alteration in urinary system.ppt22222

8/8/2019 Alteration in Urinary System.ppt22222

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Medical Surgical Nursing


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` Pair of bean-shaped, brownish-red structures

located retroperitoneal on the posterior wall of the

abdomen

` Weighs 113-170 g (about 4.5 oz)` 10-12 cm long

` 6 cm wide

` 2.5 cm thick

` Slightly lower than the left due to the location ofthe liver


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` Adrenal gland lies on top of the kidney

` Renal parenchyma: 1)cortex 2)medulla

` Medulla : 5 cm wide, inner portion of the kidney

Contains loop of Henle, vasa recta, collecting ducts of thejuxtamedullary nephrons

` Cortex : 1 cm wide located farthest from the center

of the kidney and around the outermost edges

It contains the nephrons (functional units of the kidney)


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` Urine formation` Excretion of waste products

` Regulation of electrolytes

` Regulation of acid-base balance

` Control of water balance` Control of blood pressure

` Renal clearance

` Regulation of RBC production

` Synthesis of Vitamin D to active form` Secretion of prostaglandin

` Regulates Ca and Phosphorous balance

` Activates growth hormone


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` Kidneys receive 20% to 25% of the total cardiacoutput, which means that all of the bodys bloodcirculates through the kidneys approximately 12times per hour

` Renal artery divides into smaller and smallervessels, forming the afferent arterioles

` Each afferent arteriole branches form aGLOMERULUS, responsible for GLOMERULAR

FILTRATION` Blood leaves the glomerulus through efferent

arteriole and flows back to the inferior vena cavathrough capillaries and veins


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` URETERS long, fibromuscular tubes that

connects each kidney to the bladder Each 24 to 30 cm long, originate at the lower portion of

the renal pelvis and terminate in the trigone of the

bladder wall

` BLADDER muscular, hollow sac located just

behind the pubic bone Capacity : 300-500ml

` URETHRA arises from the base of the bladder Male : passes through the penis

Female : opens just anterior to the vagina


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` Urinalysis and urine culture

` Renal function tests

` Ultrasonography

` CT and MR

I

` Nuclear scans

` Intravenous urography, retrograde pyelography,cystography, renal angiography

` Endoscopic procedures

` Biopsies


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Key Signs and Symptoms of

Urological Problems

EDEMA

x associated with fluid retention

x Renal dysfunctions usually

produce ANASARCA


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Urological Problems

PAIN

x Suprapubic pain= bladder

x Colicky pain on the flank= kidney


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Key Signs and Symptoms ofUrological Problems

HEMATURIAx Painless hematuria may indicate

URINARY CANCER!

x Early-stream hematuria= urethrallesion

x Late-stream hematuria= bladder lesion


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Urological Problems

DYSURIA

x Pain with urination= lower UTI


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Key Signs and Symptoms ofUrological Problems

POLYURIAx More than 2 Liters urine per day

OLIGURIAx Less than 400 mL per day

ANURIAx Less than 50 mL per day


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Urological Problems

Urinary Urgency

Urinary retention

Urinary frequency


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PHYSICAL EXAMINATION

Inspection

AuscultationPercussion

Palpation


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Laboratory examination

1. Urinalysis

2. BUN and Creatinine levels of theserum

3. Serum electrolytes


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Laboratory examination

Radiographic

IVP KUB x-ray

KUB ultrasound

CT and MRI Cystography


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Provide PAIN relief

` Assess the level of pain

` Administer medications usually narcotic

ANALGESICS


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Maintain Fluid and Electrolyte Balance

` Encourage to consume at least 2 liters of fluid

per day

` In cases of ARF, limit fluid as directed` Weigh client daily to detect fluid retention


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Ensure Adequate urinary elimination

` Encourage to void at least every 2-3 hours

` Promote measures to relieve urinary retention:

Alternating warm and cold compress Bedpan

Open faucet

Provide privacy

Catheterization if indicated


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`Bacterial invasion of the

kidneys or bladder

(CYSTITIS) usually

caused by Escherichia

coli


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Predisposing factors include

