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Medical surgical nursing II for second year BSC nursing student

By Berihun Assefa April 5/2012

Course information
Course Title Medical surgical nursing II Credit hour: 4 Course number: Nurs 322 ? Duration : April 5 August 5 / 2012 Course instructor: Berihun Assefa Address: berihunassefa21@yahoo.com

General objective
After completion of this course, the student will be able to assess, diagnose and manage patients with medical surgical disorders related to GUT ,musculoskeletal , and GIT and / or refer those requiring higher level of management.

Cont--Course prerequisite Student must completed medical surgical I Course logistics Location : at blue Nile college class room first floor Contact Date : every Thursday and Friday time: 8:00-10:0 AM

Cont---Teaching method Interactive presentation Individual or group assignment and presentation Teaching Aids
Printed materials LCD projectors blackboard

Cont--Assessment [tentative] Home Take Assignment Group presentation Mid-sem. Exam final exam Total

10% 10% 30% 50% 100%

Contents
Unit 1: Genito urinary tract (GUT) disorders Unit 2: Musculoskeletal system disorders Unit 3: Gastrointestinal tract (GIT) disorders

.
References: 1. Donna D. IGNATAVICIUS. A Nursing Process approach Medical surgical 2. Medical surgical Brunner 11th Edition 3. Lackman and Sorensson medical surgical nursing 4. Sharon medical surgical Nursing5. Harrisons principle of internal Medicine 16th edition

Anatomy &Physiology
GUT consists of kidneys, ureter, urethra and bladder The kidneys are paired, bean-shaped organs. Adult human kidney, weighs 120 to 170 g, are approximately 8-12 cm long, 6 cm wide, and 3 cm thick.

Nephrons
Nephrons are the functional units of the kidney that transfer waste products from the blood to urine. Each human kidney has approximately one million nephrons. Nephron consists of glomerulus and a tubule Glomeruli are the filtration units of the nephron.

Fig.

Function of Kidneys
Regulate fluid, electrolyte and acid base composition (main role) Remove toxic waste products, excess water and salts Play a part in controlling blood pressure Produce erythropoietin which stimulates red cell production Helps to keep calcium and phosphate in balance for healthy bones Maintains proper pH for the blood

Composition of urine
Urine is composed primary of water. The normal person ingests approximately 1-2 lts of water per day , about 400-500 ml of this fluid intake is excreted in the urine. Electrolytes: Na, K, Cl, bicarbonates and others also excreted by the kidneys. N.B. amino acids and glucose are usually filtered in the glumerulus and reabsorbed, so neither excreted in the urine

cont --Na Filtered /24hrs 540.0gm Reabsorbed /24hrs 532.0gm Excreted/ 24hrs 3.3gm

Chloride
Bicarbonate Potassium Glucose Urea Creatinine Uric acid

630.0gm
300.0gm 28.0gm 140.0gm 53.0gm 1.4gm 8.5gm

625.0gm
~300.0gm 24.0gm 140.0gm 28.0gm 0.0gm 7.7gm

5.3gm
0.3gm 3.9gm 0.0gm 25.0gm 1.4gm 0.8gm

Cont-- Creatinine: is an endogenous waste products of skeletal muscles/ an end products of muscle and protein metabolism.

Creatinine clearance is a good measure of glomerular filtration /GF i.e. 1.4gm filtered and 1.4gm excreted. The normal adult glomerular filtration rate/GFR is about 100-120ml/minute or 1.67-2ml/second.

Cont-- Urea nitrogen (UN): nitrogenous waste in the urine. Blood urea nitrogen (BUN): it measures the renal excretion of urea nitrogen /a by product of protein metabolism in the liver./ BUN levels indicate the extent of renal clearance of this nitrogenous waste products. BUN level is not always elevated with kidney diseases and is not best indicator of kidney function. But elevated BUN is highly suggestive of kidney diseases. Normal value: 10-20 mg/dl

Bladder pressure
Normally very low even urine accumulation is there. b/c the bladder smooth muscle adapts to the increased stretch as the bladder is slowly filled. The first sensation of bladder filling occurs w/n about 100-150ml of urine are present in the bladder. In most cases the desire to void occurs w/n the bladder contains approximately 200-300ml of urine. With 400 ml a marked feeling of fullness is usually present.

Clinical manifestations of urinary and renal dysfunction

A) Pain: Kidney pain Pain in the flank Bladder pain Scrotal pain Back and leg pain

Cont--b) Change in voiding Is normally a painless function occurring 3-6 times daily and occasionally once at night. The average person forms and voids 12001500ml of urine in 24hrs. The amount is modified by fluid intake, sweating, environmental temperature, vomiting, and diarrhea.

