Ms. Louradel M. Ulbata, MAN, RN The Renal System Renal and Urinary Systems The urinary system produces urine, but physiologically it may be better understood as a system that maintains appropriate levels of many substances in blood plasma.
Anatomy of the Urinary System Consists of two kidneys, two ureters (upper urinary tract), a urinary bladder, and a urethra (lower urinary tract).
Urinary system parts and their functions: two kidneys - a pair of purplish-brown organs located below the ribs toward the middle of the back. Their function is to: remove liquid waste from the blood in the form of urine. keep a stable balance of salts and other substances in the blood. produce erythropoietin, a hormone that aids the formation of red blood cells.
Nephron The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney. T h e
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Urinary system parts and their functions: two ureters - narrow tubes that carry urine from the kidneys to the bladder.
Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys.
If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters. Urinary system parts and their functions:
bladder - a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder's walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours. Normal daily output 1200-1500 mL
Urinary system parts and their functions: two sphincter muscles - circular muscles that help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder.
nerves in the bladder -alert a person when it is time to urinate, or empty the bladder. Urinary system parts and their functions: urethra - the tube that allows urine to pass outside the body. The brain signals the bladder muscles to tighten, which squeezes urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax to let urine exit the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs. Women approx 1 -2 in (3-5 cm) Men approx 8 in (20 cm)
Receives 25% of cardiac output The renal artery arises from abdominal aorta Divides into smaller arterioles to form glomerulus (capillary bed) responsible for filtration of plasma Blood is returned to the IVC
Vasculature of the kidney - The blood supply of the kidney is central to its function. Process of Micturation Process of emptying the bladder Urine collects in the bladder until the pressure stimulates the nerve endings in the bladder wall called (strech receptors).
This occurs when the adult bladder contains about 250-450 ml of urine, while in children, this can occur at a smaller volumes (50-200) ml.
Those receptors transmit impulses to the spinal cord causing the internal sphincter of the bladder to relax and stimulate the urge to urinate.
Factors Affecting voiding 1. Developmental considerations 2. Food and fluid intake 3. Psychological factors 4. Muscle tone 5. Pathologic conditions 6. Medications Developmental Considerations Children Toilet training can start at the age of 2 years. Nocturnal enuresis or bed wetting, is the involuntary passing of urine during sleep. Effects of aging Nocturia, increased frequency, urine retention and stasis, voluntary control affected by physical problems. (bladder muscle tone and contractility diminish). FUNCTIONS OF THE URINARY SYSTEM Functions of the Kidneys Urine Formation: Formed in the nephrons through a complex three-step process: GF, tubular reabsorption, and tubular secretion Excretion of waste products: eliminates the bodys metabolic waste products (urea, creatinine, phosphates, sulfates) Regulation of electrolytes: volume of electrolytes excreted per day is exactly equal to the volume ingested Na allows the kidney to regulate the volume of body fluids, dependent on aldosterone (fosters renal reabsorption of Na) K kidneys are responsible for excreting more than 90% of total daily intake RETENTION OF K IS THE MOST LIFE- THREATENING EFFECT OF RENAL FAILURE
Renin-Angiotensin System http://en.wikipedia.org/wiki/Image:Renin-angiotensin-aldosterone_system.png Normal pH 7.35 to 7.45
Kidney performs two major functions Reabsorbs and returns Bi carbonate from the urine filtrate to the circulation Excrete acids in the urine Regulation of acid base balance Lost bicarb is replaced in the renal tubular cells through regeneration of new bicarb via chemical reactions Bicarbonate Result of catabolism of proteins Phosphoric acid Sulfuric acid Unlike CO2 phosphoric and sulfuric acid cant be eliminated by the lungs
Accumulation of these acids makes blood more acidic ( lowers the pH) and inhibits cell function The body acid produciton More acid needs to be excreted than can be directly eliminated as free acid
Binds to ammonia and phosphate to be excreted and then further excreted by the kidney Body acid elimination Kidney function Control of water balance: Normal ingestion of water daily is 1-2L and normally all but 400-500mL is excreted in the urine Osmolality: degree of dilution or concentration of urine (#particles dissolved/kg urine (glucose & proteins are osmotically active agents) Specific Gravity: measurement of the kidneys ability to concentrate urine (weight of particles to the weight of distilled water) ADH: vasopressin regulates water excretion and urine concentration in the tubule by varying the amount of water reabsorbed.
Adult Average Fluid Gains and Losses Fluid Gains Oral fluids 1100-1400ml Solid foods 800-1000ml Metabolism 300ml
Total Gains 2200-2700ml Fluid Losses Kidneys 1200-1500ml Skin 500-600ml Lungs 400ml GI 100-200ml
Total Losses 2200-2700ml
One pound equals approximately 500mL
So a weight change on 1 lb could indicate fluid gain or loss of 500 Regulation of Water Excretion Kidney function Synthesis of vitamin D to active form: final conversion of vit D into active form to maintain Ca balance Secretion of prostaglandins: important in maintaining renal blood flow. They have a vasodilatory effect. Vasa recta- monitors blood pressure as blood enters the kidney BP juxtaglomerular cells secrete renin (hormone) Renin Angiotensinogen Angiotensin I Angiotension II =powerful vasoconstriction ( PVR)
Adrenal Cortex-secrete aldosterone (stimulated by pituitary) In response to poor perfusion and increasing serum osmolality Retained Na and water increase circulating volume and increase BP Auto regulation of blood pressure The ability of the kidneys to clear solutes from the plasma. 24 hour urine is the primary test Creatinine is most useful, but any substance can be measured
Renal Clearance An endogenous waste product of skeletal muscle that is filtered at the glomerulus almost unchanged. Provides good measure of GFR Adult GFR 125mL/min -200mL/min. (1.67-2.0mL/sec) Decrease in creatinine clearance indicated decline in renal function
Creatinine KIDNEY FUNCTION Regulation of red blood cell production: Erythropoeitin - is released in response to decreased oxygen tension in renal blood flow. - This stimulates the productions of RBCs (increases amount of hemoglobin available to carry oxygen) The bladder stores urine Sensation of full bladder is transmitted by CNS when 150-200mL of urine is reached At night vasopressin release in response to decrease intake cause in urine production making it more concentrated.
Urine Storage In spinal cord injury, reflex contraction of the bladder is maintained, but the voluntary control is lost Contraction is not sufficient to empty the bladder completely leaving residual. 50-100mL in the older adult is normal residual
Bladder emptying Assessment of the Renal and Urinary Tract Systems NURSING HISTORY ASSESSMENT SUBJECTIVE DATA 1. Childhood Strep throat 2. Presence of renal or urologic congenital defect 3. Exposed to nephrotoxic chemicals(carbon tetrachloride (fire extinguisher and petroleum refining, insecticides), phenol (plastics)and ethylene glycol (antifreeze for heating and cooling) 4. Smoking cigarettes 5. ABX- aminoglycosides, amphotericin B, Sulfonamides Health History 5. Diet- high calcium intake , dehydration (n/v) 6. Level of activity;immobility leads to demineralization of bones infection and calculi 7. PAIN- dysuria, flank, costovertebral or suprapubic 8. Changes in patterns (frequency, urgency, enuresis, incontinence or nocturia) 9. Changes in consistency (hematuria, pyuria, dilute or concentrated) Health History 10. Current medications that affect renal function 11. Chronic health problems that affect kidney DM HTN Allergies MS
Health History Urologic symptoms can mimic N/V/D, appendicitis, PUD, and cholecystitis
Unexplained anemia
Misc. Warning Signs of Kidney Disease 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. PHYSIOLOGIC RESPONSES TO RENAL DYSFUNCTION ANEMIA ACIDEMIA HYPERKALEMIA HYPERPARATHYROIDISM HYPERTENSION GI BLEEDING UREMIA -> <15 ml/min ANEMIA Brought about as result of decreased erythropoietin production, the shortened life span of RBCs, nutritional deficiencies and the patients tendency to bleed, particularly from GI tract
Erythropoietin : substance produced by the kidneys, stimulates the bone marrow to produce RBCs Renal Failure: erythropoietin productxn -> anemia -> fatigue, angina and SOB ACIDOSIS Metabolic acid-base regulation is controlled primarily by tubular cells located in the kidney, while respiratory compensation is accomplished in the lungs.
Failure to secrete hydrogen ions and impaired excretion of ammonium may initially contribute to metabolic acidosis.
As kidney disease continues to progress, accumulation of phosphate and other organic acids, such as sulfuric acid, hippuric acid, and lactic acid, creates an increased metabolic acidosis.
Inability to reabsorb Sodium Bicarbonate
Metabolic acidosis may contribute to other clinical abnormalities, such as hyperventilation, anorexia, stupor, decreased cardiac response (congestive heart failure), and muscle weakness. HYPERKALEMIA Hyperkalemia (potassium >6.5 mEq/L) may be an acute or chronic manifestation of renal failure, but regardless of the etiology, a potassium level of greater than 6.5 mEq/L is a clinical emergency.
