Urinary NURS 242 Winter 2024 Student.pptx

 Renal failure  Urinary Incontinence  Nephrotic syndrome  Urinary tract infection  Kidney Stones  Benign Prostatic Hypertrophy Copyright © 2017, Elsevier Inc. All rights reserved. 1 Goals for This Concept Presentation 1. Define and describe the concept. 2. Notice risk factors that place indivi...

 Renal failure  Urinary Incontinence  Nephrotic syndrome  Urinary tract infection  Kidney Stones  Benign Prostatic Hypertrophy Copyright © 2017, Elsevier Inc. All rights reserved. 1 Goals for This Concept Presentation 1. Define and describe the concept. 2. Notice risk factors that place individuals at risk for elimination problems. 3. Recognize when an individual has problems with elimination. Copyright © 2017, Elsevier Inc. All rights reserved. 2 Definitions  Urinary elimination is passage of urine out of the urinary tract through the urinary sphincter and urethra Copyright © 2017, Elsevier Inc. All rights reserved. 3 Functions of the Urinary System  Controls volume and concentration of body fluids  Excretion of metabolic wastes  Acid-base regulation  Blood pressure regulation  RBC synthesis and maturation Copyright © 2017, Elsevier Inc. All rights reserved. 4 Review of Anatomy and Physiology  Urinary Elimination  Bladder  Urethra  Internal sphincter  External sphincter Copyright © 2017, Elsevier Inc. All rights reserved. 5 Risk Factors: Populations at Greatest Risk  All individuals, regardless of age, gender, or race, are potentially at risk  Populations at greatest risk for problems with bowel and urinary elimination are  Children  Pregnant women  Older adults Copyright © 2017, Elsevier Inc. All rights reserved. 6 Structures of the Kidney  Kidneys  Retroperitoneal  Renal capsule  Renal fascia  Hilum Copyright © 2017, Elsevier Inc. All rights reserved. 7 Structures of the Kidney (Cont.) From Patton KT, Thibodeau GA: The human body in health & disease, ed 6, St Louis, 2014, Mosby. Copyright © 2017, Elsevier Inc. All rights reserved. 8 Structures of the Kidney (Cont.)  Cortex  Medulla  Pyramids  Calyces  Minor and major  Renal pelvis  Lobe Copyright © 2017, Elsevier Inc. All rights reserved. 9 Structures of the Kidney (Cont.) From Solomon E: Introduction to human anatomy and physiology, ed 4, St Louis, 2016, Saunders. Copyright © 2017, Elsevier Inc. All rights reserved. 10 Nephron   1.2 million nephrons per kidney  Cortical nephrons  Midcortical nephrons  Juxtamedullary nephrons Functional unit of the kidney Copyright © 2017, Elsevier Inc. All rights reserved. 11 Nephron (Cont.)   Renal corpuscle  Glomerulus  Bowman capsule  Mesangial cells Bowman space/capsule Copyright © 2017, Elsevier Inc. All rights reserved. 12 Nephron (Cont.) From Patton KT, Thibodeau GA, Douglas MM: Essentials of anatomy & physiology, St Louis, 2012, Mosby; Damjanov I: Pathology for the health professions, ed 4, St Louis, 2012, Mosby. Copyright © 2017, Elsevier Inc. All rights reserved. 13 Nephron (Cont.)  Glomerular filtration membrane  Inner capillary endothelium  Basement membrane  Outer capillary epithelium   Contains podocytes  Filtration slits Filtrate passes through the three layers and forms the primary urine Copyright © 2017, Elsevier Inc. All rights reserved. 14 Nephron (Cont.)  Juxtaglomerular apparatus  Juxtaglomerular cells   Renin releasing Macula densa  Sodium sensing Copyright © 2017, Elsevier Inc. All rights reserved. 15 Juxtaglomerular Apparatus Copyright © 2017, Elsevier Inc. All rights reserved. 16 Nephron  Renal tubules  Proximal convoluted tubule  Loop of Henle  Distal convoluted tubule  Collecting duct  Principal cells  Intercalated cells Copyright © 2017, Elsevier Inc. All rights reserved. 17 Structures of the Kidney Copyright © 2017, Elsevier Inc. All rights reserved. 18 Blood Vessels Renal arteries  Interlobar arteries   Afferent arteries Arcuate arteries  Glomerular capillaries  Afferent arteriole  Efferent arteriole  Peritubular capillaries  Vasa recta  Renal veins  Copyright © 2017, Elsevier Inc. All rights reserved. 19 Structures of the Kidney From Patton KT, Thibodeau GA, Douglas MM: Essentials of anatomy & physiology, St Louis, 2012, Mosby. Copyright © 2017, Elsevier Inc. All rights reserved. 