RENAL INTRODUCTION.pdf

NCM 112 MANAGEMENT OF PATIENT WITH RENAL DISORDER : INTRODUCTION Prepared by: Mrs. Carmela Asuro RN,MAN OBJECTIVE: 1. Discuss the role of the kidneys in regulating fluid and electrolyte balance, acid–base balance, and blood pressure. 2. Identify the assessment parame...

NCM 112 MANAGEMENT OF PATIENT WITH RENAL DISORDER : INTRODUCTION Prepared by: Mrs. Carmela Asuro RN,MAN OBJECTIVE: 1. Discuss the role of the kidneys in regulating fluid and electrolyte balance, acid–base balance, and blood pressure. 2. Identify the assessment parameters used for determining the status of upper and lower urinary tract function 3. Describe the diagnostic studies used to determine upper and lower urinary tract function. 4. Initiate education and preparation for patients undergoing assessment of the urinary system.  COMMON TERMINOLOGIES: ▪ aldosterone: hormone synthesized and released by the adrenal cortex; causes the kidneys to reabsorb sodium ▪ antidiuretic hormone: hormone secreted by the posterior pituitary gland; causes the kidneys to reabsorb more water; also called vasopressin ▪ anuria: total urine output less than 50 mL in 24 hours ▪ bacteriuria: bacteria in the urine; bacterial count higher than 100,000 colonies/mL ▪ creatinine: endogenous waste product of muscle energy metabolism ▪ diuresis: increased formation and secretion of urine ▪ dysuria: painful or difficult urination ▪ frequency: voiding more frequently than every 3 hours COMMON TERMINOLOGIES  glomerular filtration: plasma filtered at the glomerulus into the kidney tubules  glomerulus: tuft of capillaries forming part of the nephron through which filtration occurs  hematuria: red blood cells in the urine  micturition: urination or voiding  nephron:structural and functional unit of the kidney responsible for urine formation  nocturia: awakening at night to urinate  oliguria: total urine output less than 500 mL in 24 hours COMMON TERMINOLOGIES  proteinuria: protein in the urine  pyuria: white blood cells in the urine  renal clearance: volume of plasma that the kidneys can clear of a specific solute (eg, creatinine); expressed in milliliters per minute  renal glycosuria: recurring or persistent excretion of glucose in the urine  specific gravity: reflects the weight of particles dissolved in the urine; expression of the degree of concentration of the urine COMMON TERMINOLOGIES  tubularreabsorption: movement of a substance from the kidney tubule into the blood in the peritubular capillaries or vasa recta  tubularsecretion: movement of a substance from the blood in the peritubular capillaries or vasa recta into the kidney tubule  urea nitrogen: nitrogenous end-product of protein metabolism STRUCTURE OF THE KIDNEY  A pair of bean-shaped, brownish-red ; right kidney is slightly lower than the left due to the location of the liver LOCATION:  retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of the abdomen—  12th thoracic vertebra to the third lumbar vertebra WEIGHT :  The average adult kidney weighs approximately 113 to 170 g (about 4.5 oz) and is 10 to 12 cm long, 6 cm wide, and 2.5 cm thick (Porth &Matfin, 2009). KIDNEY: FUNCTIONS OF THE KIDNEY Urine formation https://www.youtube.com/watch?v=SFhvjPk_7I8 Excretion of waste products Regulation of electrolytes Regulation of acid–base balance Control of water balance Control of blood pressure URINE FORMATION: 1. GLOMERULAR FILTRATION 2. TUBULAR REABSORTION 3. TUBULAR SECRETION FUNCTION OF KIDNEY Renal clearance Regulation of red blood cell production Synthesis of vitamin D to active form Secretion of prostaglandins Regulates calcium and phosphorus balance https://www.youtube.com/watch?v=cc8sUv2SuaY  ASSESSMENT OF THE KIDNEY AND URINARY SYSTEM A. Health History Obtaining a urologic health history requires excellent communication skills, because many patients are embarrassed or uncomfortable discussing genitourinary function or symptoms(Bickley, 2007; Weber & Kelley, 2007) When obtaining the health history, the nurse should inquire about the following: The patient’s chief concern or reason for seeking health care, the onset of the problem, and its effect on the patient’s quality of life The location, character, and duration of pain, if present , and its relationship to voiding; factors that precipitate pain, and those that relieve it History of urinary tract infections, including past treatment or hospitalization for urinary tract infection Fever or chills Previous renal or urinary diagnostic