As renal function declines, the nephron is unable to excrete a normal potassium load
Caused by decreased excretion, metabolic acidosis, catabolism and excessive intake (diet, medications, fluids) SODIUM AND WATER RETENTION Kidneys cannot concentrate or dilute urine normally
Cannot excrete sodium and water -> EDEMA, CHF, HYPERTENSION CALCIUM AND PHOSPORUS IMBALANCE Serum Calcium & Phosphate levels have RECIPROCAL relationship
In renal failure: excretion of PHOSPHATE of the kidneys serum phosphate level serum calcium level stimulate the PARATHYROID GLAND to release PTH (Hyperparathyroism) calcium leaves the bones bone changes (RENAL OSTEODYSTROPHY/ UREMIC BONE DISEASE)
production of the active metabolite of Vitamin D (1,25- Dihydroxycalciferol
Cardiovascular Manifestations 1. Hypertension - Sodium and water retention - activation of RAAS
3. Pericarditis - irritation of the pericardial lining by the uremic toxins Genitourinary Effects Loss of nephrons and increased burden on those remaining nephrons Oliguria or anuria in later stages Albuminuria and increased creatinine and BUN in urine Nocturia Effects on Musculoskeletal System Disordered Vitamin D metabolism causes poor absorption of dietary calcium Overproduction of parathyroid hormone leaches calcium from bone. Hypocalcemia and osteoporosis weakens bone Hyperuricemia seldom causes gout, but can cause pericarditis in heart muscle Effects on Cardiovascular System Fluid retention leads to edema, CHF and pulmonary edema Hypertension is aggravated by vessel wall remodeling from renin/angiotensin effects Aldosterone increases vascular volume and pressure by promoting osmotic resorption of water and sodium Cardiac arrest risk from sudden rise in potassium Respiratory Effects Shortness of breath and tachypnea related to CHF or pulmonary edema May develop uremic fetor when urea is converted to ammonia in saliva, causing very bad breath Increased respiratory rate and depth due to acidosis Sensory Effects Peripheral neuropathy- usually in upper extremities, but may include restless leg syndrome Weakness and dizziness Irritability with risk of developing convulsions, and mental confusion from cerebral edema May notice a characteristic smell from uremia Hyperkalemia may cause tingling around the mouth Damage to retina from longstanding diabetes or HTN may cause visual deficits Gastrointestinal Effects Peptic Ulcer Disease is common Gastroenteritis Anorexia Nausea/vomiting Hematologic Effects Anemia related to bone marrow suppression Elevated Parathyroid hormone causes bone marrow fibrosis May have blood loss and induced folate deficiency from dialysis and abnormal homeostasis due to prolonged bleeding time
Effects on Endocrine System Decreased estrogen due to effects of uremic toxins Decreased testosterone Increased half-life of insulin, causing it to be active for longer time, and increased risk of hypoglycemia Dermatologic Effects Sallow yellow discoloration Skin color changes to increased pallor, gray/bronze, or increased pigment excreted through skin causing a sickly tan color Skin thicker and leathery Increased ecchymosis and hematoma Pruritos and excoriation from itching or from calcium deposits Dry skin and mucus membranes Uremic frost similar to sand on skin
DERMATOLOGIC SYMPTOMS Uremic Frost deposits of urea crystal in the skin
Metabolic Effects Unable to excrete medications or waste products Medications and chemotherapy may cause severe toxicity problems Unable to maintain electrolyte balance Increased rate of catabolism, especially with fever, trauma, or infection Neurological Effects Sleep disorders Impaired concentration and memory, sometimes mental confusion due to cerebral edema, and sometimes coma Irritabilities- hiccups, cramps, twitching, asterixis (hands flapping during uremic coma) Peripheral neuropathies Apprehension and irritability Reproductive Effects of Uremia Increased risk for hypertension and severe complications during pregnancy due to extra fluids and waste products. High risk of pre-eclampsia . Chronic high blood pressure and waste products in mothers bloodstream can seriously affect growth and cause harm to the babys health PHYSIOLOGIC RESPONSES TO RENAL DYSFUNCTION Nausea Vomiting Fatigue Anorexia Weight loss Muscle cramps Pruritus Changes in mental status OBJECTIVE DATA Landmarks for Physical Assessment of the Urinary System
Costovertebral angle Costovertebral Angle - Area on the Lower Back Formed by the Vertebral Column and Downward Curve of the Last Posterior Rib Anatomical location of the kidneys and ureters Landmarks for Physical Assessment of the Urinary System
Figure 20.3A Landmarks for urinary assessment. A. The costovertebral angle. A Landmarks for Physical Assessment of the Urinary System
Symphysis pubis Figure 20.3B Landmarks for urinary assessment. B. The rectus abdominis muscles and the symphysis pubis. B Landmarks for Physical Assessment of the Urinary System Rectus Abdominis Muscles - Longitudinal Muscles Extending from the Pubis to the Ribs on Either Side of the Midline Guides the location kidney palpation Landmarks for Physical Assessment of the Urinary System Symphysis Pubis - Joint Formed by the Union of Two Pubic Bones at the Midline Bladder is cradled under this structure Other Considerations in Physical Assessment Age Gender Culture Physical Assessment of the Urinary System Techniques
Inspection Auscultation Palpation Percussion INSPECTION Assessment of hydration status and skin color Inspection of the abdomen Figure 20.5 Inspecting the abdomen from the foot of the bed. Inspection: Skin- pallor, yellow-gray, excoriations, changes in turgor, bruises, texture(e.g. rough, dry skin) Mouth: stomatitis, ammonia breath. Face & extremities- generalized edema, peripheral edema, bladder distention, masses, enlarged kidney. Abdomen-abdominal contour for midline mass in lower abdomen (may indicate urinary retention) or unilateral mass. Weight: weight gain 2 nd to edema, weight loss & muscle wasting in renal failure.
Deep tendon reflex of knee (and walking heel to toe (same nerve innervation of continence) General fatigue and level of alertness
INSPECTION AUSCULTATION Auscultation of the right and left renal arteries Auscultation of the lungs Figure 20.6 Auscultating the renal arteries. costovertebral angles Inspection of the costovertebral angles Inspection of the flanks Palpation of the costovertebral angles Figure 20.7 Palpating the costovertebral angle. costovertebral angles Percussion of the costovertebral angles Figure 20.8 Blunt percussion over the left costovertebral angle. costovertebral angles
Palpation of the kidneys Figure 20.9 Palpating the left kidney. Should be non palpable with no discomfort Kidney is located at the costovertebral angle (12 rib)
Palpating the kidney and bladder Bladder Palpation of the bladder Normal : occasionally feel lower pole of RIGHT kidney; LEFT KIDNEY is higher than RIGHT so not palpable
Palpate by placing hands in duck-bill position at persons RIGHT flank Press hands together and have person take deep breath Figure 20.10 Palpating the bladder. BLADDER
Percussion of the bladder Percussion of the bladder after voiding beginning midline at the umbilicus and percussing down ward listening for change in sound from tympany to dullness. Renal system (physical assessment) Palpation- No costovertebral angle tenderness, nonpalpable kidney & bladder, no palpable masses. Percussion: Tenderness in the flank may be detected by fist percussion. If CVA tenderness & pain are present, indicate a kidney infection or polycystic kidney disease.
Auscultation: The abdominal aorta & renal arteries are auscultated for a bruit, which indicates impaired blood flow to the kidneys
DIAGNOSTICS NON- INVASIVE Urine examination of Urine color Clarity and odor pH and specific gravity Detect protein, glucose, and ketone bodies Sediment-RBC (hematuria) WBC (pyuria) Casts ( cylinduria), crystals and bacteria 1. Urinalysis and urine culture Urine can be a variety of colors, most often shades of yellow, from very pale or colorless to very dark or amber. O b j e c t i v e
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Visual Examination The depth of urine color is also a crude indicator of urine concentration Pale yellow or colorless urine indicates a dilute urine where lots of water is being excreted. Dark yellow urine indicates concentrated urine and the excretion of waste products in a smaller quantity of water, such as is seen with the first morning urine, with dehydration, and during a fever.
Visual Examination Urine clarity refers to how clear the urine is. clear, slightly cloudy, cloudy, or turbid. "Normal" urine can be clear or cloudy.
Substances that cause cloudiness but that are not considered unhealthy include mucus, sperm and cells from the skin, normal urine crystals, and contaminants such as body lotions and powders.
Other substances that can make urine cloudy, like red blood cells, white blood cells, or bacteria, indicate a condition that requires attention. RBC May be asymptomatic Acute infection Cyctitis, urethritis, prostatitis, renal calculi, neoplasm Bleeding disorders Medications (heparin, coumadin)
Urinalysis Proteinuria Occasional up to 150mg/day primarily albumin is normal
Dipstick can detect 30 to 1000mg/L of protein Affected by urine concentration , radiocontrast, pH, hematuria
Benign causes-fever strenuous exercise, and prolonged standing
Persistent proteinuria can be- glomerular disease, malignancies, collagen disease, diabetes, preeclampsia, hypothyroidim, heart failure, exposure to heavy metals, medications (NSAIDS, ACE inhibitors)
Urinalysis Measures density of a solution compared to water (which is 1.000) Altered by presence of blood, protein, and casts in the urine, hydration status Normal range 1.010-1.030
High fluid intake Decreased specific gravity Kidney disease Fixed specific gravity DM, Nephritis, FVD Increases specific gravity
Specific gravity Most accurate measure of the kidney ability to concentrate urine. Meaures solute in kg of water.
