Nursing Care of Client Nursing Care of Client ExperiencingExperiencing

Kidney and Bladder Kidney and Bladder Disorders Disorders

Objectives for Class:Objectives for Class: Describe the anatomy and physiology of the upper and lower Describe the anatomy and physiology of the upper and lower

urinary tract (self review)urinary tract (self review) Describe diagnostic studies used to determine upper and lower Describe diagnostic studies used to determine upper and lower

urinary tract function and client educationurinary tract function and client education Discuss the functions of the kidneyDiscuss the functions of the kidney Discuss urinary retention & urinary incontinenceDiscuss urinary retention & urinary incontinence Discuss the causes, pathophysiologic changes, clinical Discuss the causes, pathophysiologic changes, clinical

manifestations, management & nursing care for clients with manifestations, management & nursing care for clients with UTIs, glomerulonephritis, pyelonephritis, nephrotic syndrome, UTIs, glomerulonephritis, pyelonephritis, nephrotic syndrome, renal calculi (kidney stones)renal calculi (kidney stones)

Describe nursing management of the client with dialysisDescribe nursing management of the client with dialysis Discuss care of clients undergoing renal surgeryDiscuss care of clients undergoing renal surgery Develop a teaching plan for clients with acute/chronic renal Develop a teaching plan for clients with acute/chronic renal

failure, UTIs, renal calculi (kidney stones)failure, UTIs, renal calculi (kidney stones)

Topics to be Considered Common bladder & renal Common bladder & renal

problems:problems: calculi infections neoplasms diverticuli pyleonephritis (review pediatric content) neurogenic incontinence kidney failure /dialysis (presentation) transplant

This is material you are required to know -

some is from 3rd year It is testable in N405 & RNs

Review changes in the urinary tract due to agingReview changes in the urinary tract due to aging Review common laboratory findings: Review common laboratory findings:

CreatinineCreatinine BUNBUN ratio ratio

Urinalysis lab profileUrinalysis lab profile Preparing clients for tests involving contrast Preparing clients for tests involving contrast

mediamedia Follow up care after Renal Biopsy Follow up care after Renal Biopsy Preventing UTIs Preventing UTIs

Readings:Readings:

In your text Chapters 43, 44, 45In your text Chapters 43, 44, 45 Recommended readingsRecommended readings WebsitesWebsites

Kidney foundation Canadian Society of Nephrology College of Family Physicians of Canada

Elimination SystemElimination System

The structures of this system precisely maintain the The structures of this system precisely maintain the internal chemical environment of the body internal chemical environment of the body (Smeltzer & Bare, (Smeltzer & Bare, 2007, pg. 1255)2007, pg. 1255)

Comprised of:Comprised of:

Upper urinary tractUpper urinary tract Kidneys:Kidneys: “balance the urinary excretion of substances “balance the urinary excretion of substances

against the accumulation within the body through against the accumulation within the body through ingestion or production”.(Balck Hawkes & Keene, 2001, ingestion or production”.(Balck Hawkes & Keene, 2001, p.732)p.732)

Ureters:Ureters: connect the kidney from the renal pelvis to the connect the kidney from the renal pelvis to the bladder.bladder.

Lower urinary tractLower urinary tract Bladder:Bladder: hollow elastic organ that holds urine hollow elastic organ that holds urine Urethra:Urethra: extends from base of bladder to the surface of extends from base of bladder to the surface of

the body.the body.

http://www.youtube.com/watch?v=zEpUQkQ-uKM&feature=related

http://www.youtube.com/watch?v=Pz5DHAv_Mw4

Anatomy Anatomy Renal PyramidRenal Pyramid of the of the KidneyKidney

http://www.youtube.com/watch?http://www.youtube.com/watch?v=Pz5DHAv_Mw4v=Pz5DHAv_Mw4

http://www.youtube.com/watch?v=glu0dzK4dbU&feature=related

Nephron and Associated Vascular Structureshttp://www.youtube.com/watch?v=glu0dzK4dbU&feature=related

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%3DAfjUru7nTsk&tit=Urinary+part+2&c=11&sigr=11agcl1d3%3DAfjUru7nTsk&tit=Urinary+part+2&c=11&sigr=11agcl1d3&&

Major Functions: KidneysMajor Functions: Kidneys

Urine formationUrine formation Excretion of Excretion of

waste productswaste products Electrolyte Electrolyte

regulationregulation Water balanceWater balance Acid Base Acid Base

BalanceBalance Blood Pressure Blood Pressure

regulationregulation

Renal clearanceRenal clearance Blood Blood

component component production production (RBC’s)(RBC’s)

Vitamin D Vitamin D synthesissynthesis

ProstaglandinProstaglandin secretionsecretion

Why do problems occur with the bladder?

Why do problems occur with the kidney?