Common problems associated with voiding includes.

Urinary frequency: voiding that occurs more than usual. Urgency: strong desire to void. Dysuria: painful or difficult voiding. Hesitancy: undue delay and difficult in initiating voiding. Nocturia: excessive urination at night.

Cont-- Urinary incontinence: involuntary loss of urine. Stress incontinence: intermittent leakage of urine due to sudden strain. Enuresis: involuntary voiding during sleep. Polyurea: excessive amount of urine voided in a given time

Cont-- Oligurea: a small amount of urine /urine out put 100500ml/24hrs i.e. usually <400ml/24hrs Anuria: absence of urine in the bladder/urine out put <100ml/24hrs , if <50ml complete anuria, usually indicate obstruction of urinary tract. Hematuria: reed blood cells in the urine Protein uria /albumin uria: abnormal amount of protein in the urine. Burning on urination

Cont--C) Gastrointestinal symptoms nausea, vomiting, diarrhea, abdominal discomfort, paralytic ileus and etc.

Cont--D) Others Edema Shortness of breath Vital sign change Etc.

Assessment of kidney (rgt)

Assessment of kidney (left)

Bladder examination

Diagnostic evaluations
Normal findings in the routine urinalysis
Components Colour Specific gravity PH Opacity Glucose Ketone Protein/albumin Billuribin Bacteria Parasites Casts Crystals RBCs WBCs Normal values Pale, yellow to deep amber 1.002 - 1.035 4.5 8 Clear Negative Negative Negative negative None None None none 0-3 0-5

Disorders of the urinary tracts

Infections of the urinary tract (UTI) UTIs is defined a the presence of significant bacteria or any microorganisms in the urinary tract with or with out sign and symptoms. It can be divided in two general anatomic categories. i.e.

Cont--1) Lower UTI urethritis /urethra Cystitis/ bladder Prostatitis /prostate 2) Upper UTI Pyelonephritis /kidney Ureteritis /ureter

Cont--Etiology The most common organisms causing UTI are found in the fecal /by ascending from the perineum to the urethra and bladder. More than 80% are caused by E. coli.

Cont--Others kelbsiela strep.facalis enterobacter Pseudomonas. Staph. etc

Epidemiology:
2nd to RTI in incidence. Common in females Reasons Short female urethra Anatomical proximity to vagina/urethra and rectum Pregnancy N.B. bactericidal properties of prostatic fluid protects men from UTIs.

Risk factors
1) Abnormalities of the UT that obstruct or slow urine flow /increase the adherence of bacteria to mucosal surface. This may be due to : Congenital abnormalities Urethral stricture Contracture of bladder neck Bladder tumors

Cont-- Caliculi /stones in the ureters or kidneys BPH in men Compression of ureters Neurologic abnormalities Pregnancy

Cont--2) Catheterization /especially prolonged. 3) DM/ increases urinary glucose level and decrease immunity of the pt. 4) Neurologic bladder 5) Pregnancy

Clinical manifestations of UTIs

Bacteriuria Frequent pain Burning on urination Hematuria Back pain - fever - chills - CVAT - pain in urination - etc

Diagnosis
Colony count (> 105 /ml of urine mid stream urine Cellular findings- hematuria Urine culture Etc

Diseases of ureters, bladder and urethra

Uretric disorders Primary disorder of the ureters occurs less frequently than disease of the other part of the urinary system. congenital anomaly or rarely a neoplasm may occur in ureters. This may lead to a back flow of urine from ureter to kidney.

Cont-- Ureteritis occurs with pyelonephritis Calculus may become lodged with in a ureters causing an obstruction of the flow of urine as well as severe pain. Mgt
- Surgery is carried out to correct the defect primary neoplasm of the ureters and to remove obstruction. - Abs for infection.

Ureteral constriction
Dfn: Narrowing of the ureters Cause: Infection, foreign body congenital anomaly and tumors.

Cont-Clinical Manifestation Patient shows all the sign and symptom of infection Eg. Pain Mgt Surgical intervention Analgesics / Antispasmodics Antibiotics

Disorders of the bladder

CYSTITIS Cystitis is an acute or chronic inflammation of the urinary bladder that is most often by ascending infection from urethra. Cause Ascending bacteria infection from the urethra Urethrovesicular reflux; flowing back of urine from the urethra in the bladder

 Organisms from rectal and vaginal discharge can enter easily /fecal contamination. Use of catheters and other examination objects e.g. cytoscope Mechanical : trauma of the tissue, stagnation of urine. In male prostatic hyperplasia or infection may cause cystitis.

