional attention

must be given (skin care, frequent change of position keeping the pt safe e.t.c…).

◦ Following transurethral prostatic resection the catheter must drain well.

◦ Furosemide is given to initiate post operative diuresis to keep the catheter potent.

222


Cont…dCont…d◦Check V/S.◦Analgesics.◦Patient Education.

Encourage to walk not to sit for long times.

Keep bowel movement soft. Should be advised not to urinate as soon as the desire to do so felt.

Avoid heavy exercise and lift. Spice food, alcohol, coffee etc should be avoided may cause discomfort .

Encourage to take fluid.

223


C. Cancer of the prostate C. Cancer of the prostate gland gland Cancer of the prostate is the

second most common cause of cancer.

The most prevalent cancer overall in black men with increasing number of men in the old age group.

Due to this greater attention will be focused on this condition .

224


Cont…dCont…d

Risk factor Age A familial predisposition A diet high in red meat and fat.

Cause Unknown/Idiopathic.


5

Cont…dCont…dClinical manifestation Early Ca of the prostate does

not usually produce symptoms if the neoplasm is large enough to encroach on the bladder neck and cause obstruction of urine.

There are signs and symptoms of obstruction namely;◦Difficulty & frequent urination.◦Urinary retention.◦Decreased size and force of urinary

stream.

226


Cont…dCont…dMethod of Diagnosis Finger rectal examination; palpable of it

is advanced, stony hard. Histological examination by surgically

transurethral resection, open prostatectomy or needle biopsy perennial or trans rectal.

Serum acid phosphate level is frequently increased.

Skeletal x-ray to revel osteoblastic metastasis.

Urogram to demonstrate changes from urethral obstruction.

RFT.

227


Cont…dCont…dMgx Radical Prostatectomy. Radiation as a palliative therapy. Hormonal therapy maybe selected to

suppress all androgenic stimulation to the prostate due to orchiectomy or administration of estrogen.

Blood transfusion. Analgesics. Strict observation. V/S check up. Sign of anemia, shock, fluid balance

etc... Should be checked.

228


D. HydroceleD. HydroceleA hydrocele is a collection of fluid

generally in the tunica vaginalis of testis.

The tunica vaginalis become widely distended with fluid.

Cause ◦Occurs in association with acute

infectious disease of the epididymitis, such as mumps .

◦The cause of chronic hydrocele is unknown.

229


Cont…dCont…dMgxUsually therapy is not required.Treatment is necessary only of the

hydrocele become tense and comprise testicular circulation or if the scrotal mass becomes large, uncomfortable or embarrassing.

Withdrawing the fluid through a large needle or removing the sac of the fluid.

230


Cont…dCont…dSurgical incision through the

wall of the scrotal down to the distended tunica vaginalis.

Some time sclerotic substance is injected in to the sac after aspirating fluid to cause the wall of hydrocele to become inflamed and disappear.

Eventually post operative scrotal support is done.

231


D. VaricoceleD. VaricoceleA varicocele is an abnormal

dilation of the veins of the pampiniform venous plexus in the scrotum (the network of veins from the testis and the epididymis that constitute part of the spermatic cord).

Varicoceles usually occur in the veins on the upper portion of the left testicle in adults.

232


Cont…In some men, a varicocele has been associated with infertility.

Few, if any, subjective symptoms may be produced by the enlarged spermatic vein.

233


Cont…d

C/MPain.Tenderness.Discomfort in the inguinal region.

234


Cont…dCont…dMgxNo treatment is required unless

fertility is a concern.It is corrected surgically by

ligating the external spermatic vein at the inguinal area.

An ice pack may be applied to the scrotum for the first few hours after surgery to relieve edema.

The patient then wears a scrotal supporter.

235


E. EpididymitisEpididymitis is an infection of the epididymis that usually descends from an infected prostate or urinary tract.

CauseComplication of gonorrhea. Chlamydia trachomatis (In men younger than age 35).

236


Cont…dC/MUnilateral pain and soreness in the

inguinal canal along the course of the vas deferens.

Pain and swelling in the scrotum and the groin.

The epididymis becomes swollen and extremely painful.

Temperature is elevated.Pyuria and bacteriuria.Chills and fever.

237


Cont…dMedical management If the patient is seen within the first 24 hours

after onset of pain, the spermatic cord may be infiltrated with a local anesthetic agent to relieve pain.

If the epididymitis is from a chlamydial infection, the patient and his sexual partner must be treated with antibiotics.

The patient is observed for abscess formation as well.

If no improvement occurs within 2 weeks, an underlying testicular tumor should be considered.

An epididymectomy (excision of the epididymis from the testis) may be performed for patients with recurrent, incapacitating episodes of epididymitis or for those with chronic, painful conditions.

238


Cont…dNursing ManagementBed rest.Scrotum is elevated with a scrotal

bridge or folded towel to prevent traction on the spermatic cord and to promote venous drainage and relieve pain.

Antimicrobial agents are administered as prescribed until the acute inflammation subsides.

Intermittent cold compresses to the scrotum may help ease the pain. Later, local heat or sitz baths may help resolve the inflammation.

239


Cont…dAnalgesic medications are

administered for pain relief as prescribed.

Health education;◦to avoid straining, lifting, and sexual stimulation until the infection is under control.

◦continue taking analgesic agents and antibiotics as prescribed and

◦using ice packs if necessary to relieve discomfort.


0

F. Orchitis OrchitisOrchitis is an inflammation of

the testes (testicular congestion).

Cause Pyogenic (bacterial). Viral. Spirochetal. Parasitic. Traumatic. Chemical. Unknown factors.

241


Cont…d

Medical ManagementDirected at the specific infecting

organism.Rest.Elevation of the scrotum.Ice packs to reduce scrotal

edema.Antibiotics.Analgesic agents.Anti-inflammatory medications.

242


G. Hypospadias and EpispadiasG. Hypospadias and Epispadias

Hypospadias and epispadias are congenital anomalies of the urethral opening.

In hypospadias, the urethral opening is a groove on the underside of the penis.

In epispadias, the urethral opening is on the dorsum.

These anatomic abnormalities may be repaired by various types of plastic surgery, usually when the boy is very young.

243


H. Phimosis and himosis and Paraphimosis Paraphimosis 1. Phimosis, a condition in which

the foreskin is constricted so that it cannot be retracted over the glans.

CauseCongenitally.Inflammation.Edema.

244


Cont…dWith the trend away from routine

circumcision of newborns, early instruction should be given about cleansing the prepuce.

In elderly men, penile carcinoma may develop.

MgxPhimosis is corrected by circumcision.


5

Cont…d

2. Paraphimosis is a condition in which the foreskin is retracted behind the glans and, because of narrowness and subsequent edema, cannot be returned to its usual position (covering the glans).

246


Cont…d

Mgx◦Manual reduction:-by firmly compressing the glans to reduce its size and then pushing the glans back while simultaneously moving the prepuce forward.

◦Circumcision is usually indicated after the inflammation and edema subside.


7

I. Cancer of the penisI. Cancer of the penisPenile cancer occurs in men older than age 60.

Since most penile cancers occur in uncircumcised men, it has been suggested that the etiology of this cancer may be the irritative effect of smegma and poor hygiene.