20 Urinary Structures  Ureters  30 cm long  Long, intertwining smooth muscle bundles  Pass obliquely though posterior aspect of bladder  Peristaltic activity  Micturition compresses the lower end of the ureter to avoid urine reflux Copyright © 2017, Elsevier Inc. All rights reserved. 21 Urinary Structures (Cont.)   Bladder  Detrusor muscle  Trigone Urethra  Internal and external sphincters  3 to 4 cm in females  18 to 20 cm in males Copyright © 2017, Elsevier Inc. All rights reserved. 22 Bladder and Urethra From Patton KT, Thibodeau GA: The human body in health & disease, ed 6, St Louis, 2014, Mosby. Copyright © 2017, Elsevier Inc. All rights reserved. 23 Renal Blood Flow  Receive 1000 to 1200 mL of blood per minute  Glomerular filtration rate (GFR)   The filtration of the plasma per unit of time Autoregulation  Tubuloglomerular feedback Copyright © 2017, Elsevier Inc. All rights reserved. 24 Renal Blood Flow (Cont.)   Neural regulation  Sympathetic fibers regulate size of afferent and efferent arterioles, thus renal blood flow  No significant parasympathetic regulation Hormones  Renin-angiotensin-aldosterone system  Natriuretic peptides  Urodilantin Copyright © 2017, Elsevier Inc. All rights reserved. 25 Nephron Function  Filters plasma  Reabsorbs and secretes  Tubular reabsorption and secretion  Forms a filtrate of protein-free fluid  Regulates the filtrate to maintain fluid volume, electrolytes, and pH Copyright © 2017, Elsevier Inc. All rights reserved. 26 Nephron Function (Cont.)  Glomerular filtration  Permeable to water; impermeable to large molecules (proteins)  Tubular reabsorption vs. tubular secretion  Net filtration pressure   Glomerular capillary oncotic/hydrostatic pressure Filtration rate  180 L/day Copyright © 2017, Elsevier Inc. All rights reserved. 27 Glomerular Filtration Modified from Hockenberry MJ et al: Wong’s nursing care of infants and children, ed 8, St Louis, 2007, Mosby Copyright © 2017, Elsevier Inc. All rights reserved. 28 Nephron Function (Cont.)  Tubular transport  Proximal convoluted tubule   Glomerulotubular balance   Active reabsorption of sodium Adjustment of reabsorption of sodium and water Loop of Henle and distal tubule  Concentration or dilution of urine   Countercurrent exchange system Production of uromodulin Copyright © 2017, Elsevier Inc. All rights reserved. 29 Nephron Function (Cont.) Copyright © 2017, Elsevier Inc. All rights reserved. 30 Concentration and Dilution of Urine  Countercurrent exchange system  Contributes to production of concentrated urine  Fluid flows in opposite direction through parallel tubes  Fluid moves up and down the parallel limbs of the loop of Henle  The longer the loop, the greater the concentration gradient Copyright © 2017, Elsevier Inc. All rights reserved. 31 Hormones and Renal Function  Antidiuretic hormone (ADH)  Aldosterone  Natriuretic peptides   Atrial natriuretic peptide  Brain natriuretic peptide  C-type natriuretic peptide  Urodilantin Diuretics  Increases urine output Copyright © 2017, Elsevier Inc. All rights reserved. 32 Renal Hormones  Vitamin D   Necessary for the absorption of calcium and phosphate Erythropoietin  Released when decreased oxygen to the kidney  Stimulates RBC production Copyright © 2017, Elsevier Inc. All rights reserved. 33 Alterations in Urinary Elimination Copyright © 2017, Elsevier Inc. All rights reserved. 34 Functions of the Urinary System  Controls volume and concentration of body fluids  Excretion of metabolic wastes  Acid-base regulation  Blood pressure regulation  RBC synthesis and maturation Copyright © 2017, Elsevier Inc. All rights reserved. 35 Other Key Terms      Micturition Voiding Continence Incontinence Retention Copyright © 2017, Elsevier Inc. All rights reserved. 36 Tests of Renal Function  Clearance and renal blood flow  Clearance and glomerular filtration rate   Female, 50 years Serum creatinine = 3mg/dl (high) Cystatin C = 1.4 mg/l  GFR varies with age, sex, and body size, declines with age (above 90 normal)  Cystatin C (protein that kidneys excrete)  Creatinine clearance = volume of blood plasma cleared of creatinine per unit of time (comparison of blood and urine creatinine)  https://www.kidney.org/professionals/kdoqi/gfr_calculator Blood tests  Plasma creatinine concentration  Blood urea nitrogen (BUN) Urinalysis  culture Copyright © 2017, Elsevier Inc. All rights reserved. 