Clinical Manifestation
Urgency, frequency and dysuria Pyuria Suprapubic Pain baterimia Foul Smelling urine Haematuria etc

Cont--Method of diagnosis urinalysis, urine for culture and sensitivity, clinical finding and radiological examination and cystoscopy

Fig. Cystoscopic examination

Cont--Management In uncomplicated cases about 80% of pts will be cured with 3 days. Analgesic (Antispasmodics) Sodium bicarbonate relives bladder irritation regular emptying of bladder etc.

Cont- Antibiotics e.g. Cotrimoxazole 960 mg PO BID for 7 days or Norfloxacillin 400mg PO BID for 7 days or Ciprofloxacillin 500 mg QID for 7 days

Disorders of the urethra

A) urethral strictures is a narrowing of the lumen of urethra due to scar tissue and contraction. Cause: urethral injury /due to surgery or indwelling catheter urethritis congenital abnormalities

Cont-- N.B. stricture causes urine to back up and resulting in cystitis, prostatitis, and pyelonephritis.

Cont--Mgt gradual dilation of narrowed area with metal sounds or surgery /internal urethrotomy Prevention avoid prolonged urethral catheter safe use of instrumentation including catheter treatment of urethral infection.

Cont--B) Urinary retention Refers to inability to urinate despite the urge or desire to do so. Cause: Post operative results in reflex spasms of the sphincters. General anesthesia: reduce bladder muscle innervations and urge to void is suppressed.

Cont-- Acute illness Prostatic enlargement Anxiety Urethral pathology/infection, tumor, calculus/ Medications e.g. antispasmodics, antidepressants, antihistamines, B-adergenic blockers, antihypertensive.

Cont--Mgt Encourage voiding Providing privacy Assisting pt to bath room Provide warmth to relax sphincter i,e. stiz baths, warm compress over perineum, shower Giving pt hot tea to drink

Cont-- Provide a more natural setting for voiding or allowing the male pt to stand beside the bed while using urinal. If not catheterization- if prostatic obstruction : suprapubic catheter. Reliving pain and discomfort Treatment of the underlying cause

Cont--C) Urethritis - is an inflammation of the urethral mucosa usually an ascending. - - it may be gonorrheal and non-gonorrheal urethritis. I) Gonorrheal Urethritis Is caused by N. gonorrhea Transmitted by sexual intercourse

Clinical manifestation
Gonorrhea most frequently present with local manifestations In men: infection involves the tissues around the urethra. Inflammation of the meatal orifice occurs with burning on urination Purulent urethral discharge present

Cont--In women
Urethral discharge is not always present Diseases may also asymptomatic i.e. Gonorrhea in female is not frequently diagnosed and reported. The most common complication of gonoccocal infection in women is PID, in which organism infects the ureters, and fallopian tube and increase the risk of ectopic pregnancy.

Cont--Diagnosis s/sx

culture and sensitivity

Cont--Mgt ciftriaxone , ciprofloxacin, or ofloxaxin + doxycycline 100mg PO BID for & days. N.B. both partners should be treated.

Cont--B) Non gonococal urethritis Not associated with N. gonorrhea Caused by Chlamydia trachomatis or other microbes Characterized by mild to sever dysuria and scanty to moderate urethral discharge

Cont--Mgt Doxycycline or tetracycline Erythromycin.

Disorders of prostate gland

A) Prostatitis (male reproductive system) Prostatitis is inflammation of prostate gland caused by infections agent (bacteria, Fungi and mycoplasma) or by a variety of other problems.

Cont--Cause Infections agents - bacterial, fungi & mycoplasma Urethral stricture & hyperplasia of prostate Microorganisms usually are carried to the prostate from the urethra.

Cont--Clinical Manifestation Perineal pain and discomfort Urethrtitis Urgency , frequency and dysuria Prastatodynia (pain in the prostate) on voiding.

Cont-- Acute bacterial Prostatitis may produce a sudden onset or fever & chills and perineal, rectal, low back pain and dysuria may be evident.

Cont--Methods to Diagnosis Careful history, c culture of prostate fluid or tissue and urine culture digital examination.

Cont--Mgt The goal of treatment is to avoid the complication of abscess formation and septicemia. A broad spectrum antimicrobial drugs for 10 14 days, I.V administration of the drug may be necessary to achieve high serum and tissue level.

