5- RENAL.pdf

NCM 112- MEDICAL- SURGICAL NURSING...

NCM 112- MEDICAL- SURGICAL NURSING 3rd Year, 1st Semester __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HHH MANAGEMENT OF CLIENTS WITH PROBLEMS OF EXCRETION RENAL SYSTEM HUMAN OSMOREGULATION Aka Urinary System Kidney regulates amount of water reabsorbed from the Group of organs in the body that filters out excess fluid and glomerular filtrate in kidney tubules other substances from the bloodstream. Controlled by ADH, renin, aldosterone, angiotensin I and Metabolic wastes and excess ions are filtered out of the angiotensin II. blood, along with water, and leave the body in the form of Most important function of the renal system = maintain blood urine. volume, BP, and blood osmolarity (ion conc.) Retroperitoneal area = contains kidneys + adrenal glands, pancreas, nerve roots, lymph nodes, abdominal aorta, and inferior vena cava. ○ Left kidney is higher; Right kidney is lower due to presence of liver on the right side ○ Costovertebral angle Kidneys filter about 45 gallons (170.3 L) of fluid each day IAAP (In assessing the kidneys) ○ No bruits ○ (+) bruits = fistula The respiratory and cardiovascular systems have certain functions that overlap with renal system functions. A complex network of hormones controls the renal system to maintain homeostasis. FUNCTION OF THE RENAL SYSTEM A WET BED ACID BASE BALANCE Excreting excess hydrogen ions (H⁺) to reduce acidity. Reabsorbing bicarbonate (HCO₃⁻), a key buffer that neutralizes acids. Producing new bicarbonate when needed, helping to keep blood pH within a healthy range. WATER BALANCE Regulates body fluid Regulates water removal by filtering blood in the kidneys Reabsorbing water through the renal tubules influenced by hormones like ADH and aldosterone and excreting excess water in the urine. ERYTHROPOIESIS Kidney produces erythropoietin (hormone) = stimulates RBC @ bone marrow ○ essential for transport of O2 throughout the PARTS OF THE RENAL SYSTEM tissues and organs. KIDNEYS Most complex and critical part of the urinary system TOXIN REMOVAL Function: maintain a stable internal environment Filters metabolic wastes from the bloodstream and (homeostasis) for optimal cell and tissue metabolism. eliminates them as urine. ○ Maintain normal comp. & volume of urine Urea (95% H2O & 5% solutes) ○ Countercurrent exchange system ⬇️ BLOOD PRESSURE CONTROL If BP = RAAS will activate Have an extensive blood supply from the renal arteries that Renal system alters water retention = influencing thirst leave the kidneys via renal vein. Kidney produces renin → angiotensinogen → angiotensin 1 3 regions of each kidney ⬆️ in liver → angiotensin 2 in lungs → constrict blood vessels ○ Cortex → BP ○ Medulla ○ Pelvis ELECTROLYTE BALANCE Glomerular Filtration Retention of fluid ○ Influenced by number of functional nephrons, (+) kidney problems = electrolyte imbalance permeability of filtration membrane, net filtration Loop of Henle pressure ○ Reabsorbs water in the descending limb and NaCl Formation of Urine in the ascending limb contributing to urine ○ Glomerular Filtration concentration. Hydrostatic and osmotic pressure NV in adults: 120-125 mL/min. VITAMIN D ACTIVATION ○ Tubular reabsorption Helps with Ca absorption Active or passive Sunlight → Vitamin D is converted by liver → converted by ○ Tubular secretion kidneys to form usable by the body → CALCITRIOL Reabsorption in reverse Patients with kidney problems have bone problems or prone Disposes of undesirable substances. to fractures Renal clearance ○ Volume of plasma that is cleared of a particular substance in a given time (usually 1 minute). ○ TRANSCRIBED BY: DAR (‘26) NCM 112- MEDICAL- SURGICAL NURSING 3rd Year, 1st Semester __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HHH MANAGEMENT OF CLIENTS WITH PROBLEMS OF EXCRETION NEPHRONS Main functional component inside the parenchyma of the kidneys, which filter blood to remove urea, a waste product formed by the oxidation of proteins, as well as ions like K+ and Na+. Made up of capsule capillaries (glomerulus) and a small renal tube. ○ The renal