37 Tests of Renal Function   Urodynamic tests  Cystometry (pressure)  Uroflowmetry (volume and speed of urination)  Postvoid residual  Electromyography (muscles, sphincters)  Video urodynamics Direct visualization tests  Cystoscopy  Ureteroscopy Copyright © 2017, Elsevier Inc. All rights reserved. 38 Pediatric Renal Function  Decreased ability to remove excess water and solutes  Decreased concentrating ability  Narrow margin for fluid and electrolyte balance  Increased risk of drug toxicity Copyright © 2017, Elsevier Inc. All rights reserved. 39 Aging and Renal Function  Decrease in renal blood flow and GFR  Altered sodium and water balance  Number of nephrons decrease due to renal vascular and perfusion changes  Response to acid-base changes delayed  Increased risk for drug toxicity  Alterations in thirst and water intake Copyright © 2017, Elsevier Inc. All rights reserved. 40 Urinary Tract Obstruction  Urinary tract obstruction is an interference with the flow of urine at any site along the urinary tract  The obstruction can be caused by an anatomic or functional defect  Obstructive uropathy Copyright © 2017, Elsevier Inc. All rights reserved. 41 Urinary Tract Obstruction  Severity based on:  Location  Completeness  Involvement of ureters and/or kidneys  Duration  Cause Copyright © 2017, Elsevier Inc. All rights reserved. 42 Upper Urinary Tract Obstruction  Hydroureter   Hydronephrosis   Accumulation of urine in the ureter Enlargement of the renal pelvis and calyces Ureterohydronephrosis  Dilation of both the ureter and the pelvicaliceal system Copyright © 2017, Elsevier Inc. All rights reserved. 43 Consequences: Urinary Retention  Cause: External sphincter does not open for release of urine or blockage of urethra  Leads to increased urine volume and bladder distention  Backflow to the upper urinary tract  Dilation of the ureters and renal pelvis  Pyelonephritis and renal atrophy Copyright © 2017, Elsevier Inc. All rights reserved. 44 Urolithiasis (Kidney Stones)  Pathophysiology Overview     Presence of calculi (stones) in urinary tract Most common associated condition is dehydration Risk Factors  Metabolic risk factors (e.g., dehydration)  Family history, obesity, diabetes, gout increase risk  Diet (e.g., increased sodium) Incidence  Varies with geographic location, race, family history  About 12% of adults will have at least one episode  Most common type of stones = calcium Copyright © 2021, Elsevier Inc. All Rights Reserved. Urolithiasis: Assessment  History of urologic stones  Diet history  Past treatment (if a history of stone formation)  Recognize that urinary tract obstruction is an emergency and must be treated to preserve kidney function Copyright © 2021, Elsevier Inc. All Rights Reserved. Kidney Stones  Manifestation   Renal colic (pain) Evaluation  Imaging studies (CT, IVP)  24-hour urinalysis  Blood tests Copyright © 2017, Elsevier Inc. All rights reserved. 47 Lower Urinary Tract Obstruction  Neurogenic bladder   Dyssynergia  Detrusor hyperreflexiad---overactive  Detrusor areflexia---underactive Overactive bladder syndrome (OBS)   Frequency, urgency, nocturia Obstruction  Urethral stricture, prostate enlargement, pelvic organ prolapse  Partial obstruction of bladder outlet or urethra  Low bladder wall compliance Copyright © 2017, Elsevier Inc. All rights reserved. 48 Incontinence Copyright © 2017, Elsevier Inc. All rights reserved. 49 Consequences: Loss of Control  Cause: Involuntary release of urine  Leads to  Skin breakdown  Changes in daily activities  Changes in social relationships Copyright © 2017, Elsevier Inc. All rights reserved. 50 Types of Urinary Incontinence Discuss how the following types of urinary incontinence differ. A patient experiences  Stress incontinence incontinence while coughing and not making it to the bathroom to  Urge incontinence urinate in time.  Overactive bladder A patient that lives at home is  Functional incontinence experiencing incontinence  Overflow incontinence because he is unable to ambulate to the bathroom by himself  Mixed incontinence A patient complains of having A patient experiencing incontinence shortly after incontinence when coughing or urinating small amounts laughing Copyright © 2017, Elsevier Inc. All rights reserved. 