microsoft power point renal system disorders

Renal System DisordersRenal System DisordersRenal System DisordersRenal System DisordersNio C. Nio C. NovenoNoveno, , RNRN, MAN, MAN

The Human KidneyThe Human Kidney

2Renal Disorders [email protected]

The NephronThe Nephron


Functions of the Renal SystemFunctions of the Renal System

� Excretion of waste

� Regulation of acid-base balance

4Renal Disorders

� Formation of erythropoietin

� Regulation of fluid and electrolyte balance (RAAS)

� Regulation of phosphate and calcium

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Classification of Renal DisordersClassification of Renal Disorders

Obstructive disorders

Acute renal failure

5Renal Disorders

Acute renal failure

Chronic renal failure

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Obstructive disordersObstructive disorders

�Can occur anywhere in the urinary tract

6Renal Disorders

� Signs and symptoms depend on the site of location and size of obstruction

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Causesof urinary tract obstructionCausesof urinary tract obstruction

Lower urinary tract

� Bladder neoplasms

� Urethral strictures

Calculi

Ureteral obstruction

� Calculi

� Trauma

� Enlarged lymph nodes

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� Calculi

� Tumors

� Benign prostatic

hypertrophy

� Enlarged lymph nodes

� Congenital anomalies

Kidney

� Calculi

� Polycystic kidney disease

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Renal stonesRenal stones

�Crystallization of minerals around an organic matrix (blood, pus, devitalization tissue)

8Renal Disorders

�Usually idiopathic:

– Infection

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SITES OF STONE FORMATIONSITES OF STONE FORMATION


Composition of renal stonesComposition of renal stones

Calcium (oxalate and phosphate)

Hypercalcemia

� Hyperthyroidism

� Vitamin D intoxication

Uric acid

� High purine diet

� Gout

� Chemotherapy

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� Immobilization

� Tumors

� Renal tubular acidosis

� Intake of steroids

Cystine

� Genetic disorder

Struvite

� Infection related

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Renal StonesRenal Stones

Diagnostics

� Urinalysis

� KUB-UTZ

�KUB-IVP

CT scan

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� CT scan

� Cystoscopy

� BUN, Creatinine

Clinical manifestations

� Pain

� Hematuria

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Diagnostic ProceduresDiagnostic Procedures


Medical managementMedical management

Medications

� Pain medications

� Medications to � Ca & PO4 content

– Ascorbic acid

� Medications to � uric acid formation

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� Medications to � uric acid formation

– Sodium bicarbonate

– Allopurinol

� Surgery

� Extracorporeal shockwave lithotripsy

� Percutaneous lithotripsy

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EXTRACORPOREAL

SHOCKWAVE LITHOTRIPSY


Nursing managementNursing management

� Administer medications as ordered

� Strain urine to detect passage of stones

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of stones

� Monitor I & O

� Encourage to increase OFI

>3 L/day

� Instruct client on infection prevention

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Bladder carcinomaBladder carcinoma

� Most common among 60-70 years old

� Males>females

Predisposing factors:

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Predisposing factors:

– Cigarette smoking

– Exposure to rubber dyes

– Abuse of phenacetin-containing analgesics

– Recurrent UTI

– Recurrent nephrolithiasis

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– Gross painless hematuria

– Dysuria

– Frequent urination

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– Frequent urination

Diagnostics

– Urinalysis

– IVP

– Cystoscopy with biopsy

– CT [email protected]


Medical Management

� Surgical treatment

Radiation

Nursing management

� Encourage to:

– Increase OFI

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� Radiation

� Chemotherapy

– Increase OFI

– Quit smoking

� Assess for presence

of UTI

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Care of the STOMA

Immediate post-OP:

� Color of drainage is bright red/pink

Report: gray or black discoloration

� Teach patient on stoma care

Opening should be no more than 2-3 mm larger than the stoma

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Report: gray or black discoloration

� Position pouch at the side of bed for drainage

� Monitor urine output daily

� Monitor for signs of peritonitis

Abdominal pain, distention, fever

stoma

Change every 3-5 days

Report signs of UTI

– Cloudy urine

– Hematuria

– Strong odor

– Fever– Flank pain

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Benign Prostatic Hyperplasia (BPH)Benign Prostatic Hyperplasia (BPH)

