III. RENAL SYSTEMA. ANATOMY AND PHYSIOLOGY OF RENAL SYSTEM

The urinary system is composed of Upper Urinary Tract & Lower Urinary Tract:1. Upper Urinary Tract Kidney Ureters

2. Lower Urinary Tract Bladder Urethra Prostrate Glands (for male) A thorough understanding of the urinary system and renal physiology is necessary both to assess and to plan and implement appropriate nursing care for healthy patient and those with renal and urinary dysfunction.

a. UPPER URINARY TRACT ( Anatomy & Physiology )

KIDNEY - Kidneys are two reddish-brown, lima-bean shaped organs.

Location: Located retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of the abdomen from the 12th vertebra to the 3rd lumbar vertebra.

Size: An adult kidney is about 12 cm (4.5 inches) long, 6 cm wide, and 2-5 c, thick

Weight: Between 120 g to 170 g (45 oz.)

1. Parts of the kidney

If the kidney is cut longitudinally, and opened, three distinct area of the kidney can be seen:

Renal Cortex is pale and has a granular appearance. Most parts of the nephron, the functional unit of the kidney, lie in this are.

Renal Medulla has a striated appearance. In the medulla there are 8 to 10 triangular wedges or pyramids. The bases of the pyramids face the cortex, and their apexes or renal papillae face the center of the kidney. The kidney have a striated appearance because of the segment of the nephrons and collecting ducts located here.

Renal Sinus It is a cavity almost completely filled with blood vessels and structures formed by expanded upper end of the ureter.

The Kidney is well protected by the ribs, muscle, fascia, per-renal fat, and renal capsule with surrounds each kidney

The HILUM is the concave portion of the kidney through which the renal artery enters and the renal vein exists.

Renal Artery divides into smaller and smaller vessels, eventually forming the afferent arteriole

The afferent arterioles branches to form the glomerulus, which is the capillary bed responsible for glomerular filtration

b. Nephron

The kidney is composed of about 1 million of NEPHRON, the functional unit of the kidney.

Two Types of Nephron

The Cortical Nephron comprises 85% of the total nephrons and perform excretory and regulatory function

The Juxtamedullary Nephron make up the remaining 15% of nephron and play the important role in the concentration and dilution of urine by generating a steep interstitial fluid osmotic gradient between the cortex and deep medulla.

Structures of Nephron that involve in the Formation of Urine:

Renal Corpuscle is responsible for the formation of ultrafiltrate from the blood consist of: Glomerulus Bowmans Capsule

Renal Tubules are responsible for the re-absorption and secretion that alter the volume and composition of the ultrafiltrate to form the final urine product consists of: Proximal Convoluted Tubule Distal Convoluted Tubule Loop of Henley

Collecting Duct - received tubular fluid from the cortex to the minor calyx.

Functions of kidney

Urine Formation Excretion of Waste Product Regulation of Electrolytes Regulation of Acid-Base Balance Control of Water Balance Control of Blood Pressure Renal Clearance Regulation of Red Blood Cell Production Synthesis of Vitamin D to Active Form Secretion of Prostaglandin

c. URETERS

The function of the ureter is to propel urine from the renal pelvis to the bladder.

The Ureters are composed of smooth muscle and are innervated by the sympathetic nervous system

Arise the extension of the pelvis and empty into the bladder in an area known as the Trig one

The Trig one is a fold of mucous membrane that serves as a valve preventing the backflow or reflux of the urine into the ureter when the bladder contract

2. LOWER URINARY TRACT (ANATOMY & PHYSIOLOGY) a. URINARY BLADDER

Is a muscular, hollow sac located just behind the pubic bone and can hold about 300 to 500 ml of urine.

Located behind the symphysis pubis in the pelvic region

Serve as a collecting bag of urine

The mucous membrane is arranged in folds called RUGAE, that together with the elasticity of the muscular wall, can distend the bladder considerably to hold large amount of urine

External Urinary Sphincter is a layer of skeletal muscle encircle the base of the bladder

b. URETHRA

Serves as the outlet for urine from the bladder.

Male urethra is about 20 cm (8 inches) in length

Female urethra is about 4 cm (1.5 inches) long

The Urinary Meats is the opening through which the urine is excreted from the body

c. PROSTRATE GLAND

Is a male reproductive organ about the size of a wall nut that encircles the upper portion of male urethra

It is a doughnut shaped with the urethra passing through the hole.

When the prostrate is enlarged, the urethra is squeeze causing obstruction of urinary flow

HEALTH HISTORY: Person with a family history of urinary tract problems are at increased risk for renal disorders. Persons with diabetes who have consistent hypertension are at risk for renal dysfunction. Older men are at risk for prostatic enlargement, which causes urethral obstruction and result in UTI and renal failure. Persons with history of SLE develop lupus nephritis.

When obtaining the health history, the nurse should inquire about the following: The patient chief concern or reason for seeking health care, the onset of the problem and its effect on the patients quality of life The location, character and duration of pain, if present and its relationship to voiding; factors that precipitate pain and those that relieve History of UTI, including past treatment or hospitalization for UTI Fever or chills Previous renal or urinary diagnostic tests or use of indwelling urinary catheters Dysuria and when it occurs during voiding Hesitancy, straining or pain during or after urination Urinary incontinence Hematuria or change in color, volume of urine Nocturia and its date of onset Renal calculi, passage of stones or gravel in the urine Female Patients: number and type of delivery; use of forceps; vaginal infection, discharge or irritation, contraceptive practices Presence or history of genital lesions or sexually transmitted disease Habits: use of tobacco, alcohol or recreational drugs Any prescription and OTC

PHYSICAL ASSESSMENT:

Assess the general appearance of the client and check for a yellowish skin color and the presence of rashes, bruising or other discoloration. The skin and tissues may show edema, which renal disorders maybe detected in the pedal, pretibial, sacral tissues and around the eyes. Auscultate the lungs to determine whether fluid is present. Weight the client and take his or her BP as a baseline comparison. Assess the clients LOC and the level of alertness, recording any deficits in concentration, thought processes or memory.

1. Inspection: Inspect the abdomen and the flank regions with the client in both the supine and the sitting position. Observed for asymmetry or discoloration in the flank region especially in the area of the costovertebral angle (CVA is located between the lower portion of the 12th rib and the vertebral column

2. Auscultation: Listen for a bruit over each renal artery on the midclavicular line.

3. Palpation: Help locate masses and areas of tenderness in or around the kidney Asks about areas of tenderness or discomfort and examine non tender areas first. Bladder maybe seen as high as the umbilicus in the client with severe bladder distention.

4. Percussion: A distended bladder sounds dull when percussed If the client identifies flank pain or tenderness, percuss the Nontender flank first. CVA tenderness often occurs with kidney infection and inflammation.

DIAGNOSTIC EVALUATION:5. Urinalysis and Urine Culture: Urine examination includes the following: Urine color Urine clarity and odor Urine pH and specific gravity Tests to detect protein, glucose and ketone bodies Microscopic examination of the urine sediment after centrifuging to detect RBCs, WBCs, Casts, Crystals, pus and bacteria

6. Renal Function Tests: Used to evaluate the severity of kidney disease and to assess the patients clinical progress. Provide information on the effectiveness of the kidney in carrying out its excretory function. Creatinine (0.6 1.2 mg/dl) Measures effectiveness of the renal function. Creatinine is end product of muscle energy metabolism.

BUN (7 18 mg/dl) Serves as the index of renal function. Tests values are affected by protein intake, tissue breakdown and fluid volume changes.

7. Ultrasound: The structures of the urinary system create characteristic ultragraphic images. Abnormalities such as fluid accumulation, masses, congenital malformations, changes in organ size or obstruction can be identifies. Requires a full bladder, fluid intake before the procedure.

8. Nuclear Scan: Require injection of a radioisotope into the circulatory system The isotope is then monitored as it moves through the blood vessels of the kidney. Provides information about kidney perfusion and information about kidney function Used to evaluate ARF and CRF, renal masses and kidney perfusion before and after kidney transplant.

9. Intravenous Urography: Excretory urography, intravenous pyelography and infusion drip pyelography. A Radiopaque contrast agent is administered IV used as initial assessment of any suspected urologic problem. Provides rough estimate of renal function.

10. Retrograde Pyelography: Catheters are advanced through the ureters into the renal pelvis by means of cystoscopy. A contrast agent is then injected. Used before extracorporeal shock wave lithotripsy. Performed if IV urography provides inadequate visualization of the collecting systems. Complication: Infection, Hematuria and Perforation of the ureter.

B. MANAGEMENT OF PATIENTS WITH URINARY AND RENAL DISORDERS

Disorder of the urinary tract and kidneys ranges from easily treated infections to life-threatening disorders that necessitate organ replacement or long-term treatment with dialysis, Recent advances in pharmacy-therapeutics and technology have improved the diagnostic and treatment possibilities for these disorders. Additionally, those disorders that once required surgical intervention and prolonged recuperation can be treated today with non-invasive, non-surgical techniques.

a. URINARY TRACT INFECTION

Urinary Tract Infection (UTIs) are caused by pathogenic microorganism in the urinary tract ) the normal urinary tract is sterile above the urethra.) Classification Of Urinary Tract Infection1. Lower UTI consist of: Cystitis inflammation of the urinary bladder Prostatitis inflammation of the prostrate gland Urethritis inflammation of urethra

2. Upper UTI - are much and less common consists of: Acute and Chronic Pyelonephritis inflammation of the renal pelvis Interstitial Nephritis inflammation of kidney Renal Abscess

3. Uncomplicated Lower or Upper UTI Community-acquired infection; common in young women

4. Complicate Lower or Upper UTI Nosocomial ( acquired in hospital ) and related to catheterization; occur in patients with urological abnormalities, pregnancy, immunosuppression, diabetes mellitus, obstruction.

a.1. LOWER URINARY TRACT INFECTION

Several mechanism maintain the sterility of the bladder; the physical barrier of the urethra, urine flow, ureterovesical junction competence, various antibacterial enzymes and antibodies, and anti-adherant effect mediated by the mucosal cells of the bladder.Abnormalities or dysfunction of these mechanism are contributing factors to lower UTIs.