Normal osmolality of urine is 200-800mOsm/kg 24hr Urine is 300-900 mOsm/kg Osmolality URINE STUDIES 2. URINE CULTURE and SENSITIVITY - diagnoses bacterial infections of the urinary tract.
3. RESIDUAL URINE - amount of urine left in the bladder after voiding measured via catheter (permanent or temporary) in bladder.
4. CREATININE CLEARANCE - determines amount of creatinine (waste product of protein breakdown) in the urine over 24 hours - measures overall renal function; measures GFR URINE COLLECTION METHODS
1. ROUTINE URINALYSIS
Wash perineal area if soiled. Obtain first voided morning specimen. Send to lab immediately.
FEMALE Spread labia and cleanse meatus front to back using antiseptic sponges. MALE Retract foreskin (if uncircumcised) and cleanse glans with antiseptic sponges.
Have client initiate urine stream then stop. Collect specimen in a sterile container. Have client complete urination, but not in specimen container. URINE COLLECTION METHODS 3. 24-hour URINE SPECIMEN - preferred method for creatinine clearance test. Have client void and discard specimen; note time. Collect all subsequent urine specimens for 24 hours. If specimen is accidentally discarded, the test must be restarted. Record exact start and finish of collection; include date and time.
Renal concentration tests, creatine clearance and BUN levels are evaluated together
Evaluate severity of kidney disease and kidney function Results may be WNL unitl GFR is <50% of normal
4. Renal function test Creatinine (CR) Measures effectiveness of renal function End product of muscle energy metabolism Remains fairly constant Normal range 0.6mg/dL
Blood urea nitrogen (BUN) Serves as index of renal function Urea is end product of protein metabolism Levels affected by protein intake, tissue break down and Fluid volume changes Normal 7-18 mg/dL Serum test Renal Systems (Diagnostic test) Vanillymandelic acid (VMA) - to diagnose pheochromocytoma, a tumor of the adrenal gland. - The test identifies an assay of urinary catecholamines in the urine. - Instruct to avoid foods such as caffeine, cocoa, cheese, gelatin at least 2 days prior to beginning of the collection & during collection. - Save all urine on ice or refrigerate. Instruct to avoid stress & to maintain adequate food & fluids during the test. Renal Systems (Diagnostic test) Uric acid- A 24-hour collection to diagnose gout & kidney disease. Encourage fluids & a regular diet during testing. Place the specimen on ice or refrigerate. KUB (Kidney, ureters, bladder) radiograph-An x-ray film that views the urinary system & adjacent structures; used to detect urinary calculi. Bladder ultrasonography-A noninvasive method of measuring the volume of urine in the bladder. Computed tomography (CT) & MRI- provide cross-sectional views of the kidney & urinary tract.
OTHER Diagnostics
PROSTATE SPECIFIC ANTIGEN S/Sx of prostate CA mimic BPH Digital Rectal Exam for patients over 40 (yearly) Blood specimen for Prostate Specific antigen(PSA) Manipulation of prostate can PSA
Digital Rectal Exam To examine the prostate, position finger palmar surface down and palpate posteriorly to locate prostate. Palpate in a circular motion to increase ability to identify the lobes and groove.
The prostate should be 2-4 cm long and triangular. The two lateral lobes are separated by a deeper central grove.
Consistency should be firm and rubbery. Softness can occur with infection and hardness can occur with tumors and diseases.
Any feces on finger of gloved hand should be tested for occult blood. INVASIVE TESTS INTRAVENOUS PYELOGRAM (IVP)
Fluoroscopic visualization of the urinary tract after injection with a radiopaque dye.
NURSING CARE (PRE-TEST) Assess for iodine sensitivity. Obtain consent Inform client he will lie on a table throughout procedure. Administer cathartic or enema the night before. Keep the client NPO for 8 hours pretest. Inform client about possible throat irritations, flushing of face, warmth or a salty taste that may be experienced during the test
NURSING CARE (POST-TEST) Force fluids. Assess venipincture site for bleeding Monitor V/S for U/O CYSTOSCOPY Use of a lighted scope (cystoscope) to inspect the bladder. - Inserted into the bladder via the urethra. - May be used to remove tumors, stones, or other foreign material or to implant radium, place catheters in ureters.
NURSING CARE (PRE-TEST) Explain to client that the procedure will be done under general/local anesthesia. Obtain CONSENT Confirm consent form is signed. Administer sedatives 1 hour before test, as ordered. General anesthesia: Keep client on NPO. Local anesthesia: offer liquid breakfast. CYSTOCOPY
NURSING CARE (POST-TEST)
Monitor V/S & I/O -PINK TINGED/TEA COLORED URINE is expected -BRIGHT RED URINE/PRESENCE OF LARGE CLOTS shld be reported Advise client that burning on urination is normal and will subside. Encourage DBE to relieve bladder spasms Administer sitz baths for back & abdominal pain Administer analgesics as Rx Force fluids as prescribed
RENAL ANGIOGRAPHY the injection of a radiopaque dye through a catheter for examination of the renal artery supply NURSING CARE ( PRE-TEST) Obtain consent Assess client for allergies to iodine, seafoods & radiopaque dyes Inforn pt about possible burning sensation along the vessel NPO postmidnight before the test Instruct client to void immediately before the procedure Shave injection sites as prescribed Assess & mark the peripheral pulses
RENAL ANGIOGRAPHY NURSING CARE ( POST TEST) Assess V/S & peripheral pulses Provide bedrest & use of sandbag @ the insertion site for 4-8 hrs NPO postmidnight before the test Assess color & temp of the involved extremity Force fluids unless C/I Monitor urinary output Cystography Evaluating reflux of bladder to ureters or bladder injury Contrast agent is used
Voiding Cystourethrography Fluoroscopy to visualize lower urinary tract and assess urine storage in the bladder Evaluate relfux Catheter is inserted and contrast is instilled;catheter is removed when urge to void ;and the patient voids
Diagnostics Retrograde Pyelography Catheters are advanced through the ureters into the renal pelvis by cystoscopy Contrast agent Complications Infection Hematuria Perforation of ureter
Diagnostics Nuclear scans Injection of radioisotope (iodine 123) Provides information about kidney perfusion, function and GFR
Diagnostics Renal Arteriogram Catheter is threaded through the axilla or femoral artery to visualize renal blood vessles
Renal Biopsy Percutaneous needle biopsy to evaluate renal disease by obtaining a specimen (rarely done if client has only one kidney) Diagnostics COMMON HEALTH PROBLEMS I. URINARY TRACT DISORDERS 128 Urinary Tract Infection (UTI) Classifications: 1. Upper UTIs are known as Pylonephritis. - inflammation of renal pelvis 2. lower UTIs: a. Ureteritis. b. Cystitis. c. Urethritis. Women develop UTI more than men because their shorter urethras.
CYSTITIS Cystitis is an inflammation of the urinary bladder. The most common route of infection is transurethral, often from fecal contamination, ureterovesical reflux, or the use of a catheter or cystoscope.
Bacteria may enter the urinary tract in three ways: A. by the transurethral route (ascending infection), B. through the bloodstream (hematogenous spread), C. by means of a fistula from the intestine (direct extension) E.Coli accounts for 54% of UTIs Cystitis occurs more often in women, particularly sexually active women. Cystitis in men is secondary to some other factor (eg, infected prostate, epididymitis, or bladder stones). CLINICAL MANIFESTATIONS Urgency, frequency, burning, and pain on urination. Nocturia, incontinence, and back, suprapubic, or pelvic pain. Hematuria With complicated UTIs (eg, patients with indwelling catheters), symptoms can range from asymptomatic bacteruria to a Gram-negative sepsis with shock Assessment and Diagnostic Methods Urine cultures, colony counts, cellular studies Leukocyte esterase test and nitrite testing Tests for sexually transmitted diseases (STDs) CT scans and transrectal ultrasonography; cystourethroscopy may be indicated to visualize the ureters or to detect strictures, calculi, or tumors
Gerontologic Considerations Elderly patients often lack the typical symptoms of UTI and sepsis. Nonspecific symptoms, such as altered sensorium, lethargy, anorexia, new incontinence, hyperventilation, and low-grade fever may be the only clues to UTIs in these patients. Medical Management Management of UTIs typically involves pharmacologic therapy and patient education. The nurse teaches the client about the prescribed medication and infection prevention measures. Acute Pharmacologic Therapy Ideal treatment is an antibacterial agent that eradicates bacteria from the urinary tract with minimal effects on fecal and vaginal flora.