Changes related to Aging:

NocturiaNocturia Decreased Bladder CapacityDecreased Bladder Capacity Weakened sphincter & shortened Weakened sphincter & shortened

urethra in womenurethra in women Tendency to retain urineTendency to retain urine Decreased glomerular filtration rateDecreased glomerular filtration rate HydrationHydration

ensure adequate hydrationensure adequate hydration administer nephrotoxic drugs with careadminister nephrotoxic drugs with care

AssessmentAssessment

Health historyHealth history Risk factors Risk factors Unexplained anemia - whyUnexplained anemia - why Pain Pain Changes in voiding Changes in voiding GI symptoms ?GI symptoms ? Physical ExamPhysical Exam

Risk FactorsRisk Factors

Risk FactorsRisk Factors

Bladder PalpationBladder Palpation

Genitourinary PainGenitourinary Pain

Changes in VoidingChanges in Voiding

Changes in VoidingChanges in Voiding

Urine ColorUrine Color

Diagnostic Evaluation Diagnostic Evaluation (See Plan of Nursing Care Pg. (See Plan of Nursing Care Pg.

1424)1424) Urinalysis and Urine CultureUrinalysis and Urine Culture Renal Function Tests (P. 1419 table Renal Function Tests (P. 1419 table

43-4)43-4) X-ray and other imaging modalitiesX-ray and other imaging modalities Urological Endoscopic ProceduresUrological Endoscopic Procedures BiopsyBiopsy Urodynamic TestsUrodynamic Tests

Goal of Clean Catch UrineGoal of Clean Catch Urine (Mid Stream)(Mid Stream)

To minimize contamination of the specimen by organisms on the skin

Do you remember how to collect a midstream sample ???

A 12 or 24 hr specimen??

Renal Function Tests: Table 43-Renal Function Tests: Table 43-44

BUN (Bld urea nitrogen)BUN (Bld urea nitrogen) (table 43-4)(table 43-4)

Adult: 7-18 mg/dl Adult: 7-18 mg/dl or 2.5-6.4 mmol/L or 2.5-6.4 mmol/L

Elderly 8-20 mg/dl Elderly 8-20 mg/dl or 2.9-7.5 mmol/Lor 2.9-7.5 mmol/L

Child 5-18 mg/dl or Child 5-18 mg/dl or 1.8-6.4 mmol/L 1.8-6.4 mmol/L

Urea forms in the liver, along with CO2, constitutes the final product of protein metabolism. The amount of excreted urea varies directly with dietary protein intake. The test for BUN which measures the nitrogen portion of urea is used as an index of glomerular function in the production & excretion of urea. Thus, serves as an index of renal functioning.

A marked increase in BUN = severe impaired renal function

Urine Creatinine (table 43-4)(table 43-4) Amino acid waste product derived from muscle creatine (a Amino acid waste product derived from muscle creatine (a

product of protein metabolism)product of protein metabolism)

All creatinine filtered by kidneys in a certain timeframe goes All creatinine filtered by kidneys in a certain timeframe goes into the urine, creatinine levels thus are equal to the into the urine, creatinine levels thus are equal to the glomerular filtration rate. Disorders of kidney interfere with glomerular filtration rate. Disorders of kidney interfere with normal secretion of creatininenormal secretion of creatinine

Thus creatinine measures effectiveness of renal functioning (serum Creatinine)

Keep in mind that rate normally decreases as we age urine creatinine men 0.8 -1.8 g/24h urine creatinine women 0.6 - 1.6 g/24h blood creatinine: 0.4-1.5 mg/dl

Renal Function Tests: Table 43-Renal Function Tests: Table 43-44

Creatinine Clearance

Decreased Impaired kidney

function Kidney Disease Shock & dehydration COPD CHF

Increased State of high

cardiac output Pregnancy Burns Carbon monoxide

poisoning

What causes them?Who is at risk?

What helps prevent UTIs?

Classifications of UTIClassifications of UTI

Lower UTILower UTI Cystitis, prostatitis, Cystitis, prostatitis,

urethritisurethritis

Upper UTIUpper UTI Acute pyelonephritis, Acute pyelonephritis,

chronic pyelonephritis, chronic pyelonephritis, renal abcess, interstitial renal abcess, interstitial nephritis, perirenal abcessnephritis, perirenal abcess

Classifications of UTIClassifications of UTI

Uncomplicated Lower or Upper UTIUncomplicated Lower or Upper UTI Community acquiredCommunity acquired

Complicated Lower or Upper UTIComplicated Lower or Upper UTI Often nosocomial related to Often nosocomial related to

catheterization, urologic abnormalities, catheterization, urologic abnormalities, pregnancy, immunosuppression, pregnancy, immunosuppression, diabetes, obstructionsdiabetes, obstructions

Risk Factors: UTIRisk Factors: UTI

See Chart 45-2 Pg. 1483See Chart 45-2 Pg. 1483

PathophysiologyPathophysiology

Bacterial invasion: colony Bacterial invasion: colony count 10^5 per ml/L urinecount 10^5 per ml/L urine

RefluxReflux Most common cause is Most common cause is

gram negative organisms – gram negative organisms – E.coli, Klebsiella, E.coli, Klebsiella, Enterobacter & ProteusEnterobacter & Proteus

Males & catheterized-Males & catheterized-psuedomonas & psuedomonas & enterococcusenterococcus

Routes of infection- urethra, Routes of infection- urethra, bloodstream, fistulabloodstream, fistula