248


Cont…dCancer of the penis appears on the skin of the penis as a painless, wartlike growth or ulcer.

Cancer of the penis can involve the glans, the coronal sulcus under the prepuce, the corporal bodies, the urethra, and regional or distant lymph nodes.


9

Cont…dCont…dMedical ManagementExcision (for smaller lesions involving only

the skin).Topical chemotherapy with 5-

fluorouracil cream. Radiation therapy is used to treat small

squamous cell carcinomas of the penis or for palliation in advanced tumors or lymph node metastasis.

Partial penectomy (removal of the some part of penis).

Total penectomy is indicated when the tumor is not amenable to conservative treatment.


0

Congenital malformation Congenital malformation of the urinary tractof the urinary tract1. Horseshoe kidney1. Horseshoe kidney

Horseshoe kidney is abnormal fusion of the lower portion of the kidneys during fetal development.

It is often associated with other anomalies.

The two kidneys are normally separated.

The condition is asymptomatic but it can increase the risk of kidney disease and complications. Lecture note for regular second


1

Cont…dCont…d

CauseCongenital disorder. Wilm's tumour. Transitional cell carcinoma. Turner syndrome. Vesicourethral reflux.


2

Cont…dCont…d

C/M Asymptomatic. Fusion of kidney.

DxHx.P/E.

MgxIt depends on the renal problem that

occur following this problem.


3

2. Duplication of the 2. Duplication of the ureterureter

Duplicated ureter is a congenital condition in which the ureteric bud (the embryological origin of the ureter), splits (or arises twice), resulting in two ureters draining a single kidney.

It is the most common renal abnormality, occurring in approximately 1% of the population.

The additional ureter may result in a ureterocele, or an ectopic ureter.


4

Cont…dCont…d

ClassificationUreteral duplication is either:

◦Partial The two ureters drain into the

bladder via a single common ureter. Partial, or incomplete, ureteral

duplication is rarely clinically significant.


5

Cont…dCont…d◦Complete The two ureters drain separately. Complete ureteral duplication may result in one ureter opening normally into the bladder, and the other being ectopic, ending in the vagina, the urethra or the vulval vestibule.

These cases occur when the ureteric bud arises twice (rather than splitting).


6

Cont…dCont…d

C/MUrinary tract infection - most commonly due to vesicoureteral reflux.

Urinary incontinence in females occurs in cases of ectopic ureter entering the vagina, urethra or vestibule.


7

Cont…dCont…d


8

Cont…dCont…d

MgxIt depends on the renal problem

associated to this congenital problem.


9

DialysisDialysisDialysis also defined as movement

of fluid and particles across a semi permeable membrane from one compartment to another.

Dialysis is the process of separating crystalloids and colloids in solution by the difference in their rates of diffusion through a semi permeable membrane: crystalloids pass through readily, colloids very slowly or not at all.

260


Cont…dCont…dUsed to remove fluid and uremic waste products from the body when the kidneys cannot do so.

The two methods used as an artificial membrane (cellophane or cuprophane) as the dialyzing surface which is in contact with the client’s blood.


1

Cont…dCont…dDialysis in general, used to

correct fluid & electrolyte imbalances, remove wastes products and drugs, and replace renal function in acute and chronic renal failure.

262


Cont…dCont…dMethods of therapy include hemodialysis, continuous renal replacement therapy (CRRT) and various forms of peritoneal dialysis.

The need for dialysis may be acute or chronic.


3

Cont…dCont…d

Acute dialysis;◦It is indicated when there is a high and rising level of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis, and severe confusion.


4

Cont…dCont…dIt may also be used to remove certain medications or other toxins (poisoning or medication overdose) from the blood.


5

Cont…dCont…dChronic or maintenance dialysis;

It is indicated in chronic renal failure, known as end-stage renal disease (ESRD), in the following instances: the presence of uremic signs and symptoms affecting all body systems (nausea and vomiting, severe anorexia, increasing lethargy, mental confusion), hyperkalemia, fluid overload not responsive to diuretics and fluid restriction, and a general lack of well-being.

An urgent indication for dialysis in patients with chronic renal failure is pericardial friction rub.


6

HemodialysisHemodialysisThe most commonly used method of

dialysis which is used for patients who are acutely ill and require short-term dialysis (days to weeks) and for patients with ESRD who require long-term or permanent therapy.

A dialyzer (once referred to as an artificial kidney) serves as a synthetic semipermeable membrane, replacing the renal glomeruli and tubules as the filter for the impaired kidneys.


7

Cont…dCont…dFor patients with chronic renal

failure, hemodialysis prevents death, although it does not cure renal disease and does not compensate for the loss of endocrine or metabolic activities of the kidneys.

Patients receiving hemodialysis must undergo treatment for the rest of their lives or until they undergo a successful kidney transplantation.


8

Cont…dCont…dHemodialysis system:

◦Blood from an artery is pumped into a dialyzer where it flows through the cellophane tubes, which act as the semipermeable membrane (inset).

◦The dialysate, which has the same chemical composition as the blood except for urea and waste products, flows in around the tubules.

◦The waste products in the blood diffuse through the semipermeable membrane into the dialysate.Lecture note for regular second


9


0

Cont…dCont…d

Complications of HemodialysisHypotension.Painful muscle cramping.Dysrhythmias.Air embolism.Chest pain because of anemia or on pt with arteriosclerotic heart disease.


1

Peritoneal dialysisPeritoneal dialysisPeritoneal dialysis may be the

treatment of choice for patients with renal failure who are unable or unwilling to undergo hemodialysis or renal transplantation.

In peritoneal dialysis, the peritoneum, a serous membrane that covers the abdominal organs and lines the abdominal wall, serves as the semipermeable membrane.Lecture note for regular second


2

Cont…dCont…dSterile dialysate fluid is introduced

into the peritoneal cavity through an abdominal catheter at intervals.

Urea and creatinine, metabolic end products normally excreted by the kidneys, are cleared from the blood by diffusion and ossmosis as waste products move from an area of higher concentration (the peritoneal blood supply) to an area of lower concentration (the peritoneal cavity) across a semipermeable membrane (the peritoneal membrane).


3


4

Cont…dCont…d

Complications of Peritoneal Dialysis;

Peritonitis.Leakage of diayalysate. Bleeding.Long-term complications includes hernias (inscisional), cardiodiovascular.


5

Nursing responsibilities Nursing responsibilities for a patient with for a patient with

Cystostomy Cystostomy A cystotomy is a surgical opening created in the wall of the urinary bladder.

This procedure allows the surgeon to look inside the bladder.

Indications removal of bladder stones, bladder

tumors, and blood clots to obtain a biopsy sample of the

urinary bladder to repair a rupture or severe trauma

to the urinary bladder abnormal insertion of the ureters into

the bladderLecture note for regular second year Nursing student, February 2003/2011. 27

6

Cont…dCont…d

Preoperative careLab test

Radiographs (x-rays) abdominal ultrasound complete blood count serum biochemical test urinalysis EKG

General anesthesia Lecture note for regular second year Nursing student, February 2003/2011. 27

7

Cont…dCont…dPostoperative care safe and effective pain medicines. urinary catheter will have been placed at

surgery. home care requires reduced activity until

the stitches are removed in 10 to 14 days. inspect the suture line daily for signs of

redness, discharge, swelling, or pain and monitor your pet's urinary habits.

