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NCM103GUT
NCM103GUT
UTI
Pylenephritis
Renal Failure
Acute
-Reverses - Abrupt renal functions
Chronic
Progressive/ Irreversible
Complete Renal Failure GFR gradually Intra renal Acute tubular necrosis Acute glomerulonephritis Renal Vascular Obstruction Cortical Necrosis Allograft Rejection Transplant
Nephrons destroyed
Dialysis
Bladder = infection
Renal
Tumors
Bladder
Obstruction
Hydroureter Hydronephrosis
Lower Urinary Tract Obstructions Kidney Stones Neurogenic Bladder
Bladder Neck Dyssynergia Interruption of nerve supply
Wilms Tumor
Embryonal Tumor Nephroblastoma Sporadic and inherited origins Associated with other anomalies
Prostate Enlargement
Urethral Stricture
Gender Race Geographic Location Seasonal Factors Fluid Intake Diet Occupation
Congenitally abnormal ureter Reflux of urine from bladder to kidney Infection, renal scarring, pyelonephritis
Vesicoureteral Reflux
UTI
Pyleonephritis Virulence of Uropathogens Host Defense Mechanisms
Periurethral Mucus Secreting Gland
Bacteria Form Biofilm Body Immune System (Bladder Wall) Acute
Cystitis
Tumors
Association: Tobacco Use, Obesity, Long-term Analgesic use
Common Causes: Kidney Stones Vesicoureteral Reflux Pregnancy Neurogenic Bladder Instrumentation Female Sexual Trauma
Secondary
Increase Risk
Smokers (men)
Pyelonephritis
Acute
Common Cause: E Coli
Chronic
Recurrent Autoimmune Infections
Common Causes Kidney Stones Vesicoureteral Reflux Pregnancy Neurogenic Bladder Instrumentation Female Sexual Trauma
Usually localized abscesses Healing occurs Deposition of Scar tissue Atrophy of affected tubules
Affects primarily the pelvis, calyces, and medulla Rarely causes renal failure
Renal Failure
Glomerular Disorders
Glomerulonephritis
Acute Glomerulonephritis S/S Hematuria Red Blood Cell Casts Protenuria GFR Oliguria Edema HTN Abrupt onset 7-10 after infection Group A Strep S/S 10-21days after infections
Nephrotic Syndrome
Most Common Form Most individuals Children recover with minimal loss of renal function Disturbance in Glomerular Basement Memb (metabolic, biochemical, physiochemical) leads to increase permeability to protein
Chronic Glomerulonephritis
Antiglomerular Basement Membrane (Good-pasture Syndrome) Prognosis variable 20-50% progress to Renal Fail
Hypoalbuminema
Hyperlipidemia
Proteinuria
Lipiduria
Tubular dilation and atrophy Cause: Immune response Toxin/Drugs Vasc. Disorders Damage: Biochemical Mediators of Inflammation Complement activation Neutrophils/Monocytes Poor Prognosis
Hypocalcemia
Poor Prognosis
Treatment: Normal, Low-fat Diet; Salt Restriction Diuretics; Antigoagulants; Removal of toxins; Steroids; Albumin Replacements
Renal Failure
Definition
Congenital condition in which the urethral meatus is located on the ventral side of the penis
Facts
Related to disruption in male hormones Accompanied by Chordee or penile torsion Corrective Surgery
Urethral opening small and situated behind the glans with fissure extending the length of penis Constant dribbling of urine Caused by intrauterine failure of the abdominal wall and the mesoderm of the anterior bladder to fuse Reconstructive surgery girls teens Boys 2-3 yrs of age Intrinsic malformation of smooth muscle or urothelial development produces obstruction in 90% of cases. Causes kinking and scarring Polyps rarely arise form the prostatic urethra often cause sever obstruction and impair renal embrogenesis leading to UTI, Vesicoureteric reflux, and renal failure. Resection as soon as possible Associated with a functional or organic obstruction of the collecting system Obstruction may begin prior to birth
Extensive congenital anomaly in which the lower urinary tract is exposed directly to the surface of the body
Ureteropelvic Junction Obstruction Bladder Outlet Obstruction Hypoplastic(Dysplastic Kidneys Renal Agenesis Polycystic Kidneys
Blockage of the tapered point where the renal pelvis transitions into the ureter
A urethral valve is a thin membrane of tissue that occludes the urethral lumen and obstructs urinary outflow in males.
