oum tutorial 1 sbns3504 renal[1]

8/3/2019 OUM Tutorial 1 SBNS3504 Renal[1]

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PUAN NORAINI MASRI

Nursing Tutor/ OPEN

UNIVERSITY


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TOPIC 1 :

ASSESSMENT OF THE RENAL NURSING


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KIDNEY FUNCTION

y Removing wastes and water from the blood

y Balancing chemicals in your body

y Releasing hormonesy Helping control blood pressure

y Helping to produce red blood cells

y Producing vitamin D, which keeps the bones strongand healthy


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Structure of kidney

y Location-retro-peritoneal

y The left kidney is typically slightly

larger than the right.


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KIDNEY STRUCTURE


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BLOOD

CIRCULATION

y Each kidney is perfused at arate of 600 ml/min by way ofthe renal artery

y Each renal artery branchesinto interlobar arteries,arcuate arteries, interlobulararteries, and then into 1.2million afferent arterioles thateach feed each nephron, thefunctional unit of the kidney.

y After blood has been filteredthrough the glomerulus andtransported through thenephron's vasculature it

passes through theinterlobular, arcuate, andinterlobar that merge into therenal vein and back in tosystemic circulation.


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The kidney is made up of approximately one

million functioning units called nephrons.Each nephron consists of the followingcomponents:

y Glomerulus: mechanically filters blood

y Bowman's Capsule: mechanically filters

blood

y Proximal Convoluted Tubule: Reabsorbs75% of the water, salts, glucose, and aminoacids

y Loop of Henle: Countercurrent exchange,which maintains the concentrationgradient

y Distal Convoluted Tubule: Tubular secretionof H ions, potassium, and certain drugs.


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URINEFORMATI

ON

STEP

y Filtration

yReabsorption

y Secretion


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URINE FORMATION


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ASSESSMENT OF RENAL FUNCTIONS

PURPOSE:

1. General health screening to detect renal andmetabolic disease

2. Diagnosis of disease or disorders of the kidneys orurine tract

3. Monitoring of patients with diabetes


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METHOD

1. Urinalysis PHYSICAL TEST & BIOCHEMICALTEST

2. Blood analysis3. Radiograpy

4. Other test


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URINALYSIS-PHYSICAL

TEST

Urine output

- volume minimal daily urine volume 500mls - max. can beup to 20 liters.

- < 400ml per day oliguria(low urine production)- > 2 liters per day polyuria (common in D.M &D.I)

Colour

- Normal straw yellow to amber in colour- Abnormal bright yellow, brown,

black(gray), red & green.


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Transparency

- Normal transperent.

- Turbid (cloudy) maybe cause by either normal orabnormal process.

- Normal conditons mucus, vaginal discharge

- Abnormal condition- presence of blood cells, yeast &bacteria.


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Specific gravity/urine density

Normal values are between 1.020 to 1.028.

Increased urine specific gravity may be due to:y Dehydration

y Diarrhea that causes dehydration

y Glucosuria (glucose in urin)-rare

yHeart failure (related to decreased blood f low to the kidneys)

y Renal arterial stenosis

y Shock

Decreased urine specific gravity may be due to:y

Aldosteronism (very rare)y Excessive fluid intake

y Diabetes insipidus

y Renal failure

y Renal tubular necrosis

y Severe kidney infection (pyelonephritis)


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Odor of urin

- Urine odor varies. Urine does not usually have a strongsmell.

- Foul smelling urine may be due to bacteria, such as thatresponsible for urinary tract infections.

- Sweet smelling urine may be a sign of uncontrolleddiabetes or a rare disease of metabolism.

- Liver disease and certain metabolic disorders may causemusty smelling urine.

Abnormal urine odor may indicate:y Dehydration (concentrated urine can have an ammonia-like scent)

y Ketonuria

y

Urinary tract infection


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URINALYSIS - BIOCHEMICALTEST

PH

PROTEIN

CAST Signal of renal disease or infection -

GLUCOSE glocosuria maybe the first indicator thatdiabetes or hyperglycaemia condition is present.