51 Urinary Incontinence: Incidence and Prevalence  As many as 45% of women over 65 report this condition  Risk increases with:  Chronic conditions  Vaginal deliveries  Pelvic prolapse  Prostate problems  Diabetes  Heart failure  Obesity Copyright © 2021, Elsevier Inc. All Rights Reserved. Urinary Incontinence: Assessment: Recognize Cues  History   Use effective screening methods Physical Assessment/Signs and Symptoms  Assess abdomen  Inspect females for prolapse  Health care provider will perform comprehensive examination include DRE Copyright © 2021, Elsevier Inc. All Rights Reserved. Urinary Incontinence: Assessment: Recognize Cues  Laboratory assessment   Urinalysis Imaging assessment  Bladder scan  CT of kidneys and ureters  VCUG  Urodynamic testing  EMG of pelvic muscles Copyright © 2021, Elsevier Inc. All Rights Reserved. Urinary Incontinence: Analysis: Analyze Cues and Prioritize Hypotheses  Altered urinary elimination due to incontinence  Potential for altered tissue integrity Copyright © 2021, Elsevier Inc. All Rights Reserved. Urinary Tract Infection (UTI)  Most common pathogens   Escherichia coli Virulence of uropathogens  Host defense mechanisms Copyright © 2017, Elsevier Inc. All rights reserved. 57 Urinary Tract Infection (UTI)  Acute cystitis  Cystitis is an inflammation of the bladder  Irritants can cause cystitis without infection  Manifestations  Frequency  Dysuria  Urgency  Lower abdominal and/or suprapubic pain, low back pain Copyright © 2017, Elsevier Inc. All rights reserved. 58 Cystitis: Etiology and Genetic Risk  More than 80% of UTIs are caused by E. coli  Catheters are most common factor associated with new onset UTI in hospital and long-term care settings (CAUTI)  Interstitial cystitis (noninfectious) Copyright © 2021, Elsevier Inc. All Rights Reserved. Cystitis: Incidence and Prevalence  Incidence of UTI is second only to URI in primary care  Most common health-care associated infection Copyright © 2021, Elsevier Inc. All Rights Reserved. Cystitis: Health Promotion and Maintenance  Sterile technique when inserting catheters  Clean technique when using intermittent catheters at home  Single-use catheter recommended for home settings  NPSG – CAUTI prevention  Liberal intake of water Copyright © 2021, Elsevier Inc. All Rights Reserved. Cystitis: Assessment   Laboratory assessment  Clean catch urine specimen (urinalysis, culture, and sensitivity)  Serum WBC with differential Other diagnostic assessment  Pelvic ultrasound or CT may be needed  Voiding cystourethrography  Cystoscopy Copyright © 2021, Elsevier Inc. All Rights Reserved. Urinary Tract Infection (UTI)  Painful bladder syndrome/Interstitial cystitis  Nonbacterial infectious cystitis; noninfectious  Manifestations   Most common in women 20 to 30 years old  Bladder fullness, frequency, small urine volume, chronic pelvic pain Treatment  No single treatment effective, symptom relief Copyright © 2017, Elsevier Inc. All rights reserved. 63 Elimination Concept Exemplar: Pyelonephritis  Pathophysiology Overview Bacterial infection that starts in the bladder and moves upward to infect the kidneys  Acute versus chronic  Abscesses can develop on kidneys  Copyright © 2021, Elsevier Inc. All Rights Reserved. Pyelonephritis: Etiology and Genetic Risk  Acute – results from bacterial infection with or without obstruction or reflux  Chronic – usually occurs with structural deformities, urinary stasis, obstruction, or reflux  Commonly caused by Escherichia coli or Enterococcus faecalis Copyright © 2021, Elsevier Inc. All Rights Reserved. Pyelonephritis: Incidence and Prevalence  Most common in young women who are sexually active  Common in second trimester and beginning of third trimester of pregnant women Copyright © 2021, Elsevier Inc. All Rights Reserved. Pyelonephritis: Assessment: Recognize Cues   History  Ask about recurrent UTIs, diabetes, stone disease, GU defects, reduced immunity, kidney function  Ensure woman is not pregnant before radiographic imaging Physical Assessment/Signs and Symptoms   Flanks and CVA Psychosocial Assessment  Anxiety, embarrassment, guilt Copyright © 2021, Elsevier Inc. All Rights Reserved. Pyelonephritis: Assessment: Noticing   Laboratory assessment  Urinalysis  Blood cultures  WBC count with differential  C-reactive protein  ESR  BUN, creatinine, GFR Imaging assessment   KUB or CT Other diagnostic assessment  Antibody-coated bacteria in urine  Radionuclide renal scan Copyright © 2021, Elsevier Inc. All Rights Reserved. Pyelonephritis: Analysis: Analyze Cues and Prioritize Hypotheses  Pain (flank and abdominal) due to inflammation and infection  Potential for chronic kidney disease (CKD) due to kidney tissue destruction Copyright © 2021, Elsevier Inc. All Rights Reserved. Urinary Tract Infection (UTI)  Pyelonephritis  Acute pyelonephritis  Acute infection of the ureter, renal pelvis, interstitium   Vesicoureteral reflux, E. coli, Proteus, Pseudomonas Chronic pyelonephritis  Persistent or recurring episodes of acute pyelonephritis that lead to scarring  Risk of chronic pyelonephritis increases in individuals with renal infections and some type of obstructive pathologic condition Copyright © 2017, Elsevier Inc. All rights reserved. 70 Glomerular Disorders  Glomerulonephritis  Acute poststreptococcal glomerulonephritis  Occurs after a throat or skin infection with certain strains of group A beta-hemolytic streptococci  Experience a sudden onset of hematuria, edema, hypertension, and renal insufficiency Copyright © 2017, Elsevier Inc. All rights reserved. 71 Glomerular Disorders  Glomerulonephritis  Inflammation of the glomerulus  Immunologic abnormalities (most common)  Drugs or toxins  Vascular disorders  Systemic diseases (secondary)  Viral causes Copyright © 2017, Elsevier Inc. All rights reserved. 72 Glomerulonephritis (Cont.)  Manifestations  Two major symptoms if severe  Hematuria with red blood cell casts  Proteinuria exceeding 3 to 5 g/day with albumin (macroalbuminuria) as the major protein  Oliguria  Hypertension  Edema  Nephrotic sediment  Nephritic sediment Copyright © 2017, Elsevier Inc. All rights reserved. 73 Acute Glomerulonephritis: Assessment  History   Ask about recent infections, illnesses, surgery, systemic diseases Physical Assessment/Signs and Symptoms  Inspect skin for lesions, incisions  Edema  Blood pressure Copyright © 2021, Elsevier Inc. All Rights Reserved. Acute Glomerulonephritis  Primary versus secondary  Develops suddenly from excess immunity response within kidney tissues  Cause is usually infectious Copyright © 2021, Elsevier Inc. All Rights Reserved. Acute Glomerulonephritis: Assessment: Recognize Cues   Laboratory assessment  Urinalysis  24-hour urine collection  Serum albumin  Serum creatinine  BUN  GFR Other diagnostic assessment  Kidney biopsy Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Glomerulonephritis Develops over years to decades  Symptoms may include mild proteinuria, hematuria, hypertension, fatigue, occasional edema  Exact cause not known  Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Glomerulonephritis: Assessment: Noticing  History    Other health problems, recent exposure to infection, fatigue, lethargy, elimination patterns Physical Assessment/Signs and Symptoms  Systemic circulatory overload  Lung crackles  Uremic symptoms Psychosocial Assessment  Uncertainty, loss, fear Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Glomerulonephritis: Assessment: Noticing  Diagnostic assessment  Urinalysis  GFR  Serum creatinine  BUN  Sodium and phosphate levels  ABGs  X-ray or CT Copyright © 2021, Elsevier Inc. All Rights Reserved. Nephrotic Syndrome  Nephrotic syndrome is a symptom complex related to loss of protein in the urine  Minimal change nephropathy (MCN)  Focal segmental glomerulosclerosis (FSGS)  Congenital nephrotic syndrome  Nephrotic syndrome can be primary or secondary in relation to cause  Onset can be insidious with periorbital edema as the usual first sign Copyright © 2017, Elsevier Inc. All rights reserved. 80 Nephrotic Syndrome  Excretion of 3.5 g or more of protein in the urine per day  The protein excretion is caused by glomerular injury  Findings  Hypoalbuminemia  Edema  Hyperlipidemia and lipiduria  Vitamin D deficiency Copyright © 2017, Elsevier Inc. All rights reserved. 81 Acute Kidney Injury (AKI)  Pathophysiology Overview Rapid reduction in kidney function resulting in failure to maintain waste elimination, fluid and electrolyte balance, and acid–base balance  Occurs over a few hours or days  Copyright © 2021, Elsevier Inc. All Rights Reserved. Acute Kidney Injury (AKI)  Renal insufficiency  Renal failure  End-stage renal failure (ESRF) Copyright © 2017, Elsevier Inc. All rights reserved. 