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Renal system disorders with nursing and medical implications in Adobe format.
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Renal System DisordersRenal System DisordersRenal System DisordersRenal System DisordersNio C. Nio C. NovenoNoveno, , RNRN, MAN, MAN
The Human KidneyThe Human Kidney
2Renal Disorders [email protected]
The NephronThe Nephron
3Renal Disorders [email protected]
Functions of the Renal SystemFunctions of the Renal System
� Excretion of waste
� Regulation of acid-base balance
4Renal Disorders
� Formation of erythropoietin
� Regulation of fluid and electrolyte balance (RAAS)
� Regulation of phosphate and calcium
Classification of Renal DisordersClassification of Renal Disorders
Obstructive disorders
Acute renal failure
5Renal Disorders
Acute renal failure
Chronic renal failure
Obstructive disordersObstructive disorders
�Can occur anywhere in the urinary tract
6Renal Disorders
� Signs and symptoms depend on the site of location and size of obstruction
Causesof urinary tract obstructionCausesof urinary tract obstruction
Lower urinary tract
� Bladder neoplasms
� Urethral strictures
Calculi
Ureteral obstruction
� Calculi
� Trauma
� Enlarged lymph nodes
7Renal Disorders
� Calculi
� Tumors
� Benign prostatic
hypertrophy
� Enlarged lymph nodes
� Congenital anomalies
Kidney
� Calculi
� Polycystic kidney disease
Renal stonesRenal stones
�Crystallization of minerals around an organic matrix (blood, pus, devitalization tissue)
8Renal Disorders
�Usually idiopathic:
– Infection
SITES OF STONE FORMATIONSITES OF STONE FORMATION
9Renal Disorders [email protected]
Composition of renal stonesComposition of renal stones
Calcium (oxalate and phosphate)
Hypercalcemia
� Hyperthyroidism
� Vitamin D intoxication
Uric acid
� High purine diet
� Gout
� Chemotherapy
10Renal Disorders
� Immobilization
� Tumors
� Renal tubular acidosis
� Intake of steroids
Cystine
� Genetic disorder
Struvite
� Infection related
Renal StonesRenal Stones
Diagnostics
� Urinalysis
� KUB-UTZ
�KUB-IVP
CT scan
11Renal Disorders
� CT scan
� Cystoscopy
� BUN, Creatinine
Clinical manifestations
� Pain
� Hematuria
Diagnostic ProceduresDiagnostic Procedures
12Renal Disorders [email protected]
Medical managementMedical management
Medications
� Pain medications
� Medications to � Ca & PO4 content
– Ascorbic acid
� Medications to � uric acid formation
13Renal Disorders
� Medications to � uric acid formation
– Sodium bicarbonate
– Allopurinol
� Surgery
� Extracorporeal shockwave lithotripsy
� Percutaneous lithotripsy
Nursing managementNursing management
� Administer medications as ordered
� Strain urine to detect passage of stones
15Renal Disorders
of stones
� Monitor I & O
� Encourage to increase OFI
>3 L/day
� Instruct client on infection prevention
Bladder carcinomaBladder carcinoma
� Most common among 60-70 years old
� Males>females
Predisposing factors:
16Renal Disorders
Predisposing factors:
– Cigarette smoking
– Exposure to rubber dyes
– Abuse of phenacetin-containing analgesics
– Recurrent UTI
– Recurrent nephrolithiasis
Bladder carcinomaBladder carcinoma
Clinical manifestations
– Gross painless hematuria
– Dysuria
– Frequent urination
17Renal Disorders
– Frequent urination
Diagnostics
– Urinalysis
– IVP
– Cystoscopy with biopsy
– CT [email protected]
Bladder carcinomaBladder carcinoma
Medical Management
� Surgical treatment
Radiation
Nursing management
� Encourage to:
– Increase OFI
18Renal Disorders
� Radiation
� Chemotherapy
– Increase OFI
– Quit smoking
� Assess for presence
of UTI
Bladder carcinomaBladder carcinoma
Care of the STOMA
Immediate post-OP:
� Color of drainage is bright red/pink
Report: gray or black discoloration
� Teach patient on stoma care
Opening should be no more than 2-3 mm larger than the stoma
19Renal Disorders
Report: gray or black discoloration
� Position pouch at the side of bed for drainage
� Monitor urine output daily
� Monitor for signs of peritonitis
Abdominal pain, distention, fever
stoma
Change every 3-5 days
Report signs of UTI
– Cloudy urine
– Hematuria
– Strong odor
– Fever– Flank pain
Benign Prostatic Hyperplasia (BPH)Benign Prostatic Hyperplasia (BPH)
� Most common
problem of adult male
reproductive organ
Cause is not
20Renal Disorders
� Cause is not
completely
understood
� Not a predisposing
factor for prostatic
carcinoma
Benign Prostatic Hyperplasia (BPH)Benign Prostatic Hyperplasia (BPH)
Clinical manifestations
� Dribbling
� Hesitancy
� Diminution in caliber
Diagnostics
� Digital rectal exam
� Urinalysis
� BUN/Creatinine
21Renal Disorders
� Diminution in caliber and force of urinary stream
� Feeling of incomplete emptying
� Irritative symptoms
� BUN/Creatinine
� Cystourethroscopy
� PSA
Benign Prostatic Hyperplasia (BPH)Benign Prostatic Hyperplasia (BPH)
22Renal Disorders [email protected]
Benign Prostatic Hyperplasia (BPH)Benign Prostatic Hyperplasia (BPH)
Medical Management
� Pharmacologic treatment
� Anti-androgens
Non-surgical procedures
� Thermotherapy
� Prostatic balloon device
23Renal Disorders
� Anti-androgens
– Finasteride
– Alpha-adrenergic blockers
– Terazosin
device
� Stents/coils
� TULIP (transurethral ultrasound-guided laser prostatectomy)
� Surgical procedures
Benign Prostatic Hyperplasia (BPH)Benign Prostatic Hyperplasia (BPH)
Nursing management:
1. Provide medications as ordered
2. Maintain patency of 3-way Foley
• Observe aseptic technique
24Renal Disorders
• Irrigate with NSS (as ordered)
3. Control & treat bladder spasms
• Short, frequent walks
• Decrease frequency of bladder irrigation
• Administer anti-cholinergics and anti-spasmodics
Benign Prostatic Hyperplasia (BPH)Benign Prostatic Hyperplasia (BPH)
4. Prevent hemorrhage
• Prevent straining (heavy lifting, constipation), prolonged periods of travel, sexual activity until doctor approves so.
• Avoid rectal procedures.5. Provide for bladder training after Foley
25Renal Disorders
5. Provide for bladder training after Foley catheter removal
• Perineal exercise• Limit fluid intake in the evening• Restrict intake of caffeine-containing
compounds• Withhold anti-cholinergics and anti-
spasmodics if permitted
Benign Prostatic Hyperplasia (BPH)Benign Prostatic Hyperplasia (BPH)
5. Provide health teaching on:
• Increasing OFI
• Signs of UTI and report once noted
• Avoidance of heavy lifting, straining and
26Renal Disorders
• Avoidance of heavy lifting, straining and
prolonged travel.
• Possible impotence
Prostate cancerProstate cancer
� Highest incidence in African-American over age 60
� Adenocarcinoma; growth related to presence of androgens
Clinical manifestations:
27Renal Disorders
Clinical manifestations:– Same as BPH– Hard, nodular, fixed mass upon rectal exam
Laboratory diagnostics:
– Elevated PSA, acid & alkaline phosphatase– Bone scan
Prostate cancerProstate cancer
28Renal Disorders [email protected]
Prostate cancerProstate cancer
Medical management:
Drug therapy:
Estrogens,
chemotherapeutic
Nursing interventions:
1. Administer prescribed medications
2. If with radiotherapy:
• Double flush the toilet
29Renal Disorders
chemotherapeutic
agents
Radiation therapy
Surgery: Perineal
prostatectomy
• Double flush the toilet after use.
• Advise to avoid placing children on their lap.
• Avoid sexual intercourse for the whole duration of therapy.