Pathophysiology of E.Coli UTI

Clinical Manifestations Clinical Manifestations Uncomplicated Lower UTIUncomplicated Lower UTI

Dysuria (burning pain on urination)Dysuria (burning pain on urination) FrequencyFrequency UrgencyUrgency Voiding in small amts. or inability to voidVoiding in small amts. or inability to void NocturiaNocturia IncontinenceIncontinence PainPain Cloudy urine & hematuriaCloudy urine & hematuria Gerontologic considerations-generalized Gerontologic considerations-generalized

fatigue, change in cognitive functioningfatigue, change in cognitive functioning

Medical/Nursing InterventionsMedical/Nursing Interventions

Inhibit bacterial growth with antibacterials – Inhibit bacterial growth with antibacterials – often short courseoften short course

Pain: urinary tract anesthetics – PyridiumPain: urinary tract anesthetics – Pyridium Modify diet – avoid foods that irritate such as Modify diet – avoid foods that irritate such as

caffeine, alcohol, tomatoescaffeine, alcohol, tomatoes Increase fluid intake (3-4 litres/day)Increase fluid intake (3-4 litres/day) Education: Education:

risk factors, early symptomsrisk factors, early symptoms Use of antibiotics (self-care)Use of antibiotics (self-care) Health promotion: p. 1488 table 45-4Health promotion: p. 1488 table 45-4

Nursing DiagnosesNursing Diagnoses

Acute painAcute pain Altered health maintenanceAltered health maintenance PC: sepsisPC: sepsis PC: Renal failurePC: Renal failure

Goal is to prevent renal damage Goal is to prevent renal damage

CatheterizationCatheterization

Indwelling devices and Indwelling devices and infectionsinfections

Suprapubic catheterizationSuprapubic catheterization Bladder retrainingBladder retraining Intermittent self-catheterizationIntermittent self-catheterization

Suprapubic Catheterization

Catheter inserted Catheter inserted through an through an incision or incision or puncture made puncture made above the pubisabove the pubisMay be inserted:May be inserted:

When urethral When urethral route is route is impassableimpassableAfter abdominal After abdominal or gynecologic or gynecologic surgerysurgeryPelvic fracturesPelvic fractures

Preventing Infection in the Preventing Infection in the Catheterized PatientCatheterized Patient

Chart 45-9 Page 1500Chart 45-9 Page 1500

KNOW!!KNOW!!

Condom Drainage and Leg Condom Drainage and Leg BagBag

UrethritisUrethritis Inflammation of the urethraInflammation of the urethra Commonly associated with Commonly associated with

STIs (gonorrhea, chlamydia), STIs (gonorrhea, chlamydia), feminine hygiene products, feminine hygiene products, scented toilet paper, scented toilet paper, spermicidal jelliesspermicidal jellies

S & S include pain & pyuriaS & S include pain & pyuria Management includes Management includes

removing the cause, removing the cause, antibiotics (if bacterial) and antibiotics (if bacterial) and drinking plenty of fluids, use drinking plenty of fluids, use of lubricants with of lubricants with intercourse, teaching re STIintercourse, teaching re STI

PyelonephritisPyelonephritis Is a bacterial infection causing Is a bacterial infection causing

inflammation ofinflammation of the renal pelvis, tubules, and the renal pelvis, tubules, and

interstitial tissue of one or both interstitial tissue of one or both kidneys.kidneys.

Common cause is E. coliCommon cause is E. coli

May also be caused by candidiasis.May also be caused by candidiasis.

May be acuteMay be acute Usually enlarged kidney, maybe Usually enlarged kidney, maybe

abscesses, & possibly abscesses, & possibly destruction of glomerulidestruction of glomeruli

May be chronicMay be chronic Kidneys scarred, contracted, & Kidneys scarred, contracted, &

nonfunctioningnonfunctioning

Acute PyelonephritisAcute Pyelonephritis

Clinical manifestationsClinical manifestations Appears acutely illAppears acutely ill Fever, chills, flank pain, nausea, Fever, chills, flank pain, nausea,

headache, muscle pain, dysuria, headache, muscle pain, dysuria, urgency, frequencyurgency, frequency

Urine cloudy, bloody, foul smelling, Urine cloudy, bloody, foul smelling, increased WBC & castsincreased WBC & casts

DiagnosisDiagnosis

Ultrasound or CT to check for obstructionUltrasound or CT to check for obstruction

Urine C & SUrine C & S

X-ray (KUB), MRIX-ray (KUB), MRI

Acute PyelonephritisAcute Pyelonephritis Medical managementMedical management

May be outpatient or inpatient May be outpatient or inpatient treatmenttreatment

Antibiotic therapy based on C & S, Antibiotic therapy based on C & S, usually for 7-10 days, up to 2 weeks for usually for 7-10 days, up to 2 weeks for outpatientsoutpatients

Analgesics Analgesics Follow up urine C&S 2 weeks after Follow up urine C&S 2 weeks after

completing therapycompleting therapy

Chronic PyelonephritisChronic Pyelonephritis

Likely to occur after repeat acute bouts of Likely to occur after repeat acute bouts of AcuteAcute