Ureteric duct grows into the metanephric tissue, triggering the formation of the kidneys in utero. If this growth does not occur the kidney is absent or hypoplastic (small) Renal dysplasia results from abnormal differentiation of renal tissue Absence of one or both kidneys Potter syndrome (bilateral renal agenesis) Autosomal dominant inherited disorder PKD-1 and PKD-2 mutations account for the disease
Clearly hereditary Bilateral agenesis is usually fatal Unilateral males more affected The gene products regulate epithelial growth and differentiation.
References
Corwin, E. J. (2000). Handbook of Pathophysiology (2nd ed.). Philadelphia, PA: Lippincott. Gray, M., Huether, S., & Forshee, B. (2006). Alterations of renal and urinary tract function. In K. L. McCance & S. Huether (Eds.), Pathophysiology: The Biologic Basis for Disease in Adults & Children (pp.13011336). St Louis, MO: ElSevier Mosby. Huether, S. (2006) Alteration of renal and urinary tract functions in children. In K.
ureters, urinary bladder and urethra. The urinary system eliminates wastes, controls blood volume regulates blood ion concentration and pH, and regulates blood cell production.
THE KIDNEYS
Each kidney is behind the peritoneum, and
surrounded by a renal capsule and a renal fat pad. The ureter expands to form the renal pelvis within the renal sinus, and the renal pelvis has flower-like extensions called renal calyces. The kidney is divided into an outer cortex and an inner medulla. Each renal pyramid in the medulla has a base that extends into the cortex. The apex of each renal pyramid projects to a calyx.
THE NEPHRON
The functional unit of the kidney is the
nephron. The parts of the nephron are the renal corpuscle, the proximal convoluted tubule, the loop of Henle, and the distal convoluted tubule. The filtration membrane is formed by the glomerular capillaries, the basement membrane and the podocytes of Bowmans capsule.
the urinary bladder. The urethra carries urine from the urinary bladder to the outside of the body. The ureters and the urinary bladder are lined with transitional epithelium and have smooth muscle in their walls. The internal and external urinary sphincter muscles regulate the flow of urine through the urethra.
HEALTH HISTORY
Urinary symptoms: Dysuria Hesitancy or straining Intermittency Terminal Dysuria Urgency Strangury
HEALTH HISTORY
Urinary volume and frequency: Frequency Polyuria Nocturia Oliguria (< 400 cc/day) Anuria (<50 cc/day)
HEALTH HISTORY
Urinary appearance / sediments: Hematuria (gross and microscopic) Pyuria (gross and microscopic) Lithuria
HEALTH HISTORY
Inquire about the following:
Presence or history of genital lesions Habits: use of tobacco, alcohol or recreational drugs Any prescription and over-the-counter medications (including those prescribed for renal or urinary problems)
HEALTH HISTORY
RISK FACTORS FOR SELECTED RENAL OR UROLOGIC DISORDERS RISK FACTOR Childhood disease: strep throat, impetigo, nephrotic syndrome POSSIBLE RENAL OR UROLOGIC DISORDER Chronic renal failure
Advanced age
Instrumentation of urinary tract, cystoscopy, catheterization
Immobilization
Occupational, recreational, or environmental exposure to chemicals (plastics, pitch, tar, rubber) Diabetes mellitus
HEALTH HISTORY
RISK FACTORS FOR SELECTED RENAL OR UROLOGIC DISORDERS RISK FACTOR Hypertension POSSIBLE RENAL OR UROLOGIC DISORDER Renal insufficiency, chronic renal failure
Radiation therapy to the pelvis Recent pelvic surgery Spinal cord injury
PHYSICAL EXAMINATION
Head-to-toe assessment with special
emphasis on the abdomen, suprapubic region, genitalia and lower back, and lower extremities Direct palpation of the kidneys Rectal examination (men) Vulva, urethral meatus and vagina (women) Valsalva maneuver (men and women)
Burning or difficulty during urination. Increase in the frequency of urination, especially at night. Passage of bloody appearing urine. Puffiness around the eyes, or swelling of the hands and feet, especially in children. Pain in the small of the back just below the ribs (not aggravated by movement). High blood pressure.