PATHOPHYSIOLOGY OF LOWER UTI

Risk Factors Inability or failure to empty the bladder completely Obstructed urinary flow, possibly from congenital anomalies, urethral strictures, contracture of the bladder neck, bladder tumors, calculi (stones) in the ureters or kidney, compression of the ureters, and neurologic abnormalities Decreased natural host defenses or immunosuppression Instrumentation of the urinary tract ( eg, catheterization, cyctoscopic procedures) Inflammation or abrasion of the urethral mucosa Contributing conditions ( certain populations of patients are more prone to UTI than others); including those with: Diabetes Mellitus Pregnancy Neurologic disorders Gout

Clinical Manifestation Frequent pain and burning sensation on urination Urinary incontinence Suprapubic or pelvic pain Hematuria Back pain

Bacterial Invasion of the Urinary Tract

By increasing the normal slow shedding of bladder epithelial cells (resulting in bacterial removal), the bladder can clear itself of even large number of bacteria. Glycosaminoglycan (GAG), a hydrophilic protein, normally exerts a non-adherent protective effect against various bacteria. The GAG molecule attracts water molecules, forming a water barrier that serves as a defensive layer between the bladder and the urine. GAG may be impaired by certain agents ( cyclamate, saccharin, aspartame, and tryptophan metabolites. The normal bacterial flora of the vagina and the urethral are also interfere with adherence of Escherichia Coli (the most common microorganism causing UTI) Urinary immunoglobulin A (IgA0 in the urethra may also provide a barrier to bacteria.

Etiologic Agent (organisms)responsible for UTI E. Coli Staphylococcus Saprophyticus Enterococcus species Proteus mirabilis Pseudomonas aeruginosa Klebsiella Enterobacter species

RefluxAn obstruction to free-flowing urine is a problem known as urethrovesical reflux, which is the reflux (backward flow) of urine from the urethra into the bladder. With coughing, sneezing, or straining, the bladder pressure rises, which may force urine from the bladder into the urethra.

When the pressure return to normal, the urine flows back into the bladder, bringing into the bladder bacteria from the anterior portion of the urethra. Urethrovesical angle and urethral closure pressure may be altered with menopause, increasing the incidence of infection in postmenopausal women. Reterovesical or vesicoureterral reflux refers to the backward flow of urine from the bladder into one or both ureters. Normally, the ureterrovesical junction prevents urine from traveling back into the ureter. The ureters are tunneled into the bladder wall so that a small portion of the ureter is compressed by the bladder musculature during normal voiding. When the ureterovesical valve is impaired because of congenital causes or ureteral abnormalities, the bacteria may reach and eventually destroy the kidneys.

Uropathogenic Bacteria

Bacteriuria is generally defined as more than 105 colonies of bacteria per milliliter of urine. Because urine sample (especially in women) are commonly contaminated by bacteria normally present in the urethral area, a bacterial count exceeding 105 colonies/ml of clean-catch urine is the measure that distinguishes true bacteruiria from contamination. In men, contamination of the collected urine sample occurs less frequently; hence, bacteruria can be defined as 104 colonies /ml urine.

Routes of Infection Up the urethra (ascending infection) Through the bloodstream (hematogenous spread) By means of a fistula from the intestine (direct extension) Transurethral most common route of infection, colonize the peri-urethral area and subsequently enter the bladder by means of the urethra.

Assessment and Diagnostic Findings

Colony counts UTI is diagnosed by bacteria in the urine. A colony count of at least 105 colony-forming I\units (CFU) per milliliter of urine on a clean catch midstream or catheterized specimen is a major criterion for infection.

Cellular Findings Microscopic Hematuria (greater than four red blood cells [RBCs] per high-power field) is present in about half patients with acute infection.

Pyuria (greater than 4 white blood cells [WBCs] occurs in all patient with UTI; however, it is not specific for bacterial infection. Pyuria can also seen with kidney stones, interstitial nephritis, and renal tuberculosis.

Urine Cultures remain the gold standard in documenting a UTI and can be identify the specific organism present. Because of the high probability that the organism in young women with their first UTI is E. Coli, cultures are often omitted.

The Following group of patients should have urine cultures obtained when bacteriuria is present:

1. All men (because of like-hood of structural or functional abnormalities)2. All children 3. Women with history of compromised immune function or renal problem4. Patient with DM5. Patient who have undergone recent instrumentation6. Patient who hospitalized recently7. Patient with prolonged or persistent symptoms8. Patients with three or more UTIs in past years9. Pregnant women.

Gerontologic Considerations

Factors Contributing to Urinary Tract Infection in Older Adults1. High incidence of chronic illness2. Frequent use of anti-microbial agent3. Presence of infected pressure ulcers4. Immobility and incomplete emptying of bladder5. Use of a bedpan rather then a commode or toilet

Medical Management

Drug Therapy - ( Acute pharmacologic therapy and Long Term Pharmacologic Therapy Patient Education

Acute Pharmacologic Therapy

Usually a short course of medication regimen ( 3 4 days or 7 10 days therapeutic course) Commonly use medication includes: Trimethoprim-sulfamethoxazole ( TMP-SMZ, Bactrim, Septra) Nitrofurantoin (Macrodantin ) Amoxicillin Ampicillin

Long Term Pharmacologic Therapy

Infection that recur within 2 weeks after therapy (referred to as relapse) If infection recurs after completing anti-microbial therapy, an other short course (3 4 days) of full-dose anti-microbial therapy followed by a regular bedtime dose of anti-microbial medication may be prescribed. If there is no recurrence, the medication should be taken every other night for 6 to 7 months.

Nursing Process:

1. The Patient with Lower Urinary Tract Infection

Nursing care of the patient with lower UTI focuses on treating the underlying infection and preventing its recurrence.

Assessment Pain and burning sensation during urination Frequency, urgency and changes in urine Assess for volume, color, concentration, cloudiness, and odor Infrequent emptying of the bladder Personal hygiene Use of contraceptive (for female) Previous anti-microbial agent taken

Diagnosis

Base on assessment data, the nursing diagnoses may include: Pain r/t inflammation and infection of the urethra, bladder and other urinary tract structures Knowledge deficit r/t factors predisposing the patient to infection and recurrence, detection and prevention of recurrence and pharmacologic therapy

2. Collaborative Problem/Potential Complications

Base on assessment data, potential complication may include the ff: Renal failure due to extensive damage of kidney Sepsis

Planning and Goals

Major goal for the patient may include relief of pain and discomfort; increased knowledge of preventive measures and treatment modalities; and absence of complications.Nursing Interventions

Relieving Pain Monitor and Managing Potential Complications Promoting Home and Community-Base Care Teaching Patient Self-Care Preventing Recurrent Urinary Tract Infection

Evaluation

Expected Outcomes:

Experience relief of pain Reports absence of pain, urgency, dysuria, or hesitancy on voiding Take analgesic and ant-biotic agent as prescribed by the doctor

Explains UTIs and their treatment Demonstrate knowledge of preventive measures and prescribed treatments Drink 8 10 glasses of fluid daily Void every 2 3 hours Voids urine that is clear and odorless

Experience no complications Report no symptoms of infection or renal failure (nausea, vomiting, fatigue, pruritus) Has normal BUN and serum creatinine levels, negative urine and blood cultures Exhibit normal vital sign and temperature; no signs of sepsis Maintain adequate urine output more than 30 ml/hr.

B. UPPER URINARY TRACT INFECTION

a. Acute Pyelonephritis

Pyelonephritis is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one both kidneys. Upper UTI is associated with anti-body coating of the bacteria in the urine. (this occur in the renal medulla; when the bacteria are excreted in the urine, the immunofluorescent test can detect the anti-body coating).Bacteria reach the bladder by means of the urethra and ascend to the kidney. Although the kidney receives 20% to 25% of the cardiac output, bacteria rarely reach the kidney from the blood. Less than 3% of cases are due to hematogenous spread.

Pyelonephritis is frequently secondary to ureterovesical reflux, in which an incompetent ureterovesical valve allows the urine to back up (reflux) into the ureters. Urinary tract obstruction (which increases the susceptibility of the kidneys on infection), bladder tumors, strictures, benign prostatic hyperplasia, and urinary stones are among other causes. Pyelonephritis may be acute or chronic.

Patients with acute pyelonephritis usually have enlarged kidneys with interstitial infiltrations of inflammatory cells. Abscesses may be noted on the renal capsule and at the corticomedullary junction. Eventually, atrophy and destruction of tubules and the glomeruli may result. When pyelonephritis becomes chronic, the kidneys become scarred, contracted and nonfunctioning.

Clinical ManifestationsThe patient with acute pyelonephritis appears: Acutely ill with chills and fever Leukocytes Bacteriuria Pyuria Flank pain CVA tenderness. Dysuria and frequency are common.

Assessment and Diagnostic Findings Ultrasound or CT scan- study may be performed to locate any obstruction in the tract. Relief of obstruction is essential to save the kidney form destruction. IVP - is rarely indicated during acute pyelonephritis because findings are normal in up to 75% patients. Radionuclide Imaging with citrate and indium-111-labeled WBCs - may be useful to identify occult sites of infection that may not be visualized on CT scan or ultrasound. Urine Culture and Sensitivity Tests - are performed to determine the causative organism so that appropriate antimicrobial agents can be prescribed.

Medical Management

Patients with acute uncomplicated pyelonephritis are usually treated as outpatients if they are not dehydrated, not experiencing nausea or vomiting, and not showing signs or symptoms of sepsis. In addition, they must be responsible and reliable to ensure that all medications are taken as prescribed. Other patients, including all pregnant woman, should be hospitalized for at least 2 or 3 days of parenteral therapy. Oral agents may be substituted once the patient is afebrile and showing clinical improvement.