Progressive with recurrent attacksProgressive with recurrent attacks

Clinical ManifestationsClinical Manifestations No symptoms of infection , unless acute No symptoms of infection , unless acute

exacerbationexacerbation May have fatigue, headache, poor appetite, May have fatigue, headache, poor appetite,

polyuria, excessive thirst, weight losspolyuria, excessive thirst, weight loss Lab values are abnormalLab values are abnormal

ComplicationsComplications

ESRD, Hypertension, Renal calculiESRD, Hypertension, Renal calculi

Chronic PyelonephritisChronic Pyelonephritis

Medical managementMedical management Goal is prevention of further renal Goal is prevention of further renal

damagedamage Antibiotics - cautious use depending Antibiotics - cautious use depending

on degree of renal functionon degree of renal function High fluid intake may be contra-High fluid intake may be contra-

indicatedindicated Control hypertension Control hypertension

Chronic pyelonephritisChronic pyelonephritis

Nursing careNursing care

Monitor fluid balance, may require IV Monitor fluid balance, may require IV fluids (nausea, IV antibiotics)fluids (nausea, IV antibiotics)

Monitor blood workMonitor blood work Address pain: analgesic & 3-4L fluids Address pain: analgesic & 3-4L fluids

unless contraindicated ?unless contraindicated ? V/S – T q4hV/S – T q4h BedrestBedrest

Client educationClient education

Follow-up urine culturesFollow-up urine cultures Appropriate use of antibioticsAppropriate use of antibiotics Perineal hygienePerineal hygiene Acidification of urine by drinking Acidification of urine by drinking

cranberry juice or taking ascorbic acidcranberry juice or taking ascorbic acid Frequent emptying of bladderFrequent emptying of bladder Adequate fluid intakeAdequate fluid intake Early detection of infectionEarly detection of infection

Primary Glomerular Primary Glomerular DiseasesDiseases

Definition: “a group of kidney diseases caused by Definition: “a group of kidney diseases caused by inflammation of the capillary loops in the glomeruli inflammation of the capillary loops in the glomeruli of the kidney” (Hogan & Maydayag, 2004)of the kidney” (Hogan & Maydayag, 2004)

Caused by an immunologic reaction to an antigen, Caused by an immunologic reaction to an antigen, causing inflammatory response that damages the causing inflammatory response that damages the glomeruliglomeruli

IgG can be found in glomerular capillary wallsIgG can be found in glomerular capillary walls Often preceded by group B hemolytic strep Often preceded by group B hemolytic strep

infectioninfection Primary presenting feature is hematuriaPrimary presenting feature is hematuria Includes: acute & chronic glomerulonephritis, Includes: acute & chronic glomerulonephritis,

rapidly progressive glomerulonephritis, & rapidly progressive glomerulonephritis, & nephrotic syndromenephrotic syndrome

Manifestations: proteinuria, hematuria, decreased Manifestations: proteinuria, hematuria, decreased GFR, alterations in sodium excretionGFR, alterations in sodium excretion

Acute GlomerulonephritisAcute Glomerulonephritis

Primarily in children over 2, but can Primarily in children over 2, but can occur at any ageoccur at any age

Most cases preceded 2-3 weeks by Most cases preceded 2-3 weeks by group A strep infection of throatgroup A strep infection of throat

May follow impetigo or viral infectionsMay follow impetigo or viral infections Medications or other foreign Medications or other foreign

substances may causesubstances may cause Occasionally, autoimmuneOccasionally, autoimmune

Group A Streptococcus

Clinical Manifestations Clinical Manifestations

Hematuria – may be micro or macroscopicHematuria – may be micro or macroscopic Urine may be cola coloured due to RBC castsUrine may be cola coloured due to RBC casts Proteinuria - albuminuria, Proteinuria - albuminuria, Headache, malaise, flank pain in severe formHeadache, malaise, flank pain in severe form Tenderness over CVATenderness over CVA Elderly may experience circulatory overloadElderly may experience circulatory overload Some edema & hypertension in 75%Some edema & hypertension in 75% Atypical: confusion, somnolence, seizuresAtypical: confusion, somnolence, seizures

Diagnostics & Assessment Diagnostics & Assessment

May require renal biopsyMay require renal biopsy Poststreptococcal – usually elevated Poststreptococcal – usually elevated

serum antistreptolysin O or anti-serum antistreptolysin O or anti-DNase B titresDNase B titres

Over half have elevated serum IgA & Over half have elevated serum IgA & normal complementnormal complement

About 70% of adults recoverAbout 70% of adults recover

ComplicationsComplications

Hypertensive encephalopathy - Hypertensive encephalopathy - therapy aimed at decreasing blood therapy aimed at decreasing blood pressure without impacting renal pressure without impacting renal functionfunction

Heart failureHeart failure Pulmonary edemaPulmonary edema Optic neuropathy - rareOptic neuropathy - rare