Medications may include Cephalexin (Keflex), Cotrimoxazole (TMP-SMZ, Bactrim Septra) Nitrofurantoin (Macrodantin Furadantin), ciprofloxacin (Cipro), levofloxacin(Levaquin), and Phenazopyridine (Pyridium)
Occasionally, ampicillin or amoxicillin (but Escherichia coli has developed resistance to these agents).
Long-Term Pharmacologic Therapy About 20% of women treated for uncomplicated UTIs experience a recurrence. Recurrence in men is usually due to persistence of the same organism; further evaluation and treatment are indicated. Reinfection of women with new bacteria is more common than persistence of the initial bacteria NURSING PROCESS THE PATIENT WITH UTI Assessment
Take careful history of urinary signs and symptoms. Assess for pain and urinary frequency, urgency, and hesitancy and changes in urine Determine usual pattern of voiding to detect factors that may predispose patient to infection. Assess for infrequent emptying of the bladder, association of symptoms of UTIs with sexual intercourse, contraceptive practices, and personal hygiene. Check urine for volume, color, concentration, cloudiness, and odor. Nursing Diagnoses
Acute pain related to infection within the urinary tract Deficient knowledge related to factors predisposing to infection and recurrence, detection and prevention of recurrence, and pharmacologic therapy Collaborative Problems/Potential Complications
Sepsis Renal failure, which may occur as the long-term result of either an extensive infective or inflammatory process Planning and Goals Goals of the patient may include relief of pain and discomfort, increased knowledge of preventive measures and treatment modalities, and absence of complications. Nursing Interventions Relieving Pain
Use antispasmodic drugs to relieve bladder irritability and pain. Relieve pain and spasm with analgesic agents and heat to the perineum. Encourage patient to drink liberal amounts of fluid (water is best). Instruct patient to avoid urinary tract irritants (eg, coffee, tea, citrus, spices, colas, alcohol). Encourage frequent voiding (every 2 to 3 hours) Monitoring and Managing Complications
Recognize and teach patient to recognize the signs and symptoms of UTIs early; initiate prompt treatment. Manage UTIs with appropriate antimicrobial therapy, liberal fluids, frequent voiding, and hygiene measures. Instruct patient to notify physician if fatigue, nausea, vomiting, or pruritus occurs. Provide for periodic monitoring of renal function and evaluation for strictures, obstructions, or stones. Avoid indwelling catheters if possible; remove at earliest opportunity. Use strict aseptic technique if an indwelling catheter is necessary. Check vital signs and level of consciousness for impending sepsis. Report positive blood cultures and elevated WBC counts.
Nursing Interventions TEACHING PATIENTS SELF-CARE
Teach patient health-related behaviors that help prevent recurrent UTIs, including practicing careful personal hygiene, increasing fluid intake to promote voiding and dilution of urine, urinating regularly and more frequently, and adhering to the therapeutic regimen.
Teaching should meet the patients individual needs 144 Prevention:
Avoid products that may irritate the urethra (e.g., bubble bath, scented feminine products). Cleanse the genital area before sexual intercourse. Change soiled diapers in infants and toddlers promptly. Drink plenty of water to remove bacteria from the urinary tract. Do not routinely resist the urge to urinate. Take showers instead of baths. Urinate after sexual intercourse. Women and girls should wipe from front to back after voiding to prevent contaminating the urethra with bacteria from the anal area Expected Patient Outcomes
Experiences relief of pain Explains UTIs and their treatment Experiences no complications 2. URINARY CALCULI/ UROLITHIASIS
Urolithiasis refers to stones (calculi) in the urinary tract. Stones are formed in the urinary tract when the urinary concentration of substances such as calcium oxalate, calcium phosphate, and uric acid increases. Stones vary in size from minute granular deposits to the size of an orange. Factors that favor formation of stones include infection, urinary stasis, and periods of immobility, all of which slow renal drainage and alter calcium metabolism. The problem occurs predominantly in the third to fifth decades and affects men more often than women. GENERAL INFORMATION
Frequent compositions of stones: - calcium (phosphate), calcium oxalate, uric acid and cystine (rare) stones Most often occurs in men age 20-55 years; more common in the summer
PREDISPOSING FACTORS Diet: large amount of calcium, oxalate Increased uric acid levels Sedentary lifestyles, immobility Family history of gout or calculi Hyperparathyroidism Types of Calculi Clinical Manifestations
Manifestations depend on the presence of obstruction, infection, and edema. Symptoms range from mild to excruciating pain and discomfort. Stones in Renal Pelvis Intense, deep ache in costovertebral region Hematuria and pyuria Pain that radiates anteriorly and downward toward bladder in female and toward testes in male Acute pain, nausea, vomiting, costovertebral area tenderness (renal colic) Abdominal discomfort, diarrhea Stones in Renal Pelvis Ureteral Colic (Stones Lodged in Ureter)
Acute, excruciating, colicky, wavelike pain, radiating down the thigh to the genitalia
Frequent desire to void, but little urine passed; usually contains blood because of the abrasive action of the stone (known as ureteral colic) Ureteral Stones Stones Lodged in Bladder
Symptoms of irritation associated with urinary tract infection and hematuria Urinary retention, if stone obstructs bladder neck Possible urosepsis if infection is present with stone Assessment and Diagnostic Methods
Diagnosis is confirmed by x-rays of the kidneys, ureters, and bladder (KUB) or by ultrasonography, IV urography, or retrograde pyelography. Blood chemistries and a 24-hour urine test for measurement of calcium, uric acid, creatinine, sodium, pH, and total volume. Chemical analysis is performed to determine stone composition Medical Management
Basic goals are to eradicate the stone, determine the stone type, prevent nephron destruction, control infection, and relieve any obstruction that may be present. Pharmacologic and Nutritional Therapy
Opioid analgesic agents (to prevent shock and syncope) and nonsteroidal anti-inflammatory drugs (NSAIDs). Increased fluid intake to assist in stone passage, unless patient is vomiting; patients with renal stones should drink eight to ten 8-oz glasses of water daily or have IV fluids prescribed to keep the urine dilute . For calcium stones: reduced dietary protein and sodium intake; liberal fluid intake; medications to acidify urine, such as ammonium chloride and thiazide diuretics if parathormone production is increased. For uric stones: low-purine and limited protein diet; allopurinol (Zyloprim). For cystine stones: low-protein diet; alkalinization of urine; increased fluids. Bacteria causing a urinary tract infection or bacterial contamination will produce alkaline urine. A diet rich in citrus fruits, most vegetables, and legumes will keep the urine alkaline For oxalate stones: dilute urine; limited oxalate intake (spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran). Pharmacologic and Nutritional Therapy
DIET MODIFIED/STONE CALCIUM STONES Low calcium diet ( 400 mg daily) Achieved by eliminating milk/dairy products Provide acid-ash diet to acidify urine - Cranberry or prune juice - Meat - Eggs - Poultry - Fish - Grapes - Whole grains - Take vitamin A & C, Folic acid supplements and Riboflavin Renal Calculi
DIET MODIFIED/STONE OXALATE STONES Avoid excess intake of foods/fluids high in oxalate - Tea - Chocolate - Rhubarb - Spinach Maintain alkaline-ash diet to alkalinize urine - Milk - Vegetables - Fruits except prunes, cranberries and plums Renal Calculi DIET MODIFIED/STONE
URIC ACID STONES Uric acid is a metabolic product of purines
Reduce foods high in purine - Liver, brains, kidneys, venison, shellfish, meat soups, gravies, legumes and whole grains
Maintain alkaline urine - Alkaline-ash diet Renal Calculi DIET MODIFIED/STONE CYSTINE STONES (rare) Low methionine - Methionine is the essential amino acid from which the non- essential amino acid cystine is formed
Limit protein foods - Meat, milk, eggs, cheese
Maintain alkaline-ash diet Renal Calculi Stone Removal Procedures
Ureteroscopy: stones fragmented with use of laser, electrohydraulic lithotripsy, or ultrasound and then removed. Extracorporeal shock wave lithotripsy (ESWL). Percutaneous nephrostomy; endourologic methods. Electrohydraulic lithotripsy. Chemolysis (stone dissolution): alternative for those who are poor risks for other therapies, refuse other methods, or have easily dissolved stones Surgical removal is performed in only 1% to 2% of patients
1. SURGERY A. PERCUTANEOUS NEPHROSTOMY - Tube is inserted through skin and underlying tissues into renal pelvis to remove calculi.
B. PERCUTANEOUS NEPHROLITHOTOMY - Delivers U/S waves thorough a probe placed on the calculus
2. PERCUTANEOUS ULTRASONIC LITHOTRIPSY (PUL) - Nephroscope is inserted through skin into kidney. - Ultrasonic waves disintegrate stones that are then removed by suction and irrigation. MEDICAL MANAGEMENT
3. EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY (ESWL)
- Client is placed in water and exposed to shock waves that disintegrate stones so that they can be passed with urine.
- This procedure is non-invasive.