1. Pharmacologic Therapy

For outpatients, a 2-week course of antibiotics is recommended because renal parenchymal disease is more difficult to eradicate than bladder mucosal infections.

Commonly prescribed agents include: Trimethoprim-sulfamethoxazole Ciprofloxacin Gentamicin With or without ampicillin Third-Generation Cephalosporin.

A possible problem in acute pyelonephritis treatment is a chronic or recurring symptomless infections persisting for months or years. After the initial antibiotic regimen, the patients may need antibiotic therapy for up to 6 weeks if evidence of a relapse is seen. A follow-up urine culture is done 2 weeks after completion of antibiotic therapy to document clearing on the infection.

b. Chronic pyelonephritis

Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis. Evidence suggests that chronic pyelonephritis is now a les common cause of end-stage renal disease (ESRD).

Clinical ManifestationsThe patient with chronic pyelonephritis usually has no symptoms of infections unless an acute exacerbation occurs. Noticeable signs and symptoms may include: Fatigue Headache Poor appetite Polyuria Excessive thirst Weight loss. Persistent and recurring infections may produce progressive scarring of the kidney, with renal failure the end result.

Assessment and Diagnostic FindingsThe extent of the disease is assessed by: Intravenous Urogram Measurements of creatinine clearance, BUN and creatinine levels. Bacteria, if detected in the urine, are eradicated if possible.

ComplicationsComplications of chronic pyelonephiritis include: ESRD (from progressive loss of nephrons secondary to chronic inflammations and scarring) Hypertension Formation of kidney stones (from chronic infection with urea-splitting organisms).

Pharmacologic TherapyThe choice of an antimicrobial agent is based on which pathogen is identified through urine culture. 1. If the urine cannot be made bacteria free nitrofurantoin or trimethoprim-sulfamethoxazole may be used to suppress bacterial growth. 1. Impaired renal functions alter the excretion of renal function, especially if the medications are potentially toxic to the kidneys.

Nursing ManagementThe patient may require hospitalizations or may be treated as an outpatient. When the patient is hospitalized the nurse should:1. Fluid intake and output are carefully measured and recorded. Unless contraindicated, fluids are encouraged to dilute the urine, decreases burning on urination, and prevent dehydration. 1. The nurse assesses the patients temperature every 4 hours and administers antipyretics and antibiotics as prescribed. 1. Often the patient is more comfortable on bed rest during the acute phase of the illness. 1. Patient teaching focuses on prevention of urinary tract infections by consuming an adequate fluid intake, emptying the bladder regularly, and performing recommended perineal hygiene.

c. Primary Glomerular DiseasesA variety of diseases can affect the glomerular capillaries including: 1. Acute and chronic glomerulonephritis, 1. Rapidly progressive glomerulonephritis 1. Nephrotic syndrome. In all of these disorders, the glomerular capillaries are primarily involved. Antigen-antibody complexes form in the blood and become trapped in the glomerular capillaries (the filtering portion of the kidney), inducing an inflammatory response. IgG, the major immonoglobulin (antibody) found in the blood, can be detected in the glomerular capillary walls. The major clinical manifestations of glomerular injury include:1. Proteinuria 1. Hematuria 1. Decreased GFR 1. Alterations in excretion of sodium (leading to edema and hypertension).

1. Acute Glomerulonephritis

Glomerulonephritis - an inflammation of the glomerular capillaries. Acute glomerulonephritis is primarily a disease of children older than 2 years of age; however, it can occur at nearly any age.

Pathophysiology

In most cases of acute glomerulonephritis, there is a history of a group A beta-hemolytic streptococcal infection of the throat preceding the onset of glomerulonephritis by 2 or 3 weeks. It may also follow impetigo (infections of the skin) and acute viral infections (upper respiratory infections, mumps, Varicella zoster virus,

Acute Glomerulonephritis

Antigen(group A beta-hemolytic streptococcus)

Antigen-antibody product

Deposition of antigen-antibody complex in the glomerulus

Increased productions of epithelial cells lining the glomerulus

Leukocytes infiltrate the glomerulus

Thickening of the glomerular filtration membrane

Scarring and loss of glomerular filtration membrane

Decreased glomerular filtration rate (GFR)

Epstein-Barr virus, hepatitis B, and human immunodeficiency virus infection). In some patients, antigen outside the body (e.g. medication, foreign serum) initiate the process, resulting in the complexes being deposited in the glomeruli. In other patients, the kidney tissue itself serves as the inciting antigen.

Clinical Manifestation1. Hematuria ( blood in the urine)1. Oliguria1. Proteinuria1. Increase in BUN and Creatinine level1. Headache1. Flank pain1. Body malaise1. Tenderness over the CVA is common

Assessment and Diagnostic Findings1. KUB UTZ1. Urinalysis1. Kidney Biopsy

Complication1. Hypertensive1. Encephalopathy1. Congestive Heart Failure1. Pulmonary Edema1. ESRD ( if with treatment)

Medical Management1. Pharmacologic Therapy (depends on the cause of AGN) 1. Penicillin (if residual streptococcal infection is suspected)1. Corticosteroids & Immunosuppressive agent (for progressive AGN)1. Loop Diuretics & Antihypertensive agent (to control hypertension)

1. Dietary Protein is restricted

Nursing Management

1. Monitoring of Intake and Output1. Monitoring Blood Pressure1. Daily weight taking1. Patients education for safe1. Effective self care at home

2. Chronic Glomerulonephritis

Pathophysiology

Chronic Glomerulonephritis may be due to repeated episodes of: 1. Acute Glomerulonephritis 1. Hypertensive Nephrosclerosis1. Hyperlipidemia 1. Chronic Tubulointestinal Injury 1. Hemodynamically mediated glomerular sclerosis.

The kidney are reduced to as little as one fifth their normal size ( consisting largely of fibrous tissue. The cortex shrink to a layer 1 2 mm thickness or less. Bands of scar tissue distort the remaining cortex, making the surface of the kidney rough and irregular. Numerous glomeruli and their tubules become scarred, and the branches of the renal artery are thickened. The result is severe glomerular damage that result to ESRD.

Clinical Manifestation1. Headache ( in am ), dizziness1. Difficulty of breathing1. Blurring of vision1. Lassitude1. Weakness1. Fatigue1. Weight loss1. Edema 1. Increased need to urinate at night (nocturia)

Assessment and Diagnostic Findings1. Urinalysis ( Albumin, Casts, Blood ) 1. Chest X-ray1. KUB UTZ1. ECG

Medical Management1. Rest1. Duiretic is prescribed ( to treat fluid overload1. Anti-hypertensive agent1. Low Na diet1. CHO diet; CHON ( if BUN and s. creatinine is )1. Initiation of dialysis is considered ( to prevent complication of renal failure)

Nursing Management1. Observe changes in fluid and electrolyte status1. Monitoring Intake and Output1. Monitoring the degree of edema1. Blood pressure is monitored1. Promotion of rest1. Teaching patient self care

3. Nephrotic Syndrome

Nephrotic syndrome is a primary glomerular disease characterized by the following:1. Marked increase in protein in the urine ( Proteinuria )1. Decrease in albumin in the blood ( hypoalbuminemia )1. Edema1. High in serum cholesterol and low-density lipoproteins ( hyperlipidemia)

Causes:1. Allergy1. Infection ( herpes zoster )1. Systemic disease ( DM, Sickle Cell Disease )1. Circulatory Problem ( Pericarditis )1. Pregnancy

Pathophysiology

Derangement of Cell in GBM

Membranene Porosity

Proteinuria / Hypoalbuminemia

________________________________

HCHO breakdownHyperlipidemia C.O.P / O.PIVC ISC

IVC

Aldosterone

Na and H20 retentionEdema, HPN

Clinical Manifestation1. Edema Usually soft and pitting found in the periorbital area, sacrum, ankles, and hand1. Ascites1. Malaise1. Headache1. Irritability1. Fatigue

Assessment and Diagnostic Findings1. Urinalysis ( reveals proteinuria, increased in WBCs, granular and epithelial cast)1. Needle Biopsy of kidney1. KUB UTZ

Medical Management1. Diuretics1. ACE inhibitor ( Angiotensin Converting Enzyme )1. Antineoplastics agent ( Cyclophosphamide [ cytoxan ] )1. Immunosuppressive agents ( azathioprine [ Imuran ], chlorambucil [ leukoran ], or cyclosporine ). 1. Corticosteroids ) if relapses occur )1. On low sodium, liberal potassium, low saturated-fat diet.1. Protein intake should be about 0.8 g/kg/day

Nursing Management1. Nursing management is similar to that of the patient with acute glomerulonephritis.

C. RENAL FAILURE

Renal failure results when the kidney are unable to remove the bodys metabolic wastes or perform their regulatory functions. The substances normally eliminated in the urine accumulate in the body fluids as a result of impaired renal excretion and lead to a disruption in the endocrine and metabolic functions as well as fluid, electrolyte, and acid-base disturbances.

Renal failure is a systemic disease and is final common pathway of many different kidney and urinary tract disease. Each year, an estimated 50,000 American die from irreversible kidney failure.

Types of Renal Failure1. Acute Renal Failure1. Chronic Renal Failure

a. ACUTE RENAL FAILURE ( ARF )

Acute Renal Failure is a sudden and almost complete loss of kidney function ( decreased GFR ) over a period of hours to days. Although ARF is often seen only in hospitalized patients, it may occur in the outpatient setting as well.