Cont-- Bed rest, antispasmodics, laxatives to soften stool and sitz bath Patient education, therapy, fluid intake but not force fluid, diet and drinks which have diuretic action e.g. Coffee, Tea, alcohol, coca etc--- increase prostatic secretion should be avoided, avoidance of sexual intercourse. prolonged sitting also be avoided and medical follow up for at least 6 months to 1 year.

B) Benign prostate hyperplasia (Hypertrophy) BPH

The most common problem of the adult male reproductive system This problem occurs in about 50 percent of men over 50 years of age and 75% of men over 70 years. The prostate gland enlarges extending up ward in to the bladder and obstructing the outflow of urine by encroaching on the vesical orifice.

Cont--Cause (Etiology) Uncertain but evident suggests a hormonal cause as initiating hyperplasia of the supporting stromal tissue and a glandular element in the prostate.

Clinical Manifestation & Diagnostic Evaluation

Increasing potency of urination nocturia, hesitancy in starting urination increasing of force of urinary stream interruption of urinary stream, a sensation of incomplete emptying of the bladder,

Cont-- urine dribbles out after urination, an acute urinary retention (infection) fatigue secondary to nucturia anorexia nausea and vomiting due to impaired renal function epigastria discomfort due to distended bladder Heamaturia, urimia at the later stage

Diagnosis
History and c/ms Symptoms of prostatism (frequency , dysuria, urgency, dribbling, hesitancy) P/E On rectal examination the prostate is found to be enlarged. Complete hematological investigation, x-ray and Cystoscopy examination.

Cont--Mgt The plan of treatment depends on the cause, the severity of obstruction and the condition of the patient (Mgt also depends on age) Catheterization to treat an acute urinary retention. Some times a supra pubic cystostomy to give adequate drainage.

Cont-- Water and electrolyte replacement is necessary. Antimicrobial drugs may be necessary to treat UTI Surgery to remove the hyper plastic prostate tissue to provide permanent relief of the obstruction it is referred to as a prostatectomy.

3) DISEASE OF THE KIDNEY

1) Pyelonephritis: It is bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys. Cause: Ascending infection /bacteria ----- urethra --bladder --- ureter ---- kidney/

Cont--- secondary to uretero vesical reflux, in which incompetent uretero vesical valve allows the urine to back up into the ureters. Bladder tumor, strictures, BPH, urinary stones are among other causes Due to hematologic spread

Cont-- It can be acute or chronic A) Acute pyelonephritis Active infection manifested by fever, chills, CVA tenderness,

nausea, vomiting, tachycardia, and symptoms of lower UTI such as dysuria and frequency.

CAVAT

Cont--B) Chronic Pyelonephrjitis May be due to repeated attack of acute pyelonephritis Noticeable signs include - fatigue, - poor appetite - head ache, - polyuria, - excessive thirst, and weight loss. complication: end - stage renal disease

Cont--Diagnosis Urinalysis urine culture /colony count, pyuria /WBCs, hematuria /RBCs, Ultrasound for stone and obstruction along urinary tract. BUN measurement Creatinine level

Cont--Management Abs Amoxicillin 500 mg PO TID or ampicillin 500 mg IV QID or cloxacillin 500 mg IM/IV QID or Gentamicine 80 mg IV TID followed by Po for 14 days

Cont--Current drug of choice Norfloxacillin 400 mg PO BID or Ciprofloxacillin 500 mg PO BID for 14 days For hospitalized patients Ceftraxoine 250 -500 mg PO BID for 14 days mild cases can be treated with cotrimoxazole 960 mg Po TID for 7-10 days

Cont--for pregnant mothers ampicillin, amoxa, or ceftraxione are used Norfloxacillin and cipro are CI Cotrimoxazole and Gentamycin are CI for pts with renal failure /decreases urine out put.

Cont-- Nursing Intervention - Accurate record of intake and output - Protection from infection (URI) - Encouragement of fluid intake - Education concerning, Medication, followup , Identification of reoccurrence of infection

2) Glomerulonephritis (GN)
Is abroad term refers to a group of kidney disease in which there is an inflammatory reaction in the glomeruli. It can be acute or chronic

Cont--I) Acute glomerulonephritis (AGN) It is not an infection of the kidney but rather the result of unwanted side effect of the defense mechanism of the body. As a result of antigen antibody reaction/ exaggerated immune response.

cont--Cause In most cases is due to group A beta hemolytic streptococcal infection of the throat, by interval of 2 to 3 wks. GN may also follow impetigo/skin infection and acute viral infection such as URTIs, mumps, varicella, EBV, HBV, and HIV/AIDS/

Cont--Clinical manifestation
Facial or generalized edema, kidneys become large, swollen, and congested gross heamaturia, and protienuria, headache, malaise and flak pain /CVA tenderness, mild or sever hypertension, History of pharyngitis or tonsillitis with fever Some times and asymptomatic and rarely renal failure.