bodies Microscopic examination of urine sediments after centrifuging to detect RBCs, WBCs, casts, crystals, and bacteria
disease and to assess the patients clinical progress. Provide information on the effectiveness of the kidney in carrying out its excretory function. Renal concentration tests, creatinine clearance, serum creatinine and blood urea nitrogen levels
24-Hour Urine Test Creatinine clearance Age < 30 30-40 40-50 50-60 60-70 70-80 Male Female 88-146 81-134 82-140 75-128 75-133 69-122 68-126 64-116 61-120 58-110 55-113 52-105
BUN
BUN:Creat
About 10:1
ureters and bladder (KUB plain) may be performed to delineate the size, shape and position of they kidneys. They reveal any abnormalities such as calculi, hydronephrosis, cysts, tumors, or kidney displacement by surrounding tissue abnormalities.
abnormalities such as fluid accumulation, masses, congenital malformations, changes in kidney size, or obstructions. Lower abdomen or genitalia may need to be exposed. Requires a full bladder, fluid intake should be encouraged before the procedure.
excellent cross-sectional views of the kidney and urinary tract. Used in evaluating GUT masses, lithiases, chronic renal infections, renal or urinary tract trauma, metastatic disease and soft tissue abnormalities. Claustrophobia is often a problem especially with the MRI.
metallic objects such as jewelry and clothing with metallic clasps. MRI is contraindicated in patients with pacemakers, surgical clips, or any metallic objects anywhere in the body. Oral or intravenous radiocontrast agent may be used to enhance visualization
Computed Tomography
infusion drip pyelography. An intravenous dye is administered and, via x-ray imaging, the dye is observed as it moves through the upper and lower urinary system. Visualizes the collecting system of the kidneys and the length of the ureters, the appearance of the bladder lumen and the urethra.
bladder, ureters and into the renal pelvis by means of cystoscopy, and a contrast agent is then injected. X-ray films are taken to visualize the collecting system of the kidneys to assess kidney structure in patients who are allergic to intravenous contrast agents.
UROLOGIC ENDOSCOPE
Can be performed in two ways: through a
cystoscope inserted into the urethra, or percutaneously through a small incision. Used to directly visualize the urethra and bladder. The nurse describes the examination to the patient and family to prepare them and to allay their fears. If an upper cystoscopy is to be performed, the patient is usually kept on NPO for several hours beforehand.
UROLOGIC ENDOSCOPE
Post-procedural management directed at
relieving any discomfort resulting from the examination Moist heat to the lower abdomen and warm sitz baths are helpful in relieving pain and relaxing the muscles. Monitor for urine retention Monitor for signs and symptoms of UTI
KIDNEY BIOPSY
Used in diagnosing and evaluating the extent
KIDNEY BIOPSY
Patient is placed on NPO 6 to 8 hours before
the test and an IV line is established. Urine specimen is obtained and saved for comparison with the post-biopsy specimen. Usually performed under sonographic guidance. After the biopsy, pressure is applied to the site and the patient is placed flat on bed for 6 to 8 hours to minimize bleeding. Vital signs monitoring every 15 minutes for 4 hours or until stable, whichever comes first.
KIDNEY BIOPSY
Collect all voided urine, one bottle per
voiding, for comparison. Patient instruction: avoid strenuous activities, sports, heavy lifting for at least 2 weeks.
disorders The micturition process involves several highly coordinated neurologic responses that mediate bladder function. A functional urinary system allows for appropriate bladder filling and complete bladder emptying. Usually involves the lower urinary system in adults, but may progress to involve the upper urinary system if not treated promptly.
