3. Urinary system Disorder WK 3.pptx

URINARY SYSTEM Product urine Transports urine towards bladder Temporarily store urine Conduct urine to exterior Functions of the kidney: • Excretion of the metabolic waste product as urea. • Regulation of acid base balance of the blood. • Control water balance . • Maintain homeostasis • Renin t...

URINARY SYSTEM Product urine Transports urine towards bladder Temporarily store urine Conduct urine to exterior Functions of the kidney: • Excretion of the metabolic waste product as urea. • Regulation of acid base balance of the blood. • Control water balance . • Maintain homeostasis • Renin the primary stimuli for renin release include reduction of renal perfusion pressure and hyponatremia. • Regulation of red blood cell (RBC) production by production of erythropoietin hormone which stimulate formation of RBC in the bone marrow. • Control water excretion in the tubules by anti diuretic hormone (ADH). • It changes vitamin D from the inactive form to the active form. 2 • Homeostasis is the body’s ability to maintain a Mechanisms of Fluid Gain and Loss Gain • Fluid intake 1500ml • Food intake 1000ml • Oxidation of nutrients 300ml (10ml of H20 Kcal) per 100 Loss • “Sensible” Can be seen. Urine 1500ml Insensible” Not visible. Skin (evaporation) 600ml Lungs 400ml Assessment of urinary system Nursing History: • Normal voiding pattern and frequency (oliguria – urinary urgency – poyluria – anuria - dysuria – hematuria - enuresis) • Appearance of the urine, urine culture and any recent changes (amount – color). Normal colure yellow-straw • Family history of kidney problems (polycystic kidney and all types of hereditary nephritis are genetically transmitted, The present illness such as pain or burning sensation, UTI, Past history and current problems with urination: (syphilis, gonorrhea, sexual transmitted disease STD) DM and HTN . • Factors influencing the elimination pattern: • Medications: Diuretics, Anti-hypertensive. 4 Physical Assessment of Urinary System • Inspection • Inspection including examination of abdomen and urethral meatus • Auscultation including renal arteries • Percussion includes the kidneys to detect tenderness • Palpation to detect any mass, lumps, tenderness Percussion of the bladder • To detect difference in sound, percuss toward the base of the bladder. Percussion normally produces a tympanic sound. 5 Inspection fluid loss Skin Turgorcommonly used to assess degree of dehydration or fluid loss fluid retention• Swelling caused by fluid retentionexcess fluid is trapped in the body's tissues DIAGNOSTIC TESTS 1. Renal clearance volume of the plasma that the kidney can clear 2. A 24 hours collection of urine is the test used to evaluate how well the kidney perform excretory function 3. Creatinine An endogenous waste product of skeletal muscle that is filtered It provide good measures of GFR Decrease in creatinine clearance indicate decrease in renal function. Normal creatinine from 0.2 to 1.2 mg/dl Lab Tests • BUN (blood urea nitrogen): • Normal range is-10-20mg/dl of blood • serves as index of renal function, it is the end product of protein metabolism. The level of BUN affected by. • Protein intake • Fluid volume change • Tissue breakdown Specific Renal Systems (Diagnostic test) Gravity- • A decrease in SG (less conc. urine) occurs with measure increased fluid intake, s the diuretic administration,. kidney’s • An increase SG (more conc. Urine) occurs with ability to insufficient fluid intake, decreased renal perfusion, concentr or the presence of ADH. ate • High fluid intake urine. • High fluid intake lead to decrease specific gravity Normal • Decrease fluid intake lead to range increase specific gravity • Kidney diseases lead to Fixed from specific gravity 1.010- Diagnostic tests KUB, X-RAY-To visualize size , shape ,position & stone in kidney. • Nuclear scan • Injection of radioisotope .It provide information about kidney perfusion ,function and GFR • Intravenous Pyelography inject dye into vein to detect any blood vessels problem of the urinary system. - COMPUTED TOMOGRAPHY SCAN. To detect renal masses & blood vessels disorders - CYSTOSCOPIC EXAMINATION Allows direct endoscopic visualization of entire urinary tract. - ULTRASOUND STUDIES To study the structure of kidney - BIOPSY Bladder & kidney biopsy to determine the renal disease it is rarely