tests or use of indwelling urinary catheters Dysuria and when during voiding (ie, at initiation or at termination of voiding) it occurs  HEALTH ASSESSMENT..CONT. Hesitancy, straining, or pain during or after urination Urinary incontinence (stress incontinence, urge incontinence,overflow incontinence, or functional incontinence) Hematuria or change in color or volume of urine Nocturia and its date of onset Renal calculi (kidney stones), passage of stones or gravel in urine Female patients: number and type (vaginal or cesarean)of deliveries; use of forceps; vaginal infection, discharge, or irritation; contraceptive practices History of anuria (decreased urine production) orother renal problem Presence or history of genital lesions or sexually transmitted diseases Use of tobacco, alcohol, or recreational drugs Any prescription and over-the-counter medications(including those prescribed for renal or urinary problems  COMMON SYMPTOMS : PAIN IDENTIFYING CHARACTERISTICS OF GENITOURINARY PAIN Type Location Character Associated s/s Possible etiology Kidney Costovertebral angle, may Dull constant ache; if sudden Nausea & vomiting, Acute obstruction, kidney extend to umbilicus distention of capsule, pain diaphoresis, pallor, signs of stone, blood clot, acute Male: along penis to is severe, sharp, stabbing, shock pyelonephritis, trauma meatus; female: urethra to meatus and colicky in nature Bladder Suprapubic area Dull, continuous pain, may be Urgency, pain at end of Overdistended bladder, intense with voiding, may voiding, painful straining infection, interstitial be severe if bladder full cystitis; tumor Ureteral Costovertebral angle, flank, Severe, sharp, stabbing pain, Nausea and vomiting, Ureteral stone, edema or lower abdominal area, testis, or colicky in nature paralytic ileus stricture, blood clot labium Prostatic Perineum and rectum Vague discomfort, feeling of Suprapubic tenderness, Prostatic cancer, acute or fullness in perineum, vague obstruction to urine flow; chronic prostatitis back pain frequency, urgency, dysuria, nocturia Urethral Male: along penis to Pain variable, most severe Frequency, urgency, dysuria, Irritation of bladder neck, meatus; female: urethra during and immediately nocturia, urethral discharge infection of urethra, to meatus after voiding trauma, foreign body in lower urinary tract  CHANGES IN VOIDING Problem Definition Possible etiology Frequency Frequent voiding—more than Infection, obstruction of lower urinary tract leading to residual urine and overflow, anxiety, diuretics, benign every 3 h prostatic hyperplasia, urethral stricture, diabetic neuropath Dysuria Painful or difficult voiding Infection, chronic prostatitis, urethritis, obstruction of lower urinary tract leading to residual urine and overflow, anxiety, diuretics, benign prostatic hyperplasia, urethral stricture, diabetic neuropathy Urgency Strong desire to void Lower urinary tract infection, inflammation of bladder or urethra, acute prostatitis, stones, foreign bodies, tumors in bladder Hesitancy Delay, difficulty in initiating voiding Benign prostatic hyperplasia, compression of urethra, outlet obstruction, neurogenic bladder Nocturia Excessive urination at night Decreased renal concentrating ability, heart failure, diabetes mellitus ,incomplete bladder emptying, excessive fluid intake at bedtime, nephrotic syndrome, cirrhosis with ascites Incontinence Involuntary loss of urine External urinary sphincter injury, obstetric injury, lesions of bladder neck, detrusor dysfunction, infection, neurogenic bladder, medications,neurologic abnormalities Enuresis Involuntary voiding during sleep Delay in functional maturation of central nervous system (bladder control usually achieved by 5 y of age), obstructive disease of lower urinary tract, genetic factors, failure to concentrate urine, urinary tract infection, psychological stress Polyuria Increased volume of urine voided Diabetes mellitus, diabetes insipidus, use of diuretics, excess fluid intake, lithium toxicity, some forms of kidney disease (hypercalcemic and hypokalemic nephropathy) Oliguria Urine output less than 500 mL/day Acute or chronic renal failure (see Chapter 44), inadequate fluid intake Anuria Urine output less than 50 mL/day Acute or chronic renal failure (see Chapter 44), complete obstruction Hematuria Red blood cells in the urine Cancer of genitourinary tract, acute glomerulonephritis, renal stones, renal tuberculosis, blood dyscrasia, trauma, extreme exercise, rheumatic fever, hemophilia, leukemia, sickle cell trait or disease Proteinuria Abnormal amounts of protein in Acute and chronic renal disease, nephrotic syndrome, vigorous exercise, the urine heat stroke, severe heart failure, diabetic nephropathy, multiple myeloma  Gastrointestinal Symptoms The most common signs and symptoms are nausea , vomiting, diarrhea, abdominal discomfort, and abdominal distention. Urologic symptoms can mimic such disorders as appendicitis, peptic ulcer disease, and cholecystitis ;t his can make diagnosis difficult, especially in the elderly , who have decreased neurologic innervation to this area(Goshorn, 2005).  