URINARY INCONTINENCE
Risk factors:
Pregnancy: vaginal delivery, episiotomy Menopause Genitourinary surgery Pelvic muscle weakness Incompetent urethra due to trauma Immobility High-impact exercise Diabetes mellitus Stroke
URINARY INCONTINENCE
Risk factors:
Age-related changes in the urinary tract Morbid obesity Cognitive disturbances: dementia, Parkinsons disease Medications: diuretics, sedatives, hypnotics, opioids Caregiver or toilet unavailable
Overflow incontinence
Classifications of Incontinence
Stress incontinence: leakage of urine from coughing, laughing, jogging, dancing, etc. Urge incontinence: occurs when a person is unable to suppress the sudden urge to urinate. Overflow incontinence: when the bladder becomes so full and distended that urine leaks out. Total incontinence: when no urine can be retained in the bladder, usually due to neurologic problem.
Nocturnal
history of medication use Voiding history and diary of fluid intake and output Urodynamic tests (cystometrogram) Urinalysis and urine culture
Anticholinergics (oxybutynin, dicyclomine) Tricyclic antidepressants (imipramine, doxepin) Pseudoephedrine (Sudafed) Estrogen
continence using behavioral and pharmacologic therapy. Options vary according to the underlying anatomic and physiologic problem
URINARY RETENTION
Inability to empty the bladder completely
during attempts to void. Chronic urine retention often leads to overflow incontinence. Residual urine is urine that remains in the bladder after voiding (Normal: complete bladder emptying in healthy adults younger than 60; if > 60: 50 to 100 ml).
URINARY RETENTION
Can occur postoperatively in any patient
particularly if the surgery affected the perineal or anal regions. General anesthesia reduces bladder muscle innervation and suppresses the urge to void, impeding bladder emptying.
prostatic enlargement, urethral pathology, trauma, pregnancy, or neurologic disorders such as cerebrovascular accident, spinal cord injury, multiple sclerosis, or Parkinsons disease. May also be caused by medications
uropathy and chronic renal failure Urine leakage with perineal skin breakdown and irritation
Urinary Catheterization
CATHETERIZATION
Relieve urinary retention
Assist with postoperative drainage in urologic
and other surgeries Provide means to monitor accurate urine output in critically ill patients Promote urinary drainage in patients with neurogenic bladder dysfunction or urine retention Prevent urinary leakage in patients with stage III to IV pressure ulcers
using aseptic techniques Change drainage bags every three days using aseptic techniques
SUPRAPUBIC CATHETER
Following some surgeries
Long term situations Suprapubic catheter indwelling
catheter directly inserted through an incision into the lower abdomen directly into the bladder Nursing: Keep area clean & dry
an appropriate-sized catheter. Lubricate the catheter adequately with a water-soluble lubricant during insertion. Insert the catheter far enough into the bladder to prevent trauma to the urethral tissues when the retention balloon is inflated. Secure catheter properly.
URINARY DISORDERS
UTI
Caused by pathogenic microorganisms in the
urinary tract and classified as either upper or lower urinary tract infections Lower UTI:
Cystitis (inflammation of the urinary bladder) Prostatitis (inflammation of the prostate gland) Urethritis (inflammation of the urethra
Upper UTI: Acute and chronic pyelonephritis (inflammation of the renal pelvis) Interstitial nephritis (inflammation of the kidney)
UTI
One of the most common reasons patients
seek health care. Most cases occur in women, with one of every five women in the US developing a UTI sometime during her life (higher incidence in developing countries). Urinary tract is also the most common site of nosocomial infection.