Cont-- Diagnosis hx of URTIs Raised antibody titers to the streptococcal antigens (ASO) hematuria cola colored urine due to RBCs and protein or casts protein urea due to increase permeability of glomerular membranes BUN increases Serum ceratinine increases Urine output decreases Anemia /due to loss of RBCs

Mgt
Objectives: to preserve the kidney to treat complication This include: Penicillin if strep. Suspected. Bed rest Dietary protein is restricted. Na/salt restricted w/n HPN, edema, and CHF Diuretics and antihypertensive drugs to control HPN CHO is given for energy and to reduce catabolism of protein. Treatment with steroids and cytotoxic drugs to decrease inflammation

Cont--Nsg intervention Heath Promotion and maintenance E.g. early diagnosis and treatment of sore throat and skin lesion . If streptococcus is found in the culture treatment with appropriate antimicrobial drug (Usually penicillin) is essential. Pt education concerning diet, rest, regular follow up etc...

Cont--Complications: Hypertensive encephalopathy, congestive heart failure and pulmonary edema. In some cases the diseases may progress to chronic GN.

Cont--II) CHRONIC GLOMERULDNEPHRITIS (CGN) It occurs due to repeated occurrence of antigen antibody reaction. is a syndrome that reflects the end stage of glomerular inflammatory disease. Repeated occurrence of this reaction makes the kidney reduced to as little as one fifth (1/5) at their normal size.

Cont-- the surface of the kidney becomes rough and irregular. Numerous glomeruli and their tubules are thickened/scared results sever glomerular damage.

c/ms
Edema/ pedal edema massive protienuria, hypoalbuminia, elevated B/P, HA, dizziness, and digestive disturbances Loss of weigh and strength, irritability, Progress S/Sx of renal insufficiency and chronic renal failure may develop anemia, ascites and , hydrothorax Pericarditis with effusion. Signs of CHF

Diagnosis
Hyperkalemia Anemia Hypoabuminia with edema Increases serum phosphorus GFR falls below 50ml/minute Decreases serum calcium Impaired nerve conduction Chest X-ray shows cardiac enlargement and pulmonary edema.

Cont--Prognosis: Poor (majority fail progressively and die 1or 2 yrs. A few patients will improve & they may enjoy fair health for many years.

Cont--Mgt Depends on the pt and c/ms The goal of treatment is to:- Relieve edema - Cure or control the primary disease - Treat hypertension and renal infection

Cont-- This include:

Diuretics

Low salt sodium Prednisolone Elevate the head of the bed to promote comfort Adequate calories

Bed rest Initiation of dialysis Prevent fluid and electrolyte imbalance

Cont-- Nsg intervention Daily weight control accurate record of intake and out, observation of edema high protein diet protect from infection, Psychological treatment Pt education about the worsening signs of renal failure i.e. nausea, vomiting, diminished urine out put.

Cont--Complication End stage renal diseases. Cardiovascular disorder Respiratory Disorder Metabolic

3) Nephrotic Syndrome
is a clinical disorder characterized by Protienuria Hypoalbuminemia: the primary manifestation Edema and Hypercholesterolemia and low density of lipids lipoproteins

Phatophysiolgy
any condition that seriously damages the glemerular capillary membrane Increased glomerular permeability Marked losses of protein in the urine Decrease albumin in the blood

Cont--diminished protein in the serum stimulates synthesis of lipo proteins in the liver leading to an elevated lipid concentration in the blood /hyperlipidemia

Cont--Decrease albumin in the blood decreased oncotic pressure. fluid moves from the vascular system into the extra cellular fluid spaces. leads generalized edema

Cont--A decreased circulating blood volume activates renine angiotension aldestrone system leading to retention of sodium further edema.

Summary

Cont--Causes
Chronic glomerulonephritis (mostly) Diabetes mellitus with intercapillary glomerulosclerosis, intrinsic renal diseases or systemic diseases that affects the glomerulus. E.g. - systemic lupus erythematous - renal vein thromboses and others, e.g. Syphilis, etc..