� Most common

problem of adult male

reproductive organ

Cause is not

20Renal Disorders

� Cause is not

completely

understood

� Not a predisposing

factor for prostatic

carcinoma

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� Dribbling

� Hesitancy

� Diminution in caliber

Diagnostics

� Digital rectal exam

� Urinalysis

� BUN/Creatinine

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� Diminution in caliber and force of urinary stream

� Feeling of incomplete emptying

� Irritative symptoms

� BUN/Creatinine

� Cystourethroscopy

� PSA

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Medical Management

� Pharmacologic treatment

� Anti-androgens

Non-surgical procedures

� Thermotherapy

� Prostatic balloon device

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� Anti-androgens

– Finasteride

– Alpha-adrenergic blockers

– Terazosin

device

� Stents/coils

� TULIP (transurethral ultrasound-guided laser prostatectomy)

� Surgical procedures

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Nursing management:

1. Provide medications as ordered

2. Maintain patency of 3-way Foley

• Observe aseptic technique

24Renal Disorders

• Irrigate with NSS (as ordered)

3. Control & treat bladder spasms

• Short, frequent walks

• Decrease frequency of bladder irrigation

• Administer anti-cholinergics and anti-spasmodics

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4. Prevent hemorrhage

• Prevent straining (heavy lifting, constipation), prolonged periods of travel, sexual activity until doctor approves so.

• Avoid rectal procedures.5. Provide for bladder training after Foley

25Renal Disorders

5. Provide for bladder training after Foley catheter removal

• Perineal exercise• Limit fluid intake in the evening• Restrict intake of caffeine-containing

compounds• Withhold anti-cholinergics and anti-

spasmodics if permitted

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5. Provide health teaching on:

• Increasing OFI

• Signs of UTI and report once noted

• Avoidance of heavy lifting, straining and

26Renal Disorders

• Avoidance of heavy lifting, straining and

prolonged travel.

• Possible impotence

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Prostate cancerProstate cancer

� Highest incidence in African-American over age 60

� Adenocarcinoma; growth related to presence of androgens

Clinical manifestations:

27Renal Disorders

Clinical manifestations:– Same as BPH– Hard, nodular, fixed mass upon rectal exam

Laboratory diagnostics:

– Elevated PSA, acid & alkaline phosphatase– Bone scan

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Medical management:

Drug therapy:

Estrogens,

chemotherapeutic

Nursing interventions:

1. Administer prescribed medications

2. If with radiotherapy:

• Double flush the toilet

29Renal Disorders

chemotherapeutic

agents

Radiation therapy

Surgery: Perineal

prostatectomy

• Double flush the toilet after use.

• Advise to avoid placing children on their lap.

• Avoid sexual intercourse for the whole duration of therapy.

3. Provide care post-prostatectomy

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Acute renal failure (ARF)Sudden cessation of kidney function; reversibleAcute renal failure (ARF)Sudden cessation of kidney function; reversible


Acute renal failure (ARF)Sudden cessation of kidney function; reversibleAcute renal failure (ARF)Sudden cessation of kidney function; reversible

Causes:

1. Ischemic (pre-renal)

• Dehydration

• Blood loss (surgery, trauma)

• Cardiac failure

• Shock

3. Obstruction (post-renal)

• Stones

• Tumors

• Strictures/stenosis

31Renal Disorders

2. Toxic substance (renal)

• Solvents (carbon tetrachloride, methanol, ethylene glycol)

• Heavy metals (lead, arsenic, mercury)

• Antibiotics (aminoglycosides, amphotericin B)

• Pesticides

• Mushrooms

4. Other causes:

• Acute glomerulonephritis

• Malignant hypertension

• Hemolysis

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Physiologic effect Findings Symptoms

OliguricInability to excrete wastes

Inability to regulate electrolytes

Inability to excrete fluid loads

↑ BUN, Crea

↑ K+, ↓ Na+, acidosis

Fluid overload

Drowsiness, Confusion, Coma

GI bleeding

Asterixis

Pericarditis

Cardiac dysrhythmias

Kusmaull’s breathing

Coma

CHF

Pulmonary edema

Hypertension

32Renal Disorders

Hypertension

Diuretic

Hypovolemia

↓ Na+

↓ K+

Urine output of 4-5 L/day

Hypotension

Tachycardia

Improving mental alertness

Weight loss

Dry mucous membranes

Muscle weakness

Constipation

Recovery Return to normal

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Nursing management:Nursing management:

Medical management:

� Supportive

� Dialysis


1. Maintain F & E balance

• Accurate I & O

• Weigh daily

• Maintain fluid restrictions

• Assess for signs of fluid overload

2. Maintain nutrition

• Moderate CHON, low K+, high CHO, high fat

• Measures to relieve nausea



3. Maintain rest-activity balance

• Provide assistance in ADL

• Maintain strict bed rest in acute phase

4. Prevent injury

• Keep side rails elevated (pad if necessary)• Keep side rails elevated (pad if necessary)

• Protect from bleeding

5. Prevent infection

• Maintain asepsis

• Reverse isolate

• Turn frequently

• Meticulous skin care

• Relieve pruritus


Chronic renal failure (CRF)Chronic renal failure (CRF)

Causes:

Chronic systemic disease

DM, HTN

Polycystic kidney disease

35Renal Disorders

Polycystic kidney disease

Long standing obstruction

Chronic glomerulonephritis

Recurrent infections

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Stages of CRFStages of CRF

1. Decreased renal reserve (renal impairment)• GFR: 40-50%• BUN & crea are normal• Asymptomaitc

2. Renal insufficiency• GFR: 20-40%

4. End-stage renal disease

• GFR: <10%• BUN & crea severely

increased• Signs of CHF• Hypocalcemia,

36Renal Disorders

• GFR: 20-40%• BUN & crea begins to rise• Mild anemia, mild azotemia• Polyuria, nocturia

3. Renal failure• GFR: 10-20%• BUN & crea increase• Anemia, azotemia,

metabolic acidosis

• Hypocalcemia, hyperphosphatemia, hyperkalemia, hyponatremia

• Fractures, joint pains• Infertility, amenorrhea• Uremia

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Stages of CRFStages of CRF

�Decreased renal reserve

37Renal Disorders

�Renal insufficiency

�Renal failure

�End-stage renal disease

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Diagnostics:

Blood chemistry

Urinalysis

KUB-TUZ

Medical management:

� Anemia

– Epoieitin alfa

– Iron

– Folate and Vitamin B12

– Blood transfusion

39Renal Disorders

Conservative TX

� Fluid and electrolyte control

– Hyperkalemia

� Diet

� Dialysis

� Exchange resins

– Hypocalcemia/ hyperphosphatemia

� Phosphate binders

� Diet

� Vitamin D

� Hypertension

Dialysis

Renal transplant

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Peritoneal DialysisPeritoneal Dialysis


Peritoneal DialysisPeritoneal Dialysis

Intermittent:

8-12 H x 3-5x/week

Ambulatory:

42Renal Disorders

Ambulatory:

3-5 passes/day

Continuous cycling:

3-7x during sleep

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Peritoneal dialysis� Must consider:

– Explaining procedure

– Monitor VS (+

� (+) pink-tinged effluent or presence of small strings is normal

� Blood is normal for

43Renal Disorders

– Monitor VS (+ weight)

– Note for signs of infection

– Assess skin integrity

� Blood is normal for several days

� With ascites from other source, substitute a lower concentration of dialysate

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Hemodialysis

AV Fistulas

– Internal AVF

– Internal Graft AVF

– Internal AV Graft

44Renal Disorders

– Internal AV Graft

with external

access device

Complications

– Thrombosis

– Local infections

– Aneurysms

– Steal [email protected]

Hemodialysis Hemodialysis


HEMODIALYSIS PERITONEAL DIALYSIS

ACCESS

AVF

Subclavian vein

Arteriovenous graft

Peritoneum

DURATION 2-4 H 36 H

COMPLICATIONS

Disequilibrium syndrome

Hypotension

Bleeding

Sepsis

Exit site infection

Peritonitis

Hernias

Pulmonary complications

46Renal Disorders

Sepsis

Hepatitis

Pulmonary complications

Protein loss

NURSING INTERVENTIONS

Weigh before and after HD

VS q 15 mins

Monitor I & O, signs of DE

WOF signs of bleeding

Do NOT use the AVF other than for

dialysis

Provide diversional activities

Monitor for VS and changes in

behavior

Check patency of catheter

May procaine HCl in the

dialysate to minimize

discomfort

Observe for signs of peritonitis

Maintain aseptic technique

during insertion of [email protected]