UTI
Risk factors: Inability or failure to empty the bladder completely Obstructed urinary flow Decreased natural host defenses or immunosuppression Instrumentation of the urinary tract Inflammation or abrasion of the urethral mucosa Contributing conditions:
LOWER UTI
Mechanisms which maintain the sterility of the
bladder:
Physical barrier of the urethra Urine flow Ureterovesical junction competence Various antibacterial enzymes and antibodies Antiadherent effects mediated by the mucosal cells of the bladder
to and colonize the epithelium of the urinary tract to avoid being washed out during voiding. Pathogens evade host defense mechanisms. Inflammation is initiated. Most UTIs result from fecal organisms that ascend from the perineum to the urethra and the bladder and then adhere to the mucosal surfaces.
colony count of 105 colony-forming units per mL of urine on a clean-catch midstream or catheterized specimen (major criterion). UTI have subsequent sepsis have occurred with lower bacterial colony counts, however. Cellular studies:
documenting a UTI and can identify the specific organisms present. The following groups of patients should have urine cultures obtained when bacteriuria is present:
All men All children Women with a history of compromised immune function or renal problems Diabetic patients
Patients who have undergone recent instrumentation (including catheterization) of the urinary tract Patients who were hospitalized recently Patients with prolonged or persistent symptoms Patients with 3 or more UTIs in the past year Pregnant women Postmenopausal women Sexually-active women or with new partners
Uncomplicated in women: single-dose, shortcourse (3 to 4 days), or 7- to 10-day therapeutic courses Complicated UTI: cephalosporin or ampicillin/aminoglycoside combination for 7 to 10 days; TMP-SMZ; quinolones Emphasize completion of regimen even if symptoms subside
and interstitial tissue of one or both kidneys. Frequently secondary to ureterovesical reflux; other causes include urinary tract obstruction, bladder tumors, strictures, BPH, urinary stones Kidneys are often enlarged with interstitial infiltration of inflammatory cells. Abscesses may be noted on the renal capsule.
performed to locate any obstruction in the urinary tract. IVP is rarely indicated during acute pyelonephritis (normal findings in 75% of patients) Urine culture and sensitivity tests are performed to determine the causative organism so that appropriate antimicrobial agents can be prescribed.
may be hospitalized for at least 2 to 3 days of parenteral therapy. Once afebrile, oral agents may be substituted. Pharmacologic therapy:
2-week course of TMP-SMZ, ciprofloxacin, gentamicin with or without ampicillin, or a thirdgeneration cephalosporin Analgesics to relieve pain Antipyretics to lyse the fever
CHRONIC PYELONEPHRITIS
Usually results from repeated bouts of acute
pyelonephritis May cause end-stage renal disease Usually no symptoms of infection unless an acute exacerbation occurs Fatigue, headache, poor appetite, polyuria, excessive thirst, weight loss Tests to determine the extent of the disease: intravenous urogram, measurement of creatinine clearance, BUN and creatinine levels.
CHRONIC PYELONEPHRITIS
Complications: End-stage renal disease Hypertension Nephrolithiasis
Medical management: Nitrofurantoin or TMP-SMZ to suppress bacterial growth Careful monitoring of renal function with proper adjustment of dosages depending on renal clearance
CHRONIC PYELONEPHRITIS
Nursing management: Monitoring of fluid intake and output Unless contraindicated, liberal fluid intake up to 3 to 4 li/day Monitor TPR every 4 hours and administer antipyretic drugs and antibiotics as prescribed Patient education on the prevention of UTI: adequate fluid consumption, regular bladder emptying and proper perineal hygiene
CHRONIC PN
Recurrent APN Slow, imperceptible Chronic, irreversible Early: Insidious Late: toxic
CHRONIC PN
Labs
Treatment
Outcomes
KUB-UTZ: enlarged, inflamed kidney Aggressive antibx for > days Acute renal failure Sepsis, septic shock Recover or death
KUB-UTZ: small, scarred kidney Symptomatic, dialysis in CRF Chronic renal failure ESRD Death
glomerulonephritis, rapidly progressive glomerulonephritis, and nephrotic syndrome. The glomerular capillaries are primarily involved: antigen-antibody complexes form in the blood and become trapped in the glomerular capillaries, inducing an inflammatory response. IgG can be detected in the glomerular capillary walls.
injury:
Proteinuria Hematuria Decreased glomerular filtration rate Alterations in excretion of sodium Edema Hypertension
ACUTE GLOMERULONEPHRITIS
Glomerulonephritis is an inflammation of the
glomerular capillaries. AGN is a disease of children older than 2 years of age but can occur at any age group.