Unexplained ANEMIA Fatigue, shortness of breath, and exercise intolerance all result from the condition known as “anemia of chronic disease.”  PHYSICAL EXAMINATION Technique for palpating the right kidney : Place one hand under the patient’s back with the fingers under the lower rib. Place the palm of the other hand anterior to the kidney with fingers above the umbilicus. Push the hand on top forward as the patient inhales deeply. The left kidney is palpated similarly by reaching over to the patient’s left side and placing the right hand beneath the patient’s lower left rib.  From Weber, J. & Kelley, J. (2007). Health assessment in nursing (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.  The kidneys are not usually palpable. However, palpation of the kidneys may detect an enlargement that could prove to be very important (Bickley, 2007). Dullness to percussion of the bladder after voiding indicates incomplete bladder emptying (Bickley, 2007; Weber & Kelley, 2007). DIAGNOSTIC PROCEDURES :  Urinalysis and Urine Cultures  useful for documenting a UTI and identifying the specific organism present. A colony count of at least 105colony-forming units (CFU) per milliliter of urine on a clean-catch midstream or catheterized specimen is a major criterion for infection (Smythe, Moore & Goldsmith,2006). Components of urine examinations: ❖ Urine color - ❖ Urine clarity and odor ❖ Urine pH and specific gravity ❖ Test to detect protein, glucose, and ketone bodies ❖ Urine sediments: RBC , Pyuria, cast, crystals and bacteria  Renal Function Test Test Purpose Normal value Renal Concentration Tests Evaluates ability of kidneys to concentrate solutes in urine. 1.010–1.025 Specific gravity Concentrating ability is lost early in kidney disease; hence, these test 300–900 mOsm/kg/24 h, 50–1200 Urine osmolality findings may disclose early mOsm/kg random sample defects in renal function 24-Hour Urine Test Detects and evaluates progression of renal disease. Test Measured in mL/min/1.73 m2 Creatinine clearance measures volume of blood cleared of endogenous Age Male Female creatinine in 1 min, which provides an approximation of the Under 30 88–146 81–134 glomerular filtration rate. Sensitive indicator of renal disease 30–40 82–140 75–128 used to follow progression of renal disease. 40–50 75–133 69–122 50–60 68–126 64–116 60–70 61–120 58–110 70–80 55–113 52–105 Serum Tests 0.6–1.2 mg/dL (50–110 Creatinine level Measures effectiveness of renal function. mmol/L) Serves as index of renal function. Urea is Urea nitrogen (blood nitrogenous end-product of protein metabolism. 7–18 mg/dL urea nitrogen [BUN]) Patients >60 yrs: 8–20 mg/dL Evaluates hydration status. An elevated ratio is seen BUN-to-creatinine ratio in hypovolemia; a normal ratio with an elevated BUN and creatinine is seen with intrinsic renal About 10:1 disease.  DIAGNOSTIC IMAGING:  Kidney, Ureter, and Bladder Studies An x-ray study of the abdomen or kidneys, ureters, and bladder (KUB) may be performed to delineate the size , shape, and position of the kidneys and to reveal urinary system abnormalities (Labus , 2008).  General Ultrasonography Ultrasonography is a noninvasive procedure that uses sound waves passed into the body through a transducer to detect abnormalities of internal tissues and organs. Abnormalities such as fluid accumulation, masses, congenital malformations, changes in organ size, and obstructions can be identified. During the test, the lower abdomen and genitalia may need to be exposed. Ultrasonography requires a full bladder; therefore,fluid intake should be encouraged before the procedure.Because of its sensitivity, ultrasonography has replaced manyother tests as the initial diagnostic procedure (Burrows-Hudson, 2005).  