83 Acute Kidney Injury (AKI): Etiology  Reduced perfusion to kidneys, damage to kidney tissue, obstruction of urine outflow  Risk factors – shock, cardiac surgery, hypotension, prolonged mechanical ventilation, sepsis  Older adults or adults with chronic diseases are at higher rtisk Copyright © 2021, Elsevier Inc. All Rights Reserved. Acute Kidney Injury (AKI) (Cont.)  Prerenal  Most common cause of ARF  Caused by impaired renal blood flow  GFR declines because of the decrease in filtration pressure Copyright © 2017, Elsevier Inc. All rights reserved. 85 Acute Kidney Injury (AKI) (Cont.)  Intrarenal   Acute tubular necrosis (ATN) is the most common cause of intrarenal renal failure  Postischemic or nephrotoxic  Oliguria Postrenal  Occurs with urinary tract obstructions that affect the kidneys bilaterally Copyright © 2017, Elsevier Inc. All rights reserved. 86 Acute Kidney Injury (AKI) (Cont.)    Initiation phase  Kidney injury is evolving  Prevention of injury is possible Maintenance (oliguric) phase  Established kidney injury and dysfunction  Urine output is lowest during this phase, and serum creatinine and blood urea nitrogen both increase Recovery (polyuric) phase  Injury repaired and normal renal function reestablished  Diuresis common  Decline in serum creatinine and urea  Increase in creatinine clearance Copyright © 2017, Elsevier Inc. All rights reserved. 87 Acute Kidney Injury (AKI): Assessment: Recognize Cues (1 of 3)  History  Changes in urine appearance, frequency, volume  Recent surgery or trauma, transfusions, allergic reactions  Drug history  Coexisting conditions  Immunity-mediated AKI  Anticipate AKI after hypotension or shock  History of obstructive problems Copyright © 2021, Elsevier Inc. All Rights Reserved. Acute Kidney Injury (AKI): Assessment: Recognize Cues (2 of 3)  Physical Assessment/Signs & Symptoms  Hourly urine output  Assess for fluid overload  Evaluate vital signs for hypoperfusion and hypoxemia Copyright © 2021, Elsevier Inc. All Rights Reserved. Acute Kidney Injury (AKI): Assessment: Recognize Cues (3 of 3)   Laboratory assessment  Creatinine, BUN  Blood electrolyte values  Urine tests Imaging assessments   US, CT, x-rays (pelvis, kidneys, KUB), MAG3 Other diagnostic assessments  Kidney biopsy Copyright © 2021, Elsevier Inc. All Rights Reserved. Elimination Concept Exemplar: Chronic Kidney Disease (CKD)  Pathophysiology Overview      Progressive, irreversible disorder End-stage kidney disease (ESKD) Azotemia Uremia Uremic syndrome Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (CKD): Changes Kidney changes  Metabolic changes     Cardiac changes        Fluid and electrolyte balance is disrupted Acid-base balance is disrupted Hypertension Hyperlipidemia Heart failure Pericarditis Hematologic and Immunity changes GI changes Cognitive and functional changes Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (CKD): Etiology and Genetic Risk  More than 100 different disease processes can result in progressive loss of kidney function  Two main causes of CKD leading to dialysis or kidney transplantation  Hypertension  Diabetes mellitus Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (CKD): Incidence and Prevalence About 15% of adults in U.S. are estimated to have CKD  Most adults that have CKD do not know they have the disease (CDC, 2019)  Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (CKD): Health Promotion and Maintenance  Control diseases that lead to CKD  Dietary adjustments  Weight maintenance  Smoking cessation  Exercise  Limitation of alcohol Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (CKD): Assessment: Recognize Cues  History  Weight and height; weight gain or loss  Medical history, especially of kidney or urologic origin  Drug use  Dietary habits  GI and GU problems Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (CKD): Assessment: Recognize Cues  Physical Assessment/Signs and Symptoms  Neurologic changes  Cardiovascular symptoms  Respiratory symptoms  Hematologic symptoms  Skeletal symptoms  Urine symptoms  Skin symptoms Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (CKD): Assessment: Recognize Cues  Psychosocial Assessment  Anxiety, fear  Coping mechanisms  Support recommendation of mental health professional Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (CKD): Assessment: Recognize Cues   Laboratory assessment  Creatinine, BUN  Sodium, potassium, calcium, phosphorus, bicarbonate  Hemoglobin and hematocrit  GFR  Urinalysis Imaging