Assessment of Renal and Urinary Tract Function (Chap. 43)

Functions of the Kidneys:

1. Urine formation2. Excretion of water products3. Regulation of electrolytes4. Regulation of acid-base balance5. Regulation of water balance6. Control of blood pressure7. Renal clearance ( the ability of the kidneys to clear solutes

from the plasma8. Regulation of red blood cell production9. Synthesis of vit.D to active form10. Secretion of prostaglandins (PGE2) ( vasodilatation effect

and maintaining renal flow

Assessment:

Health history Patient chief concern Pain ( characteristic, location, duration,….

Etc) Dysuria, Hesitancy, urine incontinence,

urinary frequency, Hematuria, Nocturia, polyuria, oliguria (less than 400/day), and anuria ( urine less than 50 ml/day)

The present of renal calculi History of GI symptoms History of UTI

Cont…

History of sexual transmitted disease Habits: smoking, alcohol, drugs Medication History of any renal diagnostic test

( catheterization) Any risk factors ( DM, Hypertension,

Sickle cell anemia, Benign prostatic hypertrophy, spinal cord injury, immobilization

Physical examination

Diagnostic Evaluation:

1. Urine analysis: urine color (light yellow), Urine clarity ( clear and translucent), urine odor ( arometic), urine PH ( acidic: 6.0 or 4.6-8), urine specific gravity, detect protein, glucose and ketone bodies in the urine, microscopic examination of the urine sediments to detect RBC’s, WBC’s, casts, crystals, pus (pyuria), and bacteria

2. Urine Culture and sensitivity3. Renal function test (KFT): Renal concentrate test

(Specific gravity, and urine osmolarity) creatinine clearance test ( 24-hour urine collection test), serum creatinine, BUN, and serum electrolyte level

Continue X-Ray film and other Imaging

modalities:1. KUB studies: to detect size, shape, location and

position of the kidneys, to reveal stone, hydronephrosis ( distention of the kidney pelvis), Cysts, tumors, and any surrounding tissue abnormalities.

2. CT scan and MRI: cross section view of the kidney and urinary tract: metal objects should be removed, sedative or certain contrasts may given, contraindicated in patient has pacemaker, surgical clips, or any metal objects

Cont…

3. General Ultrasonography: assess fluid accumulation, masses, congenital malformation, changes in size, shape, or any obstruction, fluid intake should be encouraged before the procedure

4. Bladder Ultrasonography: to measure fluid volume in the bladder, indicated for urinary frequency, inability to void after removal of FC or postoperative, measuring residual volume of urine after voiding

Cont….

5. Intravenous urography: intravenous pyelography (IVP) or intravenous urogram (IVU). History of iodine or any contrast allergy should be obtained before the procedure. Patient should be instructed he may have temporary feeling of wormth, flushing of the face and unusual flavor (seafood) in the mouth. Monitor the patient closely for any allergic reaction.

Cont.

6. Retrograde pyelography: catheter induced through ureters to the kidney pelvis by means of cystoscopy. Provide direct visualization of the kidney.

7. Cystography: direct visualization of the bladder walls. Assessing vesicoureteral reflux ( back flow of urine from the bladder to one or both of the ureters), bladder injury

8. Renal Angiography: provide an image of the renal arteries preparation done same as Cardiac cathetarization

Cont……

9. Urologic Endoscopic Procedure ( Endourology): through Cystoscope inserted via urethra or percataneously. Direct visualization of the system, removal of stone, obtaining urine specimen from the kidney. Sedation or anesthesia may performed, patient should be

kept NPO. Post- procedure: moist heat to the lower abdomen and warm sitz bath are

helpful in relieving pain and relaxing the muscles, monitor the patient with prostatic hyperplasia for urine

retention, intermittent catheterization may needed for few hours monitor for S/S of UTI, monitor for signs of retention

Cont…10. Kidney biopsy: Indications: 1. Unexplained acute renal failure, 2. persistent proteinuria or hematuria,3. transplant rejection, 4. and glomerulopathies. Contraindications: 1. Serious bleeding disorders,2. excessive obesity, and sever hypertension. It is usually performed percataneously with a biopsy

needle

Procedure for kidney biopsy include:

1. Place patient in prone position with a sandbag under the abdomin

2. The skin site of biopsy is infiltrated with local anesthesia3. The needle biopsy is inserted just inside the renal capsule4. The patient is instructed to breath in and hold the breath to

immobile the kidney during insertion of the needle Nursing diagnosis for the patient undergoing

assessment of urinary or renal function include the following:

1. Knowledge deficit regarding the procedure and diagnostic test

2. Acute pain related to renal invasive diagnostic procedure3. Fear related to possible procedure or serious illness

Chapter 44 & 45 (1514-1607)

Management of patients with Urinary Disorders

Dysfunctional Voiding pattern: (1578)

I. Urinary Retention: Is the inability to empty the bladder completely during

attempt to void. Residual urine is the urine remain in the bladder

- Causes: 1. DM, 2. prostatic enlargement, 3. urethral pathology ( infection , tumor, calculus),4. trauma, 5. pregnancy, 6. Neurological disorder, 7. some medication ( anti-cholinergic agent, tricyclic

antidepressant, alpha-adrenergic, beta-adrenergic blockers, and estrogens

.

• Complication:

1. may lead to chronic infection which may lead to calculi formation,

2. polynephritis, 3. sepsis, 4. back flow of urine lead to

deterioration of the kidney, 5. leakage of the urine may lead to

peripheral skin damage

Nursing Management:

1. Promote normal urinary elimination: Provide privacy, ensure the environment and position

is conducive to voiding, assisting the patient to use bathroom, and offering reassurance

Applying warmth to relax sphincter Simple trigger techniques, such as turning on the

water while voiding attempt, stroking the abd or inner thigh, tapping above the pubic area

After surgery the prescribed analgesia should be given

Cont…

2. Promote urinary elimination: Catheterization is used to prevent overdistention of the bladder

3. Promote home and community-based care: Provide easy, safe access to the bathroom Installing support bars in the bathroom Placing a bedpan or urinal within easy reach Leaving a light on the bedroom, and bathroom Wearing clothing that is easy to remove

Chart 45-8 (Strategies for promoting Urinary Continence:

II. Urinary Incontinence:

Is the involuntary or uncontrolled loss of urine from the bladder

Types of Incontinence:1. Stress incontinence: as a result of a sudden

increase in intra-abdominal pressure (sneezing, coughing, or changing position

2. Urge Incontinence: associated with a strong urge to void that can not be suppressed.

3. predominantly medications

Cont…

3. Reflex incontinence: due to hyperflexia in the absence of normal sensation usually associated with voiding.

4. Overflow incontinence: due to overdistention of the bladder

5. Functional incontinence: lower urinary tract function is intact but other factors such as sever cognitive impairment, or physical impairment

6. Latrogenic incontinence: due to extrinsic medical factors,

Medical management:

I. Behavioral intervention:1. Fluid management: encourage fluid intake of 1500-

1600ml daily between breakfast and evening2. Standardized voiding frequency: voiding on a

schedule• Time voiding, promote voiding ( in patient has

cognitive difficulties), Habit retraining, pelvic muscle exercise (PME) (Kegel exercise): to strengthen the voluntary muscles ( gently tightening the same muscle used to stop the stream of urine 5-10 sec. follow by 10 sec resting phase.

Cont…

II. Pharmacological therapy:1. Anticholinergic agents: (oxybutynin, dicyclomic)

which inhibit bladder contraction, first line medication for urge incontinence

2. Tricyclic antidepressant (impramine): decrease bladder contraction as well as strengthen bladder neck resistance

3. Estrogen: restoring the mucosal integrity, vascular, and muscular integrity of the urethra

III.Surgical management: surgical correction of the bladder and urethra if the patient not responding to the previous management

III. Neurogenic Bladder:

Is a dysfunction of the bladder due to a lesion of the nervous system caused by spinal injury, spinal tumor, herniated vertebral disk, multiple sclerosis, infection, congenital anomalies, and DM.

Pathophysiology:1. Spastic (or reflex) bladder: is the most common

type and is caused by any spinal cord injury above the voiding reflex arc ( Upper motor neuron lesion).

• The result is a loss of conscious sensation and cerebral motor control.

• A spastic bladder empties on reflex, with minimal or no controlling influence to regulate its activity

Cont..

2. Flaccid bladder: caused by lower motor neuron lesion, commonly result from trauma.

• Mainly recognized in DM Pt.. • The bladder continues to fill and becomes

greatly distended, and overflow incontinence occurs. The bladder is not contracted forcefully at any time. Because of sensory loss the patient feels no discomfort.