1. Poor hygiene

2. Irritation from bubble baths3. Urinary reflux

4. Instrumentation

5. Residual urine, urinary stasis6. Dehydration


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PATHOPHYSIOLOGY

` The invading organism ascends the urinary

tract, irritating the mucosa and causing

characteristic symptoms Ureter= ureteritis

Bladder= cystitis

Urethra=Urethritis

Pelvis= Pyelonephritis


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Assessment findings

` Low-grade fever

` Abdominal pain` Enuresis

` Pain/burning on urination

` Urinary frequency

` Hematuria


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Assessment findings: Upper UTI

` Fever and CHIILS

` Flank pain` Costovertebral angle tenderness


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Laboratory Examination

1. Urinalysis

2. Urine Culture


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Nursing interventions` Administer antibiotics as ordered

` Provide warm baths and allow client to void in

water to alleviate painful voiding.

` Force fluids. Nurses may give 3 liters of fluidper day

` Encourage measures to acidify urine

(cranberry juice, acid-ash diet).


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`

Provide client teaching and dischargeplanning concerning

a. Avoidance of tub baths

b. Avoidance of bubble baths that might irritate

urethrac. Importance for girls to wipe perineum from

front to back

d. Increase in foods/fluids that acidify urine.


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Pharmacology` 1. Sulfa drugs

Highly concentrated in the urine

Effective against E. coli!

Can cause CRYSTALLURIA

` 2. Quinolones Not given to less than 18 because they can cause

cartilage degradation

` 3. Pyridium= urinary antiseptic Can cause urine discoloration


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`Presence of stones

anywhere in the urinary tract

Calciumoxalate

and uric acid


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Pathophysiology

` Predisposing factors

a. Diet: large amounts of calcium and oxalate

b. Increased uric acid levels

c. Sedentary life-style, immobility

d. Family history of gout or calculi

e. Hyperparathyroidism


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Pathophysiology

Supersaturation of crystals due to stasis

Stone formation

May pass through the urinary tract

OBSTRUCTION, INFECTION and HYDRONEPHROSIS


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Assessment findings

1. Abdominal or flank pain

2. Renal colic radiating to thegroin

3. Hematuria

4. Cool, moist skin

5. Nausea and vomiting


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Diagnostic tests1. KUB Ultrasound and X-ray:

pinpoints location, number, and size

of stones2. IVP: identifies site of obstruction

and presence of non-radiopaque

stones3. Urinalysis: indicates presence of

bacteria, increased protein, increased

WBC and RBC (hematuria)


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Medical management

1. Surgery

` a. Percutaneous nephrostomy: tube is insertedthrough skin and underlying tissues into renal

pelvis to remove calculi.` b. Percutaneous nephrostolithotomy: delivers

ultrasound waves through a probe placed onthe calculus.


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Medical management

2. Extracorporeal shock-wave lithotripsy:

delivers shock waves from outside the body

to the stone, causing pulverization3. Pain management : Morphine or Meperidine

4. Diet modification


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Nursing interventions

` 1. Strain all urine through gauze to

detect stones and crush all clots.

` 2. Force fluids (30004000 cc/day).

` 3. Encourage ambulation to prevent

stasis.


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` 4. Relieve pain by administration of

analgesics as ordered and

application of moist heat to flank

area.

` 5. Monitor intake and output


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Nursing interventions` 6. Provide modified diet,depending upon stone

consistency: Calcium, Oxalateand Uric acid stones


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Nursing interventionsCalcium stones` limit milk/dairy productsprovide acid-ash diet to acidifyurine (cranberry or prune juice,meat, eggs, poultry, fish, grapes,

and whole grains)


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Nursing interventionsOxalate stones

` avoid excess intake of foods/ fluids

high in oxalate (tea, chocolate,spinach)

` maintain alkaline-ash diet to

alkalinize urine (milk; vegetables;fruits except prunes, cranberries,and plums)


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Nursing interventionsUric acid stones` reduce foods high in purine

(liver, beans, kidneys, venison,shellfish, meat soups, gravies,legumes)

`

maintain alkaline urine


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` 7. Administer allopurinol (Zyloprim) as

ordered, to decrease uric acid production

Allopurinolx Rashes

x Nasal congestion


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8. Provide client teaching and discharge

planning concerning

`

Prevention of Urinary stasis bymaintaining increased fluid intake

especially in hot weather and during

illness; mobility; voiding whenever

the urge is felt and at least twiceduring the night


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8. Provide client teaching and discharge

planning concerning:

`

Adherence to prescribed diet` Need for routine urinalysis (at least

every 34 months)

` Need to recognize and report signs/

symptoms of recurrence (hematuria,

flank pain).