AGN: Pathophysiology
In most cases, a group A -hemolytic
streptococcal infection of the throat precedes the onset of glomerulonephritis (Poststreptococcal GN) by 2 to 3 weeks. May also follow impetigo and acute viral infections (Post-infectious GN) In some patients, antigens outside the body (medications, foreign serum) initiate the process, resulting in antigen-antibody complexes being deposited in the glomeruli.
AGN: Pathophysiology
ANTIGEN (GROUP A BETA-HEMOLYTIC STREPTOCOCCI) ANTIGEN-ANTIBODY PRODUCT
AGN: Pathophysiology
LEUKOCYTES INFILTRATE THE GLOMERULUS THICKENING OF THE GLOMERULAR FILTRATION MEMBRANE
RENAL FAILURE
creatinine levels) Oliguria/anuria Anemia Edema and hypertension (75% of patients) Headache, malaise, flank pain CVA tenderness
neck veins Cardiomegaly and pulmonary edema Confusion, somnolence and seizures (uremic encephalopathy)
swollen and congested kidneys Electron microscopy and immunofluorescent analysis if kidney biopsy samples: demonstration of immunoglobulins and typical glomerular changes Serologic tests: increased serum complement levels (within 2 to 8 weeks) Urinalysis showing RBC casts and other sediments
AGN: Complications
Hypertensive encephalopathy
Heart failure Pulmonary edema
Uremia
Pharmacologic therapy: Penicillin (if with residual streptococcal infection) Corticosteroids and immunosuppresants Loop diuretics and antihypertensive medications
Dietary protein restriction when renal
CHRONIC GLOMERULONEPHRITIS
May be due to repeated episodes of acute
glomerulonephritis, hypertensive nephrosclerosis, hyperlipidemia, chronic tubulointerstitial injury, or hemodynamicallymediated glomerular injury and sclerosis. Kidneys are reduced to as little as one-fifth their normal size consisting largely of scar or fibrous tissue. The renal cortex decreases in thickness. Glomeruli become scarred and branches of the renal artery become thickened.
Uremia
Nutritional derangements Skin appears yellowish gray
Anemia
Cardiomegaly and pulmonary edema Peripheral neuropathy
about 1.010, variable proteinuria, and urinary casts Hyperkalemia Metabolic acidosis Anemia Hypoalbuminemia Hyperphosphatemia Hypocalcemia Impaired nerve conduction
NEPHROTIC SYNDROME
Apparent in any condition that seriously
damages the glomerular capillary membrane and results in increased permeability Primary glomerular disease characterized by:
Marked increase in protein in the urine (proteinuria) Decrease in albumin in the blood (hypoalbuminemia) Edema High serum cholesterol and low-density lipoproteins
disease or systemic disease that affects the glomerulus Generally considered a disease of childhood but it does occur in adults, including the elderly. Causes:
Chronic glomerulonephritis Diabetes mellitus Amyloidosis and systemic lupus erythematosus Multiple myeloma
HYPERLIPIDEMIA
SODIUM RETENTION
EDEMA
sufficient for the diagnosis of nephrotic syndrome. Pyuria and granular and epithelial casts on urinalysis Needle biopsy of the kidney may be performed for histologic diagnosis of the etiology Serum markers (anti-C1q antibodies is the most reliable for assessing disease activity in lupus nephritis)
with emphasis on high biologic value proteins (dairy products, eggs, meats) Diet should be low in saturated fats
RENAL FAILURE
Transient or permanent inability of the
kidneys to perform their normal function of urine formation (filtration, secretion and reabsorption. Two types:
renal failure reversible, transient Chronic renal failure irreversible, permanent
Acute
phase azotemia Diuretic phase increased urine output Recovery phase full recovery of renal function
Oliguric/anuric
Types:
Pre-renal
I: 80-125 ml/min (normal renal function) Stage II: 50-80 ml/min (diminished renal reserve; chronic renal impairment) Stage III: 20-50 ml/min (chronic renal impairment) Stage IV: 5-20 ml/min (chronic renal insufficiency Stage V: < 5 ml/min (ESRD)
MANIFESTATIONS
Azotemia / Uremia
Uremic
frost Uremic fetor Uremic encephalopathy Uremic cardiomyopathy / pericarditis Uremic gastropathy
MANIFESTATIONS
Edema
Multiple electrolyte imbalance
Hypernatremia Hyperkalemia Hypermagnesemia Hyperphosphatemia Hypocalcemia
MANIFESTATIONS
Metabolic acidosis
Anemia Hypertension
MANAGEMENT
Aggressive Management
Supportive Management
Pre-renal: hypo-perfusion of kidney (shock, hemorrhage,etc.) Intra-renal: damaged renal tissue (infection, transfusion rxs, burns, drugs, etc.) Post-renal: an obstruction somewhere distal to kidneys: renal flow (ex. calculi, stricture, tumor etc.)