Medical management:

Prevention of overdistention of the bladder Emptying the bladder frequently and completely Maintaining urine sterility with no stone formation Maintain adequate bladder capacity without reflux Pharmacological therapy: Parasympathomimetic

medication (Urecholine) Surgical management: to correct bladder neck

contractures or vesicoureteral reflux, perfoming some type of urinary diversions procedures

Catheterization (1585)

Is the introduction of the catheter through the urethra into the bladder for the purpose of withdrawing urine.

Indications:1. relieve urinary tract retention,2. monitor accurate urine output in critically ill patients, 3. promote urinary drainage, 4. prevent urinary leakage in patient with advance

pressure ulcer, 5. obtain a sterile urine specimen, 6. emptying the bladder before, during, after surgery and

before certain diagnostic procedure.

Types of catheters:

1. Indwelling urethral catheter (Folly’s catheter) is remains in the place for continuous drainage . Types (Double and triple lumen catheter).

2. Intermittent catheter: is used to drain the bladder for short time (5-10 min)

3. Suprapubic catheter: it is surgical inserted into the bladder through a small incision above the pubic area.

Nursing Management during catheterization:

1. Assessing the patient and the system:2. Assessing for age-related complication:

infection, elderly patient doesn’t exhibit the S/S of infection but any physical and mental changes should be considered and reported.

3. Minimizing trauma: using proper size, use lubricate, proper technique, and securing the catheter

Cont….4. Bladder retraining after indwelling

catheterization: chart 45-10).• place patient on timed voiding schedule

usually every 2-3 hours• the patient instructed to void as scheduled• scan the bladder for residual urine• if more equal or more than100 ml straight

catheter may inserted for complete bladder emptying.

5. Assisting with intermittent self catheterization every 4-6 hours and at bed time (or when ever needed)

Cont…..

5. Prevent infection in the catheterized patient:

Use aseptic technique during insertion of the catheter Use sterile closed urinary drainage system Prevent contamination of the closed system: never

disconnect the tubing, the drainage bag should not touch the floor

The bag and collecting tubing are changed if contamination occurs, if urine flow become obstructed, if tubing start to leak.

Clamp the urine drainage if you raised the system above the kidneys level

Ensure free flow of urine

Cont… Empty the collection bag frequently Never irrigate the catheter routinely Never disconnect the tubing to collect urine sample Avoid routine catheter changes Wash the perineal area with soap and water at least

twice a day Monitor the patient’s voiding when the catheter is

removed. The patient must void within 8 hours Instruct the patient to drink measure fluid fro 8 am-

10 pm and stop drinking after 10pm

Dialysis:

Is the process used to remove fluid and uremic waste products from the body when the kidneys are unable to do so.

Indications:1. Acute dialysis: is indicated when there is a high and rising

level of serum potassium, fluid overload, impeding pulmonary edema, increased acidosis, pericarditis, and sever confusion. May also used to remove toxin from the blood.

2. Chronic or maintenance dialysis: is indicated in ESRD, in the presence of uremic signs and symptoms affecting all the body systems ( nausea, vomiting, sever anorexia, increasing lethargy, mental confusion). Hyperkalemia, fluid overload not responsive to diuretics and fluid restriction.

Hemodialysis

The objective of Hemodialysis are1. to extract toxic nitrogenous substances from the blood 2. and to remove excess water. Indicated for:1. the patient who are acutely ill and require short-term

dialysis (day to weak) 2. and for patient with ESRD who require long-term or

permanent therapy. A dialyzer or artificial kidney serves as a synthetic,

semipermeable membrane.

Principles of Hemodialysis:

1. Diffusion principle: dialysate ( is a solution made up of all the important electrolytes in their ideal Extracellular concentrate.

2. Osmosis principle:3. Ultrafiltration principle

Hemodialysis System

Preprocedure:

A predialysis assessment include: patient’s history and clinical findings, response to previous dialysis treatment, and laboratory results

Evaluates fluid balance before dialysis treatment so that corrective measures may be initiated at the beginning of the procedure: blood pressure, pulse, Wt, intake and output, tissue turgor, dry Wt or ideal WT

Procedure:..

Check the equipment Access to the circulation is gained by

inserting two large gauge needles to a graft or fistula

Blood being to flow through the tubing, assisted by the blood pump

A clamped saline bag always is attached to the circuit, just before the blood pump to use it if hypotension occurred

Heparin infusion can be attached to the circuit

Cont… Blood flows into the compartment of the

dialyzer, where exchange of fluid and waste products takes place

Blood leaving the dialyzer passes through an air detector that shuts down the blood pump if any air is detected

After the located time finished, dialysis is terminated by clamping off blood from the patient, opening the saline line, and rinsing the circuit to return the patient’s blood

The nurse should monitor, support, assessing, and educating the patients.