Lithotripsy NURSING PROCESS THE PATIENT WITH KIDNEY STONES Assessment
Assess for pain and discomfort, including severity, location, and radiation of pain. Assess for associated symptoms, including nausea, vomiting, diarrhea, and abdominal distention. Observe for signs of urinary tract infection (chills, fever, frequency, and hesitancy) and obstruction (frequent urination of small amounts, oliguria, or anuria). Observe urine for blood; strain for stones or gravel. Focus history on factors that predispose patient to urinary tract stones or that may have precipitated current episode of renal or ureteral colic. Assess patients knowledge about renal stones and measures to prevent recurrence. Nursing Diagnoses
Acute pain related to inflammation, obstruction, and abrasion of the urinary tract
Deficient knowledge regarding prevention of recurrence of renal stones Collaborative Problems/Potential Complications
Infection and urosepsis (from urinary tract infection and pyelonephritis)
Obstruction of the urinary tract by a stone or edema, with subsequent acute renal failure Planning and Goals
Major goals may include relief of pain and discomfort, prevention of recurrence of renal stones, and absence of complications. Nursing Interventions
Relieving Pain
Administer opioid analgesics (IV or intramuscular) with IV NSAID as prescribed. Encourage and assist patient to assume a position of comfort. Assist patient to ambulate to obtain some pain relief. Monitor pain closely and report promptly increases in severity Nursing Interventions Monitoring and Managing Complications
Encourage increased fluid intake and ambulation. Begin IV fluids if patient cannot take adequate oral fluids. Monitor total urine output and patterns of voiding. Encourage ambulation as a means of moving the stone through the urinary tract. Strain urine through gauze. Crush any blood clots passed in urine, and inspect sides of urinal and bedpan for clinging stones Instruct patient to report decreased urine volume, bloody or cloudy urine, fever, and pain. Instruct patient to report any increase in pain. Monitor vital signs for early indications of infection; infections should be treated with the appropriate antibiotic agent before efforts are made to dissolve the stone Nursing Interventions TEACHING PATIENTS SELF-CARE
Explain causes of kidney stones and ways to prevent recurrence. Encourage patient to follow a regimen to avoid further stone formation, including maintaining a high fluid intake. Encourage patient to drink enough to excrete 3,000 to 4,000 mL of urine every 24 hours. Recommend that patient have urine cultures every 1 to 2 months the first year and periodically thereafter. Recommend that recurrent urinary infection be treated vigorously. Encourage increased mobility whenever possible; discouage excessive ingestion of vitamins (especially vitamin D) and minerals. If patient had surgery, instruct about the signs and symptoms of complications that need to be reported to the physician; emphasize the importance of follow-up to assess kidney function and to ensure the eradication or removal of all kidney stones to the patient and family. TEACHING PATIENTS SELF-CARE
If patient had ESWL, encourage patient to increase fluid intake to assist in the passage of stone fragments; inform the patient to expect hematuria and possibly a bruise on the treated side of the back; instruct patient to check his or her temperature daily and notify the physician if the temperature is greater than 38C (about 101F), or the pain is unrelieved by the prescribed medication.
Provide instructions for any necessary home care and follow-up.
TEACHING PATIENTS SELF-CARE
PROVIDING HOME AND FOLLOW- UP CARE AFTER ESWL Instruct patient to increase fluid intake to assist passage of stone fragments (may take 6 weeks to several months after procedure). Instruct patient about signs and symptoms of complications: fever, decreasing urinary output, and pain. Inform patient that hematuria is anticipated but should subside in 24 hours. Give appropriate dietary instructions based on composition of stones. Encourage regimen to avoid further stone formation; advise patient to adhere to prescribed diet. Teach patient to take sufficient fluids in the evening to prevent urine from becoming too concentrated at night. 3. URINARY TRACT TUMOR/ BLADDER CANCER May be benign or malignant: Common sites of metastasis include bone, lungs, liver, spleen or other kidney. Obstructive Disorder: Urinary Bladder Tumors
Renal Tumors
CANCER OF THE BLADDER Cancer of the urinary bladder is more common in people older than 55 years, affects men more often than women (4:1), and is more common in Caucasians than in African Americans. Bladder tumors usually arise at the base of the bladder and involve the ureteral orifices and bladder neck. Tobacco use continues to be a leading risk factor for all uri nary tract cancers. People who smoke develop bladder cancer twice as often as those who do not smoke. Cancers arising from the prostate, colon, and rectum in males and from the lower gynecologic tract in females may metastasize to the bladder.
Cancer of the Bladder Clinical Manifestations Visible, painless hematuria is the most common symptom. Infection of the urinary tract is common and produces frequency and urgency. Any alteration in voiding or change in the urine is indicative. Pelvic or back pain may occur with metastasis. Assessment and Diagnostic Methods
Biopsies of the tumor and adjacent mucosa are definitive, but the following procedures are also used: Cystoscopy (the mainstay of diagnosis) Excretory urography CT scan Ultrasonography Bimanual examination under anesthesia Cytologic examination of fresh urine and saline bladder washings Medical Management Treatment of bladder cancer depends on the grade of tumor, the stage of tumor growth, and the multicentricity of the tumor. Age and physical, mental, and emotional status are considered in determining treatment. Surgical Management Transurethral resection (TUR) or fulguration for simple papillomas with intravesical bacille CalmetteGuri (BCG) is the treatment of choice. Monitoring of benign papillomas with cytology and cystoscopy periodically for the rest of patients life. Simple cystectomy or radical cystectomy for invasive or multifocal bladder cancer. Trimodal therapy (TUR, radiation, and chemotherapy) to avoid cystectomy remains investigational in the United States. SURGICAL MANAGEMENT: Radical nephrectomy: Removal of the entire kidney, adjacent adrenal gland & renal artery & vein.
Radiation therapy & chemotherapy.
Surgery cystectomy - removal of bladder ileal conduit - creation of urinary diversion portion of ilium from small intestine is formed into a pouch the end brought to skin surface to form a stoma wears a pouch, empty frequently good skin care urine has mucous flecks SURGICAL MANAGEMENT: Stoma for ileal conduit Pharmacologic Therapy Chemotherapy with a combination of methotrexate (Rheumatrex), 5-fluorouracil (5- FU), vinblastine (Velban), doxorubicin (Adriamycin), and cisplatin (Platinol) has been effective in producing partial remission of transitional cell carcinoma of the bladder in some patients. Intravesical BCG (effective with superficial transitional cell carcinoma) RADIATION THERAPY Radiation of tumor preoperatively to reduce microextension and viability Hydrostatic therapy: for advanced bladder cancer or patients with intractable hematuria (after radiation therapy) Formalin, phenol, or silver nitrate instillations to achieve relief of hematuria and strangury (slow and painful discharge of urine) in some patients Implementation: Monitor abdomen for distention caused by bleeding Observe bed linens under the client for bleeding Monitor for hypotension, decreases in urinary output & alterations in LOC, indicating hemorrhage. Monitor urinary ouput Do not irrigate or manipulate the nephrostomy tube if in place.
4. URINARY RETENTION 201 IV. URINARY RETENTION
Urinary retention is the inability to empty the bladder completely during attempts to void. Chronic urine retention often leads to overflow incontinence (from the pressure of the retained urine in the bladder). Residual urine is urine that remains in the bladder after voiding. In a healthy adult younger than age 60, complete bladder emptying should occur with each voiding. In adults older than age 60, 50 to 100 mL of residual urine may remain after each void because of the decreased contractility of the detrusor muscle.
Distended Bladder
203 URINARY RETENTION Urinary retention can occur postoperatively in any patient, particularly if the surgery affected the perineal or anal regions and resulted in reflex spasm of the sphincters. General anesthesia reduces bladder muscle innervation and suppresses the urge to void, impeding bladder emptying
204 Pathophysiology
Urinary retention may result from: diabetes prostatic enlargement urethral pathology (infection, tumor, calculus) trauma (pelvic injuries) pregnancy, neurologic disorders such as cerebrovascular accident, spinal cord injury, multiple sclerosis, or Parkinsons disease. Some medications cause urinary retention, either by inhibiting bladder contractility or by increasing bladder outlet resistance. 205 Pathophysiology
Medications that cause retention: anticholinergic agents (atropine sulfate, dicyclomine hydrochloride [Antispas, Bentyl]), antispasmodic agents (oxybutynin chloride [Ditropan], belladonna, and opioid suppositories), and tricyclic antidepressant medications (imipramine [Tofranil], doxepin [Sinequan]). alpha-adrenergic agents (ephedrine sulfate, pseudoephedrine), beta adrenergic blockers (propranolol), and estrogens.
206 Assessment and Diagnostic Findings
The assessment of a patient for urinary retention is multifaceted because the signs and symptoms may be easily overlooked. The following questions serve as a guide in assessment:
What was the time of the last voiding, and how much urine was excreted? Is the patient voiding small amounts of urine frequently? Is the patient dribbling urine? Does the patient complain of pain or discomfort in the lower abdomen? (Discomfort may be relatively mild if the bladder distends slowly.)