Medical treatmentMedical treatment

Treat symptomsTreat symptoms Preserve kidney functionPreserve kidney function Prevent complicationsPrevent complications Drugs for cause & symptomsDrugs for cause & symptoms Restrict protein with elevated BUNRestrict protein with elevated BUN Restrict sodium as necessaryRestrict sodium as necessary

Nursing ManagementNursing Management

Most uncomplicated are treated at homeMost uncomplicated are treated at home High carbohydratesHigh carbohydrates Fluid replacement as per losses & body Fluid replacement as per losses & body

weight – remember insensible lossweight – remember insensible loss Usually diuresis begins 1 week after onsetUsually diuresis begins 1 week after onset Client education – fluid/diet restrictions, Client education – fluid/diet restrictions,

aware of symptoms of renal failure, S&S aware of symptoms of renal failure, S&S infection, medication knowledgeinfection, medication knowledge

Follow up assessmentsFollow up assessments

Medical managementMedical management

Reduce inflammationReduce inflammation Plasmapheresis in conjunction with Plasmapheresis in conjunction with

corticosteroids & immunosuppressive corticosteroids & immunosuppressive agentsagents

Antibiotic therapyAntibiotic therapy DialysisDialysis

Chronic GlomerulonephritisChronic Glomerulonephritis

May be due to repeated episodes of acuteMay be due to repeated episodes of acute Hypertensive nephrosclerosisHypertensive nephrosclerosis HyperlipidemiaHyperlipidemia Chronic tubulointerstitial injuryChronic tubulointerstitial injury Hemodynamically mediated glomerular Hemodynamically mediated glomerular

sclerosissclerosis Kidneys shrink, surface rough & irregular, Kidneys shrink, surface rough & irregular,

glomeruli & tubules scarred, branches of renal glomeruli & tubules scarred, branches of renal artery thickenedartery thickened

Results in ESRDResults in ESRD

Some may have no symptoms for many years and Some may have no symptoms for many years and may be secondary diagnosismay be secondary diagnosis Malaise, weight loss, edema, increasing Malaise, weight loss, edema, increasing

irritability, nocturia (kidney’s inability to irritability, nocturia (kidney’s inability to concentrate urine), headache, dizziness and concentrate urine), headache, dizziness and digestive disturbancesdigestive disturbances

Edema increases as heart failure increases & Edema increases as heart failure increases & serum albumin decreasesserum albumin decreases

Severe anemiaSevere anemia S&S of renal insufficiency & chronic renal S&S of renal insufficiency & chronic renal

failure as disease progressesfailure as disease progresses Peripheral neuropathy & neurosensory changesPeripheral neuropathy & neurosensory changes

Clinical ManifestationsClinical Manifestations

Diagnostics & Assessment Diagnostics & Assessment

Many lab abnormalities as GFR Many lab abnormalities as GFR decreasesdecreases

CXR cardiac enlargement & CXR cardiac enlargement & pulmonary edemapulmonary edema

EKG may be normal or abnormalEKG may be normal or abnormal

Chronic GlomerulonephritisChronic Glomerulonephritis

Medical ManagementMedical Management Reduce inflammationReduce inflammation

Plasmapheresis in conjunction with Plasmapheresis in conjunction with corticosteroids & immunosuppressive agents.corticosteroids & immunosuppressive agents.

Antibiotic therapyAntibiotic therapy Maintain fluid & electrolyte balanceMaintain fluid & electrolyte balance

Volume overload & HT are treated with Volume overload & HT are treated with diuretics, antihypertensives & restriction of Na diuretics, antihypertensives & restriction of Na & H2O& H2O

Monitor vs, intake & output, wtMonitor vs, intake & output, wt Careful assessment for complications Careful assessment for complications

Medical treatmentMedical treatment

Treat symptoms – especially UTITreat symptoms – especially UTI Hypertension – treatHypertension – treat Restrict sodium as necessaryRestrict sodium as necessary Weigh dailyWeigh daily DiureticsDiuretics High value protein, adequte calorie High value protein, adequte calorie

intakeintake Dialysis – use earlyDialysis – use early

Nursing ManagementNursing Management Assess fluid & electrolyte statusAssess fluid & electrolyte status Assess for indications of decreasing Assess for indications of decreasing

renal functionrenal function Report changes in cardiac or neurologic Report changes in cardiac or neurologic

status alsostatus also Psychosocial supportPsychosocial support Client education – fluid/diet restrictions, Client education – fluid/diet restrictions,

aware of symptoms of renal failure, S&S aware of symptoms of renal failure, S&S infection, medication knowledge, dialysisinfection, medication knowledge, dialysis

Follow up assessmentsFollow up assessments

Nephrotic Syndrome:Nephrotic Syndrome:Cluster Clinical FindingsCluster Clinical Findings

Nephrotic SyndromeNephrotic Syndrome Marked increase of protein in urine Marked increase of protein in urine

(proteinuria)(proteinuria) Decrease in albumin in blood Decrease in albumin in blood

(hypoalbuminemia)(hypoalbuminemia) EdemaEdema High serum cholesterol and High serum cholesterol and

hyperlipidemiahyperlipidemia Any condition that damages the Any condition that damages the

glomerular capillary membrane glomerular capillary membrane causing increased permeabilitycausing increased permeability

