The Urinary System Assessment & Disorders

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The kidneys, ureters, and bladder. (Source: Dorling Kindersley Media Library)

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An illustration of the internal structures of the kidney.

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The structure of the nephron and the processes of urine formation.

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Age-Related ChangesNephrons lost with aging

Reduces kidney mass and GFR

Less urine concentrationRisk for dehydration

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AssessmentUse simple languageAssess for incontinence (esp. muliparous)Family historyChief concernLocation and character of painPrevious UTI, stones, urinary problemsPattern or urination

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AssessmentColor, clarity, amount of urineDifficulty initiating urination or changes in streamChanges in urinary patternDysuria, nocturia, hematuria, pyuria

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AssessmentHistory of urinary problemsUrinary or abdominal surgeriesSmoking, alcohol useChance of pregnancyHistory of diabetes or other endocrine disordersUnexplained anemia

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Diagnostic TestsClean-catch urine24-hour urine collectionCulture and sensitivityBUN, creatinine and creatinine clearance = {Vol. of urine (ML/hr) x urine creatine}/serum creatinine IVP, Retrograde Pyelography

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Diagnostic TestsCystography, voiding cystogramCT scan, MRIRenal scanUltrasound

X-ray (KUB)CystoscopyRenal AngiographyKidney biopsy (by needle or open procedure)

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GlomerulonephritisInflammatory condition of glomerulusAntigen–antibody complexes form in the blood and become trapped in the glomerular capillaries, inducing an inflammatory response. Damages capillary membrane

Blood cells and proteins escape into filtrateHematuria, proteinuria, azotemia (increase BUN & Creatinin)

Acute or chronic

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Acute Glomerulonephritis - Manifestations

Usually follows infection of group A beta-hemolytic StreptococcusAffect children > 2 yearsManifestations develop abruptly

Hematuria (? Microscopic, or frank, urine is cola color), proteinuria, edema, azotemia (High BUN and Creatineine) hypertension, fatigue, hypoalbuminemia, hyperlipidemia? headache, malaise and flank pain

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Glomerulonephritis

Glomerulonephritis – Diagnostic Tests

ASO titer (anti streptolysine O)BUNSerum creatinine

Serum electrolytesUrinalysisKUB x-rayKidney scan or biopsy

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Complications of acute glomerulonephritis

Hypertensive encephalopathy, Heart failure, Pulmonary edema,Without treatment, end-stage renal disease (ESRD) develops in a matter of weeks or months.

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Glomerulonephritis – Treatment

Focus is on identifying and treating underlying disease process and preserving kidney functionIf residual streptococcal infection is suspected, penicillin. Corticosteroids and immunosuppressant medications may be prescribed for patients with rapidly progressive acute glomerulonephritis.

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Glomerulonephritis –Treatment

Dietary protein is restricted when renal insufficiency (elevated BUN) develop. Sodium is restricted when the patient has hypertension, edema, and heart failure. Loop diuretic and antihypertensive medications may be prescribed to control hypertension. Bed rest during acute phase.18

Glomerulonephritis –Nursing Care

Decrease protein and increase CHO to prevent protein breakdown.Accurate I & O (consider insensible loss)

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Chronic Glomerulonephritis

Could be due to repeated episodes of acute glomerulonephritis, hypertensive nephrosclerosis, hyperlipidemia, glomerular sclerosisOther causes include SLE, DMKidney size reduce to 1/5th of original size and many scar tissue formed leading to ESRF.

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Chronic Glomerulonephritis/ S&S

Many are asymptomatic? Discovered when patient diagnosed with Hypertension.? severe nosebleed, a stroke, or a seizure, swollen feet at night. Heneral symptoms, such as loss of weight and strength, increasing irritability, nocturia, Headaches, dizziness, and digestive disturbances.Finally, S&S of renal failure.

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Medical Management

Control BP: Na & water restriction, antihypertensive drugMonitor weight.Diuretics. Adequate CHO diet to spare protienTreat UTI? Dialysis.