done in patient with one kidney When should you assess renal function? Older age Family history of Chronic Kidney disease (CKD) Low birth weight Diabetes Mellitus (DM) Hypertension (HTN) Autoimmune disease Urinary tract infections (UTI) Nephrolithiasis Obstruction to the lower urinary tract Medical Terms related to urinary system • Dysuria: painful or difficult voiding • Hematuria: red blood cells in the urine • Urgency: strong desired to urinate due to inflammation in bladder , prostate , urethra • Polyuria: abnormal large volume of urine voided in given time = 2500ml • Oliguria: small volume of urine between 100-500 ml • Anuria: absence of urine in bladder less than 100 ml • Enuresis: involuntary voiding during sleeping • Urinary Hesitancy: ( is delay and difficulty in initiating voiding) is associated with dysuria 13 Medical Terms related to urinary system • Nocturia: An excessive urination at night • Proteinuria (albuminuria): an abnormal amount of protein in urine due to acute and chronic renal diseases • Urinary incontinence: involuntary loss of urine caused by: a. Injury of the external urinary sphincter. b. Acquired neurogenic disease • Urinary retention: inability to urinate despite the patient’s urge to do so. Normal mechanisms that maintain sterility of urine a. Antibacterial effect of zinc in prostatic fluid b. Adequate urine volume c. Free-flow from kidneys through urinary meatus d. Complete bladder emptying e. Normal acidity of urine Infection of Urinary tract (UTI) Page From 4267-4271 Cystitis Inflammation of the mucosa of bladder due to infection Pyelonephritis UTI of renal parenchyma and renal pelvis Uncomplicated UTI Infection involving structurally and functionally normal urinary tract (simple UTI) Complicated UTI Infection involving structurally and functionally abnormal urinary tract Urethritis Inflammation of the urethra due to infection 16 Risk factors for urinary tract infection • • • Female • male older adult Use of diaphragm for birth control Personal hygiene practice Voluntary urinary retention Short straight urethra • Enlarged prostatic gland • Incomplete bladder empty • Instrumentation of urinary tract • Less acidic urine • High incidence of DM increase glucose in urine increase bacterial growth • Change in vaginal PH of women • Decrease prostatic secretion in men Manifestation of urinary tract infection cystitis acute Pyelonephri tis • • • • • • Dysuria Urgency Nocturia hematuria Pyuria Suprapubic discomfort • Symptoms of cystitis • Flank pain(costovertebral angle pain) • Vomiting • Diarrhea • Fever, chills • Malaise Urinary Tract Infection uncomplicated cystitis Causes • E.coli most common in women Treatment • Antibiotics for 3 to 7 days,antispasmodic,analgesic • Heat application to perineum to decrease pain • Increase fluid intake Prevention of infection : 1.. Cleanse the genital area from front to back after voiding to prevent contaminating the urethra with bacteria from the anal area. 19 Urinary Tract Infection (cont’d) 2. Drink plenty of water to remove bacteria from the urinary tract 3. Do not routinely resist the urge to urinate 4. Take showers instead of baths. 5. Urinate after sexual intercourse. 6-Avoid tight – fitting pants. 7-Wear cotton rather than nylon under clothes. 8-↑ The acidity of urine through regular intake of vitamin C 20 UROLITHIASIS Page From 4298-4303 • Urolithiasis: The process of forming stones in the kidney, bladder, and/or urethra (urinary tract). • Male more affected than female • Recurrence rate 50% at 10 years Etiology: 1. Immobility. 2. Hypercalcemia. 3. UTIs. 4. Urine stasis. 5. Fractures. 21 TYPES OF CALCULI 1.Calculi are formed by deposition of crystalline substances such as calcium oxalate ,calcium phosphate and uric acid. 2.Most calculi contain calcium and magnesium in combination with phosphorus or oxalate. These calculi may pass through the urinary tract or may obstruct urinary tract leading to infection or hydronephrosis. Clinical Manifestations a- kidney pelvis 1-may be asymptomatic 2-Acute sharp pain. b-urter 1-Acute severe, intermittent flank pain 2-Nausea & vomiting 3-Fever & chills, pallor cold clammy skin 4-Microscopic Hematuria. c.Bladder stone 1-may be asymptomatic 2-dull Suprapubic pain 3- Microscopic Hematuria 23 Urolithiasis (cont’d) Diagnostic tests: 1. KUB radiograph reveals visible calculi. 