Nephrotic SyndromeNephrotic Syndrome Low albumin levels in the blood lead to edema, Low albumin levels in the blood lead to edema,

stimulates retention of Na & H2O as fluids stimulates retention of Na & H2O as fluids move into interstitial spaces move into interstitial spaces

Hyperlipidemia: increased lipoprotein probably Hyperlipidemia: increased lipoprotein probably response of liver to low serum albuminresponse of liver to low serum albumin

Anemia depending on amount of renal failureAnemia depending on amount of renal failure Manifestations:Manifestations:

Massive edemaMassive edema Waxy pallorWaxy pallor Anorexia, malaise, irritability, abnormal menses.Anorexia, malaise, irritability, abnormal menses. Large amt protein in urine & low serum albuminLarge amt protein in urine & low serum albumin

Nephrotic SyndromeNephrotic Syndrome

Goal of treatment is to preserve renal Goal of treatment is to preserve renal functionfunction Maintain fluid/electrolyte balance: weight QD, Maintain fluid/electrolyte balance: weight QD,

girth measurements, intake/outputgirth measurements, intake/output Loop diuretics (Lasix) – use cautionLoop diuretics (Lasix) – use caution Plasma volume expanders such as albumin, Plasma volume expanders such as albumin,

dextran, plasma to increase oncotic pressuredextran, plasma to increase oncotic pressure Mild sodium restrictionMild sodium restriction Good skin care (edema disrupts cellular nutrition)Good skin care (edema disrupts cellular nutrition) Steroid therapy & anticoagulants (reduce Steroid therapy & anticoagulants (reduce

inflammation & prevent renal vein thrombosis) – inflammation & prevent renal vein thrombosis) – especially if infectionespecially if infection

High protein, low sodium, high potassium, low High protein, low sodium, high potassium, low saturated fat dietsaturated fat diet

EducationEducation

Nursing Care: Nursing Care: Priority DiagnosesPriority Diagnoses

Fluid volume excessFluid volume excess Altered nutrition: less than body Altered nutrition: less than body

requirementsrequirements Risk for impaired skin integrityRisk for impaired skin integrity Risk for infectionRisk for infection FatigueFatigue Knowledge of therapeutic regimenKnowledge of therapeutic regimen

Renal TransplantationRenal Transplantation

Organ DonationOrgan Donation Preoperative ManagementPreoperative Management Postoperative ManagementPostoperative Management

Immunosuppressive therapyImmunosuppressive therapy RejectionRejection InfectionInfection Urinary FunctionUrinary Function ComplicationsComplications

Renal TransplantationRenal Transplantation

URINARY CALCULIURINARY CALCULI

Urinary calculi Urinary calculi (urolithiasis)(urolithiasis)

Form primarily in the kidney Form primarily in the kidney (nephrolithiasis) but can form or (nephrolithiasis) but can form or migrate to lower urinary system.migrate to lower urinary system.

Usually asymptomatic until they pass Usually asymptomatic until they pass into lower tract.into lower tract.

Primary causes are 1) urinary stasis, Primary causes are 1) urinary stasis, 2) supersaturation of urine with 2) supersaturation of urine with poorly soluble crystalloids (leads to poorly soluble crystalloids (leads to precipitation of crystals). precipitation of crystals).

Risk factorsRisk factors InfectionsInfections DehydrationDehydration High mineral content in waterHigh mineral content in water Prolonged indwelling catheterizationProlonged indwelling catheterization Neurogenic bladderNeurogenic bladder Previous historyPrevious history Foreign bodies Foreign bodies Failure to empty bladder completelyFailure to empty bladder completely Metabolic disorders (I.e. Metabolic disorders (I.e.

hypercalcemia)hypercalcemia) Obstruction in urinary tractObstruction in urinary tract Female genital mutilationFemale genital mutilation

Abnormalities of Urine Sediment Abnormalities of Urine Sediment in Client With Renal Calculiin Client With Renal Calculi

ABNORMALITYABNORMALITY Red cellsRed cells

White cellsWhite cells

ProteinProtein

Pus + bacteriaPus + bacteria

SIGNIFICANCESIGNIFICANCE Suggests injury to Suggests injury to

urinary tracturinary tract suggests inflammation suggests inflammation

or infectionor infection

Suggest glomerular Suggest glomerular injuryinjury

InfectionInfection

Types of StonesTypes of Stones Calcium, Oxalate, Struvite, Calcium, Oxalate, Struvite,

Uric acid, CystineUric acid, Cystine

ManifestationsManifestations Severe sharp painSevere sharp pain Renal colic flank pain on Renal colic flank pain on

side of affected kidney side of affected kidney radiating to groinradiating to groin

May have nausea, May have nausea, vomiting, pallor, grunting vomiting, pallor, grunting respirations, elevated BP, respirations, elevated BP, pulse, diaphoresis & pulse, diaphoresis & anxietyanxiety

Elevated WBC & tempElevated WBC & temp

CalculiCalculi

Staghorn CalculisStaghorn Calculis

Medical ManagementMedical Management

Increase fluidsIncrease fluids Reduce painReduce pain Prevent stone recurrencePrevent stone recurrence Dietary changes – Dietary changes – see next slide see next slide Medications Medications Surgery Surgery