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Nephrotic Syndrome

Is a cluster of clinical findings, including:1. Marked increase in protein

(particularly albumin) in the urine (proteinuria)

2. Decrease in albumin in the blood (hypoalbuminemia)

3. Edema (periorbital, ascites, and dependent edema)

4. High serum cholesterol and low-density lipoproteins (hyperlipidemia)

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Treatment Diuretics (be careful not to cause sever hypovolemia as it may lead to ARF)Loop diuretics + ACE inhibitors lead to decreasing protienuria. Immunosuppresive agents (i.e. cytoxan).Coriticosteroids.

Restrict protein and sodium.

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Nephrotic Syndrome

Acute Renal Failure (ARF)Is a reversible clinical syndrome where there is a sudden and almost complete loss of kidney function (decreased GFR) over a period of hours to days with failure to excrete nitrogenous waste products and to maintain fluid and electrolyte homeostasisMay progress to end stage renal disease, uremic syndrome, and death without treatment

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Acute Renal FailurePersons at Risks

Major surgeryMajor traumaReceiving nephrotoxic medicationsElderly

ARF mostly occur within hospital settings

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Causes of ARF

1. Prerenal Failure

2. Intrarenal Failure

3. Postrenal Failure

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Prerenal Failure

Volume depletion resulting from:HemorrhageRenal losses (diuretics, osmotic diuresis)Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)

Impaired cardiac efficiency resulting from:

Myocardial infarctionHeart failureDysrhythmiasCardiogenic shock

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Prerenal FailureVasodilation resulting from:

SepsisAnaphylaxisAntihypertensive medications or other medications that cause vasodilation

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Intrarenal Failure

Prolonged renal ischemia resulting from:Pigment nephropathy (associated with the break-down of blood cells containing pigments that in turn occlude kidney structures)Myoglobinuria (trauma, crush injuries, burns)Hemoglobinuria (transfusion reaction, hemolytic anemia)

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Intrarenal FailureNephrotoxic agents such as:

Aminoglycoside antibiotics (gentamicin, tobramycin, amicacin)Radiopaque contrast agentsHeavy metals (lead, mercury)Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)Nonsteroidal anti-inflammatory drugs (NSAIDs)Angiotensin-converting enzyme inhibitors (ACE inhibitors)

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Intrarenal FailureInfectious processes such as:

Acute pyelonephritisAcute glomerulonephritis

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Postrenal failure

Urinary tract obstruction, including:

Calculi (stones)TumorsBenign prostatic hyperplasiaStricturesBlood clots

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Phases of Acute Renal Failure

Initiation period: begins with the initial insult and ends when oliguria develops. Oliguria period: UOP < 400 ml/day, increase in urea, creatinine, uric acid, K & magnesium. Some people have normal urine output (2 L/d)Diuretic – UOP ^ to as much as 4000 mL/d but BUN & Cretinine still high, at end of this stage may begin to see improvement Recovery – things go back to normal. It may take up to 3-12 months

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Acute Renal Failure S & SThe patient may appear critically ill and lethargic. The skin and mucous membranes are dry from dehydration. Central nervous system signs and symptoms include drowsiness, headache, muscle twitching, and seizures.Urine output varies (scanty to normal volume), ? hematuria & urine has a low specific gravity

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Acute Renal FailureDiagnostic tests

BUN, creatinine, potassium increase. pHHgb and HctUrine studiesUS of kidneysHigh phosphorus and low calcium.

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Prevention of ARF

Provide adequate hydrationPrevent and treat shock promptlyHourly urine output for critical patientsContinuosally assess renal functionPrevent and treat infections promptlyMonitor for effects of toxic drugs

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Medical treatment of ARFObjectives of treatment are to restore normal chemical balance and prevent complications until repair of renal tissue and restoration of renal function can occur.Management includes

maintaining fluid balance, avoiding fluid excesses, or possibly performing dialysis.

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Acute Renal FailureMedical treatment

Treat the causeFluid and replacement or restrictionsMonitor for fluid overloadDiuretics Maintain E-lytes May need dialysis (especially with high K)May need to stimulate production of urine with IV fluids, Dopomine, diuretics, etc.