Pathophysiology

Sudden loss of Kidney Function ( e.g. Trauma / V.A )Decreased Blood supply in the KidneyVasoconstriction

Reduced renal blood flow

Increased Renal IschemiaPerfusion problemRenal Tubular NecrosisFrank Renal Failure

Causes of Acute Renal Failure

1. Pre-Renal Failure (Ischemic causes)1. Volume depletion resulting from:1. Hypovolemia -Hemorrhage, blood loss ( surgery, trauma )1. Plasma loss ( burn, surgery acute pancreatitis )1. Renal losses ( diuretics, osmotic diuresis 01. Gastrointestinal losses ( prolonged diarrhea, vomiting, gastrointestinal tract drainage, nasogastric suction, sustain high fever )

1. Impaired cardiac efficiency resulting from:1. Myocardial Infarction1. Congestive Heart Failure1. Cardiac Dysrhythmias1. Cardiac Failure1. Cardiogenic shock

1. Vasodilation resulting from:1. Sepsis1. Anaphylaxis1. Antihypertensive medications or other drug that cause vasodilation.

1. Intra-Renal Failure (Toxic Substance)1. Prolonged Renal Ischemia resulting from:1. Pigment nephropathy (associated with breakdown of blood cells containing pigments that in turn occlude kidney structures)1. Myglobinuria (trauma, crush injuries, burns)1. Hemoglobinuria (transfusion reaction, hemolytic anemia)

1. Nephrotoxic agents such as:1. Aminoglycosides antibiotics ( Gentamycin, tobramycin)1. Radiopaque contrast agent1. Heavy metals (lead, mercury)1. Solvent and chemicals (ethylene glycol, carbo tetrachloride, arsenic)1. Nonsteroidal Anti-inflammatory Drugs (NSAIDs)1. Angiotensin0converting enzyme inhibitors (ACE)

1. Infectious process such as:1. Acute Pyelonephritis1. Acute Glomerulonephritis

1. Post-Renal Failure (Obstruction)1. Urethral: Calculi, blood clot, retroperitoneal tumor1. Bladder: Prostatic hypertrophy, carcinoma, tumor1. Urethral: Stricture, Stenosis

Phases (stages) of Acute Renal Failure

Oliguric Phase1. Urine output = 400 ml/, per day1. Increased BUN, serum Creatinine1. Edema, HPN1. Hyperkalemia1. Hyponatremia1. Hypermagnesemia1. Hyperphosphatemia1. Metabolic Acidosis1. Oliguric phase usually last 1 3 weeks

Duiretic Phase1. Urine output = 3 5 L/day1. BUN and S. Creatinine elevated1. BP elevated1. Metabolic Acidosis1. Hypokalemia1. Usually Last 1 week

Recovery Phase1. Takes to 3 12 months1. Avoid Nephrotoxic drugs

Clinical Manifestation

1. Appear critically ill and Lethargic1. Persistent Nausea & Vomiting1. Diarrhea1. Dry skin and mucous membrane 1. Uremic Fetor (The breath may have the odor urine)1. CNS manifestation include (drowsiness, Headache, muscle twitching, and seizures)1. Uremic Frost

Assessment and Diagnostic Findings

1. Changes in Urine1. Hematuria1. Low specific gravity ( 1.010)1. Pre-renal Azotemia

1. Increased Blood Urea Nitrogen and Creatinine Levels ( Azotemia)1. Hyperkalemia1. Metabolic Acidosis1. Calcium and Phosphorus Abnormalities 1. Anemia1. Altered biochemical environment ( Glucose intolerance )

Medical Management

1. Conservative Management1. Fluid Control1. Electrolyte Control1. Dietary Control

1. Treatment of Intercurrent Disorders1. Anemia1. Gastrointestinal Disturbance1. Other condition: Hypertension. Pulmonary edema, CHF

1. Dialysis( when the conservative management is not effective)1. Three methods of Dialysis0. Hemodialysis0. Peritoneal Dialysis0. Continuous Renal Replacement Therapy0. Slow Continuous Ultrafiltration0. Continuous Arteriovenous hemofiltration0. Continuous Arteriovenoous hemodialysis

1. Pharmacologic Therapy1. Administering Ion-exchanges resins ( Sodium Polystyrene sulfonate [Kayexalate} 0 orally or by retention enema to reduced elevated potassium level.1. Diuretics1. ACE inhibitors 1. Antibiotics ( especially Aminoglycosides)

1. Correction of Acidosis and Elevated Phosphates levels1. Nutritional Therapy

Nursing Management

NURSING PROCESS

I. Assessment:

A. Subjective DataData to be collected from the person with ARF or significant other include the following:1. Voiding pattern, including any recent changes 1. Weight gain (fluid retention)1. Nausea and Vomiting1. Patient and family history of renal disease1. Medication use (prescription and over the counter1. Recent surgery, anesthesia, or trauma1. Mental status changes

B. Objective DataData to be collected from the person with ARF or significant other include the following:1. Amount of urine excreted in 24 hours1. Blood pressure, particularly postural changes1. Fluid status: presence of peripheral, periorbital, or sacral edema, lung sounds, skin turgor, daily weight1. Halitosis as a result of acidosis and or/ ammonia secretion1. Changes in mental status1. Pulse rate and rhythm

II. Nursing DiagnosisNursing diagnoses are determined from analysis of patient data. Nursing diagnosis for the person with ARF may include but are not limited to the following:

Diagnostic TitlePossible Etiologic Factor

- Fluid volume deficit / excess

- Nutrition, altered: less than body requirement- Activity intolerance- High risk for injury- High risk for infection- Coping, ineffective (individual) - Knowledge Deficit- Abnormal fluid loss, compromised regulatory mechanism- Anorexia, nausea, restricted diet- Biochemical alteration- Sensorimotor deficits, mental confusion- Decreased nutrition, decreased immune response- Changes in health status- Lack of exposure / recall

III. Expected Patient Outcomes (Plan)

Expected outcome for the person with ARF may include the following:

1. Control fluids electrolytes, and waste products.1. Absence of pulmonary edema, absence or control of peripheral edema1. Control of blood pressure (range between 140/90 and 100/60 mm Hg.1. Control of electrolyte balance:0. Na = 125 145 mEq/L0. K = 3.0 6.0 mEq/L0. HCO3 = > 14 mEq/L2. Control of Protein catabolism:0. BUN = < 100 mg/dl0. Creatinine = < 12 mg/dl0. Absence of breakdown

1. Eat diet high in calories and fat and restricted in protein and potassium1. Does not express fatigue1. Does not fall; bleeding does not occur1. No infection occurs1. Describe alternative ways of coping

IV. Nursing Intervention1. Maintaining Fluids and Electrolyte imbalance1. Reducing Metabolic rate1. Promoting pulmonary function1. Preventing Infection1. Providing skin care1. Proving support1. Promoting Nutrition1. Promoting rest / Activity Balance1. Preventing Injury1. Promoting Coping1. Facilitating Learning

VI. EvaluationTo evaluate the effectiveness of nursing intervention, compare patient behaviors with those stated in the expected patient outcome. Successful achievement of patient outcomes for the patient with ARF is indicated by the following: 1. Lack of respiratory distress, peripheral edema, or hypertension indicating fluid volume excess.1. Blood pressures range between 14/90 to 100/60 mm Hg.1. Serum electrolytes are controlled:2. Na 125 145 mEq/L2. K 3.0 6.0 mEq/L2. HCO3 - > 14 mEq/L

1. Protein catabolism is controlled:0. BUN - < 100 mg/dl0. Creatinine - < 12 mg/dl0. Absence of skin breakdown

1. Eats diet high in calories and fat and restricted in protein and potassium1. Statement of feeling rested1. No falls or bleeding occurs1. No sign of infection are present1. Uses alternative ways of coping; as appropriate; manages ADL independently1. Correct explanation of nature of illness, diet therapy, signs and symptoms to be reported to physician, and plans for follow-up care

II. CHRONIC RENAL FAILURE ( End Stage Renal Failure )

Chronic Renal Failure (CRF) or ESRD is a progressive, irreversible deterioration in renal function in which the bodys ability to maintain metabolic and fluid electrolyte balance fails, resulting in uremia and Azotemia (retention of urea and other nitrogenous waste in the blood)

Causes of Chronic Renal Failure1. Diabetes Mellitus ( Leading causes )1. Hypertension1. Chronic Glomerulonephritis1. Pyelonephritis1. Obstruction of Urinary Tract1. Polycystic Kidney Disease1. Vascular Disorder1. Infection1. Medication or Toxic Agent1. Environmental and Occupational Agent ( Lead, Cadmium, Mercury, and Chromium)

Pathophysiology

Underlying Disease causing the destruction of the KidneySome Nephrons remain intact, while other are destroyedIntact Nephron HypertrophyProduced volume of filtrate w/ tubular re-absorption despite of decreased GFRPermits to kidney function until three to fourth of the nephrons are destroyedProduce Osmotic diuresis with Polyuria and thirstAs more nephrons are damage, Oliguria occurs, with retention of waste product

Stages of Chronic Renal Failure

1. Decreased Renal Reserve (Renal Impairment) 1. GFR 40% to 50 % of normal1. BUN and Serum Creatinine normal1. Patient is asymptomatic

1. Renal Insufficiency1. GFR 20% to 40 % of normal1. BUN and S. Creatinine begin to rise1. Mild Anemia, mild Azotemia, which worsen with pathologic stress1. Nocturia1. Polyuria

1. Renal Failure1. GFR 10% to 20% of normal1. BUN and S. Creatinine increase1. Anemia, azotemia, metabolic acidosis1. Urine specific gravity is low1. Polyuria, Nocturia1. Symptoms of renal failure

1. End Stage Renal Failure (ESRD)1. GFR < 10 % of normal1. BUN and S. Creatinine at high levels1. Anemia, Azotemia, Metabolic Acidosis1. Urine specific gravity fixed at 1.0101. Oliguria, Uremia1. Symptoms of renal failure

Clinical Manifestation CausesSign / SymptomsAssessment Parameters

Hematopoetic System Suppression of RBC production

Decreased survival time of RBC

Loss of Blood during dialysis

Mild thrombocytopenia

Decreased activity of platelets

Anemia

Leucocytes

Defects in platelet function

Thrombocytopenia

HematocritHemoglobinPlatelet CountObserve for bruising hematomesis, melena

Cardiovascular SystemFluid Overload

Renin Angiotensin mechanism

Chronic HPN

Calcification of soft tissue

Uremic toxin in pericardial fluid

Fibrin formation in epicardium

HPNTachycardiaDysrhythmiasCongestive Heart FailurePericarditisPitting EdemaPeriorbital EdemaEngorged neck veinHyperkalemiaHyperlipidemia