Nursing ManagementNursing Management

PainPain Impaired urinary eliminationImpaired urinary elimination Effective management of therapeutic Effective management of therapeutic

regimenregimen Risk for infectionRisk for infection Urinary retentionUrinary retention

KIDNEY STONES & PAINKIDNEY STONES & PAIN

OPIODSOPIODS NSAIDsNSAIDs ANTISPASMODICSANTISPASMODICS RELAXATIONRELAXATION IMAGERYIMAGERY THERAPEUTIC/THERAPEUTIC/

HEALING TOUCHHEALING TOUCH BREATHING BREATHING

TECHNIQUESTECHNIQUES

SurgerySurgery

Lithotripsy: laser and ESWLLithotripsy: laser and ESWL Nephroscopic removalNephroscopic removal PyelolithotomyPyelolithotomy Nephrolithotomy Nephrolithotomy

LithotripsyLithotripsy

Extracorporeal Shock Wave Extracorporeal Shock Wave LithotripsyLithotripsy

Nephroscopic Removal of Kidney StonesNephroscopic Removal of Kidney Stones

Pyelolithotomy Removal of Kidney Pyelolithotomy Removal of Kidney StonesStones

Nephrolithotomy Removal of Kidney Nephrolithotomy Removal of Kidney StonesStones

to the Urinary Tractto the Urinary Tract

Bladder TraumaBladder Trauma blunt or penetrating injury to bladder blunt or penetrating injury to bladder

that may cause bladder rupture.that may cause bladder rupture. Often the result of car accidents, seat Often the result of car accidents, seat

belt pressure against distended bladder.belt pressure against distended bladder. Urine spills into peritoneal cavity, Urine spills into peritoneal cavity,

causing peritonitis & pelvic cellulitis. causing peritonitis & pelvic cellulitis. Manifestations: hematuria, pain, Manifestations: hematuria, pain,

difficulty voiding.difficulty voiding. Usually require surgery, post-op have a Usually require surgery, post-op have a

urethral or suprapubic catheter.urethral or suprapubic catheter.

Ureteral traumaUreteral trauma usually the result of usually the result of

surgical accident. surgical accident. Other causes Other causes gunshot or stabbinggunshot or stabbing Symptoms include Symptoms include

flank pain, flank pain, hematuria, hematuria, eventually paralytic eventually paralytic ileus, sepsisileus, sepsis

Treatment is surgical Treatment is surgical repairrepair

• May result from pelvic fracture (falling on object such as bar on bike)

•Symptoms include inability to void or altered stream, swelling in groin, scrotum or inguinal area, may lead to sepsis and necrosis.•Complications include urethral strictures or impotence in men.•Treatment may be medical (catheter for several weeks or surgery)

Urethral traumaUrethral trauma

Renal traumaRenal trauma

Renal TraumaRenal Trauma

Traffic accidents & falls most Traffic accidents & falls most common causecommon cause

Five categoriesFive categories Complications include Complications include

hemorrhage, abscess, fistula, hemorrhage, abscess, fistula, HTHT

Treatment may be medical or Treatment may be medical or surgical- watch & seesurgical- watch & see

Manifestations:Manifestations: Type of injury is keyType of injury is key May have hematuria, May have hematuria,

shock, flank pain, palpable shock, flank pain, palpable mass, paralyticmass, paralytic ileus, ileus, bruising over flankbruising over flank

Renal CancerRenal Cancer

85% of renal tumors are malignant85% of renal tumors are malignant Most common between ages of 50 and 70Most common between ages of 50 and 70 Cause unknown but some links between Cause unknown but some links between

chemicals and cancer, I.e. smoking, exposure to chemicals and cancer, I.e. smoking, exposure to lead.lead.

Tumor starts in renal cortex and lead to Tumor starts in renal cortex and lead to obstruction, renal failure, hemorrhage invasion of obstruction, renal failure, hemorrhage invasion of surrounding tissuesurrounding tissue

Symptoms: painless hematuria, flank pain, Symptoms: painless hematuria, flank pain, palpable mass (often delayed diagnosis – 35% palpable mass (often delayed diagnosis – 35% have mets when diagnosed)have mets when diagnosed)

Renal cell carcinoma with Renal cell carcinoma with venous invasion.venous invasion.