Vascular Access:

1. Subclavian, internal Juglar, and femoral catheter (venous catheter)

2. Arteriovenous Fistula: created surgically, provide long-term access for hemodialysis, the fistula takes 4-6 weeks to mature before it is ready for use, the patient instructed to perform exercise to increase the size of these vessels, venipunctures is contraindicated in the arm with fistula, assess for the thrill.

3. Synthetic graft:• An arteriovenous graft can be created by

subcutaneously interposing a biological, semibiologic, or synthetic graft material between an artery and vein

The graft is created when the patient’s vessels are not suitable for a fistula ( DM)

Graft usualy placed in the forearm, upper arm, or upper thigh

Complication such as thrombosis, infection, aneurysm formation and stenosis at the site of anastomosis are more frequent than fistula

Hemodialysis Catheter

Internal Arteriovenous Fistula and Graft

Complication of Hemodialysis:

1. Atherosclerotic cardiovascular disease an, Angina and fatigue

2. Disturbance of lipid metabolism (hypertriglyceridemia)

3. Stroke4. Peripheral vascular insufficiency5. Gastric ulcer6. Disturbed calcium metabolism that lead to bone

pain and fractures

Cont…1. Sleep problem2. Fluid overload, malnutrition, infection,

neuropathy and pruritis3. Hypotension, nausea, vomiting,

Dysrhythmias, chest pain4. Painful muscle cramping5. Air embolism6. Dialysis disequilibrium result from cerebral

fluid shift ( headache, nausea, vomiting, restlessness, decrease level of consciousness and seizures

Long term management for Hemodialysis:

I. Pharmacologic therapy: the dosage of medications need to adjust for patient undergoing hemodialysis and monitored closely to ensure that blood and tissue levels of these medications are maintained without toxic accumulation.

• Example are antihypertensive medication which should not be taking at the day of dialysis to prevent hypotension.

II. Nutritional and fluid therapy: 1. To minimize uremic symptoms and fluid and electrolyte

imbalances.2. To maintain good nutrition status through adequate protein

calories, vitamin, and minerals intake

Cont…..

3. To enable patient to eat a palatable and enjoyable diet.

Protein intake should be restricted to about 1 g/kg ideal body wt/day, High biologic quality protein ( contain essential amino acids) should be taken ( eggs, milk, meat, poultry, and fish)

Sodium is usually restricted to 2-3 g/day Fluids are restricted to amount equal to the

urine output plus 500ml to keep interdialytic wt gain under 1.5 kg.

Potassium restriction ( Average 1.5 to 2.5 g/day).

Nursing Management of the Hospitalized Patient on Dialysis

Protect vascular access; assess site for patency and signs of potential infection, and do not use it for blood pressure or blood draws

Monitor fluid balance indicators and monitor IV therapy carefully; keep accurate I&O and IV administration pump records

Assess for signs and symptoms of uremia and electrolyte imbalance; regularly check lab data

Monitor cardiac and respiratory status carefully Monitor blood pressure; antihypertensive agents must

be held on dialysis days to avoid hypotension

Cont……..

Monitor all medications and medication dosages carefully; avoid medications containing potassium and magnesium

Address pain and discomfort

Implement stringent infection control measures

Monitor dietary sodium, potassium, protein, and fluid; address individual nutritional needs

Provide skin care: prevent pruritus; keep skin clean and well moisturized; trim nails and avoid scratching

Nursing Management:

I. Meeting psychosocial needs: Give the patient and their Families the opportunity to express feelings of anger and concern over the limitations that disease and treatment impose.

Treatment of depression with antidepressant agents Referring the pt and family to clinical nurse specialists,

and psychologist Assess noncompliant pt for the impact of renal failure

and it’s treatment on the pt and family and the coping strategies that may use

Helps pt to identify safe, effective coping strategies to cope with ever-present problems and fears

Cont…

II. Teaching patient self care:III. Teaching patient about HemodialysisIV. Continuing care.The five E’s: Bridges to Renal rehabilitation:

1. Encouragement, 2. Education, 3. Exercise, 4. Employment, and 5. Evaluation

Peritoneal Dialysis:

The goals are to remove toxic substances and metabolic wastes and to reestablish normal fluid and electrolyte balance.