2. IVP (Intravenous Pyelogram) determines size and location of calculi. 3. Renal Ultrasonography reveals obstructive changes. Management: 1-Monitor intake of fluid amount and urinary output 2- Medicate for pain as prescribed. 3- Continue antibiotic therapy as prescribed. 4-Correct diet to include reduced protein and calcium content. 24 TREATMENT 1.Administer intravenously pain medication , such as Demrol. 2.Assess the client’s level of pain on a standard pain scale. 3.Encourage bed rest. 4.Teach relaxation exercises. 5.Provide hot baths or moist heat to the flank areas. 6.Encourage high fluid intake if patient is not having nausea & vomiting.2-3 liters daily spaced through out the day 7.Administer antiemetic, to stop nausea & vomiting TREATMENT CON’T 8-Indication for hospital admission a.Renal impairment b.Refractory pain c.Pyelonephitis d.intractable nausea, vomiting 9.Prepare the client who cannot pass the calculus spontaneously for one of the following non surgical proceduresa. Lithotripsy b. Ureteroscopy c. Stone dissolution LITHOTRIPSY Extracorporal shock wave lithotripsy ( ESWL )- Used to break up calculus so that client can pass the particles during urination. URETEROSCOPY A instrument is inserted through cystoscope to visualize and reach to the calculi and to remove or break it with Laser energy or ultrasound. STONE DISSOLUTION Infusion of chemolytic solutions through a nephrostomy tube to dissolve the calculi. SURGICAL PROCEDURE Nephrolithotomy – Incision into the kidney for removal of calculus is done. Nephrosclerosis page From 4139-4140 Nephrosclerosis simply means hardening of the kidney. Nephrosclerosis is also known as hypertensive nephropathy is a medical condition referring to damage to the kidney due to chronic high blood pressure. CLINICAL MANIFESTATIONS: 1.Hypertensive retinal changes. 2.Proteinuria 3.Decrease urine out TREATMENT 1.Antihypertensive drugs are administered-Diuretics – hydrochlorthiazide -Calcium channel blockers-as Nifidipine sulphate 2.Life style modificationsa. Low salt diet b. Exercise-Brisk walking c. Low fat diet d. Avoid alcohol e. Avoid stress. Polycystic Kidney Disease • It is a hereditary disease in which there is Numerous fluid filled cysts form on the kidney the kidney enlarges and their function is gradually destroyed. it affect children and adult • Decreased function leads to end-stage renal disease • Only treatment is dialysis and kidney transplantation. Manifestation • Flank pain,hematuria,proteinuria. • sign of renal failure Hydronephrosis • Definition Abnormal dilation of renal pelvis and calyces • Causes Congenital urethral obstruction, cancer cervix, bladder cancer,BPH,prostatic cancer • Pathophysiology • first shows evidence of hyperactivity and hypertrophy than dilatation and atony • Manifestations • Acute (colicky flank pain, hematuria, pyuria, fever, nausea and vomiting, abdominal pain • Chronic (intermittent dull flank pain, hematuria, pyuria, fever, palpable mass) 34 Hydronephrosis • Diagnosis – Ultrasound – CT scan – Cystoscopy • Treatment – Stents or urine diversion • Focuses on ensuring urinary drainage • Monitor Intake & Output • Irrigate tubes only as ordered 35 ACUTE RENAL FAILURE PAGE FROM 4158 TO 4172 DEFINITION Acute renal failure (ARF) is a rapid loss of renal function due to damage to the kidneys. Depending on the duration and severity of ARF, a wide range of potentially lifethreatening metabolic complications can occur, including metabolic acidosis as well as fluid and electrolyte imbalances . CATEGORIES OF ACUTE RENAL FAILURE (ARF) *The major categories of ARF are: 1. prerenal (hypoperfusion of kidney), Prerenal ARF, which occurs in 60% to 70% of cases, is the result of impaired blood flow that leads to hypoperfusion of the kidney and a decrease in the GFR. 2. intrarenal (actual damage to kidney tissue), Intrarenal ARF is the result of actual parenchymal damage to the glomeruli or kidney tubules. Acute tubular necrosis (ATN) is the most common type of intrinsic ARF. 3. postrenal (obstruction to urine flow), postrenal ARF usually results from obstruction distal to the kidney. Pressure rises in the kidney tubules and eventually, the GFR decreases. PHASES OF ACUTE KIDNEY INJURY There are four phases of AKI: initiation, oliguria, diuresis, and recovery. • The initiation period begins with the initial insult and ends when oliguria develops. • The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid..........). In this phase, uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop. • The diuresis period is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover. • The recovery period signals the improvement of renal function and may take 3 to 12 months. SIGNS AND SYMPTOMS Almost every system of the body is affected with failure of the normal renal regulatory mechanisms. 