tube of the nephron consists of a network of tubules and loops that are selectively permeable to water and ions. URETER Urine passes from the renal tube through tubes called ureters and into the bladder. Bilateral tubes that transport urine from the kidney to the bladder. BLADDER Flexible Used as storage until the urine is allowed to pass through the urethra and out of the body. Size varies with amount of urine Stores urine until micturition. URETHRA The female and male renal system are very similar, differing only in the length of the urethra. Channels urine outside of the body. DIAGNOSTIC TESTS Blood urea nitrogen (BUN) Creatinine (serum) Creatinine clearance Cystatin C CT scan of kidneys cystometrogram (CMG) Cystoscopy, cystography Estimated G F R (eGFR) Intravenous pyelogram (IVP), retrograde pyelogram MRI ASSESSING RENAL SYSTEM FUNCTION Portable ultrasonic bladder scan Renal arteriogram or angiogram Genetic considerations Renal biopsy ○ Examples of renal system disorders Renal scan Adult polycystic kidney disease (APKD) Renal ultrasound Type 1 and type 2 diabetes mellitus Residual urine (DM) Urinalysis (UA) Bladder cancer Urine culture HA Interview Uroflowmetry ○ Color, odor, amount of urine Previous surgical ○ Difficulty initiating procedures stream Previous renal problems ○ Frequency of Family history of renal urination disease ○ Dysuria Diet ○ Nocturia Work history ○ Hematuria Usual fluid intake ○ Oliguria Tobacco use ○ Polyuria Exposure to toxic ○ Discharge industrial or ○ Pai environmental chemicals ○ Self-care measures AGE-RELATED RENAL SYSTEM CHANGES Kidney atrophy Decreased renal blood flow Decrease in renal tubule function Decrease in bladder capacity Increases risk of hyponatremia and nocturia TRANSCRIBED BY: DAR (‘26) NCM 112- MEDICAL- SURGICAL NURSING 3rd Year, 1st Semester __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HHH MANAGEMENT OF CLIENTS WITH PROBLEMS OF EXCRETION DISORDERS OF THE RENAL SYSTEM RISK FACTORS URINARY TRACT INFECTION Pregnancy Infections caused by various agents in different parts of the Urinary tract obstruction urinary system. Congenital malformation Common in young women Urinary tract trauma or scarring Uncommon in men under 50 y/o Calculi or kidney disorders Chronic diseases RISK FACTORS Both sex PATHOPHYSIOLOGY AND MANIFESTATION ○ Women Chronic inflammation of the kidney Short, straight urethra Common cause of renal failure Proximity of urinary meatus to vagina Nonbacterial in origin and anus Develops as a result of UTI, hypertension or severe reflux, Sexual intercourse obstructions to urinary tract Use of diaphragm and spermicidal Can result from metabolic, chemical, or immunological compounds for birth control inflammatory processes Pregnancy ○ Men DIAGNOSTIC TESTS Uncircumcised Urinalysis Prostatic Hypertrophy Gram stain of the urine Urine culture and sensitivity tests Aging W B C with differential Urinary tract obstruction Intravenous pyelography (IVP) Neurogenic bladder dysfunction Voiding Cystourethrography Vesicoureteral reflux Cystoscopy Genetic factors Manual pelvic or prostate examination Catheterization ○ Bacteria move to the bladder through columns of urine, or up mucous sheath of urethra outside the USE CLEAN, VOIDED SPECIMEN- MIDSTREAM OR ASPIRATE catheter. SPECIMEN FORM RETENTION Anal intercourse MANAGEMENT Uncomplicated lower UTI ETIOLOGY ○ Short-course antibiotics In women, acute UTI is often caused by E.coli. In men, the cause is usually obstructive abnormalities Patients with pyelonephritis, abnormalities, stones, or Catheter-Associated UTI (CAUTI) is caused by the history of antibiotic-resistant infection formation of biofilms by urinary pathogens common on the ○ 7-10 days course of antibiotics surfaces of catheters and collecting systems. Severely ill patients can require hospitalization, I V administration of medications. PATHOPHYSIOLOGY Follow-up urine culture 10-14 days after treatment Urinary tract sterile above urethra completion Maintained by: Surgery ○ Adequate urine volume ○ Ureteroplasty ○ Free flow from kidneys through urinary meatus ○ Ureteral