3. Provide care post-prostatectomy
Acute renal failure (ARF)Sudden cessation of kidney function; reversibleAcute renal failure (ARF)Sudden cessation of kidney function; reversible
30Renal Disorders [email protected]
Acute renal failure (ARF)Sudden cessation of kidney function; reversibleAcute renal failure (ARF)Sudden cessation of kidney function; reversible
Causes:
1. Ischemic (pre-renal)
• Dehydration
• Blood loss (surgery, trauma)
• Cardiac failure
• Shock
3. Obstruction (post-renal)
• Stones
• Tumors
• Strictures/stenosis
31Renal Disorders
2. Toxic substance (renal)
• Solvents (carbon tetrachloride, methanol, ethylene glycol)
• Heavy metals (lead, arsenic, mercury)
• Antibiotics (aminoglycosides, amphotericin B)
• Pesticides
• Mushrooms
4. Other causes:
• Acute glomerulonephritis
• Malignant hypertension
• Hemolysis
Physiologic effect Findings Symptoms
OliguricInability to excrete wastes
Inability to regulate electrolytes
Inability to excrete fluid loads
↑ BUN, Crea
↑ K+, ↓ Na+, acidosis
Fluid overload
Drowsiness, Confusion, Coma
GI bleeding
Asterixis
Pericarditis
Cardiac dysrhythmias
Kusmaull’s breathing
Coma
CHF
Pulmonary edema
Hypertension
32Renal Disorders
Hypertension
Diuretic
Hypovolemia
↓ Na+
↓ K+
Urine output of 4-5 L/day
Hypotension
Tachycardia
Improving mental alertness
Weight loss
Dry mucous membranes
Muscle weakness
Constipation
Recovery Return to normal
Nursing management:Nursing management:
Medical management:
� Supportive
� Dialysis
Nursing management:Nursing management:
1. Maintain F & E balance
• Accurate I & O
• Weigh daily
• Maintain fluid restrictions
• Assess for signs of fluid overload
2. Maintain nutrition
• Moderate CHON, low K+, high CHO, high fat
• Measures to relieve nausea
33Renal Disorders [email protected]
Nursing management:Nursing management:
3. Maintain rest-activity balance
• Provide assistance in ADL
• Maintain strict bed rest in acute phase
4. Prevent injury
• Keep side rails elevated (pad if necessary)• Keep side rails elevated (pad if necessary)
• Protect from bleeding
5. Prevent infection
• Maintain asepsis
• Reverse isolate
• Turn frequently
• Meticulous skin care
• Relieve pruritus
34Renal Disorders [email protected]
Chronic renal failure (CRF)Chronic renal failure (CRF)
Causes:
Chronic systemic disease
DM, HTN
Polycystic kidney disease
35Renal Disorders
Polycystic kidney disease
Long standing obstruction
Chronic glomerulonephritis
Recurrent infections
Stages of CRFStages of CRF
1. Decreased renal reserve (renal impairment)• GFR: 40-50%• BUN & crea are normal• Asymptomaitc
2. Renal insufficiency• GFR: 20-40%
4. End-stage renal disease
• GFR: <10%• BUN & crea severely
increased• Signs of CHF• Hypocalcemia,
36Renal Disorders
• GFR: 20-40%• BUN & crea begins to rise• Mild anemia, mild azotemia• Polyuria, nocturia
3. Renal failure• GFR: 10-20%• BUN & crea increase• Anemia, azotemia,
metabolic acidosis
• Hypocalcemia, hyperphosphatemia, hyperkalemia, hyponatremia
• Fractures, joint pains• Infertility, amenorrhea• Uremia
Stages of CRFStages of CRF
�Decreased renal reserve
37Renal Disorders
�Renal insufficiency
�Renal failure
�End-stage renal disease
38Renal Disorders [email protected]
Chronic renal failure (CRF)Chronic renal failure (CRF)
Diagnostics:
Blood chemistry
Urinalysis
KUB-TUZ
Medical management:
� Anemia
– Epoieitin alfa
– Iron
– Folate and Vitamin B12
– Blood transfusion
39Renal Disorders
Conservative TX
� Fluid and electrolyte control