Osmolarity- less then 350mOsm/kg indicative of tubuledamage.


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Assessment of renal function

Blood analysis


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CONDITION TESTS USEDINDIAGNOSIS TESTS USEDTO FOLLOW

Chronic renal failure BUN, creatinine, estimated

GFR, urinalysis

BUN, creatinine, estimated

GFR,electrolytes, calcium,

phosphate,alkaline

phosphatase, parathyroidhormone,CBC

Urinary tract infections Urinalysis, urine culture Urinalysis, urine culture

Kidney stones Imaging, urinalysis Urine sodium, calcium,

phosphorus, citrate,

oxalate, uric acid

Nephrotic syndrome Urinalysis, serum albumin,total

protein, cholesterol, urine total

protein, antinuclear antibody (ANA)

test, hepatitis B test, hepatitis C

test, complement levels

Urine total protein, serum

cholesterol, BUN, creatinine

estimated GFR

Nephritic syndrome Urinalysis,BUN,creatinine,estimatedGFR, serum albumin, urine total

protein, antinuclear antibody (ANA)

test, antistreptolysin O,

antiglomerular basement membrane

antibody, antineutrophil cytoplasmic

antibodies

BUN, creatinine, estimatedGFR, urinalysis


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COMMON RADIOGRAPHY

yRenal Scan - injected- detect abnormality of kidney structure

y Renal Arteriogram

y Kidney, Ureter And Bladder ( KUB )-

y Intravenous Pyelogram


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Other Test

y Renal Biopsy


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TOPIC 2

DISORDER OF THE RENAL SYSTEM


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1.PyelonephritisPyelonephritis is a bacterial infection of

the kidney.

How does it occur?

y Most kidney infections result fromlower urinary tract infections, usuallybladder infections.

y Bacteria can travel from the vagina or

rectal area (anus) into the urethraand bladder.

y In men the urethra extends the fulllength of the penis. Infections of thelower urinary tract in men can occur

with prostate infections.


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ETIOLOGYa)Ascending tract infection is infection spread from

bladder to the ureter and finally spread to the kidney

b) Ureterovesicle reflux- allow urine backflow to the ureterwhen urinating due to incomplete ureterovesicle valve.

c) Obstruction renal calculi, tumour or stricture willobstruct the flow of urine and cause bacterial growth.


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Clinical Manifistationy High fever

y Chills and rigor

y Nausea

y Flank(rusuk) pain/loin pain-this is due to thedistension of renal capsule

y Headache

y Muscle pain

y Dysuria- Painful or difficult urination

y Urgency and frequency in urination

y Cloudy, bloody or foul smelling urine


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Diagnostic Assesment1. Urine FEME-presence of RBC, WBC,casts, bacteria

2. Urine culture and sensitivity to determine the

pathogen and selection of appropriate antibiotic3. Blood profile- blood urea serum electrolite

4. Random blood glocose

5. Blood C&S

6. FBC

7. X-ray IVP, KUB

8. Ultrasound of kidney


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MANAGEMENTy Surgical underlying causes such as renal calculli

y Medical antibiotic therapy.

y General counceling drink more water 2-3 liter perday.


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NURSINGCARE PLAN (nursing diagnosis,

objectives, intervention & evaluation)

#1 Fever related to inflammation process

#2 Pain related to distention of renal capsule

#3 Risk of disease recurrence related to lack ofknowledge on after discharge care


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2. Glomerulonephritis


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Its an inflammation of the glomeruli caused by the

antigen-antibody reaction in the glomerular capillaries.

This disease is in the inflammatory disease category.

Glomerulonephritis usually occurs in both kidneys andcauses trouble with filtering wastes from the blood

Signs & symptoms:

Haematuria (dark cola urine), proteinuria, generalisededema,oliguria, ascites, pulmanary edema, dyspnea,pleuraleffusion, Signs & symtoms of CCF


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Pathophysiology

Is a non-infectious inflammation that occurs in theglomeruli

This inflammation is due to antigen antibody reaction in thebody defenses mechanism.