Some blood-tinged urine is expected for the first few days, but obvious pain, straining or a lack of urination is not normal and should prompt a call to your veterinarian/physician.


8

Cont…dCont…d

Complicationsgeneral anesthesiableeding (hemorrhage)postoperative infectionurine leakagewound breakdown (dehiscence)


9

Nursing responsibilities Nursing responsibilities for a patient with for a patient with

NephrectomyNephrectomy Nephrectomy is the surgical removal of a kidney.

Indications Renal cell carcinoma.A non-functioning kidney. A congenitally small kidney.Nephrectomy is also performed for the

purpose of living donor kidney transplantation.

Partial Nephrectomy has also been performed to repair injury e.g. rupture, caused by trauma such as falls and motor vehicle accidents.


0

Cont…dCont…d

Care after the procedure◦Pain medication is often given to the

patient after the surgery because of pain at the site of the incision.

◦An IV with fluids is administered.◦Electrolyte balance and fluids are

carefully monitored.◦A patient has to stay in the hospital

between 2 and 7 days depending on the procedure and complications.


1

Fluid and electrolytic

balance


2

Fundamental ConceptsFundamental ConceptsAmount and composition of body

fluids; Water is essential for life. It is the

major solvent in our body system. It surrounds and present in every cell.

Approximately 60% of a typical adult’s weight consists of fluid (water and electrolytes).

Factors that influence the amount of body fluid are;


3

Cont…dCont…dAge:-younger people have a higher

percentage of body fluid than older people,

Gender:-men have proportionately more body fluid than women.

Body fat:-Obese people have less fluid than thin people because fat cells contain little water.


4

Cont…dCont…d Body fluid is located in two fluid

compartments: intracellular space (fluid in the cells)-two

thirds of body fluid primarily in skeletal muscle mass.

extracellular space (fluid outside the cells). Intravascular:-the fluid within the blood

vessels (6L). E.g. pasma and blood cells.Interstitial:-fluid that surrounds the cell (11 to

12 L). E.g. Lymph.Transcellular:- the smallest division (1L). E.g.

cerebrospinal, pericardial, synovial, intraocular, and pleural fluids; sweat; and digestive secretions. Lecture note for regular second


5

Cont…dCont…dLoss of ECF into a space that

does not contribute to equilibrium between the ICF and the ECF is referred to as a third-space fluid shift, or “third spacing”.

Third-space shifts occur in ascites, burns, peritonitis, bowel obstruction, and massive bleeding into a joint or body cavity.


6

Cont…dCont…dElectrolytesElectrolytes in body fluids are active

chemicals (cations, which carry positive charges, and anions, which carry negative charges).

Electrolyte concentration in the body is expressed in terms of milliequivalents (mEq) per liter, a measure of chemical activity.

a milliequivalent is defined as being equivalent to the electrochemical activity of 1 mg of hydrogen. Lecture note for regular second


7

Major electrolyte contentMajor electrolyte contentin body fluidin body fluid


8

Regulation of bodyRegulation of bodyfluid compartmentsfluid compartments

Capillary membrane separates intravascular and interstitial space.

Water and molecules move in both direction across the semipermable membrane.

Body fluid compartments are regulated by two mechanisms; Passive transport

Osmosis Diffusion Filtration

Active transport


9

Cont…dCont…d Osmosis is the movement of fluid

through semipermable membrane from low solute concentration to high solute concentration until equilibrium reached.


0

Cont…dCont…d Diffusion is the movement of ions and

molecules across semipermable membrane from high concentration to low concentration until equilibrium reached.


1

Cont…dCont…dFiltration is the movement of

water and solute occurs by force of pressure (from high hydrostatic pressure to low hydrostatic pressure).

Active transport is the movement of ions by using energy (ATP). E.g. Na+ -K+ pump.


2

Routes of fluid gains and Routes of fluid gains and losseslosses

A healthy person gains fluids by;◦Drinking◦Eating

In patients with some disorders, fluids may be provided by;◦Parenteral route (intravenously or subcutaneously)

◦Enteral feeding tube in the stomach or intestine.


3

Average Daily Intake and Average Daily Intake and Output of fluid in AdultOutput of fluid in Adult


4

Cont…dCont…dKidneys

◦The usual daily urine volume in the adult is 1 to 2 L with 1 mL/kg/h formula in all age groups.

Skin◦Sensible

Sweating:- 0 to 1,000 mL . The chief solutes in sweat are sodium, chloride, and potassium. Environmental temperature (hot) increases the value.

◦ Insensible ( 600 mL/day). Fever and burn increases its value.


5

Cont…dCont…dLungs

◦400 mL every day. The loss is much greater with increased respiratory rate or depth (hyperpnoea and tahypenea), or in a dry climate.

GI Tract◦100 to 200 mL daily. Diarrhea and fistulas cause large losses.

N.B. In healthy people, the daily average intake and output of water are approximately equal.


6

Laboratory tests for Laboratory tests for evaluating fluid statusevaluating fluid status

Osmolality;It is a measure of a solution’s ability

to create osmotic pressure and affect the movement of water.

Most often used in clinical pratice.Osmolality is reported as milliosmoles

per kilogram of water (mOsm/kg). It also measures the solute

concentration per kilogram in blood and urine.


7

Cont…dCont…d

◦Serum osmolality Primarily reflects the concentration

of sodium. Normal value is 280 to 300

mOsm/kg. Formula used to calculaate it;


8

Cont…dCont…d

◦Urine osmolality Determined by urea, creatinine, and uric acid.

Normal value 250 to 900 mOsm/kg.

N.B. When measured with serum osmolality, urine osmolality is the most reliable indicator of urine concentration.


9

Cont…dCont…d


0

Cont…dCont…dTypes of solutionIsotonic:- the same osmolality

with ECF. E.g. N/S.Hypertonic:- concentrated/greater

osmolality than ECF.Hypotonic:- dilute/lower

osmolality than ECF.Tonicity is ability of all solute to cause osmotic driving force in a solution.


1

Cont…dCont…dUrine specific gravity;It measures the kidneys’ ability to

excrete or conserve water.Measured by a refractometer or

dipstick with a reagent for this purpose.

Normal value is 1.010 to 1.025.BUN;It is made up of urea, an end product of

metabolism of protein (from both muscle and dietary intake) by the liver.

The normal BUN is 10 to 20 mg/dL (3.5–7 mmol/L).


2

Cont…dCont…dFactors that increase BUN;

◦ decreased renal function ◦ GI bleeding ◦ dehydration◦ increased protein intake ◦ fever◦ sepsis

Factors that decrease BUN; ◦ end-stage liver disease,◦ a low-protein diet◦ starvation◦ any condition that results in expanded

fluid volume (e.g, pregnancy).


3

Cont…dCont…dCreatinine; It is the end product of muscle

metabolism. It is a better indicator of renal function

than BUN because it does not vary with protein intake and metabolic state.