1. The patient may appear critically ill and lethargic. 2. The skin and mucous membranes are dry from dehydration. 3. drowsiness. 4. headache, muscle twitching, and seizures. 5. low urine output (oliguria). DIAGNOSIS Assessment of the patient with ARF includes evaluation for changes in the urine, diagnostic tests that evaluate the kidney contour, and a variety of laboratory values (creatinine, GFR). * (normal creatinine is less than 1.0 mg/dL). Ultrasonography is a critical component of the evaluation of patients with renal failure. A renal sonogram or a CT or MRI scan may show evidence of anatomic changes. MEDICAL MANAGEMENT Treatment is aimed at replacing renal function temporarily to minimize potentially lethal complications and reduce potential causes of increased renal injury with the goal of minimizing long-term loss of renal function. Management includes eliminating the underlying cause; maintaining fluid balance; avoiding fluid excesses; and, when indicated, providing renal replacement therapy ARF is a problem seen in hospitalized patients and those in outpatient settings. A widely accepted criterion for ARF is a 50% or greater increase in serum creatinine above baseline. Urine volume may be normal, or changes may occur. Possible changes include oliguria (less than 500 mL/day), nonoliguria (greater than 800 mL/day), or anuria (less than 50 mL/day). MEDICAL MANAGEMENT 1. Adequate renal blood flow in patients with prerenal causes of ARF may be restored by IV fluids or transfusions of blood products. 2. Pharmacological agents. 3. Haemodialysis. 4. peritoneal dialysis. 5. continuous renal replacement therapies (CRRTs). NURSING MANAGEMENT 1.Monitoring Fluid and Electrolyte Balance. 2.Reducing Metabolic Rate. 3.Promoting Pulmonary Function. 4.Preventing Infection. 5.Providing Skin Care. 6.Providing Psychosocial Support. COMPLICATIONS 1.Excessive fluid volume. 2.chest pain. 3.Chronic renal failure. 4.Muscle weakness due to electrolytes imbalances. 5.Death. CHRONIC RENAL FAILURE PAGE FROM 4136 TO 4139 CHRONIC RENAL FAILURE • Chronic kidney disease is an umbrella term that describes kidney damage or a decrease in the glomerular filtration rate (GFR) lasting for 3 or more months. • Untreated CKD can result in end stage kidney disease (ESKD), which is the final stage of CKD ESKD results in retention of uremic waste products and the need for renal replacement therapies, dialysis, or kidney transplantation. • Also known as end-stage renal disease, its irreversible loss of kidney function characterized by low urine output, excessive fluid volume and electrolytes imbalances affecting heart function and metabolism . RISK FACTORS INCLUDE • cardiovascular disease, • Diabetes. • hypertension • obesity. Causes: cause of ESRD (End stage renal disease )include systemic diseases, such as : - diabetes mellitus . - hypertension. - chronic glomerulonephritis. - pyelonephritis . - obstruction of the urinary tract. - hereditary lesions, as in polycystic kidney disease. - vascular disorders. - infections. - medications; or toxic agents.(Environmental and occupational agents that have been implicated in chronic renal failure. - congenital disorder SIGNS AND SYMPTOMS 1.Neurologic: (Weakness and fatigue • Confusion • Inability to concentrate • Disorientation • Tremors• Seizures• Asterixis • Restlessness of legs• Burning of soles of feet • Behaviour changes). 2. Integumentary: (Grey-bronze skin colour • Dry, flaky skin • Pruritus• Ecchymosis • Purpura• Thin, brittle nails• SIGNS AND SYMPTOMS 3. Pulmonary: ( Crackles• Thick, tenacious sputum• Depressed cough reflex• Pleuritic pain• Shortness of breath• Tachypnea• Kussmaul-type respirations Uremic pneumonitis). 4. Gastrointestinal: (• Ammonia odor to breath (“uremic fetor”) • Metallic taste• Mouth ulcerations and bleeding• Anorexia, nausea, and vomiting • Hiccups• Constipation or diarrhea• Bleeding from gastrointestinal tract ) SIGNS AND SYMPTOMS 5. Hematologic: ( Anemia• Thrombocytopenia). 