Cont-- Clinical manifestations Localized and generalized edema (the major manifestation) Protienuria Hypoproteinemia Less urine output Usually pale, fatigue and anorexia. haematuria due to damage to the glemerular capillaries Malaise Headache Irritability Fatigue etc

Cont--Management The objective of management is to preserve renal function Usually it is nonspecific, depends on the cause Bed rest- promote diuresis and reduce edema If edema is sever the patient is placed on low sodium diet and diuretics are prescribed

Cont-- Diet - protein intake is increased to replace urinary

losses and restore body proteins while restrict cholesterol and fat intake. Adreno cortico steroids/ pednisone/may be used to reduce proteinuria Anti neoplastic agents /cytoxan/ or immuno suppressive agents (imuran,leulceran, or cyclosporine) Antimicrobial drugs for infection

4) Nephrosclerosis
is hardening or sclerosis of the arteries of the kidney due to prolonged hypertension. This causes decreased blood flow to the kidney and patchy necrosis of the renal parenchyma. Eventually fibrosis occurs and glomeruli are destroyed.

Cont--Cause often associated with malignant hypertension /diastolic blood pressure >130 mmHg/ and atherosclerosis

Cont--c/ms Patient complains renal symptoms urine contains protein and casts. Renal insufficiency and associated signs & symptoms of real failure occur late in the disease. Treatment Aggressive antihypertensive therapy.

5) Hydronephrosis
is dilation of the renal pelvis and calyces of one or both kidneys. Causes Obstruction of urine flow secondary to (by) - Calculus - Scar tissue - Kink in the ureter - enlarged prostate gland and pregnancy due to the enlarged uterus. etc.

Phatophysiology
Due to variety of causes the accumulating urine exerts pressure on the renal pelvis wall. At low to moderate pressures, the kidney may dilate with no obvious loss of function. over time, sustained or intermittent high pressure causes irreversible nephrone destruction and atrophy of the kidney results.

Cont-- if the obstruction is in the urethra or the bladder the back - pressure affects both kidneys . If the obstruction is in one of the ureters because of a stone only one kidney is damaged.
As one kidney undergoes gradual destruction, the contra lateral kidney enlarges (compensatory hypertrophy/renal function is impaired.

Cont--Clinical manifestation
patient may be a symptomatic if the onset is gradual Acute obstruction may produce : aching in the flank and back. if infection develops ;dysuria , chills, fever, tenderness, pyuria and hematuria. If both kidney are affected signs & symptoms of renal failure develop.

Management
The goal of managements are
To identify and correct the cause of obstruction To treat infection To restore and conserve renal function

Cont-- To relieve the obstruction, the urine may have to be diverted by nephrostomy Infection is treated by anti - microbial agents Surgical removal of the obstructive lesions/calculus, tumor, obstruction of the ureter/ If one kidney is severely damaged and its function is destroyed, nephrectomy /removal of the kidney may be performed.

6) Urolithiasis
refers to the presence of stone /Calculi/ in the urinary tract. Calculi may be found anywhere from the kidney to the bladder if the stone formation is in the kidney is called Nephrolithiasis, and if in the ureter = uretrolithiasis.

Fig. sites of calculi formation

Cont---

Cont---

Cont--cause is caused by many metabolic disorders i.e. when urinary concentrations of substances increases. E.g. absorption of excessive amount calcium through GI tract /hyper calciuria or due DHN/increase super saturation of calcium.

Cont-- 75% of stones contain calcium - Calcium oxalate (alkaline) or Calcium phosphate Others : Uric acid (8%), struvite (5%) and cystine (3%)(acidic) It can also occur when there is deficiency of substances that normally prevent crystallization in the urine such as Citrate.

Cont--Hypercalcimia can be primary or secondary Primary: absorptive (intestinal calcium absorption) and or renal( decrease renal excretion of calcium) Secondary: hyperthyroidism, vitamin D intoxication, immobilization, renal tubular acidosis.

Cont-- N.B. diet high in calcium is not believed to cause stone unless metabolic defect or renal tubular defect already exists. Low calcium diet does not prevent stone formation.

Cont-- Factors which affect the rate of stone formation include PH of the urine Urinary stasis immobilization Fluid volume status of individuals (stones tend to occur more often in dehydrated states). Urinary retention, Infection

Cont--Incidence: About 12% of adults will have at least one episode of renal stone formation. Recurrence rate vary depending on the type of treatment.

Cont--Clinical manifestation Clinical manifestations of stones in the urinary tract depends on the presence of obstruction, infection & edema. When the stones block the flow of urine; obstruction develop producing = increase in hydrostatic pressure ; distending the renal pelvis & proximal ureter and infection.