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Acute Renal FailureMedical treatment

HemodialysisSubclavian approachFemoral approach

Peritoneal dialysisNutritional Therapy

? Decrease Protein (according to BUN level)Increase CHODecrease potassium and phosphrous

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Acute Renal Failure

Nursing Diagnosis-imbalanced fluid volume= excessAltered electrolyte balanceImpaired tissue perfusion: renalAnxiety Imbalanced nutritionRisk for infectionFatigue Knowledge deficit

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Acute Renal Failure

Plan-Promote recovery of optimal kidney function.Maintain normal fluid and electrolyte balance.Decrease anxiety.Increase knowledge.

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Nursing interventions

Monitoring Fluid and Electrolyte BalanceReducing Metabolic RatePromoting Pulmonary FunctionPreventing InfectionProviding Skin Care

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Chronic Renal FailureChronic renal failure, or ESRD, is a progressive, irreversible deterioration in renal function in which the body's ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia.Results from gradual, progressive loss of renal functionOccasionally results from rapid progression of acute renal failure

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Chronic Renal FailureConditions that cause ESRD include systemic diseases, such as diabetes mellitus (leading cause); hypertension; chronic glomerulonephritis; pyelonephritis; obstruction of the urinary tract; hereditary lesions, as in polycystic kidney disease; vascular disorders; infections; medications; or toxic agents.

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Chronic Renal FailureSymptoms occur when 75% of function is lost but considered chronic if 90-95% loss of functionDialysis is necessary D/T accumulation of uremic toxins, which produce changes in major organs

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Chronic renal failure/ S&SCardiovascular: the most common cause of death

HypertensionPitting edema (feet, hands, sacrum)Periorbital edemaPericardial friction rubAcidosis (kidney can’t excrete amonia, reabsorb bicarb, high phosphate)

Engorged neck veinsPericarditisPericardial effusionPericardial tamponadeHyperkalemiaHyperlipidemia

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Chronic renal failure/ S&S Neurologic

Weakness and fatigueConfusionInability to concentrateDisorientationTremors

SeizuresAsterixisRestlessness of legsBurning of soles of feetBehavior changes

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Chronic renal failure/ S&S Pulmonary Integumentary

CracklesThick, tenacious sputumDepressed cough reflexPleuritic painShortness of breathTachypneaKussmaul-type respirationsUremic pneumonitis

Gray-bronze skin colorDry, flaky (ر TقّشWُم) skinPruritusEcchymosisPurpuraThin, brittle nailsCoarse, thinning hair

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Chronic renal failure/ S&S Gastrointestinal

HematologicAmmonia odor to breath (“uremic fetor”)Metallic taste

Mouth ulcerations and bleeding

Anorexia, nausea, vomiting

HiccupsConstipation or diarrhea

Bleeding from GI tract

AnemiaThrombocytopenia

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Chronic renal failure/ S&S Reproductive Musculoskeletal

AmenorrheaTesticular atrophyInfertilityDecreased libido

Muscle crampsLoss of muscle strengthRenal osteodystrophyBone painBone fracturesFoot drop

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Chronic Renal FailureLab findings

BUN – indicator of glomerular filtration rate and is affected by the breakdown of protein. Serum creatinine – waste product of skeletal muscle breakdown and is a better indicator of kidney function. Creatinine clearance is best determent of kidney function (GFR). Must be a 24 hour urine collection.

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Chronic Renal FailureK+

The kidneys are means which K+ is excreted. Normal is 3.5-5.0 ,mEq/L. maintains muscle contraction and is essential for cardiac function. Both elevated and decreased can cause problems with cardiac rhythmHyperkalemia is treated with IV glucose and Na Bicarb which pushes K+ back into the cellKayexalate (Sodium polystyrene sulfonate ) is also used to promote the exchange of sodium and potassium in the body.