reimplantation ○ Complete bladder emptying Non-Pharmacological Normal acidity and bacteriostatic properties ○ Homeopathy ○ Aromatherapy ○ Herbal preparations CYSTITIS (Bladder) Might feel like you need to urinate a lot or ○ Cranberry products it might hurt when you urinate Lower belly pain & cloudy/bloody urine COMPLICATIONS Pyelonephritis URETHRITIS can cause discharge and burning when Urosepsis (Urethra) you urinate ○ Systemic infection arising from UTI Lower urinary tract infection ○ May lead to SEPTIC SHOCKS and DEATH ○ s/sx = confusion, persistent hypotension, elevated CAUTI Longer left in place = greater risk of lactate level, hypoxia infection Biofilm resistant to antibiotics NURSING INTERVENTIONS Often asymptomatic ASSESS Hx of frequent UTIs ACUTE PYELONEPHRITIS (PART OF UTI) Voiding habits, personal hygiene, and contraceptive methods Bacterial infection of the kidney History of vaginal discharges, itching, irritation, and dysuria Infection usually ascends to kidneys from lower urinary tract CAUSE: E.coli Infection spreads from renal pelvis to renal cortex. MANAGEMENT ○ Primarily affects pelvis, calyces, and medulla of Systemic analgesics kidney Urinary analgesics/antispasmodics ○ White blood cell infiltration and inflammation ○ Kidney becomes grossly edematous; abscesses CLIENT TEACHING (FEMALE PTS) can develop on the cortical surface. Discuss need to void after intercourse ○ Can cause fever, chills, N/V, pain in upper back or Cleanse perineum from front to back side Wear cotton underwear Increase water intake Avoid carbonated and caffeinated fluids (eg coffee, tea, alcohol, and colas) TRANSCRIBED BY: DAR (‘26) NCM 112- MEDICAL- SURGICAL NURSING 3rd Year, 1st Semester __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HHH MANAGEMENT OF CLIENTS WITH PROBLEMS OF EXCRETION PREVENT CAUTI BY COMPLICATIONS Inserting catheters only for appropriate reasons Obstruction Leaving catheters in place only as long as needed ○ Loss of renal function Inserting catheters using aseptic technique and sterile ○ Hydronephrosis equipment Acute Maintaining a closed-drainage system Chronic Maintaining unobstructed urine flow ○ Infection Urinary Stasis URINARY CALCULI UTI -LITHIASIS Stone formation DIAGNOSIS Urinalysis NEPHROLITHIASIS LOC: Kidneys Chemical analysis Cause: Ca Oxalate Stone, Urine calcium, uric acid, and oxalate levels Hypercalcemia Serum calcium, phosphorus, and uric acid levels Diet- Acid Ash Diet KUB x-ray ○ Plums Renal ultrasonography ○ Prunes Spiral computed tomography (CT) scan ○ Cheese Cystoscopy ○ Corn Tx- Calcibind TREATMENT ○ Ca is alk in nature Acute renal colic ○ Will bind and will be excreted ○ Analgesia ○ Medications to promote stone passage UROLITHIASIS Elsewhere in the urinary tract ○ Hydration Inhibition of further lithiasis, based on stone composition URETEROLITHIASIS LOC: Ureter ○ Calcium Calculi = Thiazide Diuretic Cause: Uric Acid Stones ○ Uric Acid, Cystine, some Calcium Calculi = Diet- Alkaline Ash Diet Potassium Citrate ○ Chocolate Nutrition and Fluid Management ○ Okra ○ Increased fluid intake of 2.5-3 L/day ○ Spinach ○ Dietary Changes, based on stone composition ○ Sweet Potato Tx- Colchicine, Allopurinol, Probenecid Calcium and cystine Low-sodium, restricted protein Uric acid RISK FACTORS Low-purine Most affected Lithotripsy ○ Male ○ Extracorporeal shock-wave lithotripsy (ESWL) ○ White Hematuria IF 24 hrs = NOT normal Personal or family history (+) Bruising- there is impact from Gout crushing stones Hyperparathyroidism ○ Percutaneous nephrolithotomy Urinary Stasis Repeated UTI Ureteroscopy Dehydration Double-J stent ff. ESWL or other procedures Immobility Diet NURSING CARE Importance of maintaining fluid intake, dietary PATHOPHYSIOLOGY recommendations Information about medication Balance in kidneys bt. Ned to conserve water and need to Prevention, recognition, and management of U T I eliminate poorly soluble materials How to change dressings ○ Affected by diet, environmental temp.,activity Assessment of wound and skin Protective substances normally inhibit stone formation Management and emptying of drainage systems