6. Reproductive: (Amenorrhea• Testicular atrophy • Infertility• Decreased libido). 7. Musculoskeletal : (Muscle cramps• Loss of muscle strength • Renal osteodystrophy, Bone pain, Bone fractures ,Foot drop). 8. Cardiovascular: ( • Hypertension• Pitting edema (feet, hands, sacrum) • Periorbital edema• Pericardial friction rub• Engorged neck veins• Pericarditis• Pericardial effusion• Pericardial tamponade• Hyperkalemia• Hyperlipidemia). STAGES OF CHRONIC KIDNEY DISEASE • Stages are based on the glomerular filtration rate (GFR). The normal GFR is 125 mL/min -Stage 1 GFR ≥ 90 mL/min Kidney damage with normal or increased GFR -Stage 2 GFR = 60–89 mL/min Mild decrease in GFR -Stage 3 GFR = 30–59 mL/min Moderate decrease in GFR STAGES OF CHRONIC KIDNEY DISEASE • -Stage 4 GFR = 15–29 mL/min Severe decrease in GFR -Stage 5 GFR <15 mL/min Kidney failure Diagnoses: -Urine analysis proteinuria may be present. - RFT (blood urea ,creatinine,). - Electrolyte (Na ,K, ca) - CBC. - Ultrasonography . - A renal sonogram or a CT or MRI scan MEDICAL MANAGEMENT 1. Treatment Options: 1-Monitoring & Predialysis • Control symptoms • Preserve Residual Renal Function • Control rising BP (Antihypertensive) • Control Renal Bone Disease (Ca2+, Vit D) • Prevent/Treat Anaemia (Erythropoietin, Blood) Pharmacological agents (Erythropoietin). 2. Dialysis • Haemodialysis. • peritoneal dialysis. 4. Nutritional therapy (careful regulation of protein intake, fluid intake). 5. Renal transplant. Nursing Management: Teaching Patients Self-Care; The nurse plays an important role in teaching the patient with ESRD. -explanations of nutritional needs and dietary restrictions including fluid, sodium, potassium, and protein restriction. - patient and family need to know what problems to report to the health care provider. ( include the following: Worsening sign change in usual urine output Signs and symptoms of hyperkalemia , Signs and symptoms of access problems . -assess the patient's environment, emotional status, and the coping strategies used by the patient and family to deal with the changes associated with chronic illness. R E N A L T R A N S P L A N TAT I O N Definition: • Renal transplantation is the organ transplant in a patient with end stage renal disease. Source of the donor organ: 1-Dead donor (Cadaveric) renal transplants. 2-Living-donor renal transplants Indications: • The indication for kidney transplantation is end-stage renal disease 58 4.RENAL TRANSPLANT LRD (LIVING RENAL DONOR )SOURCE: Parents 53%  MOTHER - 76% FATHER - 24% Siblings 25%  SISTER- 66% BROTHER - 34% Spouse 22%  WIFE - 84% Husband 16% CONTRAINDICATIONS: 1-Cardiac and pulmonary insufficiency. 2-Hepatic disease. 3-Hematologic abnormalities, such as anemia and platelet dysfunction. • Requirements: Suitable age. Good health (no kidney disease). 61 POSTOPERATIVE NURSING CARE The postoperative nursing care of the renal transplant recipient is similar in many ways to the care of any patient who has undergone a major surgical procedure; the emphasis is on: 1.Access vital signs and detect early signs of infection. 2.Wound care, pain management& (I&O) chart. 3.Sutures are left in place for up to 3 weeks to accommodate for slower healing in the patient on high doses of corticosteroid. 4. Restoration of normal bowel elimination. stool softeners, bulk-forming laxatives, and enemas are administered as necessary. 62 CONTINUING CARE 1-The patient and family must understand why they should adhere continuously to the therapeutic regimen, with special emphasis on the methods of administration, rationale, and side effects of the prescribed immunosuppressive agents. 2- The nurse provides written as well as verbal instructions about how and when to take the medications. To avoid running out of medication or skipping a dose 63 CONTINUING CARE 3- the patient must make sure that an adequate supply of medication is available immunosuppression to prevent rejection, corticosteroid to prevent inflammation 4- The nurse emphasizes the importance of follow-up blood tests that assess the function of the liver and kidneys 5- The importance of routine ophthalmologic examinations is done because of the increased incidence of cataracts and glaucoma with the long-term corticosteroid therapy used with transplantation. 64 THANK YOU 65