Vital SignBody WeightElectrocardiographyHeart SoundsMonitor ElectrolytesAssess for painAssess for the degree of edema

Gastrointestinal System- Change in platelet activity- Serum uremic toxin- Electrolyte Imbalance- Urea converted to ammonia by Saliva- Anorexia- Nausea and vomiting- G.I Bleeding- Abdominal Distention- Diarrhea- Constipation- Uremic Fetor ( Halitosis )- Metallic taste- Mouth ulceration and bleeding- Monitor I and O- Hct, Hgb- GUAIAC TEST for all stools- Assess quality of stool- Assess for abdominal pain- Assess for abdominal girth

Neurologic System- Uremic toxins- Electrolyte imbalance- Cerebral swelling resulting from fluid shifting

- Weakness and Fatigue- Lethargy, Confusion- Stupor, coma- Inability to concentrate- Disorientation- Unusual Behaviors- Sleep Disturbance- Asterixis- Tremors, seizures- Restlessness of legs- Burning of soles feet- Level of Orientation- Level of Consciousness- Reflexes- Electroencephalogram- Electrolytes Level

Musculoskeletal System- Decreased calcium absorption- Decreased phosphate excretion- Osteodystrophy- Renal Rickets- Joint Pain, bone pain, bone fracture- Retard Growth- Muscle cramps- Loss of muscle strength-Serum phosphorus- Serum Calcium- Assess for level, intensity and severity of pain

Reproductive System- Hormonal Abnormalities- Anemia, HPN, Malnutrition, Medication- Infertility- Decreased in Libido- Impotence- Amenorrhea- Delayed puberty-Testicular atrophy- Monitor I and O- Monitor V/S- Hct, Hgb

Integumentary System- Anemia- Pigmented retained- Decrease size of sweat glands- Decreased activity of oil glands- Dry skin, phosphate deposit

- Gray- bronze skin color- Dry, Flaky skin- Pruritus- Ecchymosis- Purpura- Thin and brittle nails- Coarse, thinning of hair- Observe for bruising- Assess color of skin- Assess integrity of skin- Observe for scratching

Pulmonary System- Pneumonitis- Uremic Lung- Crackles- Thick tenacious sputum- Depressed cough reflex- Pleuritic pain- Shortness of Breath- Tachypnea

- Assess DOB- Assess pain- Monitor V/S- Assess cough reflex

Assessment and Diagnostic Findings1. Glomerular Filtration Rate1. Sodium and Water Retention1. Acidosis1. Anemia1. Calcium and Phosphorus Imbalance

Complication1. Hyperkalemia1. Hypertension1. Anemia1. Bone Disease and Metastatic Calcification

Medical Management1. Pharmacologic Therapy1. Antacids 1. Anti- hypertensive and Cardiovascular agent1. Anti-convulsants1. Erythropoeitin

1. Nutritional Therapy1. Protein restricted diet1. Fluid intake to balance fluid losses1. Sodium intake to balance Na losses1. Some restriction to potassium1. Adequate caloric intake and vitamin supplementation1. Fluid allowance is 500 600 ml more than the previous 24 urine output

1. Other Therapy : Dialysis

DIALYSIS:

Is used to remove fluid and uremic waste products from the body when the kidneys are unable to do so.

Indications for Dialysis4. Edema that does not responds to other treatment4. Hepatic Coma4. Hyperkalemia4. Hypercalcemia4. Hypertension4. Uremia4. Fluid overload or impending Pulmonary Edema or not responding to diuretics and fluid restrictions4. Increasing Acidosis4. Pericarditis4. Used to remove certain medications or other toxins from the blood4. End Stage Renal Failure4. Chronic Renal Failure or Acute Renal Failure with indication of pericardial friction rub

Methods of Therapy:

A. Hemodialysis:

Is the most common method of dialysis. Is used for patients who are acutely ill and require short term dialysis; and for patients with ESRD who require long term or permanent therapy.

For patients with Chronic Renal Failure, hemodialysis prevents death although it does not cure renal disease and does not compensate for the loss of endocrine or metabolic activities of the kidneys.

1. Objectives of Hemodialysis:1. To extract toxic nitrogenous substances from the blood1. To remove excess water

1. Principles of Hemodialysis:1. DiffusionToxins and waste in blood are removed from an area of higher concentration in the blood to an area of lower concentration in the dialysate

Dialysate:Is a solution made up of all the important electrolytes in their ideal extracellular concentrations

1. OsmosisExcess water is removed from the blood from an area of higher concentration to an area of lower concentration

1. FiltrationsWater moves under high pressure to an area of lower pressure. This process much more efficient than osmosis at water removal and is accomplished by applying negative pressure or a suctioning force to the dialysis membrane

Nursing Alert:

The body buffer system is maintained using a dialysate bath made up bicarbonate or acetate which is metabolized to form bicarbonate

The anticoagulant heparin is administered to keep blood from clotting in the dialysis circuit

Cleansed blood is returned to the body. By the end of the dialysis treatment, many waste products have been removed, the electrolyte balance has been restored to normal and the buffer system has been replenished.

1. Dialyzer:1. Are hollow fiber devices containing thousands of tiny cellophane tubules that act as semipermeable membrane. The blood flows through the tubules while a solution circulates around the tubules. The exchange of waste from the blood to the dialysate occurs through the semipermeable membrane of the tubules.

1. Vascular Access:1. Vascular Access DevicesImmediate access to the patients circulation for acute hemodialysis is achieved by inserting a double lumen large bore catheter into the subclavian, internal jugular or femoral vein. Can be used for 3 weeks and catheter is removed when no longer needed.

Complications:1. Hematoma1. Pneumothorax1. Infection thrombosis1. Inadequate flow

1. Arteriovenous FistulaThe preferred method of permanent access, that is created surgically by joining an artery to a vein either side to side or end to end

Needles are inserted into the vessels to obtain blood flow adequate to pass through the dialyzer

Arterial Segment (used for arterial flow to the dialyzer)Venous Segment (used for reinfusion of the dialyzed blood)

The fistula should be allowed at least 14 days to mature. This gives time for healing and for the venous segment of the fistula to dilate and to accommodate 2 large bore needles

The patient is encouraged to perform exercises to increase the size of these vessels to accommodate the large bore needles (e.g. squeezing a rubber ball for forearm fistula)

1. Arteriovenous GraftCan be created by subcutaneously interposing a biologic, semibiologic or synthetic graft material between an artery and vein. The most commonly used synthetic graft material is expanded polytetrafluoroethylene. The Vecta graft for example is made of thoralon and can be used in 24 hours

Usually a graft is created when the patients vessels are not suitable for creation of a fistula. Patients with compromised vascular systems (e.g. from diabetes) often need to have a graft to undergo dialysis.

Complications:1. Infections1. Thrombosis

Arteriovenous Fistula Care:1. Assess patency of fistula by palpating thrill or Auscultating bruits1. Instruct the patient to avoid compression of fistula by tight clothing and jewelry or when sleeping1. Instruct patient to assess fistula for signs and symptoms of infection including pain, redness, swelling or excessive warmth1. Instruct patient to monitor fistula patency by palpating the thrill daily1. Avoid venipuncture and BP in the fistula site

1. Complications of Hemodialysis:1. Atherosclerosis Cardiovascular Disease 1. Sleep disturbances1. Hypotension may occur during the treatment as fluid is removed1. Painful muscle cramping as fluid and electrolytes rapidly leave the extracellular space1. Dysrhythmias results from electrolyte and hydrogen changes or from removal of antiarrhytmic medications during the dialysis1. Air embolism if air enters the vascular system1. Chest pain 1. Dialysis Disequilibrium results from cerebral fluid shifts (headache, nausea and vomiting, restlessness, decreased level of consciousness and seizures)1. Blood borne infections: Hepatitis B

B. CONTINUOUS RENAL REPLACEMENT THERAPIES (CRRT)

Indications for CRRT1. Acute renal failure or chronic renal failure who are too clinically unstable for traditional hemodialysis1. Patients with fluid overload secondary to oliguric renal failure1. Patients whose kidneys cannot handle their acutely high metabolic or nutritional needs

CRRT does not produce rapid fluid shifts, does not require dialysis machines or personnel to carry out the procedures and can be initiated quickly in hospitals without dialysis facilities.

C. PERITONEAL DIALYSIS:

The peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the semipermeable membrane. Sterile dialysate fluids introduced into the peritoneal cavity through an abdominal catheter at intervals

Indications of Peritoneal Dialysis:1. Treatment of choice for patients with renal failure who are unable or unwilling to undergo hemodialysis or kidney transplantation1. Patients who are susceptible to the rapid fluid, electrolyte and metabolic changes that occur during hemodialysis1. Patients with Diabetes or Cardiovascular disease1. Older patients1. Patients who maybe at risk for adverse effects of systemic heparin1. Severe hypertension1. Heart failure1. Pulmonary edema

Procedure:

1. Preparing the Client:1. Explains the procedure to the patient and obtaining signed consent for it1. Baseline vital signs, weight and serum electrolyte levels are recorded1. The patient is encouraged to empty the bladder and bowel to reduce the risk of puncturing internal organs1. The nurse also assesses the patients anxiety about the procedure and provide support and instruction1. Broad spectrum antibiotic agents maybe administered to prevent infection

2. Preparing the Equipment:1. The nurse consults with the physician to determine the concentration of dialysate to be used and the added medications to be added to it1. Heparin maybe added to prevent fibrin formation and resultant occlusion of the peritoneal catheter1. KCl prevents hypokalemia1. Antibiotics to treat peritonitis1. Regular insulin for patients with diabetes1. Aseptic techniques is important1. The dialysate is warmed to body temperature to prevent patient discomfort and abdominal pain and to dilate the vessels of the peritoneum to increase urea clearance

Solutions that are too cold cause pain, cramping, vasoconstriction and reduce clearance.