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Chronic Renal FailureCa

With disease in the kidney, the enzyme for utilization of Vit D is absentCa absorption depends upon Vit DAlso, phosphate level increase leading to decreasing level of CaParathyroid hormone level increase in attempt to increase calcium, but because of the high phosphorus level, there is limited response. Body moves Ca out of the bone to compensate.Renal osteodystrophy is the end result

Hypocalcemia = tetany

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Chronic Renal Failure

Other abnormal findingsMetabolic acidosisFluid imbalanceInsulin resistanceAnemiaImmunoligical problems

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Complications

HyperkalemiaPericarditis, pericardial effusion, and pericardial tamponadeHypertensionAnemiaBone disease and metastatic and vascular calcifications

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Medical management Calcium carbonate, or calcium acetate: bind to phosphours and decrease its level. Antihypertensive and Cardiovascular AgentsAntiseizure AgentsErythropoietin

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Nutritional TherapyProtein is restricted (allowed protein should be of high biologic value)Restrict fluid (500-600 ml/day more than previous day’s urine output).Restrict K, Na, PhosphorusIncrease CHO to meat caloric needsVitamin suplements

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Treatment Dialysis Transplantation

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Chronic Renal FailureNursing diagnosis

Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and waterImbalanced nutrition: less than body requirements related to anorexia, nausea and vomiting, dietary restrictions, and altered oral mucous membranes

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Nursing diagnosis

Deficient knowledge regarding condition and treatment regimenActivity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedureRisk for situational low self-esteem related to dependency, role changes, changes in body image, and sexual dysfunction

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Chronic Renal FailureNursing care : see world document

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DialysisDialysis is used to remove fluid and uremic waste products from the body when the kidneys are unable to do so.Chronic: in ESRF when the kidney can’t remove waste products. Acute: high level of serum K+, fluid overload, or impending pulmonary edema, acidosis, to remove certain medications or other toxins from the blood.

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Dialysis½ of patients with CRF eventually require dialysisDiffuse harmful waste out of bodyControl BPKeep safe level of chemicals in body2 types

HemodialysisPeritoneal dialysis

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Principles for dialysis Diffusion: toxins and wastes in the blood are removedOsmosis: excess water is removed from the bloodUltrafiltration: helps water to move faster under high pressure to an area of lower pressure

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Hemodialysis3-4 times a weekTakes 2-4 hours Machine (dialyzer)filters blood and returns it to body

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Chronic Renal FailureHemodialysis

Vascular accessTemporary – subclavian or femoralPermanent – shunt, in arm

Care post insertion

Can be done rapidlyTakes about 4 hoursDone 3 x a week

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Types of AccessTemporary site: subclavian or femoralPermanent: shunt, in armAV fistula

Surgeon constructs by combining an artery and a vein3 to 6 months to matureAV graft

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What This Means For YouNo BP on same arm as fistulaProtect arm from injuryNever inject anything into catheterControl obvious hemorrhage

Bleeding will be arterialMaintain direct pressure

No IV on same arm as fistulaA thrill will be felt – this is normal

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Complication of dialysis HypotensionPainful muscle cramping (due to rapid alterations in electrolyte balance)Dysrhythmias may result from electrolyte and pH changes Air embolism Dialysis disequilibrium results from cerebral fluid shifts.

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Peritoneal Dialysis

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Peritoneal Dialysis

Abdominal lining filters blood3 types

Continuous ambulatoryContinuous cyclicalIntermittent

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Dialysis

Peritoneal dialysisSemipermeable membraneCatheter inserted through abdominal wall into peritoneal cavityCost lessFewer restrictionsCan be done at homeRisk of peritonitis3 phases – inflow, dwell and outflow

Automated peritoneal dialysis

Done at home at nightMaybe 6-7 times /week

CAPDContinous ambulatory peritoneal dialysisDone as outpatientUsually 4 X/d

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Chronic Renal Failure

TransplantMust find donorWaiting period longGood survival rate – 1 year 95-97%Must take immunosuppressant’s for lifeRejection

Watch for fever, elevated B/P, and pain over site of new kidney

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Chronic Renal FailurePost op care

ICUI/OB/PWeight changesElectrolytesMay have fluid volume deficitHigh risk for infection

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Transplant MedsPatients have decreased resistance to infectionCorticosteroids – anti-inflammarory

DeltosoneMedrolSolu-Medrol

Cytotoxic – inhibit T and B lymphocytesImuranCytoxanCellcept

T-cell depressors - Cyclosporin

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Renal Trauma? due to rib fractures or fractures vertebrae.80% to 90% of all renal injuries are blunt injuriesS & S: Pain, hematouria, S & S of shockRx: Bed rest, antibiotics. In sever cases, need surgical repair or ? Nephrectomy.

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