207 Does percussion of the suprapubic region elicit dullness (possibly indicating urine retention and a distended bladder)? Are other indicators of urinary retention present, such as restlessness and agitation? Does a postvoid bladder ultrasound test reveal residual urine?
Urine retention can lead to chronic infection. Infections that are unresolved predispose the patient to calculi, pyelonephritis, and sepsis. The kidney may also eventually deteriorate if large volumes of urine are retained, causing backward pressure on the upper urinary tract. In addition, urine leakage can lead to perineal skin breakdown, especially if regular hygiene measures are neglected.
Urinary Retention - Surgery Surgery (removal of obstuction, resection of prostate) Catheterization after surgery helps prevent overdistention
210 Nursing Interventions to Encourage Normal Urinary Elimination Interventions to maintain normal urinary elimination include: Maintain an adequate fluid intake. Promote normal voiding habits. Fluid Intake Increasing fluid intake increases urine production. A normal, average daily intake of 1200 to 1500 ml of fluids is adequate for most patients. Dilute urine helps prevent urinary tract stones and infection. Fluid Intake Immobilized patients may require fluid intakes of 2000 to 3000 ml per day to prevent calculi formation. Limited fluid intakes may be necessary for patients on fluid restrictions such as those with renal impairment or congestive heart failure. Fluid Intake Fluid intake can also be increased by encouraging the patient to eat plenty of raw fruits and vegetables, which have a high water content. Voiding Habits Hospital routines and prescribed medical therapies can interfere with a patients normal voiding habits. Assist patient with bedpans or with getting to the bedside commode or toilet, if needed. 5. URINARY INCONTINENCE Urinary Incontinence The involuntary loss of urine from the bladder. May be a complication of urinary tract problems or neurologic disorders and may be permanent or temporary. Nsg Measures: Minimize embarrassment; provide privacy Wash, dry, & inspect skin Prevent decubitus ulcers Provide bladder training
219 Although urinary incontinence is commonly regarded as a condition that occurs in older multiparous women, it is also common in young nulliparous women, especially during vigorous high-impact activity.
Age, gender, and number of vaginal deliveries are established risk factors. 220 221 Clinical Manifestations: Types of Incontinence
A. Stress incontinence - is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intra- abdominal pressure (sneezing, coughing, or changing position). - It predominately affects women who have had vaginal deliveries and is thought to be the result of decreasing ligament and pelvic floor support of the urethra and decreasing or absent estrogen levels within the urethral walls and bladder base. In men, stress incontinence is often experienced after a radical prostatectomy for prostate cancer because of the loss of urethral compression that the prostate had supplied before the surgery, and possibly bladder wall irritability
222 B. Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. The patient is aware of the need to void but is unable to reach a toilet in time. An uninhibited detrusor contraction is the precipitating factor. This can occur in a patient with neurologic dysfunction that impairs inhibition of bladder contraction or in a patient without overt neurologic dysfunction
223 224 C. Reflex incontinence
is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding.
This commonly occurs in patients with spinal cord injury because they have neither neurologically mediated motor control of the detrusor nor sensory awareness of the need to void.
225 D. Overflow incontinence - is the involuntary loss of urine associated with overdistention of the bladder. - Such overdistention results from the bladders inability to empty normally, despite frequent urine loss. - Both neurologic abnormalities (eg, spinal cord lesions) and factors that obstruct the outflow of urine (eg, tumors, strictures, and prostatic hyperplasia) can cause overflow incontinence
Other Classifications of Incontinence
E. Total incontinence: when no urine can be retained in the bladder, usually due to neurologic problem.
F. Nocturnal Enuresis: incontinence that occurs during sleep.
227 Medical Management
BEHAVIORAL THERAPY Behavioral therapies are always the first choice to decrease or eliminate urinary incontinence. In using these techniques, clinicians help patients avoid potential adverse effects of pharmacologic or surgical interventions
PHARMACOLOGIC THERAPY Pharmacologic therapy works best when used as an adjunct to behavioral interventions. Anticholinergic agents (oxybutynin
228 MEDICATIONS: [Ditropan], dicyclomine [Antispas]) inhibit bladder contraction and are considered first-line medications for urge incontinence. Several tricyclic antidepressant medications (imipramine, doxepin, desipramine, and nortriptyline) also decrease bladder contractions as well as increase bladder neck resistance. Stress incontinence may be treated using pseudoephedrine (eg, Sudafed).
Estrogen (taken orally, transdermally, or topically) has been shown to be beneficial for all types of urinary incontinence. Estrogen decreases obstruction to urine flow by restoring the mucosal, vascular, and muscular integrity of the urethra.
229 SURGICAL MANAGEMENT Surgical correction may be indicated in patients who have not achieved continence using behavioral and pharmacologic therapy.
Most procedures involve lifting and stabilizing the bladder or urethra to restore the normal urethrovesical angle or to lengthen the urethra.
Women with stress incontinence may have an anterior vaginal repair, retropubic suspension, or needle suspension to reposition the urethra.
10/15/2014 Miss Iman Shaweesh 230 231 Nursing Management
For behavioral therapy to be effective, the nurse must provide support and encouragemen to because it is easy for the patient to become discouraged if therapy does not quickly improve the level of continence.
Patient teaching regarding the bladder program is important and should be provided verbally and in writing.
The patient is assisted to develop and use a log or diary to record timing of Kegel exercises, changes in bladder function with treatment, and episodes of incontinence.
10/15/2014 Miss Iman Shaweesh 232 6. NEUROGENIC BLADDER 234 NEUROGENIC BLADDER
is a dysfunction that results from a lesion of the nervous system. It may be caused by spinal cord injury, spinal tumor, herniated vertebral disk, multiple sclerosis, congenital anomalies (spina bifida or myelomeningocele), infection, or diabetes mellitus.
235 Assessment and Diagnostic Findings
Evaluation for neurogenic bladder involves measurement of fluid intake, urine output, and residual urine volume; urinalysis; and assessment of sensory awareness of bladder fullness and degree of motor control. Comprehensive urodynamic studies are also performed.
236 Complications
The most common complication of neurogenic bladder is infection resulting from urinary stasis and catheterization. Urolithiasis (stones in the urinary tract) may develop from urinary stasis, infection, or demineralization of bone from prolonged immobilization. Renal failure can also occur from vesicoureteral reflux (backward flow of retained urine from the bladder into the ureters) with eventual hydronephrosis (dilation of the pelvis of the kidney resulting from obstruction to the flow of urine) and atrophy of the kidney. Indeed, renal failure is the major cause of death of patients with neurologic impairment of the bladder.
237 Medical Management
There are several long-term objectives appropriate for all types of neurogenic bladders: Preventing overdistention of the bladder Emptying the bladder regularly and completely Maintaining urine sterility with no stone formation Maintaining adequate bladder capacity with no reflux
238 Specific interventions include continuous, intermittent, or self-catheterization, use of an external condom-type catheter, a diet low in calcium (to prevent calculi), and encouragement of mobility and ambulation.
A liberal fluid intake is encouraged to reduce the urinary bacterial count, reduce stasis, decrease the concentration of calcium in the urine, and minimize the precipitation of urinary crystals and subsequent stone formation.
To further enhance bladder emptying of a flaccid bladder, the individual may try double voiding. After each voiding, the individual remains on the toilet, relaxes for 1 to 2 minutes, and then attempts to void again in an effort to further empty the bladder. This can be effective in patients with disorders characterized by neurogenic bladder (eg, multiple sclerosis)
Medical Management
239 PHARMACOLOGIC THERAPY Parasympathomimetic medications, such as bethanechol (Urecholine), may help to increase the contraction of the detrusor muscle.
SURGICAL MANAGEMENT In some cases, surgery may be carried out to correct bladder neck contractures or vesicoureteral reflux or to perform some type of urinary diversion procedure.
II. KIDNEY DISORDERS A. GLOMERULAR DISORDERS 1. GLOMERULONEPHRITIS Glomerulonephritis These diseases involving the glomerulus are the leading cause of chronic kidney disease Filtration which is the first step in urine formation occurs in the glomerulus. Inflammatory condition that affects the glomerulus. -Damages the capillary membrane and allows blood cells and proteins to escape from the vascular compartment into the filtrate Can be Acute or chronic.
GENERAL INFORMATION Immune complex disease resulting from an antigen- antibody reaction. Secondary to a beta-hemolytic streptococcal infection occurring elsewhere in the body. Occurs more frequently in boys, usually between ages 6-7 years Usually resolves in about 14 days Self-limiting Glomerulonephritis Fall in GFR activates the renin-angiotensin- aldosterone system leads to water retention and hypertension. Acute glomerulonephritis follows an infection with group A beta Strep such as strep throat. Protein complexes from the infection become trapped in the glomerular membrane causing an inflammatory response and drawing WBC to the area. Inflammation damages the glomerular capillary walls and makes them more porous. Plasma proteins and blood cells escape into the urine. Glomerulonephritis Initiating event Infection Chronic dx Increased Glomerular permeability Decreased GFR Glomerular capillary Membrane inflammation Glomerulonephritis Decreased GFR Increased Glomerular Permeability Hematuria Proteinuria Hypoalbuminemia Edema Azotemia Activation of the Renin angiotensin- Aldosterone System Na and water ret Hypertension Edema CM- Hematuria, proteinuria, loss of plasma proteins in the blood which leads to hypoalbuminemia. Edema follows caused by reduced osmotic draw within blood vessels. Glomerular filtration is disrupted, GFR falls and azotemia occurs. Azotemia- increased blood levels of nitrogenous wastes, urea, creatinine.