Contributing factors in urolithiasis Assessment of urine output ○ Supersaturation ○ Nucleation URINARY TRACT TUMOR ○ Lack of inhibitory substances in urine RISK FACTORS Types of kidney stones At Risk ○ Calcium ○ Male over 60 y/o ○ Uric acid ○ White ○ Struvite (staghorn stones) 2 major factors ○ Magnesium-ammonium phosphate ○ Presence of carcinogens in urine ○ Cystine ○ Chronic inflammation or infection of bladder mucosa MANIFESTATION Congenital or acquired risk factors Renal colic ○ Chronic U T I s or calculi ○ Acute, severe FLANK PAIN → ureteral spasm Behavioral risk factors ○ N/V, pallor, cool, clammy skin ○ Signs of UTI ○ Smoking ○ Hematuria (bloody urine) ○ Occupational exposure to chemicals ○ Residence in urban areas TRANSCRIBED BY: DAR (‘26) NCM 112- MEDICAL- SURGICAL NURSING 3rd Year, 1st Semester __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HHH MANAGEMENT OF CLIENTS WITH PROBLEMS OF EXCRETION PATHOPHYSIOLOGY MANAGEMENT Most common in bladder Indwelling or intermittent catheterization Most are papillary lesions (papillomas) Cholinergic medications Carcinoma in situ (CIS) rarer with poorer prognosis Removal of calculi ○ Grade I tumors Resection of prostate if related to BPH ○ Grade II tumors NURSING CARE MANIFESTATION Intermittent self-catheterization Painless hematuria Avoidance of O T C medications with anticholinergic effect Signs of UTI Bladder training information Obstruction of urinary outflow Care of indwelling catheter Colicky pain Signs of UTI Renal Failure NEUROGENIC BLADDER DIAGNOSIS Result from disruption of central or peripheral NS linked to Urinalysis bladder function Urine Cytology UTZ of bladder, IVP PATHOPHYSIOLOGY Cystoscopy and ureteroscopy Spastic Bladder or Dysfunction CT scan or MRI ○ Interruption of sensory/voluntary control of urination MEDICATIONS Detrusor muscle remains intact Intravesical instillation of immunological or chemotherapeutic ○ COMMON CAUSE: Spinal cord Injury above the agents sacral segment BCG Antitubercular treatment for complications Flaccid bladder dysfunction Radiation Therapy ○ Detrusor muscle contraction impaired ○ Primarily a palliative tx ○ Caused by myelomeningocele or spinal injury Surgery DIAGNOSIS ○ Transurethral resection of bladder tumor ○ Partial cystectomy Urinary culture ○ Complete or radical cystectomy Urinalysis Post Void bladder scan Prostate or hysterectomy/bilateral Cystometrography salpingo-oophorectomy indicated Urinary diversion MANAGEMENT NURSING CARE Anticholinergic Drugs = Spastic Bladder Cholinergic Drugs = stimulate micturition Signs of tumor recurrence Nutrition Care of stoma Prevention of urine reflux and infection ○ Measures to reduce risk of UTI or calculi Indications of U T I and renal calculi Bladder retraining Clean technique in self-catheterization ○ Crede Method = spastic neurogenic bladder ○ Intermittent Catheterization = flaccid neurogenic URINARY RETENTION bladder Incomplete emptying of the bladder Surgery ○ Rhizotomy PATHOPHYSIOLOGY ○ Urinary Diversion ○ Artificial Sphincter Implant Mechanical obstruction (e.g., B P H, stricture, calculi) Fecal impaction Acute inflammation URINARY INCONTINENCE Scarring from repeat U T I Involuntary urination Surgery affecting detrusor muscle function ○ Physical problems Long-standing diabetes and drugs ○ Psychosocial consequences Anticholinergic medications Incidence and prevalence Voluntary urinary retention ○ Especially common in older patients ○ More common in women COMPLICATIONS Overdistention of bladder TYPES OF URINARY INCONTINENCE Weak detrusor muscle Stress Incontinence Inability to urinate ○ Due to sudden increase in intra abdominal Hydroureter or hydronephrosis pressure Ex: sneezing, coughing, laughing, MANIFESTATIONS straining, exercising Firm, distended bladder Urge Incontinence Overflow voiding or incontinence Percussion of the lower abdomen reveals a dull ○ Involuntary loss of urine with a strong void that can’t be supported DIAGNOSIS Overflow Incontinence Bladder scan ○ Due to overdistention of bladder (spinal cord Insert a urinary catheter and measure the urine output lesion) ○ Have