Solutions that are too hot burn the peritoneum

1. Immediately before initiating dialysis, the nurse assembles the administration set and tubing. The tubing is filled with the prepared dialysate to reduce the amount of air entering the catheter and peritoneal cavity which could increase abdominal discomfort and interfere with instillation and drainage of the fluid

3. Inserting the Catheter1. Operating room or bedside using strict asepsis1. Before the procedure the skin is prepared with a local antiseptic to reduce skin bacteria and the risk of contamination and infection1. The physician anesthetizes the site with a local anesthetic agent before making a small incision in the lower abdomen 3 5 cm below the umbilicus1. A trocar is used to puncture the peritoneum as the patient tightens the abdominal muscles by raising the head1. The catheter is threaded through the trocar and positioned1. Previously prepared dialysate infused into the peritoneal cavity, pushing the omentum away the catheter1. Secure the catheter with a purse string suture and apply antibacterial ointment and a sterile dressing over the site

4. Preparing the Exchange

Exchange Defined as the infusion, dwell and drainage of the dialysate. The entire dialysate takes 30 45 minutes and the number of exchanges and their frequency are prescribed based on the patients physical status and acuity of illness

Note:

The removal of excess water during the peritoneal dialysis is achieved by using a hypertonic dialysate with a high dextrose concentration that creates an osmotic gradient

Dextrose solution of 1.5%, 2.5% and 4.25% are available in several volumes from 1000 3000 ml, allowing the dialysate selection to fit patients tolerance, size and physiologic needs.

The higher the dextrose concentration, the greater the osmotic gradient and more water will be removed

1. Infusion0. Dialysate is infused by gravity into the peritoneal activity0. 5 10 minutes is required to infuse 2 3 L of fluid

1. Dwell1. Equillibration time allows diffusion and osmosis occur1. 5 10 minutes of dwell time

1. Drainage1. The tube is unclamped and solutions drain from the peritoneal cavity by gravity through a closed system1. Drainage usually completed in 10 30 minutes1. Normal: Colorless or straw colored. Bloody drainage maybe seen in the first few exchanges after insertion of new catheter but should not occur after that time.

Complication of Peritoneal Dialysis:1. Acute complications1. Peritonitis1. Characterized by cloudy dialysate drainage, diffuse abdominal pain and rebound tenderness1. Hypotension and other signs of shock may occur if S. Aureus is responsible organism1. 1 3 rapid exchanges with a 1.5% Dextrose solution without added medications are completed to wash out inflammation and reduce abdominal pain1. Drainage fluid is examined for cell count and gram stain and culture and sensitivity test1. Antibiotic agents are usually added to subsequent exchanges1. Intraperitoneal administration of antibiotics is as effective as IV administration and continue for 10 14 days1. Peritonitis is unresolved after 2 3 days of appropriate therapy maybe necessitate catheter removal. Patient is on hemodialysis and antibiotic for 1 month before new catheter is inserted

1. Leakage1. Incision and exit site time to heal1. Abdominal muscle activity and straining during bowel movement should be avoided1. Leakage can be avoided by using small volume (500 ml) of dialysate gradually increasing the volume up to 2000 3000 ml

1. Bleeding1. Catheter displacement from the pelvis and after enema or from minor trauma

2. Long Term Complications10. Hypertriglyceridemia10. Abdominal Hernia and Hemorrhoids resulting from continuously increased intraabdominal pressure10. Low back pain and anorexia from fluid in the abdomen

4. CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD)

Is performed at home by the patient or a trained caregiver who is usually a family member; the procedure allows the patient reasonable freedom and control of daily activities

Advantages:1. Freedom from a dialysis machine1. Control over daily activities1. Opportunities to avoid restrictions, increase fluid intake, raise serum hematocrit values, improve BP control, avoid venipuncture and gain sense of well being

Disadvantages:1. Continuous dialysis 24 hours a day and 7 days a week. Patient performs exchanges 4 5x a day at intervals scheduled through out the day (before meals and bedtime)

Indications:1. Patients willingness, motivation and ability to perform dialysis at home1. Strong family and community support system particularly older adult1. Interim therapy while awaiting kidney transplantation1. Special problems with long term hemodialysis such as dysfunctional or failing vascular access devices, excessive thirsts, severe hypertension, post dialysis headaches and severe anemia1. ESRD secondary to diabetes because hypertension, uremia and hyperglycemia

Contraindications1. Adhesions from previous signs or systemic inflammatory disease1. Chronic backache and pre existing disk disease which could be aggravated by the continuous pressure of dialysis fluid in the abdomen1. Risks of complications; patients who receives immunosuppressants1. Patients with colostomy, ileostomy, nephrostomy or ileal conduit because of risk of peritonitis1. Diverticulitis because CAPD has been associated with rupture of diverticulums1. Severe arthritis or poor hand strength

Patients Teaching (CAPD)1. High protein and well balanced diet1. Increase intake of fiber to prevent constipation that can impede the flow of dialysate1. Limiting carbohydrate intake to avoid weight gain1. No fluid, K, Na restrictions1. Strict aseptic technique

NURSING MANAGEMENT FOR PATIENT ON DIALYSIS:1. Protecting Vascular Access1. Not used for measuring BP and obtaining blood specimen1. Tight dressings, restraints or jewelry over the vascular access must be avoided1. Assess for bruits and thrills over the venous access site must be evaluated at least every 8 hours. Absence of bruits or thrills indicate blockage or clotting in the vascular access1. Observe for signs and symptoms of infection over the site1. Assess the integrity of dressing and change as needed

2. Monitoring Signs of Uremia3. Detecting Cardiac and Respiratory Complications1. Pulmonary edema (Crackles in the bases of the lungs)1. Pericarditis (Substernal chest pain, low grade fever, pericardial friction rub and pulsus paradoxus decreasing in BP of > 10 mmHg during inspiration)1. Effusion (Friction rub disappears, heart sounds become distant and muffled, narrowing pulse pressure, inaudible heart sounds, crushing chest pain, Dyspnea and hypotension)

4. Controlling Electrolyte Levels and Diet1. All IV solutions and medications to be administered are evaluated for electrolyte content1. Serum laboratory values are assessed daily1. Dietary intake must also be monitored

5. Managing Discomfort and Pain1. Antihistamine and analgesics1. Keep skin clean and well moisturized using bath oils, super fatted soap, creams or lotions1. Keep nails trimmed and apply lotion to the skin instead of scratching

6. Monitoring BP7. Preventing Infection8. Caring for the Catheter Site1. Daily catheter site care is performed during bathing1. The exit site should not be submerged in bath water. Use soap and water cleaning, liquid soap is recommended1. Make sure that the catheter remains secure to avoid trauma or tension1. Gauze or semitransparent dressing over the exit site

9. Providing Psychological Support1. provide opportunities for patients to express their feelings, reactions and explore options1. the patients informed decision about discontinuation of treatment should be respected1. patient should have opportunity to discuss them with dialysis team

Surgical Management

KIDNEY TRANSPLANTATION:

It is the replacement of non working kidneys with a healthy kidney from another person (the donor).The donor kidney is typically placed inferior of the normal anatomical location

Indication: End Stage Renal Failure (ESRD) Diseases leading to ESRD include malignant hypertension, infection, DM and glomerulonephritis

Contraindications: Cardiac and pulmonary insufficiency Hepatic disease Concurrent tobacco use Morbid obesity Recent cancer Active substance abuser Failure to adhere prescribed medical regimens

Sources of Kidney: Living Donor Deceased Donor Brain Dead DonorDonor are considered dead, the donors heart continues to pump and maintain the circulation

Cardiac Death DonorPatient who do not meet the brain dead criteria but have no chance of recovery whatsoever.

Compatibility: The donor and recipient generally have to be ABO blood group compatible, although some programs are experimenting ABO incompatible transplantation using increased immunosuppression and plasmapherisis. Also, they should ideally share as many HLA and minor antigens as possible. This decreases the risk of transplant rejection and the need for another transplant. The risk of rejection maybe further reduced if the recipient is not already sensitized to potential donor HLA antigens and if immunosuppressant levels are kept in an appropriate range. However, it is important to note that HLA matching is a relatively minor predictor of transplant outcomes.

Kidney Transplant Requirements: Many programs place limits on age (the person must be less than 69 years old when put on the waiting list) Must be in good health Significant cardiovascular disease, incurable terminal infectious disease and cancer often are transplant exclusion criteria People with mental illness or significant on going substance abuse issues maybe excluded HIV was at one point considered to be a complete contraindication to transplantation

Procedure:Since in most cases the barely functioning existing kidneys are not removed because this has been shown to increase the rates of surgical morbidities, the kidney is usually placed in a location different from the original kidney (often the iliac fossa) and as a result it is often necessary to use a different blood supply:

The renal artery of the kidney, previously branching from the abdominal aorta in the donor is often connected to the external iliac artery in the recipient The renal vein of the new kidney, previously draining to the inferior vena cava in the donor, is often connected to the external iliac vein in the recipient

Post Operative Management:The goal of care is to maintain homeostasis until the transplanted kidney is functioning well. The problem whose kidney functions immediately has a more favorable prognosis than the patient whose kidney does not.

Lasts for 3 hours and in most cases kidneys will soon start producing urine.