Glomerulonephritis Glomerulonephritis CM- acute develop abruptly, 10-14 days after the initial infection Nausea, malaise, arthralgias, proteinuria. Hypertension and edema (periorbital)more often in children and young adults, not elderly Symptoms may subside spontaneously, most people recover completely, some may develop chronic glomerulonephritis never regaining full kidney function. CLINICAL FINDINGS History of a precipitating streptoccal infection, usually URTI or impetigo
Edema, anorexia, lethargy Hematuria or dark-colored urine Fever Hypertension NURSING CARE MIO, BP, urine.
Provide client teaching and planning concerning: - Medication administration - Prevention of infection - Signs of renal complications - Importance of long-term follow-up Chronic Glomerulonephritis Result of kidney damage by a systemic disease such as diabetes. May occur with no previous kidney disease or apparent cause. Slow progressive destruction of glomeruli and nephrons. Kidneys decrease in size and surfaces become granular as nephrons are destroyed. Proteinuria. CM- Develop slowly, renal failure may develop years to decades after the disease is diagnosed. Diabetic nephropathy-impairs filtration and elimination. Damage in 15-20 yrs of diagnosis Lupus nephritis- hematuria and proteinuria, inflammatory lesions in the glomerulus. Chronic or acute may progress rapidly. Diagnostic test Antistrepolysin (ASO)titer- Identifies antibodies to group A beta-hemolytic strep. ESR- erythrocyte sedimantation rate will be elevated in glomerulonephritis. Indicator of inflammation. BUN and serum creatinine levels are increased in kidney disease. Serum electrolytes- will be elevated in kidney disease UA- blood and protein in the urine, 24 hour urine and creatinine KUB to evaluate kidney size, kidney scan or biopsey. Nursing Diagnosis Excess fluid volume related to plasma protein loss and sodium and water retention. Risk for infection r/t medication regeime Risk for imbalanced nutrition: less than body requirements related to anorexia Deficient knowledge: Glomerulonephritis related to lack of information Anxiety related to prescribed activity restriction Dietary Management Glomerulonephritis Sodium intake is restricted. Dietary proteins may be increased when protein is being lost in the urine/if azotemia is present dietary protein is restricted. When protein is restricted complete proteins such as meat, fish, eggs, soy or poultry should be given; these supply all the essential amino acids required for growth and tissue maintenance. Glomerulonephritis Treatment Medications Plasma exchange therapy Dietary management 256 Medical Management The treatment of ambulatory patients is guided by symptoms. If hypertension is present, the blood pressure is lowered with sodium and water restriction, antihypertensive agents, or both. Weight is monitored daily, and diuretic medications are prescribed to treat fluid overload. Proteins of high biologic value are provided to support good nutritional status (dairy products, eggs, meats).
Urinary tract infections are treated promptly. Dialysis is considered early in the course of disease to keep patient in optimal physical condition, prevent fluid and electrolyte imbalances, and minimize the risk of complications of renal failure. Medical Management Medications No specific drug tx for glomerulonephritis. Glucocorticoids such as prednisone. Penicillin or other antimicrobials for infection. Antihypertensives and diuretics to lower BP and to reduce edema NSAID for patients with nephrotic syndrome to reduce inflammation. Nursing Management Observe for common fluid and electrolyte disturbances in renal disease; report changes in fluid and electrolyte status and in cardiac and neurologic status. Give emotional support throughout the disease and treatment course by providing opportunities for patient and family to verbalize concerns. Answer questions and discuss options. Educate patient and family about prescribed treatment plan and the risk of noncompliance. Explain about need for follow-up evaluations of blood pressure, urinalysis for protein and casts, blood for BUN, and creatinine. If long-term dialysis is needed, teach the patient and family about the procedure, how to care for the access site, dietary restrictions, and other necessary lifestyle modifications. Remind patient and family of the importance of participation in health promotion activities, including health screening. Instruct patient to inform all health care providers about the diagnosis of glomerulonephritis. Nursing Management Nursing- Health Promotion Advise to the effective treatment of streptococcal infections in all age groups. Complete the full course of antibiotic therapy to eradicate the bacteria. Effectively managing diabetes, treating hypertension and avoid drugs and substances that are potentially damaging to the kidneys. Changes in urine output, rising serum creatinine and BUN levels should be reported to charge nurse. Monitor for increased wt, increase in blood pressure or edema NEPHROTIC SYNDROME Nephrotic Syndrome Nephrotic syndrome is a primary glomerular disease characterized by proteinuria, hypoalbuminemia, diffuse edema, high serum cholesterol, and hyperlipidemia. It is seen in any condition that seriously damages the glomerular capillary membrane, causing increased glomerular permeability with loss of protein in the urine. It occurs with many intrinsic renal diseases and systemic diseases that cause glomerular damage. It is not a specific glomerular disease but a constellation of clinical findings that result from the glomerular damage. Autoimmune process leading to structural alteration of glomerular membrane that results in increased permeability to plasma proteins, particularly albumin.
Course of the disease consists of exacerbations and remissions over a period of months to years.
Commonly affects preschoolers. - boys more often than girls
Prognosis is good unless edema does not respond to steroids. Plasma CHON enter the renal tubule Excreted in urine PROTEINURIA Oncotic pressure Plasma volume HYPOVOLEMIA Release of RENIN & ANGIOTENSIN Secretion of aldosterone Reabsorption of H2O & Na in distal tubule BP Release of ADH Reabsorption of H2O General shift of plasma into interstitial spaces MASSIVE EDEMA Clinical Manifestations Major manifestation is edema. It is usually soft, pitting, and commonly occurs around the eyes (periorbital), in dependent areas (sacrum, ankles, and hands), and in the abdomen (ascites). Malaise, headache, irritability. Assessment and Diagnostic Findings
Protein electrophoresis and immunoelectrophoresis to determine type of proteinuria exceeding 3.5 g/day. Urine may contain increased white blood cells and granular and epithelial casts Needle biopsy of the kidney for histologic examination to confirm diagnosis MEDICAL MANAGEMENT Treatment is focused on treating the underlying disease state causing proteinuria, slowing progression of chronic kidney disease (CKD), and relieving symptoms. Typical treatment includes diuretics for edema, angiotensin-converting enzyme (ACE) inhibitors to reduce proteinuria, and lipid-lowering agents for hyperlipidemia. MEDICAL MANAGEMENT Drug therapy - Corticosteroids - to resolve edema - Antibiotics - for bacterial infections - Thiazide diuretics - edematous stage Bedrest Diet modification - High CHON - Low Na NURSING CARE Provide bed rest. - Conserve energy. - Find activities for quiet play. Provide high CHON, low sodium diet during edema phase only. Maintain skin integrity. - Dont use Band-Aids. - Avoid IM injections - medication is not absorbed in edematous tissue. Obtain morning urine for CHON studies. Provide scrotal support. MIO, V/S and WOD Administer steroids to suppress autoimmune response as ordered. Protect from known sources of infection. B. VASCULAR KIDNEY DISEASES Hydronephrosis An abnormal dilation of the renal pelvis and calyces. Results from urinary tract obstructions or vesicoureteral reflux. (backflow of urine from bladder to ureters) When urine outflow is obstructed pressure in the renal pelvis increases and it dilates. The nephrons and collecting tubules may be damaged thus affecting kidney function. CM- Acute renal failure may develop. Diagnosed by ultrasound or CT scan. Cystoscopy to identify the cause. Hydronephrosis Prompt treatment is vital to preserve kidney function. Reestablishing urine flow from the affected kidney. Nephrostomy tube, ureteral stent or indwelling catheter may be required. Stents- used to keep ureters open and promote healing, surgery or cystoscopy. Temporary or longer periods if necessary. Nursing Care Hydronephrosis Preventing hydronephrosis and ensuring urinary drainage. Monitor intake and output Monitor bladder emptying to identify impaired urine outflow. Pelvic or abdominal tumors, urinary calculi, adhesions and scarring from previous surgeries or neurologic deficits.
POLYCYSTIC KIDNEY DISEASE Polycystic Kidney Disease Polycystic Kidney Disease Hereditary disease in which cysts form on the kidneys, the kidneys enlarge and their function is gradually destroyed. Common affects children and adults. Adult is slow and progressive, CM in 30-40. Offspring of clients with polycystic kidney disease have 50% chance of of inheriting the disorder. Genetic counseling! CLINICAL MANIFESTATIONS flank pain micorscopic or frank hematuria proteinuria, polyuria, nocturia. UTI and stones are common. Hypertension and renal failure DIAGNOSIS Renal ultrasound.