Cont--Stones in the renal pelvis may be associated with sever pain commonly called renal colic (major c/ms) : Intense deep ache in the costo vertebral region. Flank pain suggests stone in the kidney or ureter. If it radiate to scrotum, testes, or vulva suggests stone in ureter and bladder

Cont-- others N/V/pallor Hematuria Pyuria Frequency and dysuria Oliguria /anuria: suggests obstruction Diarrhea & abdominal discomfort due to reno intestinal reflexes and anatomic proximity of kidney to stomach, pancreases and large intestine

Cont--Diagnostic Evaluation KUB Studies Radiography (stones are seen in KUB) Blood chemistry (increased serum ca, phosphate or uric acid) Urine analysis (hematuria, WBC, bacteria)

Cont--Management /Non surgical/ The immediate objective of renal or ureteral colic is to relieve the pain until its cause can be eliminated.
morphine meperidine is administered to prevent shock and syncope that may result from the excruciating/sever pain. apply hot baths or Moist heat to the flank areas

Cont-- Encourage fluid taking (2-3lts/day) unless contra indicated to dilute stone forming crystals, prevent dehydration, promote urine flow. Encourage walking. Vitamin "D" enriched foods should be avoided Table salt & high sodium foods should be reduced

Cont-- reduction of dietary calcium & phosphorus content may help to prevent further stone formation b/c most stones contain calcium combined with phosphate & other substances.

Cont-- Acidification or alkalinization of urine depends on the cause. E.g. uric acid containing stones : alkalinize the urine by using drugs such as potassium citrate, sodium citrate, sodium bicarbonate. (normal urine pH on average 5-6) For uric acid stones the patient is placed on a low purine diet to reduce excretion of uric acid in the urine.

Cont-- For oxalate stones, a dilute urine is maintained and the intake of oxalate is limited. Treatment hypercalciuria : diuretics. Treatment of infection and prevention of obstruction

Cont-- If the stone is not passed spontaneously or if complications occur treatment modalities may include. Non invasive procedure used to break up stones in the calyx of the kidney. . End urologic methods of stone removal
Extracorporeal Shock Wave Lithotripsy Ureteroscopy

fig. Extracorporeal Shock Wave Lithotripsy

Cont-- Surgical Removal- surgical intervention is indicated

if the stone doesn't respond to the other form of treatment To correct any anatomic abnormalities To improve urinary drainage

Cont--Surgical Nephrolithetomy /Incision into the kidney with removal of stone/ Nephrectomy Pyelolithotomy /in to the kidney pelvis Ureterolithotomy /in to the uerter Cystotomy

7) Renal failure
Is results from w/n the kidneys are unable to remove the bodys metabolic wastes or perform their regulatory functions. Is a systemic disease and is a final common pathway of many deferent kidney and urinary tract diseases. The Renal failure is classified in to two
Acute renal failure Chronic renal failure

A) Acute renal failure

is a sudden and almost complete loss of kidney function. Cause Three major categories of conditions cause acute renal failure. 1. Pre renal (hypo perfusion of kidney). 2. Intra renal (actual damage to the kidney) 3. Post renal /obstruction of the urinary flow/

Cont--Pre renal : This condition occur due to a blood flow problem which leads to hypo perfusion of the kidney and drop in the glomerular filtration rate, common clinical situations are Volume depletion states (hemorrhage or GI losses i.e. v/d/, renal losses i.e. diuretics

Cont-- Vasodilatation (Sepsis or anaphylaxis, antihypertensive medications that cause vasodilatation. Impaired cardiac performance (myocardial infarction, congestive heart failure, or carcinogenic shock, dysrhythimas)

Cont-- Intra renal the result of structural damage to the glameruli or kidney tubules Conditions such as Burns Crush injuries/trauma Infections ( APN, and GN) Transfusion reaction, hemolytic anemia Nephrotoxic agents ( heavy metals like lead and mercury, chemicals like carbon tetrachloride, arsenic, NSAIDs etc

Cont--Post renal Are usually the result of an obstruction somewhere distal to the kidney . Urinary tract obstruction calculi Tumors BPH Strictures and Blood clots.

Cont--Phases of acute renal failure There are four clinical phases of acute renal failure i.e. 1) The initiation period 2) The period of oligouria 3) Period of diuresis and 4) Period of recovery

Cont-- The initiation period - begins with the initial insult and ends when oligouria develops. The period of oligouria -urinary volume less than 400ml/24 hrs/ is accompanied by a rise in serum concentration of substances usually excreted by the kidneys. i.e. urea , Creatinine, Uric acid, Organic acids and potassium

Cont-- It is in this phase that uremic symptoms 1st appear, life threatening conditions such as hyperkalimia develop, BUN increases. The minimum amount of urine need to rid the body of normal metabolic waste products is 400ml.