assessment  X-ray findings (few are abnormal)  Kidney or CT scan Copyright © 2021, Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (CKD): Analysis: Analyze Cues & Prioritize Hypotheses  Fluid overload due to the inability of disease kidneys to maintain body fluid balance  Decreased cardiac function due to reduced stroke volume, dysrhythmias, fluid overload, and increased peripheral vascular resistance  Weight loss due to inability to ingest, digest, or absorb food and nutrients as a result of physiologic factors  Potential for injury due to effects of kidney disease on bone density, blood clotting, and drug elimination  Potential for psychosocial compromise due to chronic kidney disease Copyright © 2021, Elsevier Inc. All Rights Reserved. Exemplar: Chronic Kidney Disease (CKD)  Progressive loss of renal function that affects nearly all organ systems  Associated with HTN, diabetes, intrinsic kidney disease  Stages:  Normal (GFR >90 mL/min)  Mild (GFR 60-89 mL/min)  Moderate (GFR 30-59 mL/min)  Severe (GFR 15-29 mL/min)  End stage (GFR less than 15) Copyright © 2017, Elsevier Inc. All rights reserved. 101 Chronic Kidney Failure Stages  Decreased 50% loss of nephrons – may be asymptomatic  Kidney 75% Kidney Reserve Insufficiency loss of nephrons, mild azotemia  ESRD 90% loss of nephrons, severe azotemia, dialysis required  Uremic >90% syndrome nephrons lost, multi-system involvement 102 Chronic Kidney Disease (CKD) (Cont.)   Proteinuria and uremia  Due to glomerular hyperfiltration  Damages interstitial tissue of kidney via inflammation Creatinine and urea clearance  GFR falls  Plasma creatinine increases Copyright © 2017, Elsevier Inc. All rights reserved. 103 Chronic Kidney Disease (CKD) (Cont.)  Fluid and electrolyte balance    Sodium and water balance  Depends on severity  Concentration and dilution ability diminishes –at first sodium and water depletion  Sodium and water retention later phases Potassium balance  Tubular secretion increases early  Once oliguria sets in, potassium retained Acid-base balance  Metabolic acidosis when GFR 30%-40% Copyright © 2017, Elsevier Inc. All rights reserved. 104 Chronic Kidney Disease (CKD) (Cont.)  Fluid and electrolyte balance (Cont.)    Reduced renal phosphate excretion, decreased renal synthesis of 1,25-(OH)2 vitamin D3 and hypocalcemia  Fractures Protein, carbohydrate, fat metabolism   Calcium, phosphate, bone Increased triglycerides Anemia  Lethargy, dizziness, and low hematocrit are common Copyright © 2017, Elsevier Inc. All rights reserved. 105 Chronic Kidney Disease (CKD) (Cont.)  Alterations seen in following systems  Cardiovascular  Pulmonary  Hematologic  Immune  Neurologic Copyright © 2017, Elsevier Inc. All rights reserved. 106 Chronic Kidney Disease (CKD) (Cont.)  Alterations seen in following systems (Cont.)  Gastrointestinal  Endocrine and reproduction  Integumentary Copyright © 2017, Elsevier Inc. All rights reserved. 107 Functions of the Urinary System  Controls volume and concentration of body fluids S&S of fluid volume overload  Clinical manifestations of inability Electrolyte Imbalances to do this?  Excretion of metabolic wastes  Acid-base regulation  Blood pressure regulation  RBC synthesis and maturation Copyright © 2017, Elsevier Inc. All rights reserved. Electrolyte Imbalances Hyperkalemia Hypocalcemia Hyperphosphatemia HTN Pulmonary CV 108 Functions of the Urinary System  Controls volume and concentration of body fluids  Excretion of metabolic wastes S&S of build up of metabolic wastes? of  Clinical manifestations this?  Acid-base regulation  Blood pressure regulation  RBC synthesis and maturation Copyright © 2017, Elsevier Inc. All rights reserved. Increased creatinine, urea Immune system Encephalopathy GI Skin Reproductive 109 Functions of the Urinary System  Controls volume and concentration of body fluids  Excretion of metabolic wastes  Acid-base regulation  Blood pressure regulation  RBC synthesis and maturation Type of acid-base alteration Metabolic acidosis Copyright © 2017, Elsevier Inc. All rights reserved. 110 Functions of the Urinary System  Controls volume and concentration of body fluids  Excretion of metabolic wastes  Acid-base regulation  Blood  pressure regulation RBC synthesis and maturation Copyright © 2017, Elsevier Inc. All rights reserved. BP alterations? 