The final step is connecting the ureter from the donor, kidney to the bladder

Living Donor Kidney: 3 5 Cadaveric Donor Kidney: 7 15

Medicines used to suppress immune system from rejecting the donor kidney. Taken through the rest of the patients life

Complications: Infection Post transplant lymphoproliferative disorder Electrolyte imbalances Side Effects of medications Transplant rejection Types of Rejection: Hyper acute Rejection: Damage is irreversible Result of performed circulating antibodies

Accelerated Acute Rejection: With in 24 hours to 4 days after transplant Occurs prior sensitization of the recipient to the donor antigens due to transfusions and transplant Mediated by both cellular and humoral mechanism

Acute Rejection: Occurs months to years with progressive graft loss associated with diminished renal functioning Predisposed by multifactorial elements: Immune mechanism Non immune mechanism Drug toxicity Chronic ischemia Repeated bouts of acute rejection

Chronic Rejection: Second transplant

Nursing Management: Assessing the patient for transplant rejection Preventing infection Monitoring urinary function Addressing psychological concerns Promoting home and community based care Monitoring and managing potential complications

The transplant surgery lasts about 3 hours. The donor kidney will be palced in the lower abdomen and in the recipients body. When this is complete, blood will be allowed to flow through the kidney again, so the ischemia time is minimized. In most cases, the kidney will soon start producing urine. Since urine is sterile, this has no effect on the operation. The final step is connecting the ureter from the donor kidney to the bladder. Depending on its quality the new kidney usually begins functioning immediately.

Nursing Management

Nursing Diagnosis: Fluid volume excess r/t decreased urine output, dietary excess, and retention of Na and WaterGoals: Maintenance of ideal body weight without excess fluid

NURSING INTERVENTION RATIONALEEXPECTED OUTCOME

1) Assess Fluid status: Daily weight Intake and Output balance Skin turgor and presence of edema Distention of neck BP, PR, and rhythm Respiratory rate and effortAssessment provides based line and on going database for monitoring changes and evaluating interventions Demonstrate no rapid weight changes Maintains dietary and fluid restriction Exhibits normal skin turgor w/o edema Exhibit normal vital signs Exhibit no neck distention Report no DOB or shortness of breath

2) Limit fluid intake to prescribed volume

Fluid restriction will be determined on basis of weight, urine output, and response to therapy

Perform oral hygiene frequently Reports decreased of thirst

3) Identify potential source of fluid

Unrecognized source of excess fluid may be identified.

Reports decreased dryness of oral mucous membranes.

4) Explain to patient and family rationale for restrictionwith fluid restriction.

Understanding promotes patient and family cooperation

5) Assist patient to cope w/ the discomfort resulting from fluid restrictions

Increasing patient comfort promotes compliance w/ dietary restrictions

6) Provide or encourage oral hygiene.

Oral hygiene minimizes dryness of oral mucous membrane

Nursing Diagnosis: Altered nutrition; less than body requirement r/t anorexia, nausea and vomiting, dietary restriction and altered oral mucous membraneGoals: Maintenance of adequate nutritional intake

NURSING INTERVENTION RATIONALEEXPECTED OUTCOME

1) Assess nutritional status: Weight changes Anthropometric measure are appealing Laboratory valuesBaseline data allow for monitoring of changes and evaluating interventions Consume CHO of high biologic value Chooses food w/in dietary restriction that Explains in own words rationale to urea and creatinine levels

2) Assess patients nutritional dietary patterns: Dietary history Food preferences Calorie counts Past present dietary pattern can be considered in dietary restrictions and relationship to planning of meals Takes medication on schedule that does not produce anorexia or feeling of fullness

3) Assess factors contributing to: Anorexia, nausea & vomiting Diet unpalatable to patient Depression Lack of understanding of dietary restrictions. Stomatitis

Information about other factors that may be altered or eliminated to promote adequate dietary intake is provided.

Consult of written list of acceptable foods Reports increased appetite at meals Exhibits no rapid increases or decreases in weight. Demonstrates normal skin turgor w/o edema, healing and acceptable plasma Albumin levels.

4) Provide patients food preference w/in dietary restrictionsIncrease dietary intake is encouraged

5) Promote intake of high biologic value CHON food.Complete CHO are provided for positive nitrogen balance needed for growth and healing

6) Encourage high-calorie, low CHO, Low-Na, and Low K snacks between meals.

Reduces source of restricted foods, CHO and provides calories for energy, sparing CHO for tissue growth and healing

7) Alter schedule of medication so that they are not given immediately before meal

Ingestion of medication just before meals may produce anorexia and feeling of fullness.

Other Nursing Diagnosis are the following: Knowledge deficit regarding condition and treatment Activity intolerance r/t fatigue, anemia, retention of waste products, and dialysis procedure Self-esteem disturbance r/t dependency, role changes, changes in body image, and change in sexual functionCollaborative Problem are the Following: Hyperkalemia Pericarditis Pericardial effusion Pericardial Tamponade Hypertension Anemia Bone disease and Metabolic Calcification

Evaluation

To evaluate the effectiveness of nursing interventions, compare patient behaviors with those stated in the expected patient outcome, Successful achievement of patient outcomes for the patient with chronic renal failure is indicated by the following: Lack respiratory distress, peripheral edema, hypertension, or other sign of fluid and electrolyte Imbalance Correctly explains dietary plan, including fluid, protein, potassium, and sodium restriction. Shows no sign of infection, skin remain intact No injury occurs States feeling more rested and less fatigued States that no muscle cramping, itching or ocular irritation present Demonstrates metal clarity and ability to perform ADL independently and safely States satisfaction with life and self Correctly describes nature of illness, treatment regimen, and plan for follow-up care.DialysisIt is used to remove fluid and uremic waste products from the body when the kidney cannot do so. Methods of therapy includes hemodialysis, continuous renal replacement therapy and peritoneal dialysis.

Acute dialysis is indicated when there is a high and rising level of serum potassium, fluid overload and impending pulmonary edema. While chronic or maintenance dialysis is indicated in chronic renal failure known as ESRD or end stage renal disease.

Hemodialysis

It is the process of cleaning of blood through the used of a medium. A dialyzer that is referred to as an artificial kidney, that serves as a synthetic semipermeable membrane, replacing the renal glomeruli and tubules as the filter for the impaired kidneys.

Objectives of hemodialysis are to extract toxic nitrogenous substances from the blood and to remove excess water. In hemodialysis, the blood, laden with toxins and nitrogenous wastes, is diverted from the patient to a machine, a dialyzer, in which the blood is cleansed and then return to the patient.

Vascular Access

Subclavian, internal, jugular, and femoral catheters are the immediate access to the patients circulation for acute hemodialysis. Fistula are more permanent that is surgically created usually in the forearm by anastomosing an artery to a vein.

Hemodialysis Treatment Complications

Hypotension may occur during the treatment as fluid is removed. Painful muscles and cramping may occur. Dysrhythmias may result from electrolyte and pH changes. Air embolism are rare but can occur. Chest pain experiences also. It also results to disequilibrium cerebral fluid shifts.

IV. INTEGUMENTARY SYSTEM

ANATOMIC AND PHYSIOLOGIC OVERVIEWThe largest organ system of the body, the skin is the indispensable for human life. Skin forms a barrier between the internal organs and the external environment and participates in many vital body functions.

The skin is composed of three layers: epidermis, dermis, and subcutaneous tissue. The epidermis is an outermost layer of stratified epithelial cells and composed predominantly of keratinocytes. There are four distinct layers of epidermis, from innermost to outermost: stratum germinativum, stratum granulosum, stratum lucidum, and stratum corneum.

Melanocytes are the special cells of the epidermis that are primarily involved in producing the pigment melanin which colors the skin and hair. The more melanin the tissue, the darker is the color. Production of melanin is controlled by the hormone secreted from the hypothalamus of the brain called melanocyte-stimulating hormone. It is believed that melanin can absorb ultraviolet light in the sunlight.

The epidermis is modified in different areas of the body. It is thickest over the palms of the hand and soles of the feet and contains increased amount of keratin. The thickness of the epidermis can increased with use and can result in calluses forming on the hands or corns forming on the feet.

The dermis makes up the largest portion of the skin, providing strength and structure. It is also made up of blood and lymph vessels, nerves, sweat and sebaceous glands, and hair roots. It is often referred to as the true skin.

The subcutaneous tissue or hypodermis is the innermost layer of the skin. Composed of adipose tissues skin layers, muscles, and bones. It promotes skin mobility, molds body contours, and insulates the body.

An outgrowth of the skin, hair is present over the entire body except for the palms and soles. The hair consists of a root formed in the dermis and a hair shaft that projects beyond the skin. It grows in a cavity called hair follicle.

There are two types of skin glands: sebaceous and sweat glands. The sebaceous glands are associated with hair follicles. The ducts of the sebaceous glands empty sebum onto the space between the hair follicle and the hair shaft. For each hair there is a sebaceous gland, the secretions of which lubricate the hair and render the skin soft and pliable.

Sweat glands are found in the skin over most of the body surface. They are heavily concentrated in the palms of the hands and soles of the feet. Only the glans penis, margin of the lips, external ear and the nail bed are devoid of the sweat glands. Sweat glands is subclassified into two categories: eccrine and apocrine.

The eccrine sweat glands are found in all areas of the skin. The thin watery secretion called sweat is produced and it contains one half of the salt content of the blood plasma. The apocrine sweat gland are larger and their secretion contains parts of the secretory cells. They are produced in the scrotum, axillae, anal region and labia majora. Teir ducts generally open onto hair follicles. It produces milky sweat that sometimes broken down by bacteria to produce the characteristic underarm odor.

FUNCTIONS OF THE SKIN

ProtectionThe skin covering most of the body is no more than 1mm thick, but it provides very effective protection against invasion by bacteria and other foreign matter.

SensationThe receptor endings of nerves in the skin allow the body to constantly monitor the conditions of the immediate environment. The primary functions of the receptors in the skin are to sense temperature, pain, light touch, and pressure. Different nerve endings respond to each of the different stimuli.

Fluid BalanceThe stratum corneum has the capacity to absorb water, thereby preventing an excessive loss of water and electrolytes from the internal body and retaining moisture of the subcutaneous tissues.