TREATMENT Fluids Ace inhibitors preserve kidney function avoid UTIs. Will have renal failure and need dialysis or kidney transplant.
RENAL FAILURE Renal Failure Kidneys are unable to remove accumulated waste products from the blood. Acute Chronic or end stage chronic Azotemia and fluid and electrolyte and acid- base imbalances are the defining characteristics. ARF Acute renal failure is a sudden, usually reversible deterioration in normal renal function. Risk factors: Critically ill, major trauma, surgery, infection, hemorrhage, severe heart failure, lower urinary tract obstruction. Acute Renal Failure It can be classified according to underlying cause as: 1. Prerenal: Most common results from conditions that affect the blood supply to the kidney. Hemorrhage. Shock or heart failure. a. Hypovolemia. b. Impaired cardiac efficiency. c. Vasodilatation. Acute Renal Failure 2. Intrarenal: damage to the nephrons by inflammation (acute glomerulonephritis, HTN) a. Acute nephritis. b. Antibiotics. c. NSAIDs.
3. Postrenal obstruction: obstruction of urine outflow a. Urinary tract obstruction. b. Tumors.
PRERENAL CAUSES INTRARENAL CAUSES POSTRENAL CAUSES Calculi BPH Tumors Strictures Blood clots Trauma Anatomic malformation Hypotension Acute tubular necrosis (ATN) Diabetes mellitus Cardiogenic shock Acute vasoconstriction Malignant hypertension Hemorrhage Acute glomerulonephritis Tumors Burns Septicemia Blood transfusion reactions CHF Nephrotoxins Clinical Stages of ARF: Initiation period: initial insult and oliguria. Oliguric period (urine volume less than 400 mL/day): Uremic symptoms first appear and hyperkalemia may develop. Diuresis period: gradual increase in urine output signaling beginning of glomerular filtrations recovery. Laboratory values stabilize and start to decrease. Recovery period: improving renal function (may take 3 to 12 months CLINICAL FINDINGS OLIGURIC PHASE Hypernatremia Hyperkalemia Hyperphosphatemia Hypocalcemia Hypermagnesemia Metabolic acidosis DIURETIC PHASE Hyponatremia Hypokalemia Hypovolemia CONVALESCENT PHASE Normal Urine Volume Increase in LOC BUN stable and normal May develop CRF 290 Acute Renal Failure Diagnostic Evaluation: 1. Serum creatinine levelthe most reliable measure of the GFR, found to be rising 2. Radionuclide studies to evaluate GFR and renal blood flow and distribution 3. Urinalysisreveals proteinuria, hematuria, casts 4. Ultrasonography to determine anatomic abnormalities 291 Acute Renal Failure Treatment: 1. Correction of any reversible cause of acute renal failure (ie, surgical relief of obstruction) 2. Correction and control of fluid and electrolyte imbalances - 3. Restoration and maintenance of stable vital signs - 4. Maintenance of nutrition with low-sodium, low- potassium, low-phosphate, moderate-protein diet - 5. Initiation of dialysis for patients with life- threatening complications Chronic Kidney Disease/ Chronic Renal Failure Progressive, irreversible destruction of the kidneys that continues until nephrons are replaced by scar tissue. Loss of renal function is gradual. Hypervolemia can occur owing to the inability of the kidneys to excrete sodium & water, or hypovolemia can occur owing to inability of the kidneys to conserve sodium & water Highest in African Americans. Diabetes is the leading cause of ESRD, hypertension, glomerulonephritis. 293 Chronic Renal Failure Causes: 1. Recurrent UTIs. 2. Toxic agents. 3. Diabetic nephropathy. 4. Uncontrolled hypertension.
STAGE 1 DIMINISHED RENAL RESERVED Renal function decrease No accumulation of metabolic wastes the healthier kidney compensates Nocturia & polyuria occur as a result of decrease ability to concentrate urine
STAGE II RENAL INSUFFICIENCY Metabolic wastes begin to accumulate oliguria & edema occur as a result of decrease responsiveness to diuretics
STAGE III END STAGE Excessive accumulation of metabolic wastes kidneys are unable to maintain homeostasis dialysis or other renal replacement treatment is required
Nephrons are destroyed by disease, those that remain hypertrophy to compensate for the lost tissue. The increased demand on these nephrons increased their risk for damage and destruction. Chronic Renal Failure/ CKD CKD STAGES The stages of CKD (Chronic Kidney Disease) are mainly based on measured or estimated GFR (Glomerular Filtration Rate). There are five stages but kidney function is normal in Stage 1, and minimally reduced in Stage 2
STAGE GFR DESCRIPTION 1 90+ Normal kidney function but urine findings or structural abnormalities or genetic trait point to kidney disease 2 60-89 Mildly reduced kidney function, and other findings (as for stage 1) point to kidney disease CKD STAGES 3A 3B 45-59 30-44 Moderately reduced kidney function 4 15-29 Severely reduced kidney function 5 <15 or on dialysis
Very severe, or endstage kidney failure (sometimes callestablished renal failure) CLINICAL FINDINGS
1. Correction of calcium phosphorous imbalance. Administer activated vitamin D to increase calcium absorption and calcium phosphate binders with meals to bind phosphate in the gastrointestinal tract. 2. Correction of acidosis with buffers such as Bicitra 3. Diets should meet caloric needs of the child containing adequate protein for development (1.01.5 g/kg per day).
302 Treatment: 4. Correction of anemia through the use of erythropoietin (Epogen) administered subcutaneously at home 5. Growth retardation should be evaluated for possible use of growth hormone. 6. Treatment options for end-stage renal disease are hemodialysis, peritoneal dialysis, or transplantation. 7. Institute dialysis therapy while transplant work-up is in progress. Prevent neurologic complications. Assess qH for signs of uremia: fatigue, loss of appetite, decrease U/O, apathy, confusion, HPN, edema of the face & feet, itchy skin, restlessness & seizures Assess for changes in mental functioning Orient confused client to time, place, date, & persons Institute safety measures to protect client from falling out of bed Monitor serum electrolytes, BUN, & creatinine as ordered
NURSING CARE: Promote optimal GI function. assess/provide care for stomatitis Monitor N/V & anorexia Administer antiemetics as ordered Assess for signs of gi bleeding
NURSING CARE: Monitor/prevent alteration in F/E PROMOTE MAINTENANCE OF SKIN INTEGRITY Assess/provide care for pruritus Assess for uremic frost & bathe in plain water * urea crystallization on the skin
NURSING CARE: - MONITOR FOR BLEEDING COMPLICATIONS, & PREVENT INJURY Monitor Hgb, Hct, platelets, RBC Hematest all secretions Administer hematinics as ordered avoid IM injections
NURSING CARE:
Assess for hyperphosphatemia - Paresthesias - Muscle cramps - Seizures - Abnormal reflexes Normal value of phosphate= 2.5-4mg/dl; child= 6mg/dl Administer Aluminum hydroxide gels as ordered - Amphogel, AlternaGEL
Potassium= normal =3.5-5mEq/L; >6mEq/L (peak T waves, widened QRS), metabolic acidocis increase serum potassium level administer kayexalate ( sodium polysterene SO4)
Promote/maintain maximal cardiovascular function. - Cardiovascular disease is the leading cause of death in client with chronic kidney disease, HTN is common. - Most meds are excreted by the kidneys. Antihypertensive drugs are used to decrease BP. - Lasix and ACE inhibitors.
Provide care for client receiving dialysis.
309 Educating About Chronic Renal Failure
1. Because numerous issues may interfere with the patient's psychological and social development and education, help the patient and family to cope with: a. Uncertainty regarding the course of the disease and ultimate prognosis. b. Abnormal lifestyle necessitated by dialysis. c. Burden of dialysis and continuous administration of medications. d. Fear of death, present in most children, adolescents, and family members
ESRD Uremia- nausea, apathy, weakness, fatigue. Vomiting, lethargy and confusion Cardiovascular disease is the leading cause of death in client with chronic kidney disease, HTN is common. Most meds are excreted by the kidneys. Antihypertensive drugs are used to decrease BP Lasix and ACE inhibitors. Fluids and sodium intake are restricted. CHO are increased. TPN may be initiated. Renal replacement Therapy Dialysis- Diffusion of solutes across a membrane from an area of higher concentration to one of lower concentration. Used to remove excess fluid and waste products in renal failure. Blood is separated from a dialysis solution by a semipermeable membrane. Water and solutes such as urea and electrolytes diffuse across this membrane, but proteins do not. Dialysis compensates for the kidneys inability to eliminate excess water and solutes. 2 or 3 sessions per week. Outpatient center. Dialysis Hemodialysis- Electrolytes, waste products and excess water are removed from the body by diffusion and filtration. The clients blood is pumped through a dialyzer. Peritoneal Dialysis- The peritoneum serves as the dialyzing surface. Warmed dialysate is instilled into the peritoneal cavity through a peritoneal catheter. END