Bladder Ultrasonography Bladder ultrasonography is a noninvasive method of measuring urine volume in the bladder. It may be indicated for urinary frequency, inability to void after removal of an indwelling urinary catheter, measurement of postvoiding residual urine volume, inability to void postoperatively, or assessment of the need for catheterization during the initial stages of an intermittent catheterization training program.  Computed Tomography and Magnetic Resonance Imaging Computed tomography (CT) scans and magnetic resonance imaging (MRI) are noninvasive techniques that provide excellent cross-sectional views of the anatomy of the kidney and urinary tract (Labus, 2008)  Nuclear Scans Nuclear scans require injection of a radioisotope into the circulatory system; the isotope is then monitored as it moves through the blood vessels of the kidney s. A scintillation camera is placed behind the kidney with the patient in a supine, prone, or seated position. Hypersensitivity to the radioisotope is rare. The technetium scan provides information about kidney perfusion. The123I-hippurate renal scan provides information about kidney function, such as GFR.  Intravenous Urography IV urography includes various tests such as excretory urography , intravenous pyelography (IVP), and infusion drip pyelography. A radiopaque contrast agent is administered by IV. An IVP shows the kidneys, ureter, and bladder via x-ray imaging as the dye moves through the upper and then the lower urinary system.  Retrograde Pyelography 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 IV urography provides inadequate visualization of the collecting systems.  Cystography Cystography aids in evaluating vesicoureteral reflux (backflow of urine from the bladder into one or both ureters) and in assessing for bladder injury. A catheter is inserted into the bladder, and a contrast agent is instilled to outline the bladder wall. The contrast agent may leak through a small bladder perforation stemming from bladder injury, but such leakage is usually harmless. Cystography can also be performed with simultaneous pressure recordings inside the bladder.  Voiding Cystourethrography - uses fluoroscopy to visualize the lower urinary tract and assess urine storage in the bladder. It is commonly used as a diagnostic tool to identify vesicoureteral reflux. A urethral catheter is inserted, and a contrast agent is instilled into the bladder. When the bladder is full and the patient feels the urge to void, the catheter is removed,and the patient voids.  Renal angiogram, or renal arteriogram, provides an image of the renal arteries. 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. Angiography is used to evaluate renal blood flow in suspected renal trauma, to differentiate renal cysts from tumors, and to evaluate hypertension. It is used preoperatively for renal transplantation.  Endourology, or urologic endoscopic procedures, can be performed in one of two ways: using a cystoscope inserted into the urethra, or percutaneously, through a small incision. The cystoscopic examination is used to directly visualize the urethra and bladder. The cystoscope, which is inserted through the urethra into the bladder, has an optical lens system that provides a magnified, illuminated view of the bladder. The use of a high-intensity light andinterchangeable lenses allows excellent visualization and permits still and motion pictures to be taken.  Renal and Ureteral Brush Biopsy Brush biopsy techniques provide specific information when abnormal x-ray findings of the ureter or renal pelvis raise questions about whether a defect is a tumor, a stone, a blood clot, or an artifact. First, a cystoscopic examination is conducted. Then, a ureteral catheter is introduced, followed by a biopsy brush that is passed through the catheter. The suspected lesion is brushed back and forth to obtain cells and surface tissue fragments for histologic analysis. After the procedure, IV fluids may be administered to help clear the kidneys and prevent clot formation. Urine may contain blood (usually clearing in 24 to 48 hours) from oozing at the brushing site. Postoperative renal colic occasionally occurs and responds to analgesic agents.  Kidney Biopsy Biopsy of the kidney is used to help diagnose and evaluate the extent of kidney disease. Indications for biopsy include unexplained acute renal failure, persistent proteinuria or hematuria, transplant rejection, and glomerulopathies. NURSING CARE PLAN Assessment Nursing Diagnosis Planning Implementation Evaluation LETS GET READY TO MAKE OUR NCP!!!