111 Functions of the Urinary System  Controls volume and concentration of body fluids  Excretion of metabolic wastes  Acid-base regulation  Blood pressure regulation  RBC synthesis and maturation S&S of anemia Type? Copyright © 2017, Elsevier Inc. All rights reserved. 112 Signs and Symptoms of Kidney Failure From Goldman L, Schafer AI: Goldman’s Cecil medicine, ed 24, Philadelphia, 2012, Saunders; redrawn from Forbes CD, Jackson WF: Color atlas and text of clinical medicine, ed 3, London, 2003, Mosby. Copyright © 2017, Elsevier Inc. All rights reserved. 113 Alterations in Reproductive System Copyright © 2017, Elsevier Inc. All rights reserved. 114 Infection and Inflammation Exemplar: PID Pelvic inflammatory disease (PID)   Acute inflammatory process caused by infection  May involve any organ of the upper genital tract  Entire pelvic cavity in severest form  Sexually transmitted diseases migrate from the vagina to the upper genital tract  Associated with multiple sexual partners, previous PID, douches, IUD for birth control Copyright © 2017, Elsevier Inc. All rights reserved. 115 Infection and Inflammation (Cont.)  Pelvic inflammatory disease (PID) (Cont.)  Salpingitis   Inflammatory process induces changes in the columnar epithelium that line the upper reproductive tract  Localized edema  Necrosis  Gonorrhea gonococci attaches to fallopian tubes  Chlamydia enters the tubal cells and replicates, bursting the cell membrane as it reproduces, causing permanent scarring May cause infertility and tubal obstruction, ectopic pregnancy, pelvic pain, and intestinal obstruction Copyright © 2017, Elsevier Inc. All rights reserved. 116 Infection and Inflammation (Cont.)  Pelvic inflammatory disease (PID) (Cont.)  Manifestations vary from no pain to sudden severe abdominal pain with fever  Symptoms often vague  Rapid empiric treatment to prevent complications Copyright © 2017, Elsevier Inc. All rights reserved. 117 Pelvic Inflammatory Disease (PID) From Ball reserved. JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 118 2015, Copyright © 2017, Elsevier Inc. All rights Mosby. Pelvic Inflammatory Disease (PID) (Cont.) A from Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby. B from Damjanov I, Linder J, editors: Anderson’s Copyright © 2017, Elsevier Inc. All rights reserved. 119 pathology, ed 10, St Louis, 1996, Mosby. Endometriosis Presence of functioning endometrial tissue or implants outside the uterus  Responds to hormone fluctuations of the menstrual cycle  Possible causes        Coelomic metaplasia Retrograde menstruation Embryonic cell rest Iatrogenic mechanical transplantation Lymphatic and vascular dissemination Genetic predisposition Copyright © 2017, Elsevier Inc. All rights reserved. 120 Endometriosis (Cont.)  Highly associated with infertility  Dyschezia (pain on defecation) is hallmark symptom  Treatment to prevent progression, alleviate pain, and restore fertility Copyright © 2017, Elsevier Inc. All rights reserved. 121 Endometriosis (Cont.) Copyright © 2017, Elsevier Inc. All rights reserved. 122 Cancer  Cervical cancer  Almost always associated with HPV infection  Causes high-grade dysplasia and cancer   Ability of HPV to act as a carcinogen depends on the viral proteins E6 and E7   Cervical intraepithelial neoplasia (CIN) and cervical carcinoma in situ (CIS) Interfere with activity of tumor suppressor proteins Other risk factors include multiple sexual partners, young age at first sexual intercourse, high parity, immunosuppression, oral contraceptives, use of nicotine Copyright © 2017, Elsevier Inc. All rights reserved. 123 Cancer (Cont.)  Cervical cancer (Cont.)  Progresses slowly  Normal cervical epithelial cells to dysplasia to carcinoma in situ and, eventually, invasive cancer  Predominantly asymptomatic  Pap and HPV testing  Treatment based on neoplastic change, size and location of lesion, extent of metastasis Copyright © 2017, Elsevier Inc. All rights reserved. 124 Disorders of the Prostate Gland Exemplar: BPH  Benign prostatic hyperplasia (BPH)  Enlargement of the prostate gland  Symptoms associated with urethral compression  Relationship to aging  Evaluation   Digital rectal exams  Prostate-specific antigen (PSA) monitoring Treated with medications to shrink prostate  α1-adrenergic blockers  Antiandrogen agents Copyright © 2017, Elsevier Inc. All rights reserved. 125