The normal serum creatinine is approximately 0.7 to 1.5 mg/dL.

Its concentration depends on lean body mass and varies from person to person.

Serum creatinine levels increase when renal function decreases.


4

Cont…dCont…dHematocrit; It measures the volume percentage

of red blood cells (erythrocytes) in whole blood.

normally ranges from 44% to 52% for males and 39% to 47% for females.

Conditions that;◦Increase-dehydration and polycythemia.

◦Decrease-overhydration and anemia.


5

Cont…dCont…d

Urine sodium;◦Normal urine sodium levels range

from 50 to 220 mEq/24 h (50–220 mmol/24 h).


6

Homeostatic mechanismsHomeostatic mechanisms

Organs involved in homeostasis include;◦kidneys ◦lungs◦heart◦adrenal glands ◦parathyroid glands◦pituitary gland


7

Cont…dCont…dKidney;Regulation of ECF volume and

osmolality by selective retention and excretion of body fluids.

Regulation of electrolyte levels in the ECF by selective retention of needed substances and excretion of unneeded substances.

Regulation of pH of the ECF by retention of hydrogen ions.

Excretion of metabolic wastes and toxic substances. Lecture note for regular second


8

Cont…dCont…dHeart and Blood Vessel;

◦The pumping action of the heart circulates blood through the kidneys under sufficient pressure to allow for urine formation.

Lung◦The lungs also have a major role in maintaining acid–base balance.

◦The lungs remove approximately 300 mL of water daily in the normal adult.


9

Cont…dCont…dPituitary The hypothalamus manufactures ADH, which is stored in

the posterior pituitary gland and released as needed. Functions of ADH include maintaining the osmotic pressure

of the cells by controlling the retention or excretion of water by the kidneys and by regulating blood volume

Adrenal Aldosterone, a mineralocorticoid secreted by the zona

glomerulosa (outer zone) of the adrenal cortex, has a profound effect on fluid balance

Parathyroid Regulate calcium and phosphate balance by means of

parathyroid hormone (PTH). PTH influences bone resorption, calcium absorption from

the intestines, and calcium reabsorption from the renal tubules.


0

Other MechanismsOther MechanismsBaroreceptors;The baroreceptors are small nerve

receptors that detect changes in pressure within blood vessels and transmit this information to the central nervous system. ◦ low-pressure receptors:-in cardiac

atria, particularly the left atrium. ◦high-pressure receptors:-in the aortic

arch, cardiac sinus, and afferent arteriole of the juxtaglomerular apparatus of the nephron.


1

Cont…dCont…dRenin–angiotensin–aldosterone system;ADH and thirst;Osmoreceptors;

◦ Located on the surface of the hypothalamus, osmoreceptors sense changes in sodium concentration. As osmotic pressure increases, the neurons become dehydrated and quickly release impulses to the posterior pituitary, which increases the release of ADH.

Atrial natriuretic peptide; released by cardiac cells in the atria of the heart

in response to increased atrial pressure. The ANP measured in plasma is normally 20 to

77 pg/mL (20—77 ng/L).


2

FluidFluid volume imbalance volume imbalance Various types of FVI could occur. The variation is the result of which

component the fluid is excess or deficient. Types of FVI;1.Hyper osmolar imbalance:- water in ECF

is less than the solute proportion normally expected.

2.Hypo osmolar imbalance:- water in ECF is excess.

3.Isotonic volume deficit:- whole deficit in ECF (electrolyte and water).

4.Isotonic volume excess:- whole excess.


3

Fluid volume deficit Fluid volume deficit (hypovolemia)(hypovolemia)

Occurs when loss of extracellular fluid (water and electrolytes) volume in the same proportion exceeds the intake of fluid.

The ratio of serum electrolytes to water remains the same.

It is called IVD.Dehydration-to loss of water alone with serum electrolyte level is the same. Lecture note for regular second


4

Cont…dCont…dCauses inadequate intake

◦ Nausea and inability to gain access to fluids abnormal fluid losses;

◦ vomiting, diarrhea, GI suctioning, sweating, third-space fluid shifts

Risk factors diabetes insipidusadrenal insufficiencyosmotic diuresishemorrhagecoma


5

Cont…dCont…dClinical Manifestationscan be mild, moderate, or severe

◦Skin-cool, clammy, decreased skin turgor.

◦CVS-postural hypotension; a weak, rapid heart rate; flattened neck veins; increased temperature; decreased central venous pressure.

◦GUS-oliguria; concentrated urine.◦Mouth-dry mucus membrane.◦Others-acute weight loss; thirst;

anorexia; nausea; lassitude; muscle weakness; and cramps.


6

Cont…dCont…dAssessment and diagnostic findingsBUN elevated out of proportion to

the serum creatinine level (a ratio greater than 20:1).

hematocrit level is increased.Urine specific gravity is increased.Urine osmolality is greater than

450 mOsm/Kg.Hyperkalemia.Decreased central venous pressure

with normal cardiovascular function. Lecture note for regular second


7

Cont…dCont…dMedical ManagementMild to moderate; Oral fluid intake-small frequent sip. Frequent mouth care. Giving non irritating fluid. Acute and severe; IV route is required. Isotonic electrolyte solutions (e.g, lactated Ringer’s

or 0.9% sodium chloride). As soon as the patient becomes normotensive, a

hypotonic electrolyte solution (eg, 0.45% sodium chloride).

Accurate and frequent assessments of intake and output, weight, vital signs, central venous pressure, level of consciousness, breath sounds, and skin color should be performed not to avoid overload the patient.


8

Cont…dCont…dNursing ManagementMonitors and measures fluid

intake and output at least every 8 hours, and sometimes hourly.

Monitoring daily body weights.Wt loss of 0.5 kg 500 mL fluid loss.

Monitoring vital signs closely.Skin and tongue turgor is monitored on a regular basis.


9

Cont…dCont…d

PreventionIdentify patients at risk.Takes measures to minimize fluid

losses. For example, if the patient has

diarrhea, diarrhea use antidiarrheal medications and small volumes of oral fluids at frequent intervals.


0

Fluid volume excess Fluid volume excess (hypervolemia)(hypervolemia)

an 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.

is always secondary to an increase in the total body sodium content, which, in turn, leads to an increase in total body water.

related to simple fluid overload or diminished function of the homeostatic mechanisms responsible for regulating fluid balance.


1

Cont…dCont…d

CauseContributing factors;

◦heart failure, ◦renal failure, ◦cirrhosis of the liver. ◦consumption of excessive amounts of table or other sodium salts.

◦Excessive administration of sodium.


2

Cont…dCont…dClinical Manifestationsedemadistended neck veinscrackles (abnormal lung sounds)tachycardia; increasedblood pressure, pulse pressure,

and central venous pressureincreased weight increased urine outputshortness of breathwheezing.


3

Cont…dCont…d


BUN and hematocrit levels decreased.

Serum osmolality decreased.Chest x-rays may reveal

pulmonary congestion.


4

Cont…dCont…dMedical ManagementDirected at the causes.Pharmacologic;

◦Diuretics are prescribed when dietary restriction of sodium alone is insufficient to reduce edema.