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`Sudden interruption of

kidney function to regulatefluid and electrolytebalance and remove toxicproducts from the body


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`Most important

manifestation: OLIGURIA


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The Nephron producesThe Nephron produces

urine to eliminate wasteurine to eliminate waste

Impaired urine productionImpaired urine production

and azotemiaand azotemia

Secretes ErythropoietinSecretes Erythropoietin

to increase RBCto increase RBC

ANEMIAANEMIA

Metabolism of Vitamin DMetabolism of Vitamin D Calcium and PhosphateCalcium and Phosphate

imbalancesimbalances

Produces bicarbonateProduces bicarbonateand secretes acidsand secretes acids Metabolic ACIDOSISMetabolic ACIDOSIS

Excretes excessExcretes excess

POTASSIUMPOTASSIUM

HYPERKALEMIAHYPERKALEMIA


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PATHOPHYSIOLOGY1. Pre-renal failure

2. Intra-renal failure

3. Post-renal failure


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PATHOPHYSIOLOGYPrerenal CAUSE:` Factors interfering with perfusion

and resulting in diminished bloodflow and glomerular filtrate,ischemia, and oliguria; includeCHF, cardiogenic shock, acutevasoconstriction, hemorrhage,burns, septicemia, hypotension,anaphylaxis


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PATHOPHYSIOLOGYIntrarenal CAUSE:` Conditions that cause damage to the

nephrons; include acute tubularnecrosis (ATN), endocarditis, diabetesmellitus, malignant hypertension,acute glomerulonephritis, tumors,

blood transfusion reactions,hypercalcemia, nephrotoxins (certainantibiotics, x-ray dyes, pesticides,anesthetics)


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PATHOPHYSIOLOGYPostrenal CAUSE:` Mechanical obstruction anywhere

from the tubules to the urethra;includes calculi, BPH, tumors,strictures, blood clots, trauma, andanatomic malformation


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Three phases of acute renal failure

1. Oliguric phase

2. Diuretic phase

3. Convalescence or recovery phase


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Four phases of acute renal failure(Brunner andSuddarth)

1. Initiation phase

2. Oliguric phase3. Diuretic phase4. Convalescence or recovery phase


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Assessment findings: The Three Phases of AcuteRenal Failure

1. Oliguric phase` Urine output less than 400 cc/24 hours`

duration 12 weeks` Manifested by dilutional hyponatremia,

hyperkalemia, hyperphosphatemia,hypocalcemia, hypermagnesemia, andmetabolic acidosis

` Diagnostic tests: BUN and creatinine elevated


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Assessment findings: The Three Phases ofAcute Renal Failure

2. Diuretic phase` Diuresis may occur (output 35 liters/day)

due to partially regenerated tubulesinability to concentrate urine

` Duration: 23 weeks; manifested byhyponatremia, hypokalemia, and

hypovolemia` Diagnostic tests: BUN and creatinine

slightly elevated


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Assessment findings: The ThreePhases of Acute Renal Failure

3. Recovery or convalescent phase:

` Renal function stabilizes with gradualimprovement over next 312 months


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Laboratory findings:1. Urinalysis: Urine osmo and sodium2. BUN and creatinine levels increased

3. Hyperkalemia4. Anemia5. ABG: metabolic acidosis


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` Monitor fluid and Electrolyte Balance

` Reduce metabolic rate

` Promote pulmonary function` Prevent infection

` Provide skin care

` Provide emotional support


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Nursing interventions1. Monitor and maintain fluid and electrolyte

balance.` Measure l & O every hour. note excessive

losses in diuretic phase` Administer IV fluids and electrolyte

supplements as ordered.` Weigh daily and report gains.` Monitor lab values; assess/treat fluid and

electrolyte and acid-base imbalances asneeded


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Nursing interventions2. Monitor alteration in fluid volume.` Monitor vital signs, PAP, PCWP,

CVP as needed.` Weigh client daily.` Maintain strict I & O records.


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Nursing interventions2. Assess every hour forhypervolemia Maintain adequate ventilation.