As a result of this reaction, antigen antibody complexes (Ag-Ab complexes)are formed.

When Ag-Ab complexs are filtered in glomerulus, its beingtrapped and causes the inflammation process.

It may be present with isolated hematuria and/orproteinurea, or as a nephrotic syndrome, nephriticsyndrome(kidney inflammation), ARF, or CRF.


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Pathophysiology (cont.)

y They are categoried into several difference pathologicalpatterns, which are broadly groups into 2 type:

a)Non proliferative - characterised by low number of cells(lackof hypercellularity) in the glomeruli. They usually causenephrotic syndrome. These include minimal changeglomerulonephritis, Focal SegmentalGlomerulosclerosis(FSGS), membrane glomeruloneprtis.

b. Proliferative is characterised by an increase number of cells inthe glomerulus(hypercellular. )Proliferativeglomerulonephritis is usually present as a nephritic syndrome

and slowly progress to ESRF.


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Investigations

Lab tests can confirm anemia which is a sign of loss ofkidney function.

A biopsy of the kidney

may be able to visibly see signs such as swelling,

polyneuropathy, fluid retention, and hear distorted heart orlung sounds.

Imaging tests - Abdominal CT scan, Abdominal ultrasound,and chest x ray.

urinalysis - looking for is total protein, uric acid, urinecreatine, urine protein, urine RBC, and urine specificgravity. An abnormal find with any of these would causehim to suspect glomerulonephritis


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TreatmentRx depends on the underlying cause

Medication Corticosteroids may relieve symptom in somecase.

- Medication (azathioprine)cyclophosphamide)that

suppress the immune system may precribed on the cause.

Plasmapheresis- a procedure that removes the fluid part ofthe blood containing antibodies and replaces it with fluidsor donated plasma without antibodies, can be done patient

for disease caused from immune-related issues. The may be asked to be on a low sodium, low protein diet.

If the person develops kidney failure, dialysis or atransplant would be needed.


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Possible complicationy CCF

y Pulmonary edema

y HyperkalemiayARF

y CRF

y ESRF


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Nursing mxa)Edema

- Restrict fluid intake

- Daily wt

- Infusion diuretic

- Reduce salt intake

- Continously monitor the progress of edema to detect any sign ofpulmonary edema and heart failure

b) Risk of infection

- Medication

- Apply aseptic technique for all sterile prosedure

- Practise hand washing when handling patient.- Observe the sign of infection.

c) Patient teaching

- Advice pt to take precaution to prevent infection.(avoid crowdedarea/wash hand/avoid taking raw meat and vegetable/change

clothes)


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3

. Nephrotic syndrome


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Non specific disorder which the basement membrane

of capsule Bowmen is damage , causing them to leaklarge amount of protein from blood into the urine.


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CAUSE OF NEPHROTIC SYNDROME

From primary (idiopathic) glomerulonephritis:

y Lipid nephrosis (nil lesions): usually occurs in children

y Membranous glomerulonephritis

y Focal glomerulosclerosis

y Membranoproliferative glomerulonephritis


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Other causes

y Metabolic diseases: diabetes mellitusy Collagen-vascular disorders: systemic lupus

erythematosus

y Circulatory diseases: heart failure, sickle cell anemia,

and renal vein thrombosis

y Nephrotoxins: mercury, gold, and bismuth.

y Infections: tuberculosis, enteritis; allergic reactions;pregnancy; hereditary nephritis

y Neoplastic: multiple myeloma


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SIGN AND SIMPTOM

1.Proteinuria(>3.5g/day), hypoalbuminemia, hyperlipidemia

2. Edema which is generalized & also known as anasarca ordropsy.

3.L

ipiduria (lipids in urine)4. Hyponatremia also occurs with a low fractional sodiumexcretion