◦The choice of diuretic is based on severity of the hypervolemic state.

the degree of impairment of renal function.

potency of the diuretic.Lecture note for regular second year Nursing student, February 2003/2011. 32

5

Cont…dCont…d◦Thiazide diuretics;

5% to 10% of filtered sodium excreted.

Act on distal tubule. Ordered for mild to moderate

hypervolemia.

◦Loop diuretics; Act on loop of henle. 20% to 30% of filtered sodium is

excreted. Ordered for severe hypervolemia.


6

Cont…dCont…dHemodialysis/peritoneal dialysis;

◦A choice when renal function is severely impaired that diuretics cannot act efficiently.

◦Used to remove; nitrogenous wastes control potassium acid–base balance to remove sodium and fluid.


7

Cont…dCont…dNutritional;

◦An average daily diet not restricted in sodium contains 6 to 15 g of salt.

◦The restriction vary from mild to 250 mg of sodium per day.

◦It is the sodium salt, sodium chloride, rather than sodium itself that contributes to edema.


8

Cont…dCont…dNursing Management

◦measures intake and output.◦assess breath sounds.◦monitors the degree of edema in

the most dependent parts of the body, such as the feet and ankles in ambulatory patients and the sacral region in bedridden patients.

◦Maintaining semi fowlers position.◦Frequent positioning.◦Teaching patient about edema.


9

Electrolyte ImbalancesElectrolyte ImbalancesSodium Imbalance sodium is the primary determinant of

ECF osmolality. Most abundant electrolyte in ECF. Controls water distribution throughout the

body. The primary regulator of ECF volume

as its movement coupled with water. Necessary for muscle contraction and

the transmission of nerve impulses. Its normal concentration ranges from 135

to 145 mEq/L (135—145 mmol/L).


0

Cont…dCont…dSodium proportion change in plasma may be

due to; Low sodium amount with low water where

the magnitude of sodium loss is greater in proportion.

Normal sodium amount with greater amount of total body water.

Sodium is greater with an even greater body water gain.

Sodium is greater with normal body water or decreased total body water.

Sodium deficit and excess are the two most common sodium imbalances.


1

Sodium deficit Sodium deficit (hyponatremia)(hyponatremia)

Serum sodium level that is below normal (less than 135 mEq/L [135 mmol/L]).

Can be superimposed on an existing FVD or FVE.

Occurs when;◦ low quantity of total body sodium with a

lesser reduction in total body water,◦ normal total body sodium content with

excess total body water,◦ an excess of total body sodium with an

even greater excess of total body water.


2

Cont…dCont…d

CausesSodium loss due to vomiting, diarrhea, fistulas, or sweating.

Diuretics use. a low-salt diet. Adrenal insufficiency


3

Cont…dCont…dWater intoxication (dilutional hyponatremia); No loss of sodium but excess amount of water in

ECF (hyper osmolar state is created). Predisposing factors are;

◦ SIADH.◦ Hyperglycemia.◦ electrolyte-poor parenteral fluids.◦ use of tap-water enemas, or the irrigation

of nasogastric tubes with water instead of normal saline solution.

◦ excessive parenteral administration of dextrose and water solutions.

◦ compulsive water drinking (psychogenic polydipsia).


4

Cont…dCont…dClinical Manifestations depend on the cause, magnitude, and speed

with which the deficit occurs.◦ Poor skin turgor◦ dry mucosa◦ decreased saliva production, ◦ orthostatic fall in blood pressure, ◦ nausea◦ abdominal cramping◦ altered mental status◦ anorexia, muscle cramps, and a feeling of

exhaustion if it is associated with sodium loss and water gain


5

Cont…dCont…dWhen the serum sodium level

drops below 115 mEq/L (115 mmol/L);◦lethargy◦Confusion signs of ◦muscle twitching increasing ◦focal weakness intracranial

◦Hemiparesis pressure◦papilledema◦Seizures Lecture note for regular second


6

Cont…dCont…dAssessment and Diagnostic FindingsSerum sodium level is less than 135

mEq/L (regardless of th cause).Serum sodium level 100 mEq/L (100

mmol/L) or less (SIADH).Serum osmolality is also decreased.Urinary sodium content is less than 20

mEq/L (20 mmol/L) (Sodium loss).Urinary sodium content is greater than

20 mEq/L (SIADH). Urine specific gravity is 1.002 to 1.004

(Sodium loss). Urine specific gravity over 1.012

(SIADH).Lecture note for regular second year Nursing student, February 2003/2011. 33

7

Cont…dCont…dMedical Management Sodium replacement:-sodium loss

◦ For patients who can eat and drink, sodium is easily replaced by mouth.

◦ For those who cannot consume sodium, lactated Ringer’s solution or isotonic saline (0.9% sodium chloride) solution may be prescribed parenteraly.

◦ The maximum serum sodium replacement is 12 mEq/L in 24 hours, to avoid neurologic damage due to osmotic demyelination.

◦ Rapidly replacement above 140 mEq/L produce lesions in the pons that cause paraparesis, dysarthria, dysphagia, and coma.


8

Cont…dCont…dSIADH◦Administration of hypertonic

saline solution alone cannot change the plasma sodium concentration.

◦Diuretic furosemide (Lasix).Water restriction

In a patient with normal or excess fluid volume.

restricting fluid to a total of 800 mL in 24 hours.


9

Cont…dCont…dNursing ManagementIdentification of patients at risk and

early detection and treatment of to avoid complication.

Monitor fluid intake and output as well as daily body weights.

Note abnormal losses of sodium or gains of water and GI manifestations, such as anorexia, nausea, vomiting, and abdominal cramping.

Alert for central nervous system changes, such as lethargy, confusion, muscle twitching, and seizures.


0

Sodium excess Sodium excess (hypernatremia)(hypernatremia)

Serum sodium level exceeding 145 mEq/L [145 mmol/L].

Occurs when;a gain of sodium in excess of water

a loss of water in excess of sodium.

It can occur in patients with normal fluid volume or in those with FVD or FVE.


1

Cont…dCont…dCauses (common) Fluid deprivation in unconscious patients. Administration of hypertonic enteral feedings. IV administration of hypertonic saline or

excessive use of sodium bicarbonate Watery diarrhea and greatly increased

insensible water loss (e.g, hyperventilation, denuding effects of burns).

Diabetes insipidus.Less common causes are;

heat strokenear-drowning in sea water (which contains a

sodium concentration of approximately 500 mEq/L),

malfunction of either hemodialysis or peritoneal dialysis proportioning systems.


2

Cont…dCont…dClinical Manifestations Primarily neurologic and are presumably the

consequence of cellular dehydration.◦ Moderate:-restlessness and weakness◦ Severe:- disorientation, delusions, and

hallucinations Other signs;

◦ Dry swollen tongue ◦ Sticky mucous membranes.◦ Flushed skin◦ Peripheral and pulmonary edema◦ Postural hypotension◦ Increased muscle tone and deep tendon

reflexes ◦ Mild rise in body temperatureLecture note for regular second


3

Cont…dCont…dAssessment and Diagnostic Findings

Serum sodium level exceeds 145 mEq/L (145 mmol/L).

Serum osmolality exceeds 295 mOsm/kg (295 mmol/L).