Stage I: confined to Stage I: confined to kidney capsule; survival kidney capsule; survival rate 65%rate 65%

Stage II: extends beyond Stage II: extends beyond capsule into fatty tissue; capsule into fatty tissue; S.R 40%S.R 40%

Stage III: regional lymph Stage III: regional lymph nodes, renal vein, nodes, renal vein, possibly IVCpossibly IVC

Stage IV: distant mets, Stage IV: distant mets, often lungs & often lungs & mediastinummediastinum

Survival rare in III and IVSurvival rare in III and IV

ManagementManagement

Surgery: partial or radical Surgery: partial or radical nephrectomy is usual treatment nephrectomy is usual treatment

Radiation therapy: with chemotherapy Radiation therapy: with chemotherapy and/or surgery. Pre-op to shrink tumor and/or surgery. Pre-op to shrink tumor or post-op for residual cells or metsor post-op for residual cells or mets

Chemotherapy: seems to be less Chemotherapy: seems to be less effective b/c of slow growth rate. effective b/c of slow growth rate. Vinblastine is most effective single Vinblastine is most effective single agent with response rate of 25%agent with response rate of 25%

Immunotherapy: fairly new, stimulates Immunotherapy: fairly new, stimulates immune systemimmune system

Renal surgeryRenal surgery

Nursing ManagementNursing Management Pre-op teaching and emotional supportPre-op teaching and emotional support Post-op there is high risk for hemorrhage, Post-op there is high risk for hemorrhage,

monitor for signs of bleeding (may be monitor for signs of bleeding (may be incisional or internal). Also risk for incisional or internal). Also risk for pneumothorax. pneumothorax.

Post-op care requires:Post-op care requires: DB & C (how can you help??)DB & C (how can you help??) Monitor urine outputMonitor urine output Pain ManagementPain Management Monitor GI status (watch for ileus)Monitor GI status (watch for ileus)

Bladder CancerBladder Cancer

Appears to be the result of exposure Appears to be the result of exposure of bladder wall to carcinogens – of bladder wall to carcinogens – smoking, asbestos, radiation & smoking, asbestos, radiation & chemochemo

Gross hematuria is often the first Gross hematuria is often the first sign. Identified through cystoscopy, sign. Identified through cystoscopy, IVP, CT, MRI, blood work (CEA)IVP, CT, MRI, blood work (CEA)

Treatment includes surgery, radiation Treatment includes surgery, radiation therapy and chemotherapy and chemoJust read on ownJust read on own

CystoscopyCystoscopy

SurgerySurgery Transurethral resection, partial Transurethral resection, partial

cystectomy, radical cystectomy & cystectomy, radical cystectomy & urinary diversionurinary diversion

Urinary diversion procedures:Urinary diversion procedures: Ileal conduitIleal conduit Indiana pouchIndiana pouch NeobladderNeobladder Palliative procedures: percutaneous Palliative procedures: percutaneous

nephrostomy or pyelostomy (tube in renal nephrostomy or pyelostomy (tube in renal pelvis), ureterostomypelvis), ureterostomy

Indiana Pouch ProcedureIndiana Pouch Procedure

Indiana PouchIndiana Pouch Urine is removed by Urine is removed by

inserting a thin tube inserting a thin tube (catheter) into the (catheter) into the stoma when the pouch stoma when the pouch is full. is full.

A bag is not required A bag is not required and the patient simply and the patient simply wears a bandage over wears a bandage over the stoma. the stoma.

The patient is then The patient is then taught to catheterize taught to catheterize the reservoir to drain the reservoir to drain urine at regular urine at regular intervals during the intervals during the day. day.

HypertensionHypertension

May be cause of renal failure or effectMay be cause of renal failure or effect

e.g. Renal artery stenosis decreases blood flow e.g. Renal artery stenosis decreases blood flow to the kidney. This activates the renin-to the kidney. This activates the renin-angiotensin-aldosterone system which angiotensin-aldosterone system which increases BP. Renal hypertension results from increases BP. Renal hypertension results from the kidney’s inability to excrete salt and water.the kidney’s inability to excrete salt and water.

Sustained high BP causes nephrosclerosis & Sustained high BP causes nephrosclerosis & damages arteries and arteriolesdamages arteries and arterioles

Renal vascular disordersRenal vascular disorders

Renal artery Renal artery diseasedisease

Renal vein diseaseRenal vein disease

Congenital Congenital AbnormalitiesAbnormalities

May involve abnormalities May involve abnormalities in number, position or in number, position or size.size.

Agenesis: means absence Agenesis: means absence of one or both kidneysof one or both kidneys

Sizes: small with or Sizes: small with or without functioning tissuewithout functioning tissue

Horseshoe kidney: both Horseshoe kidney: both kidneys are joined, in kidneys are joined, in lower lumbar regionlower lumbar region Susceptible to Susceptible to

hydronephrosis, infection hydronephrosis, infection and calculus formation.and calculus formation.

Polycystic KidneysPolycystic Kidneys Hereditary disease Hereditary disease

characterized by cyst characterized by cyst formation & massive formation & massive enlargement – affects enlargement – affects both adults & children.both adults & children.

Disease is slow & Disease is slow & progressive results in CRFprogressive results in CRF

No cure so management No cure so management is conservative, is conservative, supportive medical supportive medical treatmenttreatment

Eventually needs dialysis Eventually needs dialysis or transplantor transplant

Renal TransplantationRenal Transplantation

Renal TransplantationRenal Transplantation

Organ DonationOrgan Donation Preoperative ManagementPreoperative Management Postoperative ManagementPostoperative Management

Immunosuppressive therapyImmunosuppressive therapy RejectionRejection InfectionInfection Urinary FunctionUrinary Function ComplicationsComplications

Renal disorder websiteRenal disorder website

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