Chronic: ESRD (Irreversible) Progressive uremia devps = affects all body systems funct. Glomeruli = GFR, *urine creatinine clearance, but serum *creatinine & *BUN , Na+ H20 retention = edema, CHF, crackles, *K+ , *metabolic acidosis
S/S :
+ JVD, peri-orbital edema, dependent/pitting edema, crackles, SOB Ammonia odor breath, anorexia, n/v Skin=uremic frost, gray-bronze skin, dry flakey, itchy skin, muscle cramps ? Bone fx Neuro = weakness, fatigue, confusion, seizures (anuria = less than 50cc/day) or *(oliguria=less 400cc/day)
Management:
dry from dehydration, breath odor (uremic fetor), h/a, muscle twitch, specific gravity urine, BUN/creatinine, * 24hour urine creatinine clearance, * K+* worry about cardiac dysrhythmias, tissue edema, uremic frost, metabolic acidosis, anemia, PO4/Ca+/and F&E imbalance.** negative nitrogen balance
Dietary: renal diet, low Protein, Na+, K+, fluid restriction, higher fats & CHO=calories, I&O Antacids: correct Po4/Ca+ imbalance, aluminum or ca+ carbonate: give meals
Anti-hypertensives, Erythropoietin (Epogen) = anemia, to K+ levels = resin *Kayexelate = po or/enema = exchg Na+/K+ bowel = loose stool or *require dialysis to lower K+
either Hemodialysis, or Peritoneal dialysis Or possibly a kidney transplantation= must find a donor match/ must worry about graft- transplantation rejection!
Chronic or ESRD
I&O, fluid restriction ex. 700-
Management:
Strict I&O K+ = Kayexelate po/enema first; if not better must use dialysis Check wt. daily,dietary protein, K+ (40-60mEq/day), & Na+ (2 gm./day) diet, K+ foods; soda, bananas, citrus Correction of *acidosis & elev PO4 levels = sodium bicarb, and phosphate binding agents like antacids (Phos-lo, Amphogel, calcium
carbonate, aluminum based antacids) thus, Ca+
1000cc/24 hr, so break-it-up / shift 1-2 gm. of low Na+diet, low K+ diet, avoid salt substitutes for they contain K+ ! BAD for you Low protein diet, however eat proteins of high biological value such as dairy products,
eggs, meat, fish in small portions only RBC, Hbg/Hct: Give Epogen or Procrit SQ to increase (*erythropoetin)
Bedrest to BMR & catabolism, thus, K+ & nitrogen waste prod (BUN/Cr)
UROLITHIASIS
Refers to stones (calculi) in the urinary tract.