The urine specific gravity and urine osmolality are increased.

What do you expect if the cause is DI?


4

Cont…dCont…dMedical ManagementInfusion of a hypotonic electrolyte

solution (e.g, 0.3% sodium chloride) or an isotonic nonsaline solution(eg, dextrose 5% in water [D5W]).

D5W is indicated when water needs to be replaced without sodium.

Hypotonic sodium solution to be safer than D5W because it allows a gradual reduction in the serum sodium level and decreases the risk of cerebral edema.


5

Cont…dCont…d Hypotonic sodium solution is the solution of

choice in severe hyperglycemia with hypernatremia.

Diuretics also may be prescribed to treat the sodium gain.

Desmopressin acetate (DDAVP) may be prescribed to treat diabetes insipidus if it is the cause of hypernatremia.

How it can act ?N.B. The serum sodium level is reduced

at a rate no faster than 0.5 to 1 mEq/L to allow sufficient time for readjustment through diffusionm across fluid compartments.


6

Cont…dCont…dNursing Management fluid losses and gains are carefully

monitored Assess for abnormal losses of water or

low water intake and for large gains of sodium.

Obtain a medication history because some prescription medications have a high sodium content.

Note the patient’s thirst or elevated body temperature and evaluates it in relation to other clinical signs.

The nurse monitors for changes in behavior, such as restlessness, disorientation, and lethargy.


7

Cont…dCont…dPreventionSupply fluids for debilitated

patients at regular intervals.If fluid intake remains

inadequate, the nurse consults with the physician to plan an alternate route for intake, either by enteral feedings or by the parenteral route.

For patients with diabetes insipidus, adequate water intake must be ensured.


8

Potassium imbalancePotassium imbalance98% of the body’s potassium is inside

the cells (major intracellular electrolyte).

Normal serum potassium concentration ranges from 3.5 to 5.5 mEq/L (3.5–5.5 mmol/L).

Important in neuromuscular function (that is 2% is in the ECF).

Under the influence of the sodium-potassium pump and based on the body’s needs, potassium is constantly moving in and out of cells.


9

Potassium deficit Potassium deficit (hypokalemia)(hypokalemia)

Serum potassium concentration level is less than 3.5mEq/L (3.5 mmol/L).

Hypokalemia may occur in patients with normal potassium stores; however, when alkalosis is present, a temporary shift of serum potassium into the cells occurs.

Hypokalemia is a common imbalance .


0

Cont…dCont…dCauses GI loss of potassium (most common).

◦Vomiting◦Diarrhea ◦Prolonged gastric suction◦Laxative

Recent ileostomyVillous adenomaAlkalosis HyperaldosteronismHigh-carbohydrate parenteral fluids.Magnesium depletion


1

Cont…dCont…dMedication

◦Potassium-losing diuretics, such as thiazides (eg, chlorothiazide)

◦Corticosteroids ◦Penicillins (e.g. sodium penicillin, Carbenicillin)

◦Amphotericin BPoor potassium diet intake;

◦Debilitated elderly people◦Alcoholics ◦Anorexia nervosa

Bulimia.Lecture note for regular second year Nursing student, February 2003/2011. 35

2

Cont…dCont…dClinical ManifestationsSevere-death through cardiac or

respiratory arrest. ◦ Dysrhythmias Anorexia ◦ Nausea Vomiting ◦ Muscle weakness Leg cramps ◦ Decreased bowel motility Fatigue ◦ Glucose intolerance Paresthesias ◦ Increased sensitivity to digitalis

If prolonged◦ Polyuria◦ Nocturia ◦ Excessive thirst


3

Cont…dCont…dAssessment and diagnostic

findingsElectrocardiographic (ECG) changes

◦Flat T waves and/or inverted T waves◦Depressed ST segments ◦An elevated U wave

Increased sensitivity to digitalis Urinary potassium excretion

exceeding 20 mEq/24 h with hypokalemia suggests that renal potassium loss is the cause.


4

Cont…dCont…dMedical Management Administration of 40 to 80 mEq/day of

potassium in adult , if no abnormal loss of potassium .

Dietary intake of potassium in the average adult is 50 to 100 mEq/day, if risky for potassium loss.

Foods high in potassium;◦ Fruits (especially raisins, bananas, apricots,

and oranges)◦ Vegetables, legumes, whole grains, milk,

and meat. Oral potassium supplements (salt substitutes

contain 50 to 60 mEq of potassium per teaspoon).

When oral administration of potassium is not feasible, the IV route is indicated.Lecture note for regular second


5

Cont…dCont…d The IV route is mandatory for patients with

severe hypokalemia (e.g., a serum level of 2 mEq/L). E.g. potassium chloride, potassium acetate or potassium phosphate.

For routine maintenance needs, potassium is suitably diluted and administered at a rate no faster than 10 mEq/h.

Even in extreme hypokalemia, however, potassium should be administered no faster than 20 to 40 mEq/h (suitably diluted).

In critical situations, more concentrated solutions (such as 40 mEq/L) may be administered through a central line.


6

Cont…dCont…dNursing Management Monitor for its early presence in patients at risk. Monitoring of fluid intake and output is necessary

because 40 mEq of potassium is lost for every liter of urine output.

When available, the ECG may provide useful information.

Patients receiving digitalis who are at risk for potassium deficiency should be monitored closely for signs of digitalis toxicity.

Physicians usually prefer to keep the serum potassium level above 3.5 mEq/L (3.5 mmol/L) in patients receiving digitalis medications such as digoxin.


7

Cont…dCont…d

Preventing hypokalemiaEncouraging the patient at risk to

eat foods rich in potassium, such as fruit and fruit juices (bananas, melon, citrus fruit), fresh and frozen vegetables, fresh meats, and processed foods. (when the diet allows).


8

Potassium excess Potassium excess (hyperkalemia)(hyperkalemia)

Serum potassium concentration greater than 5.5 mEq/L (5.5 mmol/L).

Pseudohyperkalemia ◦ Falsely high level of potassium ◦ Causes;

Use of a tight tourniquet around an exercising extremity

Hemolysis of the sample before analysis.

Marked leukocytosis (white blood cell count exceeding 200,000) or thrombocytosis (platelet count exceeding 1 million),

Drawing blood above a site where potassium is infusing.


9

Cont…dCont…dCauses Decreased renal excretion of potassium. Infection.Excessive intake of potassium in food or

medications. Hypoaldosteronism. Addison’s disease.Acidosis. Medications (in more than 60% )

◦Potassium chloride, heparin, ACE inhibitors, captopril, NSAIDs, and potassium-sparing diuretics.


0

Cont…dCont…dClinical Manifestations Not significant below a concentration of 7 mEq/L (7

mmol/L), but they are almost always present when the level is 8 mEq/L (8 mmol/L) or greater. ◦ Disturbances in cardiac conduction occur.

Peaked, narrow T waves ST-segment depression; Shortened QT interval PR interval becomes prolonged disappearance of the P waves. decomposition and prolongation of the QRS

complex Ventricular dysrhythmias and cardiac arrest Skeletal muscle weakness and even paralysis GI manifestations, Nausea intermittent intestinal colic diarrhea


1

Cont…dCont…d


Serum potassium levels.ECG changes. Arterial blood gas analysis

(metabolic acidosis).