Restrict FLUID intake Administer diuretics andantihypertensives


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Nursing interventions3. Promote optimal nutritional status.

` Administer TPN as ordered.

` With enteral feedings, check forresidual and notify physician ifresidual volume increases.

` Restrict protein intake to 1 g/kg/day

` Restrict POTASSIUM intake

` HIGH CARBOHYDRATE DIET, calciumsupplements


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Nursing interventions4. Prevent complications from

impaired mobility (pulmonaryembolism, skin breakdown, andatelectasis)

5. Prevent fever/infection. Assess for signs of infection.

Use strict aseptic technique for woundand catheter care.


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Nursing interventions6. Support client/significant others and reduce/

relieve anxiety. Explain pathophysiology and relationship to

symptoms. Explain all procedures and answer all questions in

easy-to-understand terms Refer to counseling services as needed

7. Provide care for the client receiving dialysis


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Nursing interventions8. Provide client teaching and discharge

planning concerning` Adherence to prescribed dietary regimen` Signs and symptoms of recurrent renal

disease` Importance of planned rest periods` Use of prescribed drugs only

` Signs and symptoms of UTI or respiratoryinfection need to report to physicianimmediately


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`Gradual, Progressiveirreversible destruction ofthe kidneys causing severe

renal dysfunction.`The result is azotemia toUREMIA


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Predisposing factors:

DM= worldwide leading cause

Recurrent infectionsExacerbations of nephritis

urinary tract obstruction

hypertension


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PATHOPHYSIOLOGY

As renal functions decline

Retention of end-products of

metabolism


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PATHOPHYSIOLOGY

STAGE 1= reduced renal reserve,40-75% loss of nephron function

STAGE 2= renal insufficiency, 75-90% loss of nephron function

STAGE 3= end-stage renal disease,

more than 90% loss. DIALYSIS ISTHE TREATMENT!


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Assessment findings` 1. Nausea, vomiting; diarrhea orconstipation; decreased urinary

output` 2. Dyspnea` 3. Stomatitis` 4. Hypertension (later), lethargy,convulsions, memory impairment,pericardial friction rub


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DermatologicDermatologic dry skindry skin, pruritus, uremic, pruritus, uremicfrostfrost

CNSCNS seizures, altered LOC,seizures, altered LOC,

anorexia, fatigueanorexia, fatigueCVSCVS Acute MI, edema,Acute MI, edema,

hypertension, pericarditishypertension, pericarditis

PulmoPulmo Uremic lungsUremic lungs

HemaHema AnemiaAnemia

MusculoskeletalMusculoskeletal loss of strength, footloss of strength, footdrop, osteodystrophydrop, osteodystrophy


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Diagnostic tests:` a. 24 hour creatinine clearanceurinalysis

` b. Protein, sodium, BUN, Creaand WBC elevated

` c. Specific gravity, platelets, and

calcium decreased` D. CBC= anemia


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Medical management` 1. Diet restrictions` 2. Multivitamins`

3. Hematinics and erythropoietin` 4. Aluminum hydroxide gels` 5. Anti-hypertensive` 6. Anti-seizures

`DIALYSIS


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Nursing interventions1. Prevent neurological

complications.

` Assess every hour for signs ofuremia (fatigue, loss of appetite,decreased urine output, apathy,confusion, elevated blood

pressure, edema of face and feet,itchy skin, restlessness, seizures).


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Nursing interventions1. Prevent neurological complications.` Assess for changes in mental

functioning.` Orient confused client to time, place,

date, and persons` Institute safety measures to protect

client from falling out of bed.


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Nursing interventions2. Promote optimal GI function.` Assess/provide care for stomatitis

` Monitor nausea, vomiting, anorexia` Administer antiemetics as ordered.` Assess for signs of Gl bleeding


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Nursing interventions` 3. Monitor/prevent alteration in fluid

and electrolyte balance`

4. Assess for hyperphosphatemia(paresthesias, muscle cramps,seizures, abnormal reflexes), andadministeraluminum hydroxide gels(Amphojel) as ordered


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Nursing interventions6. Monitor for bleeding complications,

prevent injury to client.

` Monitor Hgb, hct, platelets, RBC.` Hematest all secretions.` Administer hematinics as ordered.` Avoid lM injections


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Nursing interventions7. Promote/maintain maximal

cardiovascular function.`

Monitor blood pressure and reportsignificant changes.` Auscultate for pericardial friction

rub.`

Perform circulation checks routinely.