Formed when urinary concentrations of
calcium oxalate, calcium phosphate and uric acid increase (supersaturation) and dependent on the amounts of the substance, ionic strength, and pH of the urine
UROLITHIASIS: Pathophysiology
Supersaturation of calcium oxalate, calcium
phosphate, uric acid Deficiency of substances that normally prevent crystallization in the urine (citrate, magnesium, nephrocalcin, uropontin) Stones often occur in dehydrated patients They may deposit in many areas of the urinary tract, including the renal pelvis, ureters, ureterovesical junction and urinary bladder.
UROLITHIASIS: Pathophysiology
Factors that favor the formation of stones: Infection Urinary stasis Immobility Hypercalcemia Hyperuricemia
75% of renal stones are calcium based, 5 to
10% are made up of uric acid, and 10 to 15% are cystine or struvite stones which are closely associated with infections.
presence of attendant urinary tract infection Intense, deep ache in the costovertebral and flank regions Acute pain + tenderness + nausea + vomiting (renal colic) Hematuria Oligoanuria Fever and chills
kidneys, ureters and bladder (KUB) especially if the stone is calcium-based Serum chemistries for uric acid, BUN creatinine and calcium Chemical analysis of voided stones
the stone type, prevent nephron destruction, prevent recurrent stone formation Immediate goal: relieve the pain Nutritional therapy to prevent renal stones Liberal fluid intake, at least 8 8-oz glasses of water daily to keep the urine dilute Keep urine output of at least 2 li/day
if complications occur. Ureteroscopy Extracorporeal shockwave lithotripsy (ESWL) Laser lithotripsy (new technology, not yet widely performed) Percutaneous removal
Lithotripsy
HYDRONEPHROSIS/ NEPHROSTOMY
Hydronephrosis- condition resulting from untreated
obstruction in the urinary tract Usually treatable Obstruction of urine can be from tumor, enlarged prostate, kidney stones Stent placement- to hold open Nephrostomy tube may be inserted directly into kidney pelvis to drain UA
cancer of urinary tract Twice as common in men Common age between 50-70 yo
Correlation
BLADDER CANCER
S/S
Painless hematuria Bladder irritability Urinary retention (clots) Pelvic pain
CANCER OF KIDNEY
Rare, but serious
Most patients between 50-70 yo Risk factors: Smoking Obesity HTN Years of hemodialysis Radiation exposure Asbestos Industrial pollution
pouch reservoir created from segment of ileum Ileal conduit Indiana pouch
Kock
RENAL DISORDERS
Diabetic nephropathy Nephrotic syndrome Nephrosclerosis
Diabetic Nephropathy
Most common renal failure
Long term effects of diabetes Damage to small vessels in kidneys
genetic predisposition, smoking, chronic hyperglycemia Progression to urine decrease, toxic waste build up leading to kidney failure
Nephrotic Syndrome
Protein in urine >3.5g/per day
May result from other disease processes Large amts. of protein lost in UA Serum albumin/total serum protein are decreased Fluids low/leaks into tissues, causing edema Low sodium diet/low protein diet/diuretics may be
Nephrosclerosis
Thickening and hardening of the renal
blood vessels Changes in kidney- result in decreased blood supply to the kidney-can eventually destroy kidney High pressure within kidney cause damage Treatment is to reduce HTN
KIDNEY TRANSPLANTATION
Kidney transplantation has become the
treatment of choice for most patients with ESRD. Involves transplanting a kidney from a living donor or human cadaver to a patient. Transplants from well-matched living donors who are related to the patient are slightly more successful than those from cadaver donors. Success rate increases if transplantation is done before dialysis becomes necessary.
KIDNEY TRANSPLANTATION
PREOPERATIVE MANAGEMENT: Donor screening Patient and donor laboratory tests Psychological evaluation and counselling Continuation of renal replacement therapy while awaiting transplantation
INTRAOPERATIVE MANAGEMENT: Maintaining stable hemodynamic status for both donor and patient Monitoring for potential intraoperative complications
KIDNEY TRANSPLANTATION
POSTOPERATIVE MANAGEMENT Immediate postoperative monitoring for complications Monitoring for success of transplantation Immunosuppressive therapy Preventing infection Addressing psychological concerns Promoting home and community-based care