2

Cont…dCont…dMedical Management

An immediate ECG should be obtained to detect changes.

Obtain a repeat serum potassium level from a vein.

In non-acute situations;◦ Restriction of dietary potassium and

potassium-containing medications may suffice.

Administration of either orally or by retention enema, of cation exchange resins (eg, Kayexalate) may be necessary in patients with renal impairment. (Cation in paralytic ileus, hypomagnesemia, hypocalcemia, sodium retention and fluid overload).


3

Cont…dCont…d

Emergency pharmacologic therapyIV calcium gluconate. Monitoring the blood pressure. The ECG should be continuously monitored during administration.

Extra caution is required if the patient has been “digitalized”.


4

Cont…dCont…dIV administration of sodium.IV administration of regular

insulin and a hypertonic dextrose solution.

Beta-2 agonists such as salbutamol, salmeterol, terbutaline, and eformoterol shifts ptassium into the cells.


5

Cont…dCont…dNursing ManagementPatients at risk for potassium

excess monitored closely for signs of hyperkalemia.

Observes for signs of muscle weakness and dysrhythmias.

The presence of paresthesias, GI symptoms such as nausea and intestinal colic should be noted.

For patients at risk, serum potassium levels are measured periodically.


6

Cont…dCont…d Avoid prolonged use of tourniquet and

exercise. Blood sample should be delivered to the

laboratory as soon as possible.Preventing hyperkalemia Encouraging the patient to adhere to the

prescribed potassium restriction. Potassium-rich foods to be avoided include

coffee, cocoa, tea, dried fruits, dried beans, and wholegrain breads.

Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey.


7

Cont…dCont…dCorrecting hyperkalemiaWhen potassium is added to parenteral

solutions, the potassium is mixed with the fluid by inverting the bottle several times.

Potassium chloride should never be added to a hanging bottle because the potassium might be administered as a bolus (potassium chloride is heavy and settles to the bottom of the container).

Most salt substitutes contain approximately 50–60 mEq of potassium per teaspoon.


8

Calcium imbalanceCalcium imbalancesignificance of calciumMore than 99% of the body’s calcium

is located in the skeletal system; it is a major component of bones and teeth.

About 1% of skeletal calcium is rapidly exchangeable with blood calcium; the rest is more stable and only slowly exchanged.

The small amount of calcium located outside the bone circulates in the serum, partly bound to protein and partly ionized.

The normal total serum calcium level is 8.5 to 10.5 mg/dL (2.1–2.6 mmol/L).


9

Cont…dCont…dFunction;

◦Transmitting nerve impulses ◦Regulate muscle contraction and relaxation, including cardiac muscle.

◦Activating enzymes that stimulate many essential chemical reactions in the body.

◦Blood coagulation.


0

Cont…dCont…dIt exists in plasma in three forms:

◦Ionized:-About 50% (4.5 to 5.1 mg/dL (1.1–1.3 mmol/L)) and physiologically active and clinically significant.

◦Bound:-Less than half of the plasma calcium is bound to serum proteins, primarily albumin. The remainder is combined with non-protein anions: phosphate, citrate, and carbonate.

◦Complexed. Lecture note for regular second year Nursing student, February 2003/2011. 37

1

Cont…dCont…dCalcium is absorbed from foods

in the presence of normal gastric acidity and vitamin D.

Calcium is excreted primarily in the feces, the remainder in urine.

The serum calcium level is controlled by PTH and calcitonin.


2

Calcium deficit (hypocalcemia)Calcium deficit (hypocalcemia)

Lower-than-normal serum concentration of calcium.

A patient may have a total body calcium deficit (as in osteoporosis) but a normal serum calcium level.


3

Cont…dCont…d

CausesPrimary hypoparathyroidism Surgical hypoparathyroidism (more common).

Massive dministration of citrated blood (transient hypocalcemia).

Pancreatitis


4

Cont…dCont…dRenal failure Inadequate vitamin D consumption, Magnesium deficiency, Medullary thyroid carcinoma, Low serum albumin levels, Alkalosis Alcohol abuse. Medications (e.g. Aluminum-

containing antacids, Aminoglycosides, Caffeine, Cisplatin, Corticosteroids, mithramycin, phosphates, isoniazid, and loop diuretics).


5

Cont…dCont…d

Clinical ManifestationsTetany (most) Sensations of tingling the tips of

the fingers, around the mouth, and less commonly in the feet.

Spasms of the muscles of the extremities and face may occur.

PainTrousseau’s sign (positive)


6

Cont…dCont…d

Trousseau’s sign


7

Cont…dCont…dChvostek’s sign (positive)SeizuresMental changes (such as depression, impaired memory, confusion, delirium, and even hallucinations.

A prolonged QT interval Prolonged ST segment


8

Cont…dCont…dAssessment and Diagnostic FindingsDetermination of serum calcium level, by

this formula as follows;

Arterial blood gas analaysis.Determination of serum albumin level. For

every decrease in serum albumin of 1 g/dL below 4 g/dL, the total serum calcium level is underestimated by approximately 0.8 mg/dL.


9

Cont…dCont…dMedical ManagementAcute symptomatic hypocalcemia is life-threatening and requires prompt treatment with IV administration of calcium.

Parenteral calcium salts include calcium gluconate, calcium chloride, and calcium gluceptate.


0

Cont…dCont…dVitamin D therapyAluminum hydroxide, calcium

acetate, or calcium carbonate antacids.

For the patient with chronic renal failure. Increasing the dietary intake of calcium to at least 1,000 to 1,500 mg/day in the adult is recommended (eg, milk products; green, leafy vegetables; canned salmon; sardines; fresh oysters).


1

Cont…dCont…dNursing Management Observe for hypocalcemia in patients at risk. Seizure precautions. Health education about;

◦ Adequate dietary calcium intake, calcium supplements (for peoples risk for osteoporosis)

◦ Regular weight-bearing exercise ◦ Effect of medications (alcohol, caffeine,

cigarette smoking, alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), and calcitonin).

◦ Teaching also addresses strategies to reduce risk for falls.


2

Calcium excess Calcium excess (hypercalcemia)(hypercalcemia)Excess of calcium in the plasma.It is a dangerous imbalance when severe.Hypercalcemic crisis has a mortality rate

as high as 50% if not treated promptly.The more severe symptoms tend to

appear when the serum calcium level is approximately 16 mg/dL (4 mmol/L) or above. However, some patients become profoundly disturbed with serum calcium levels of only 12 mg/dL (3 mmol/L).


3

Cont…dCont…dCauses Malignancies and hyperparathyroidism (most common).

Immobility.Thiazide diuretics.Milk-alkali syndrome.Vitamin A and D intoxication, Lithium use


4


◦Muscle weakness,◦ Incoordination ◦Anorexia ◦Constipation◦Cardiac standstill (18 mg/dL (4.5

mmol/L))◦Digitalis toxicity◦Nausea◦Vomiting ◦Dehydration◦Abdominal and bone pain


5

Cont…dCont…d Excessive urination Abdominal distention Paralytic ileus Severe thirst Peptic ulcer disease like symptoms. Confusion, Impaired memory slurred speech, lethargy Acute psychotic behavior, Coma


6

Cont…dCont…dHypercalcemic crisis refers to an

acute rise in the serum calcium level to 17 mg/dL (4.3 mmol/L) or higher.