Temperature regulationThree major physical processes are involved in loss of heat from the body to the environment. First is radiation ( the transfer of heat to another object of lower temperature ) second is conduction ( transfer of heat from the body to a cooler object in contact with it ) third is convection ( movement of warm air molecules away from the body )

Vitamin ProductionWhen exposed to ultraviolet light can convert substances necessary in synthesizing vit D. that is essential for preventing rickets, a condition that cause bone deformity and results from the deficiency of vit. D, calcium and phosphorus.

a. BURNS

Involve destruction of the epidermis, dermis or subcutaneous layers of the skin.

Causes: Thermal Burn Dry heat such as flames Moist heat such as steam and hot liquids Frostbite because effects are similar to those of thermal burns

Mechanical Burn Caused by the friction or abrasion that occurs when skin is rubbed harshly against a coarse surface

Electrical Burn Faulty electrical wiring Immersion in water that has been electrified Lightning strikes

Chemical Burn Result from direct contact, ingestion, inhalation or injection of various substances: acid, alkali or vesicants

Radiation Burn Typically associated with sunburn or radiation therapy as for cancer treatment

Pathophysiology / Phases of Burn: Fluid Accumulation Phase / Hypovolemic Phase: Last for 36 to 48 hours after a burn injury Fluid shifts from vascular compartment to interstitial space; process called 3rd space shift Edema caused by shifter fluid (which typically reaches maximum extent within 8 hours after injury) Circulation possibly compromised and pulses diminished from severe edema Several reasons for fluid imbalances: Damage to capillaries from the burn injury Diminished kidney perfusion Production and release of stress hormones such as aldosterone and anti diuretic hormone in response to burn injury (cause kidneys to retain Na and water)

Respiratory Problems occurs secondary to compromised edematous airway or because of circumferential burns and edema of the neck or chest can restrict respirations and cause shortness of breath Muscle and tissue injury cause release of acids that can cause a drop in pH level and subsequent metabolic acidosis GI problems including Curlings ulcer occur as result of decreased blood flow to stomach Electrolyte imbalances (hyperkalemia, hyponatremia, hypernatremia and hypocalcemia) due to bodys hypermetabolic needs and priority that fluid replacement takes over nutritional needs during emergency phase

Fluid Remobilization Phase / Diuretic Phase: Starts about 48 hours after the initial burns Fluid shifted back to vascular compartment Edema at burn site decreased, blood flow to the kidneys increased Sodium lost through increase in diuresis, potassium either moved back into the cells or lost through urine Fluid and electrolyte imbalances present during the initial phase after burn: can change during fluid remobilization phase may include hypokalemia, hypervolemia and hyponatremia

Convalescent Phase: Begins after 1st two phases have been resolved Characterized by healing or reconstruction of burn wound Major electrolyte imbalances exist as result of inadequate dietary intake Anemia common at this time (severe burns typically destroy RBC)

Classification of Burns:

Burn injuries are described according depth of the injury and the extent of the body surface area injured.Burns are classified according to the depth of tissue destruction as superficial- partial thickness injuries, deep partial thickness injuries or full thickness injuries.

Superficial Partial Thickness Burns / First Degree Involve superficial injury to the epidermis marked by an uncomplicated erythematous area Localized pain Skin barrier remains intact; fluid and electrolyte loss not a problem

Deep Partial Thickness Burns / Second Degree Involve damage to the epidermis progressing to the dermis Blisters present Mild to moderate edema and pain Possible capillary damage Possible regeneration of the epithelial layer Fluid and electrolyte imbalances associated with second degree burns that cover significant areas of the body

Full Thickness Burns / Third Degree Involve all skin layers Regeneration impossible Skin elasticity lost, appearance altered significantly (color varies from red to black to white) No blister present No pain if nerve endings are damaged Carry greatest risk of fluid and electrolyte imbalance

Determining the Severity of Burns: MAJOR BURN Require care in a special burn facility and include: Second degree burns on > 25% of an adults BSA or more than 20% of childs BSA Third degree burns on > 10% of BSA regardless of body size Burns of the hands, face, eyes, ears, feet or genitalia All inhalation and electrical burns Burns complicated by fractures or other major trauma All burns in high risk patients, such as children younger than age 2, adults older than age 60, and patients who have preexisting medical conditions such as heart disease

MODERATE BURN Require care either burn care facility or a general health care facility and include: Third degree burns on 2% - 10% of the BSA regardless of body size Second degree burns on 15% - 25% of an adults BSA and 10% - 20% of a childs BSA

MINOR BURN Can be treated on an out patient basis and include: Third degree burns on < 2% of the BSA regardless of body size Second degree burns on < 15% of an adults BSA and on < 10% of a childs BSA

Effects on Fluids, Electrolytes, and Blood Volume: Circulating blood volume decreases dramatically during burn shock. In addition evaporative fluid loss through the burn wound may reach 3 to 5 liter or more over a 24hr. period until the burn surface is covered. During burn shock, serum sodium levels vary in response to fluid resuscitation. Usually hyponatremia is present. Hyponatremia is also common during the first week of the acute phase, as water shifts from the interstitial to the vascular space. Immediately after burn injury, hyperkalemia results from massive cell destruction. Hypokalemia may occur later with fluid shifts and inadequate potassium replacement. At the time of burn injury, some red blood cells may be destroyed and other damaged, resulting in anemia. Despite this, the hematocrit may be elevated due to plasma loss. Abnormalities in coagulation including a decrease in platelets and prolonged clotting and prothrombin times also occur with burn injury.

Cardiovascular Response: Cardiac output decreases before any significant change in blood is evident Burn Shock (as fluid loss continues and vascular volume decreases, cardiac output continues to fall and blood pressure drop). In response to symphathetic nervous system releases catecholamines resulting in an increase pulse peripheral resistance (vasoconstriction) increases pulse rate.

Pulmonary Response: Burns of the face and neck Singed nasal hair Hoarseness of voice, dry cough, stridor Bloody sputum Labored breathing or tachycardia Erythema and blistering of the oral or pharyngeal mucosa

Other Systemic Responses: Renal function maybe altered as result of decrease blood volume Destruction of RBC at the injury Myoglobulin is released from the muscle cells and excreted by the kidney Loss of the skin integrity

Compartment Syndrome: As edema increases in circumferential burns, pressure on small blood vessels and nerve in distal extremities causes obstruction of blood flow and consequent ischemia.

Diagnostic Findings: Percentage of BSA involved determined by Rule of Nines or Lund Browder Classification; greater BSA involved results in greater potential for imbalances For Adults Use Rule of Nines, divides an adults body surface areas into percentages Match the burns on your patient to the body charts Add the corresponding percentages Use the total to calculate initial fluid replacement needs

For Infants or Children Use the Lund Browder Classifications Infants and childs body section percentage differ from those of adult

ABG levels maybe normal in early stages, may reveal hypoxemia and metabolic acidosis in later stages Carboxyhemoglobin level; may reveal extent of smoke inhalation due to presence of CO

Medical Management: Removal of smoldering clothing (soaking first in NSS if stuck to patients skin), rings and other constricting items Immersion of the burned area in cool water or application of cool compresses (minor burns) Pain medications as needed or an anti inflammatory drug Coverage of the area with an antimicrobial and a non sticky bulky dressings (after debribement) Prophylactic tetanus injection as needed Prevention of hypoxia by use of several steps: Maintaining an open airway Assessing airway, breathing and circulation Checking for smoke inhalation immediately Assisting with ET insertion Administering 100% oxygen

Coverage of partial thickness burns over 30% of BSA or full thickness burns over 5% of BSA with a clean, dry, sterile bed sheet Immediate IV therapy to prevent hypovolemic shock and maintain cardiac output The Parkland Formula is a commonly used formula for calculating fluid replacement in patients with burns. Always base the volume of fluid replacement on the patients response, especially his urine output. Urine output of 30 50 ml/ hour is a sign of adequate renal perfusion Over 24 hours: 4 ml of LR x kg of body weight x % of BSA burned (using Rule of Nines or Lund Browder Classification) Give of the total over the 1st 8 hours after the burn and the remainder over the next 16 hours

Antimicrobial therapy Insertion of NGT to decompress the stomach and avoid aspiration of stomach content Irrigation of wound with copious amounts of NSS (chemical burns) Surgical intervention including skin grafting and more through surgical cleaning (major burns)

Nursing Management: Assess airway obstruction Provide oxygen therapy as ordered Assess cardiac and hemodynamic status (hypovolemia and hypervolemia) Assess skin for location, depth and extent of the burn Administer IV fluid therapy as ordered Assess for signs and symptoms of metabolic acidosis Monitor ECG readings Assess fluid and hydration status monitor ABG values and serum electrolyte levels If bowel sounds are present, provide a diet high in potassium, protein, vitamins, fats, nitrogen and calories to maintain the patients preburn weight If necessary, feed the patient enterally until he can tolerate oral feedings; if he cant tolerate oral or enteral feedings, administer TPN Monitor for signs and symptoms of infection

Management of the Patient with a Burn Injury: Emergent / Resuscitative Phase of Burn Care Assess Airway, Breathing and Circulation Breathing must be assessed and a patient airway established immediately during the initial minutes of emergency care Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen If such a high concentration of oxygen is not available under emergency condition oxygen by mask or nasal cannula is given initially No food or fluid is given by mouth and patient is placed in a position that will prevent aspiration of vomitus

Emergency Medical Management Initial priority ABC After adequate respiratory and circulatory status has been established attention is directed to the burn wound itself All clotting and jewelry are removed Flushing of chemical burns with water is continued

Transfer to Burn Center The depth and extent of the burn are considered in determining whether the patient should be transferred to a burn center If the patient is to be transported to a burn center, the following measures are instilled before transfer: A secure IV line is placed with fluid infusing at the rate required to attain urine output of at least 30 ml/hr A patent airway is secured Adequate pain relief is attended Adequate peripheral circulation is established in any burned extremities Wounds are covered with clean dry sheet and the patient is kept comfortably warm

Wound Care: Open Method: A topical agent or wound covering is placed on the wo