Nursing management:

� Maintain F & E balance

– I & O q 80

– Weigh daily

47Renal Disorders

– Weigh daily

– Assess edema

�Auscultate breath sounds

�V/S q 80

�Assess LOC q 80

�High CHO diet, within prescribed Na+, K+, and

CHON limits

�Administer medications as [email protected]

Renal TransplantRenal Transplant



Nursing management cont…:

� Prevent infection and injury

– Promote meticulous skin care

– Protect from infectious agent

– Protect confused person

– Maintain asepsis

50Renal Disorders

– Maintain asepsis

– Avoid aspirin products

– Encourage use of soft bristle toothbrush

� Promote comfort

– Give anti-pruritics

– Use emolient baths, keep skin moist

– Provide good oral hygiene

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ACID-BASE DISORDERSACID-BASE DISORDERS

Disorder Clinical manifestation Compensation

Respiratory acidosis↑Paco2, ↑ or normal

HCO3-, ↓ pH

Kidneys eliminate H+

and retain HCO3-

51Renal Disorders

Respiratory alkalosis↓ Paco2, ↓ or normal

HCO3-, ↑ pH

Kidneys conserve H+

and eliminate HCO3-

Metabolic acidosis↓ or normal Paco2,

↓HCO3-, ↓ pH

Lungs eliminate CO2

and conserve HCO3-

Metabolic alkalosis↑ or normal Paco2,

↑HCO3-, ↑ pH

Lungs hypoventilate to

↑ Paco2, kidneys

conserve H+ excrete

HCO3-

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Causes of Acid-Base DisordersCauses of Acid-Base Disorders

Metabolic acidosisCauses:

� DKA, uremia, starvation, diarrhea, severe infections

Nursing management:

� Administer sodium bicarbonate

� Monitor for signs of hyperkalemia

52Renal Disorders

severe infections

Manifestations:

� Headache, nausea and vomiting

� Signs of hyperkalemia

� Seizures, coma, hyperventilation

� Provide alkaline mouthwash

� Lubricate lips to prevent dryness

� I & O

� Institute seizure precaution

� Monitor ABG & electrolyte losses

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Metabolic alkalosis

Causes:

� Severe vomiting, NGT suctioning, diuretic therapy, excessive

Nursing management:

� Decreased respirations

� Replace fluids nad

53Renal Disorders

therapy, excessive ingestion of NaHCO3, biliary drainage

Manifestations:

� Nausea and vomiting

� Signs and symptoms of hypokalemia

� Replace fluids nad electrolytes losses

� I & O

� Assess for signs of hypokalemia

� Monitor ABG & electrolytes

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Causes of Acid-Base DisordersCauses of Acid-Base DisordersRespiratory acidosis

Causes:

� Hypoventilation: COPD, barbiturate or sedative overdose, acute airway obstruction,

Nursing management:

� Semi-Fowler’s

� Patent airway

54Renal Disorders

obstruction, neuromuscular disorders

Manifestations:

� Headache, weakness, visual disturbances, rapid respirations, confusion, drowsiness, tachycardia, coma

� Patent airway

� Turn, cough, deep-

breath

� Administer fluids

� O2 therapy

� Monitor ABG

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Respiratory alkalosis

Causes:

� Hyperventilation, mechanical overventilation, encephalitis

Nursing management:

� Offer reassurance

� Encourage breathing into a paper bag

55Renal Disorders

encephalitis

Manifestations:

� Numbness and tingling of mouth and extremities

� Inability to concentrate

� Rapid respirations, dry mouth, coma

into a paper bag

� Provide sedation as ordered

� Monitor mechanical ventilation and ABG

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Interpretation Interpretation

UC PC FC

pH ↓ or ↑ ↓ or ↑ normal

56Renal Disorders

pH ↓ or ↑ ↓ or ↑ normal

HCO3-

↓ or ↑

normal↓ or ↑ ↓ or ↑

Paco2

↓ or ↑

normal↓ or ↑ ↓ or ↑

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Renal System DisordersRenal System DisordersRenal System DisordersRenal System DisordersNio C. Noveno, USRN, MANNio C. Noveno, USRN, MAN

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