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Nursing interventions7. Promote/maintain maximal

cardiovascular function.`

Administer diuretics as ordered andmonitor output.` Modify drug doses8. Provide care for client receiving

dialysis.


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Aluminum hydroxideAluminum hydroxide

(Amphogel)(Amphogel)

Binds withBinds withPHOSPHATE toPHOSPHATE to

decrease phosphorusdecrease phosphorus

KayexalateK

ayexalate Binds withBinds withPOTASSIUM toPOTASSIUM to

manage hyperkalemiamanage hyperkalemia

DiureticsDiuretics To decrease edemaTo decrease edema

ErythropoietinErythropoietin

(Epogen)(Epogen)

To increase RBCTo increase RBC

AntiAnti--HypertensivesHypertensives To manageTo manage

HypertensionHypertension


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` a procedure that is used to remove

fluid and uremic wastes from the

body when the kidneys cannot

function


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` Two methods

` 1. Hemodialysis

` 2. Peritoneal dialysis


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` Diffusion

` Osmosis

` Ultrafiltration


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Nursing management1. Meet the patient's psychosocial

needs

2. Remember to avoid anyprocedure on the arm with thefistula (HEMO)

Monitor WEIGHT, blood pressureand fistula site for bleeding


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Nursing management3. Monitor symptoms of uremia

4. Detect complications like infection, bleeding(Hepatitis B/C and HIV infection in

Hemodialysis) Peritonitis in peritonealdialysis

5. Warm the solution to increase diffusion ofwaste products (PERITONEAL)

6. Manage discomfort and pain


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Nursing management

7. To determine effectiveness, check

serum creatinine, BUN and

electrolytes


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` BPH

` Prostatic cancer


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DIGITAL RECTAL EXAMINATION- DRE

` Recommended for men annually with age over

40 years

` Screening test for cancer

` Askpatient to BEAR DOWN


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TESTICULAR EXAMINATION

` Palpation of scrotum for nodules and masses

or inflammation

` BEGINSDURING ADOLESCENCE


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Prostate specific antigen (PSA)

` Elevated in prostate cancer

` Normal is 0.2 to 4 nanograms/mL

`

Cancer= over 4


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BENIGN PROSTATIC HYPERPLASIA

` Enlargement of the prostate that causes

outflow obstruction

` Common in men older than 50 years old


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Assessment findings

1. DRE: enlarged prostate gland that is rubbery,

large and NON-tender

2. Increased frequency, urgency and hesitancy

3. Nocturia, DECREASE IN THE VOLUME AND

FORCE OF URINESTREAM


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Medical management

1. Immediate catheterization

2.

Prostatectomy3. TRANSURETHRAL RESECTION of the

PROSTATE (TURP)

4. Pharmacology: alpha-blockers, alpha-

reductase inhibitors. SAW palmetto


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NURSING INTERVENTION: TURP

` Maintain the three way bladder irrigation to

prevent hemorrhage

` Only initially the drainage is pink-tinged and

never reddish

` Administer anti-spasmodic to prevent

bladder spasms


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` a slow growing malignancy of the prostategland

` Usually an adenocarcinoma

` This usualy spread via blood stream to the

vertebrae


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` Predisposing factor Age


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` Assessment Findings

1. DRE: hard, pea-sized nodules on the anterior

rectum

2. Hematuria

3. Urinary obstruction

4. Pain on the perineum radiating to the leg


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` Diagnostic tests

1. Prostatic specific antigen (PSA)

2. Elevated SERUM ACID PHOSPHATASE

indicates SPREAD or Metastasis


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Medical and surgical management

1. Prostatectomy

2. TURP

3. Chemotherapy: hormonal therapy to slow the

rate of tumor growth

4. Radiation therapy


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Nursing Interventions

1. Prepare patient for chemotherapy

2. Prepare for surgery


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Nursing Interventions: Post-prostatectomy1. Maintain continuous bladder irrigation. Note

that drainage is pink tinged w/in 24 hours

2. Monitor urine for the presence of blood clots

and hemorrhage3. Ambulate the patient as soon as urine begins

to clear in color

alteration in urinary system.ppt22222

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