May be treatment of choice for:1. Patient with renal failure who are unable or

unwilling to undergo hemodialysis or renal transplantation.

2. An initial treatment for renal failure while patient is being evaluated for a hemodialysis program, or when access to the blood stream is not possible

Cont…

3. Patient who are susceptible to the rapid fluid, electrolyte, and metabolic changes that occur during hemodialysis ( pt with DM, Cardiovascular diseases, older patients, and those who may be at risk for adverse effects of systemic heparin).

4. Pt with sever hypertension, congestive heart failure, and pulmonary edema ( not responsive to usual treatment regimens)

Peritoneal Dialysis

Peritoneal Dialysis (cont.)

Principles underlying peritoneal dialysis:

In peritoneal dialysis, the peritoneal serves as the semi permeable membrane ( provide about 22,000 square cm surface area)

Sterile dialysate fluid is introduced into the peritoneal cavity through an abdominal catheter at intervals.

Urea, creatinine, metabolic end products are cleared from the body by diffusion and osmosis

Cont…

It is usually takes 36-48 hours to achieve with peritoneal dialysis what hemodialysis achieve in 6-8 hours

Urea is cleared at rate of 15-20 ml/min where creatinine is removed more slowly

Ultrafiltration (water removal) occurs in peritoneal dialysis through an osmotic gradient created by using a dialysate fluid with dextrose concentration.

Preprocedure:

Prepare the patient for catheter insertion and the dialysis procedure by giving a thorough explanation of the procedure

Consent form may be signed according to hospital policy Assess the pt’s anxiety, and provide support instruction Take the pat’s history, identifying abdominal surgery or

trauma Examine the abdomen before the catheter is inserted. Ask the patient to empty the bladder and bowel just before

the procedure to avoid accidental puncture with the trocar Give a preoperative medication, as ordered, to enhance

relaxation during the procedure

Cont………..

Broad spectrum antibiotic agent may be given to prevent infection

Take and record baseline vital signs and body wt

Warm the dialyzing fluid to body temperature or slightly warmer to prevent hypothermia, increase urea clearance, prevent abd pain, and dilate the vessels of the peritoneum.

Prepare the proper concentration of dialysate and the medication to be added ( Heparin, Potassium chloride, antibiotic, and insulin may be added) as doctor order

Cont… Immediately before initiating the dialysis, the

nurse assembles the administrating set and tubing. The tube is filled with the prepared dialysate to reduce the amount of air entering the peritoneal cavity.

Preparation of equipment: 1. Peritoneal dialysis administration set,2. peritoneal dialysis catheter set, 3. Trocar set, and 4. medication such as heparin, local anesthesia,

KCL, and broad spectrum antibiotics

Performing the exchange:

Peritoneal dialysis involves a series of exchanges or cycles. This cycle is repeated through the course of the dialysis which varies from 12-36 hours

1. Infusion phase: the dialysate is infused by gravity into the peritoneum. Period about 5-10 min is usually required to infuse 2 L of fluid.

2. Dwell or equilibrium phase: is the time allows diffusion and osmosis to occur.

3. Drainage phase: the tube is unclamped and the solution drains from the peritoneal cavity by gravity through closed system. Usually completed in 10-30 min. the drainage fluid is normally colorless or straw-colored and should not be cloudy

Cont…

The entire cycle (exchange) takes 1 to 4 hours, depending on the prescribed dwell time

The removal of excess water is achieved by using a hypertonic dialysate with a high dextrose concentration that creates an osmotic gradient (1.5%, 2.5% and 4.25% are available in several volumes from 500-3000ml).

Postprocedure:

Maintain accurate records of intake and output, and weight

Monitor BP and pulse frequently. Orthostatic blood pressure changes, and increased pulse rate are valuable clues that help the nurse evaluate the pt’s volume status

Detect S/S of peritonitis early ( low-grade fever, diffuse abd pain, rebound tenderness, and cloudy peritoneal fluid)

Maintain sterility of the peritoneal system Detect and correct technical difficulties

early

Cont….

Prevent constipation which decreases the clearance of waste product and cause the patient more discomfort

Assess for the presence of complications1. Peritonitis ( inflammation of the

peritoneum) : most common2. Leakage:3. Bleeding4. Long-term complications: abdominal hernia,

hypertriglyceridemia, cardiovascular diseases, low back pain, and anorexia

Management of patients with urinary disorders (Chap.45)

Infection of the urinary Tract (UTI):

Caused by pathogenic microorganism in the urinary tract.