5. Anemia (iron resistant microcytic hypochromic type) maybepresent due to transferrin loss.

6. May have features of the underlying cause, such asthe rash associated with systemic lupus erythematosus orthe neuropathy associated with diabetes


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A few other characteristics seen in nephrotic syndrome are:

y excess fluid in the body due to the serum

hypoalbuminemia.L

ower serum oncotic pressure causesfluid to accumulate in the interstitial tissues. Sodium andwater retention aggravate the edema. This may take severalforms:

y Puffiness around the eyes, characteristically in the

morning.y Pitting edema over the legs

y Fluid in the pleural cavity causing pleural effusion. Morecommonly associated with excess fluid is pulmonary

edema.y Fluid in the peritoneal cavity causing ascites


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Investigationa) 24 hours urine sample shows proteinuria

b) Comprehensive metabolic panel(CMP) showshypoalbuminuremia

c) High level of cholesterol(hypercholesterolemia),specifically elevated LDL

d) Urea and creatinine : to evaluate renal function

e) Biopsy of kidney

f) Auto-immune markers(ANA,ASOT, C3,cryoglobulin, serum electrophoresis.


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Treatment

General measure1. Monitoring urine output,BP regularly

2. Fluid restrict to 1L

3. Diuretics

4. Monitoring kidney function

5. Prevent and treat any complication (eg. Venousthrombosis, infection,pulmonary edema)

Specific treatment underlysing cause- Immunosuppression drug prednisolone,

cyclosporin,cyclophosphamide.

- BP control - ACE inhibitor drug

- Blood glucose controle if diabetes


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Complications

1. Venous thrombosis

2. Infection

3. ARF


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Nursing Diagnosis1. Disturbed body image

2. Excess fluid volume

3. Imbalanced nutrition: Less than body requirements

4. Ineffective tissue perfusion: Renal

5. Risk for infection

6. Risk for injury


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Nursing Outcome1. Express positive feelings about him.

2. Maintain fluid balance.

3. Show no signs of malnutrition.

4. Maintain adequate urine output.

5. Free from signs or symptoms of infection.

6. Avoid or minimize complications.


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Nursing Intervention

1. Assessment and Document the location and character ofthe patient's edema

2. Measure blood pressure with the patient lying down andstanding. Immediately report a decrease in systolic or

diastolic pressure exceeding 20 mm Hg.3. If the patients receive a renal biopsy, watch for bleeding

and signs of shock.

4. Monitor intake and output and weigh the patient each

morning after he voids and before he eats. Make sure he'swearing the same amount of clothing each time youweigh him.

5. Ask the dietitian to plan a low-sodium diet with moderate

amounts ofprotein.


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Nursing Intervention

6. Frequently check urine for protein.7. Monitor plasma albumin and transferrin concentrations to

evaluate overall nutritional status.

8. Provide meticulous skin care to combat the edema thatusually occurs with nephrotic syndrome.

9.Use a reduced-pressure mattress or padding to help preventpressureulcers.

10.To prevent the occurrence of thrombophlebitis, encourageactivity andexercise, and provide antiembolism stockings

as ordered.

11.Give the patient and family reassurance and support,especially during the acute phase, when edema is severeand the patient's body image changes


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Patient Teaching & Home Care Guide1. If the patients receive immunosuppressants, teach him

and family members to report even mild signs of infection.2. If the patients receive long-term corticosteroid therapy,

teach him and family members to report muscle weaknessand mental changes.

3. To prevent GI complications, suggest to the patient that hetake steroids with an antacid or with cimetidine orranitidine. Explain that the adverse effects of steroidssubside when therapy stops, but warn the patient not todiscontinue the drug abruptly or without a physician's

consent.4. Stress the importance of adhering to the special diet.

5. If the physician prescribes antiembolism stockings forhome use, show the patient how to safely apply and remove

them.


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TERIMA KASIH

oum tutorial 1 sbns3504 renal[1]

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