It has the same clinical presentation with varying degree.


7

Cont…dCont…dAssessment and Diagnostic FindingsThe serum calcium level is greater

than 10.5 mg/dL (2.6 mmol/L).ECG changes;

◦shortening of the QT interval and ST segment.

◦PR interval is sometimes prolonged. The double-antibody PTH test.X-rays The Sulkowitch urine test


8

Cont…dCont…dMedical ManagementGeneral measures

◦Administering fluids to dilute serum calcium and promote its excretion by the kidneys.

◦Mobilizing the patient.◦Restricting dietary calcium intake.

Pharmacologic therapy◦ IV administration of 0.9% sodium

chloride solution.◦Administering IV phosphate.◦Furosemide (Lasix)


9

Cont…dCont…d◦Mithramycin◦Bisphosphonates (Pamidronate

(Aredia))◦ Inorganic phosphate salts◦ IV phosphate◦Calcitonin (salmon)◦Corticosteroids

For patients with cancer;◦surgery, ◦chemotherapy, or◦ radiation therapy.


0

Cont…dCont…dNursing Management Monitor the patients at risk. Encourage hospitalized patient to move. Fluids containing sodium should be

administered unless contraindicated. Patients are encouraged to drink 3 to 4 quarts

of fluid daily. Adequate fiber should be provided in the diet. Safety precautions are taken, as necessary,

when mental symptoms of hypercalcemia are present.

The patient and family are informed that these mental changes are reversible with treatment.

Assess for signs and symptoms of digitalis toxicity.

Cardiac rate and rhythm are monitored for any abnormalities. Lecture note for regular second


1

Acid-Base BalanceAcid-Base BalanceAcid;

A solution with a higher concentration of hydrogen ions than hydroxide ions.

An acid separates into one or more hydrogen ions and one or more negative ions.

Base;A solution with a higher

concentration of hydroxide ions than hydrogen ions.

A base separates into one or more hydroxide ions and one or more positive ions. Lecture note for regular second


2

Cont…dCont…dpH;

◦The unit of measurement used to describe the alkalinity or acidity of a substance.

◦It stands for the potential of hydrogen.

◦Measured on a scale 0-14.◦Scale represents the hydrogen ion concentration.

◦Normal Blood pH is 7.35 – 7.45.Lecture note for regular second year Nursing student, February 2003/2011. 39

3

Cont…dCont…d 14

Increasingly Basic 13

(Alkaline) 12

11 10 9 8

Neutral 7

6 5 4 3 2

Increasingly Acidic 1

0


4

Cont…dCont…dAs the value or pH decreases, the hydrogen ion concentration increases and therefore the acidity increases.

As the value or pH increases, the hydrogen ion concentration decreases and therefore the acidity decreases.


5

Regulation of Acid - Base Regulation of Acid - Base BalanceBalance

◦Buffer systems – carbonic acid-bicarbonate system.

◦Respiratory System.◦Renal System.


6

Cont…dCont…d

Carbonic Acid-Bicarbonate Buffer SystemPrimary extracellular fluid buffer system.

Maintains a ratio of 20 parts bicarbonate to 1 part carbonic acid.

Uses the process of hydration of CO2 to break it down so it can be neutralized.


7

Cont…dCont…d

Respiratory Regulation◦Respiratory System regulates by adjusting rate and depth of respirations.

◦By increasing rate and depth more CO2 will be blown off.

◦By decreasing rate and depth CO2 will be conserved.


8

Cont…dCont…dRenal Regulation

◦Works slower than respiratory compensation.

◦Effects are more long lasting.◦Primarily regulates amount of bicarbonate absorbed or excreted.

◦Also regulates ammonia and electrolytes which can effect acid-base.


9

Acid-base ImbalanceAcid-base Imbalance Alkalosis

◦Respiratory◦Metabolic

Acidosis◦Respiratory◦Metabolic


0

Respiratory AlkalosisRespiratory AlkalosisDeficiency of carbon dioxide.Too much carbon dioxide is

released.Causes:

◦Hyperventilation◦Hypoxemia◦High altitudes◦Salicylate overdose


1


Numbness/tingling in extremitiesLightheadednessConfusion/ agitationHeart palpitationsMuscle crampingDeep rapid respirationspH high (>7.45)pCO2 low (< 35)


2

Cont…dCont…d

Management ◦Treat cause◦Oxygen◦Re-breathing CO2◦Compensation – kidneys will attempt to compensate by excreting more bicarbonate


3

Cont…dCont…d

Nursing Care ◦Relieve anxiety◦Sedation◦Reassurance◦Paper bag◦Rest


4

Respiratory AcidosisRespiratory AcidosisExcess acid (CO2)Causes:

◦Hypoventilation◦Anesthesia◦Sedatives◦COPD◦Respiratory infections◦Inadequate ventilatory management

◦Excessive CO2 production


5

Cont…dCont…d

Clinical Manifestations◦Decreased rate and depth of respirations

◦Hypoxia◦Hypotension◦Hypercapnic encephalopathy◦pH low (< 7.35)◦PCO2 high (>45)


6

Cont…dCont…d

Management ◦Treat cause◦Ventilatory support◦Pulmonary hygiene◦Emotional support


7

Metabolic AlkalosisMetabolic AlkalosisExcess of baseCauses:

◦Gain of base◦Excretion of too much acid


8


◦Shallow breathing◦Nausea/vomiting/diarrhea◦Confusion◦Numbness / tingling◦Hypocalcemia◦Hypokalemia◦pH high (> 7.45)◦HCO3 high (>26)


9

Cont…dCont…d

Management◦Replace fluids and electrolytes.◦Diamox (Acetazolamide) enhances

excretion of bicarbonate.◦Proper functioning kidneys will

excrete excess bicarbonate with adequate fluid volume and appropriate potassium.


0

Cont…dCont…d

Nursing Care ◦Monitor vital signs closely.◦Monitor fluid status.◦Safety measures ( change in level of

consciousness).◦If nasogastric suction, irrigate with

NS, not water.


1

Metabolic AcidosisMetabolic AcidosisAcid excess or base deficitCauses:

Renal failureDiabetic ketoacidosisLactic acidosisLarge amount drainage from ileostomy tube

Malnutrition


2


◦Headache◦Drowsiness◦ Nausea/ vomiting/ diarrhea◦ Kussmaul’s respirations◦Fruity-smelling breathe◦Hyperkalemia◦ Hypotension◦ Bradycardia◦ GI distention◦ pH low (< 7.35)◦ HCO3 low (< 22)


3

Cont…dCont…d

Management◦Treat cause◦Administer bicarbonate in extreme cases

◦Replace fluids and electrolytes◦Safety


4

The End!


5

Medical Surgical Nursing:Geniro Urinary Tract Disorder.

Documents

Transcript of Medical Surgical Nursing:Geniro Urinary Tract Disorder.