Lower tract infection ( Urethritis, prostatitis, and Cystitis)

Upper tract infection (pyelonephritis, interstitial nephritis and renal abscesses)

Other classification: Complicated and uncomplicated lower or upper tract infection

Lower Urinary tract infections: …

Pathophysiology: for infection to occur 1. bacteria must gain access to the bladder,2. attach to and colonize the epithelium of the

urinary tract to avoid being washed out with voiding,

3. evade host defense mechanisms, and initiate inflammation

• Most UTI’s results from 1. fecal organism2. Reflux: Urethrovesical reflux ( backward flow of

urine from the urethra into the bladder

Cont…

Uropathogenic bacteria: Bacteriuria is generally defined as more than 100,000 colonies of bacteria per ml of urine

Most frequent bacteria responsible for UTI are those normally found in the lower GI tract such as E.coli , and lees common staphylococcus.

Routes of infection:

1. Up the urethra: ascending infection ( most common route)

2. Through the blood stream (hematogenous spread).3. By means of a fistula from the intestine ( direct

extension)• Risk factors:1. Inability or failure to empty the bladder completely 2. Obstructed urinary flow3. Decrease natural host defense or immunosuppression4. Instrumentation of the urinary tract5. Inflammation or abrasion of the urethral mucosa6. Contributing conditions : DM, pregnancy, neurological

disorders, gout.

Clinical manifestations:

about half patient with Bacteriuria have no symptoms. Uncomplicated: 1. pain and burning on urination, 2. frequency, 3. urgency, nocturia, incontinence, 4. Suprapubic or pelvic pain, 5. and Hematuria with low back pain may presented Complicated UTI: manifestations may range from

asymptomatic bacteriuria to a gram-negative sepsis with shock

Assessment and Diagnostic findings:

1. Colony count: at least 100,000 colony per ml of urine on a clean catch midstream or cathetarized specimen is a major criterion for infection

2. Cellular studies: microscopic hematuria ( greater than 4 RBC’s per high power field, Pyuria ( greater than 4 WBC’s per high power field)

3. Urine culture: urine culture remains the gold standard in documenting a UTI and can Identify the specific organism present

Medical management:

1. A cute pharmacologic therapy: single dose administration, short course (3-4

days) medication regimen, or 7-10 day therapeutic course used in treating uncomplicated lower UTI.

2. Long term pharmacologic therapy: If infection reoccurs within 2 weeks after

completing antimicrobial therapy, another short course of full-dose antimicrobial therapy, followed by a regular bedtime dose of an antimicrobial agent be prescribed

If there is no recurrence, medication may taken every other night for 6-7 months

Cont…

Patient education include: 1. Hygiene (shower rather than bathe tube 2. Fluid intake: drink enough fluid, avoid

coffee, tea, colas, alcohol 3. Voiding Habits: void every 2-3 hours, void

immediately after sexual intercourse 4. therapy: take medication exactly as

prescribed, if recurrence take long term treatment

Upper UTI

1. Acute pyelonephritis: is bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys

Upper UTI is associated with the antibody coating of the bacteria in the urine

Pathophysiology:1. Ascending of bacteria from the urethra, then to

bladder to reach the kidney2. Rarely from the blood ( less than 3%)3. Ureterovesical reflux4. Urinary tract obstruction, bladder tumor, strictures,

benign prostatic hyperplasia, and urinary stones

Cont…..

Usually these pt has enlarged kidneys with interstitial infiltration of inflammatory cells which may lead to destruction and atrophy of the kidney

Clinical manifestation: 1. Acutely ill with chills and fever, 2. leukocytosis, 3. Bacteriuria and Pyuria, 4. Flank pain. 5. Dysuria and frequency may associated. Assessment and Diagnostic findings: US, CT

scan to locate any obstruction, urine culture and sensitivity may performed

Medical management:

patient usually treated as outpatient if they are not dehydrated, not experiencing nausea or vomiting and not showing S/S of sepsis

For outpatient, a 2-weeks course of antibiotic is recommended , 6 weeks therapy may needed if relapse is seen, follow up urine culture is done 2 weeks after completion of antibiotic therapy

2. Chronic pyelonephritis:

Repeated of a cute pyelonephritis may lead to chronic pyelonephritis

Clinical manifestations: usually no symptoms of infection, S/S may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss

Persistent and recurring infection may produce progressive scaring of the kidney, with renal failure as the end result

Assessment and diagnostic findings: Intravenous urogram, Measurement of creatinine clearance, BUN and creatinine levels, and urine culture

Complication: ESRF, hypertension, and formation of

kidney stones Medical management: Antibiotics

depends on U/C, careful monitoring of renal function is important while giving medication due to the alteration of kidney function

Nursing Management: Monitor I&O, encourage fluid(3-4 L/day) unless contraindicated, Assess Temp. every 4 hrs, administer antibiotic as prescribed,Teach the pt the preventive measures of UTI

Acute Renal Failure:

Is a sudden and almost complete loss of kidney function ( decreased GFR)

Mnifestations: 1. Oligurea2. Anurea3. normal urine volume.

Categories of ARF:1. Prerenal: as a result of impaired blood flow to

the kidney2. Interrenal: as a result of actual parenchymal

damage to the glomeruli and kidney tubule.3. Post renal: as a result of obstruction

somewhere distal to the kidney, such as Ureterovesical reflux.

Phases of ARF:

1. Initial period: begins with initial insult2. The oliguria period( less than 400ml/day):

Characterized by increase serum urea, creatinine, K, uric acid, organic acids, and magnesium. The uremic symptoms first appears which is life-threatening such as Hyperkalemia.

3. The diuresis period: gradually increasing urine output, lab values stop rising and start to decrease

4. The recovery period: signals the improvement of renal function and may take 3-12 months, lab results return to the normal levels

Clinical manifestations:

Oliguria, anuria (less than 50 ml/day), or normal urine output are not as common.

Increased serum creatinine, and BUN level Pt may appear critically ill and lethargic, with

nausea, vomiting, and diarrhea. Skin and mucous membrane are dry from

dehydration and the breath may have the odor of the urine (uremic fetor)

Drowsiness, headache, muscle twitching, and seizures

Assessment and diagnostic findings:

Changes in the urine Changes in the kidney contour

( ultrasound) Increase BUN and creatinine levels Hyperkalemia, hypocalcemia,

hyperphosphoremia Anemia Metabolic acidosis

Medical management:

Manage fluid and electrolyte imbalance Diuretics may be given Adequate blood flow to the kidney ( by low doses of

dopamine 1-3 microgram/kg) Dialysis may be initiated to prevent serious complications

of ARF Treat Hyperkalemia: 1. administer Kayexalate ( orally or by retention edema)2. intravenouse glucose and insulin or calcium gluconate3. sodium bicharbonate to elevate plasma PH which cause

potassium to move into the cell. 4. Finally decrease the dietary intake of potassium Correction of Acidosis and elevated phosphorus level ( by

aluminum hydroxide---- phosphate binding agent) Nutritional therapy

Nursing Management

Monitor fluid and electrolyte balance Reduce metabolic rate Promote pulmonary function Prevent infection Provide skin care Provide support

Chronic renal failure:

Or ESRD is a progressive irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia ( retention of urea and other nitrogenous wastes in the blood)

May caused by systemic disease such as DM, hypertension, chronic glomerulonephritis… etc

Clinical manifestations:

Neurologic: Weakness, fatigue, confusion, inability to concentrate, tremors, seizures, behavior changes

Integumentary: gray-bronze color skin, dry, pruritis, ecchymosis, thin brittle nails

Cardiovascular: hypertension, pitting edema, periorbital edema, pericardial friction rub, engorged neck veins, pericarditis, pericardial effusion, hyperkalemia, hyperlipidemia

Pulmonary: signs of pulmonary edema Gastrointestinal: Ammonia odor to breath, mouth

ulceration and bleeding, anorexia, constipation or diarrhea

Hematology: anemia Musculoskeletal: muscle cramps, loss of muscle

strength, bone pain, bone fracture

Assessment and diagnostic findings

GFR: by obtaining a 24 hr urine collection for creatinine clearance.

Na and water retention Acidosis Anemia Ca and Ph imbalance Complications: 1. Hyperkalemia2. Hypertension3. anemia, Bone disease

Medical management:

Antacids: To treat hyperphosphatemia and hypocalcemia (Aluminum-based antiacide bind with phosphorus in the GI tract)

antihypertensive cardiovascular agents Antiseizure agents Erythropoietin Nutritional therapy Dialysis