Cont--Period of diuresis is the third phase of ARF. The patient experiences a gradually increasing urine output, which signals that glomerular filtration has started to recover. The volume of urinary output may reach normal to elevated levels. Renal function may be still abnormal.

Cont--Period of recovery signals the improvement of renal function and may be taking from 3 to 12 months. Laboratory values will return to a normal level Permanent 1-3% reduction of GFR may occur but it is not clinically significant. Elderly clients recover normal function less frequently than younger clients

Cont-- Clinical manifestations it is manifested by either anuria or oliguria. Oliguria is the most clinical situation seen in acute renal failure. The patient appears critically ill & is lethargic Persistent nausea, vomiting and diarrhea The skin and mucosa membranes are dry from DHN urine odor breath Edema Central nervous system manifestations
drowsiness head ache & seizures.

Cont-- bloody urea increased BUN (may reach 80-100mg/dl) and creatinine levels. Hyper kalemia - which may lead to dysrhythmias & cardiac arrest Metabolic acidosis an increase serum phosphate level &, serum calcium levels may be low Anemia

Cont-- Diagnostic Evaluation Urine analysis Urine specific gravity Serum creatinine level BUN Input and out put Hemoglobin & Hct level to detect Anemia

Assessment of electrolytes Na, K Ca and Po4

Cont--Management The objective of treatment of acute renal failure is To restore normal chemical balance To prevent complications so that repair of renal tissue occurs and Restoration of renal functions can take place

Cont-- Manitol 25 mg and , furosemide, with 20% of glucose I.V. solution may be prescribed to initiate a diuresis , prevent or minimize subsequent renal failure, to prevent tubular necrosis and treat shock Blood transfusion I.V. to treat hypotension and blood loss. Electrolytes I.V. to treat dehydration but should be strictly under supervision.

Cont-- Antimicrobial drugs to treat infection Diet restriction of protein in order to limit sources of nitrogen, potassium, phosphate, etc. Foods and fluids containing potassium and phosphorus /bananas, citrus fruits & juices, coffee/ are restricted. Sodium is usually restricted to 2gm/day

Cont-- Bed rest: complete bed rest to protect from infection Fluid: Restrict fluids to 400 ml/d

B) CHRONIC RENAL FAILURE

- is a progressive deterioration in renal function in which the bodys homeostatic mechanism fail. Chronic renal failure or end stage renal disease is a progressive, irreversible deterioration in renal function. The body's ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia (retention of urea & other nitrogenous wastes in the blood)

Cont-- Cause Systemic disease such as Diabetes mellitus Chronic glomerulonephritis Pyelonephritis Un controlled HPN Obstruction of urinary tract Vascular disorders Infections medications Toxic agents

Cont-- c/ms Almost all systems are affected E.g. HPN JVD N/V/D Altered consciousness etc

Fig. effects of CRF in the body

Cont--Diagnostic evaluation BUN (may reach 180-200mg/dl) and serum creatinine will be elevated KUB x-ray c/ms Urine out put etc

Cont--Management Before ESRD (end stage renal disease) medical management is aimed at slowing the progression CRF and avoiding complications Diabetes and hypertension should be aggressively treated Volume depletion, infection & nephrotoxic agents must be avoided to prevent further deterioration of renal function.

Cont-- Once the patient reaches ESRD, management is aimed at alleviating uremic symptoms & providing dialysis (is a movement of fluid and particles across a semi permeable artificial membrane from one compartment to another.) or renal transplantation in addition to other Mgts like ARF

Fig. dialysis

Comparison b/n acute and chronic renal failure

Characteristics Acute renal failure Chronic RF

Onset Duration

Acute

Chronic months to

Sudden /hrs to days, Gradual/ it may take 2-4wks. years mostly <3 months

of

nephron about 50%

90-95%

involvement Prognosis Good return of Fatal without renal

renal function

replacement i.e. dialysis

or transplantation

.
End

Thank you!!!

Quiz
1) Mention the function of kidney 2) What is the normal glomerilo filtration rate per minute in adult 3) BUN level is the best indicator of kidney function (true/false) 4) Define olgouria 5) Why UTI is common in female than men 6) Mention the risk factors of UTIs 7) Urolitiasis is mostly associated with 8) Mention the clinical features of lower UTIs 9) Write the characteristic features of nephrotic syndrome 10) List the causes of renal failure