the urge to urinate, but can only release a small amount TRANSCRIBED BY: DAR (‘26) NCM 112- MEDICAL- SURGICAL NURSING 3rd Year, 1st Semester __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HHH MANAGEMENT OF CLIENTS WITH PROBLEMS OF EXCRETION Functional Incontinence PATHOPHYSIOLOGY ○ Cognitive impairment (dementia) ○ Difficulty getting to the toilet before urination occurs Mixed Incontinence ○ A condition characterized by involuntary leakage of urine, encompassing symptoms of both stress and urge incontinence. Total Incontinence ○ Bladder cannot store any urine at all = pass urine constantly PATHOPHYSIOLOGY Results when the pressure within urinary bladder EXCEEDS urethral resistance May be acute, self-limited or chronic CAUSES: ○ Congenital ○ Acquired ○ Reversible MANIFESTATION DIAGNOSIS Flank pain Urinalysis Hematuria, proteinuria, polyuria, and nocturia Postvoiding Residual (PVR) U T I, renal calculi Bladder Stress Testing Hypertension Cystometrography Palpable, enlarged, and knobby kidney Uroflowmetry Cystoscopy or ultrasonography DIAGNOSIS Renal ultrasonography MANAGEMENT C T scan Stress UI ○ Teaching pelvic exercise MANAGEMENT ○ Duloxetine A C E inhibitors and ARBs UI associated with postmenopausal atrophic vaginitis Dialysis ○ Estrogen therapy Renal transplant Urge Incontinence ○ Preparations that increase bladder capacity Surgery ○ Suspension of the bladder neck ○ Prostatectomy ○ Artificial sphincter ○ Urethral sling ○ Bladder augmentation Complementary therapies ○ Biofeedback and relaxation techniques AGE-RELATED CHANGES IN KIDNEY FUNCTION Glomerular filtration rate (G F R) declines Decreased number of functional nephrons Lower levels of aldosterone Increased resistance to A D H Kidneys less able to concentrate urine Potassium excretion decreased CONT. RENAL DISORDERS POLYCYSTIC KIDNEY DISEASE (PCKD) Autosomal recessive GLOMERULAR DISORDERS ○ Rare, present at birth Glomerulus Autosomal dominant (A D P K D) ○ Tuft of capillaries surrounded by thin, double-walled capsule ○ Common, affects adults ○ Three layers Renal cysts enlarge and multiply Capillary endothelial layer ○ Cysts compress, destroy renal tissue Basement membrane Kidneys enlarge Capsule epithelial layer Total surface area affects GFR TRANSCRIBED BY: DAR (‘26) NCM 112- MEDICAL- SURGICAL NURSING 3rd Year, 1st Semester __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HHH MANAGEMENT OF CLIENTS WITH PROBLEMS OF EXCRETION PATHOPHYSIOLOGY PATHOPHYSIOLOGY OF ACUTE POSTINFECTIOUS Disrupts glomerular filtration GLOMERULONEPHRITIS Capillary membrane becomes more permeable, leading to hematuria, proteinuria, and edema. Falling GFR ○ Azotemia ○ Hypertension Primary glomerular disorders ○ Acute glomerulonephritis ○ Rapidly progressive glomerulonephritis ○ Nephrotic syndrome ○ Chronic glomerulonephritis Secondary glomerular disorders ○ Diabetic nephropathy ○ Lupus nephritis MANIFESTATION Hematuria, proteinuria, azotemia Brown urine Salt and water retention, hypertension, edema Fatigue, anorexia, nausea, vomiting, headache Older patients ○ Nausea ○ Malaise ○ Arthralgias ○ Proteinuria DIAGNOSIS Throat or skin cultures eGFR BUN Serum creatinine Urine creatinine Creatinine clearance Serum electrolytes Urinalysis NEPHROTIC SYNDROME Antistreptolysin O(ASO) titer Renal ultrasound Kidney scans Biopsy MANAGEMENT ACE inhibitors or ARBs, antihypertensives Plasma exchange therapy (plasmapheresis) and immunosuppressive therapy Dialysis Dietary restrictions GLOMERULONEPHRITIS PATHOPHYSIOLOGY OF CHRONIC GLOMERULONEPHRITIS Massive proteinuria Hypoalbuminemia Hyperlipidemia Edema Disruption of the coagulation system CAUSE: ○ Minimal change disease (M C D) ○ Membranous glomerulonephropathy ○ Focal sclerosis ○ Membranoproliferative glomerulonephritis TRANSCRIBED BY: DAR (‘26) NCM 112- MEDICAL- SURGICAL NURSING 3rd Year, 1st Semester __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HHH MANAGEMENT OF CLIENTS WITH PROBLEMS OF EXCRETION RENAL VEIN OCCLUSION CAUSE: unclear MANIFESTATIONS Gradual or acute deterioration of renal function MANAGEMENT Fibrinolytic drugs anticoagulant therapy