– Hyperkalemia
� Diet
� Dialysis
� Exchange resins
– Hypocalcemia/ hyperphosphatemia
� Phosphate binders
� Diet
� Vitamin D
� Hypertension
Dialysis
Renal transplant
40Renal Disorders [email protected]
Peritoneal DialysisPeritoneal Dialysis
41Renal Disorders [email protected]
Peritoneal DialysisPeritoneal Dialysis
Intermittent:
8-12 H x 3-5x/week
Ambulatory:
42Renal Disorders
Ambulatory:
3-5 passes/day
Continuous cycling:
3-7x during sleep
Peritoneal dialysis� Must consider:
– Explaining procedure
– Monitor VS (+
� (+) pink-tinged effluent or presence of small strings is normal
� Blood is normal for
43Renal Disorders
– Monitor VS (+ weight)
– Note for signs of infection
– Assess skin integrity
� Blood is normal for several days
� With ascites from other source, substitute a lower concentration of dialysate
Hemodialysis
AV Fistulas
– Internal AVF
– Internal Graft AVF
– Internal AV Graft
44Renal Disorders
– Internal AV Graft
with external
access device
Complications
– Thrombosis
– Local infections
– Aneurysms
– Steal [email protected]
Hemodialysis Hemodialysis
45Renal Disorders [email protected]
HEMODIALYSIS PERITONEAL DIALYSIS
ACCESS
AVF
Subclavian vein
Arteriovenous graft
Peritoneum
DURATION 2-4 H 36 H
COMPLICATIONS
Disequilibrium syndrome
Hypotension
Bleeding
Sepsis
Exit site infection
Peritonitis
Hernias
Pulmonary complications
46Renal Disorders
Sepsis
Hepatitis
Pulmonary complications
Protein loss
NURSING INTERVENTIONS
Weigh before and after HD
VS q 15 mins
Monitor I & O, signs of DE
WOF signs of bleeding
Do NOT use the AVF other than for
dialysis
Provide diversional activities
Monitor for VS and changes in
behavior
Check patency of catheter
May procaine HCl in the
dialysate to minimize
discomfort
Observe for signs of peritonitis
Maintain aseptic technique
during insertion of [email protected]
Chronic renal failure (CRF)Chronic renal failure (CRF)
Nursing management:
� Maintain F & E balance
– I & O q 80
– Weigh daily
47Renal Disorders
– Weigh daily
– Assess edema
�Auscultate breath sounds
�V/S q 80
�Assess LOC q 80
�High CHO diet, within prescribed Na+, K+, and
CHON limits
�Administer medications as [email protected]
Renal TransplantRenal Transplant
48Renal Disorders [email protected]
Renal TransplantRenal Transplant
49Renal Disorders [email protected]
Chronic renal failure (CRF)Chronic renal failure (CRF)
Nursing management cont…:
� Prevent infection and injury
– Promote meticulous skin care
– Protect from infectious agent
– Protect confused person
– Maintain asepsis
50Renal Disorders
– Maintain asepsis
– Avoid aspirin products
– Encourage use of soft bristle toothbrush
� Promote comfort
– Give anti-pruritics
– Use emolient baths, keep skin moist
– Provide good oral hygiene
ACID-BASE DISORDERSACID-BASE DISORDERS
Disorder Clinical manifestation Compensation
Respiratory acidosis↑Paco2, ↑ or normal
HCO3-, ↓ pH
Kidneys eliminate H+
and retain HCO3-
51Renal Disorders
Respiratory alkalosis↓ Paco2, ↓ or normal
HCO3-, ↑ pH
Kidneys conserve H+
and eliminate HCO3-
Metabolic acidosis↓ or normal Paco2,
↓HCO3-, ↓ pH
Lungs eliminate CO2
and conserve HCO3-
Metabolic alkalosis↑ or normal Paco2,
↑HCO3-, ↑ pH
Lungs hypoventilate to
↑ Paco2, kidneys
conserve H+ excrete
HCO3-
Causes of Acid-Base DisordersCauses of Acid-Base Disorders
Metabolic acidosisCauses:
� DKA, uremia, starvation, diarrhea, severe infections
Nursing management:
� Administer sodium bicarbonate
� Monitor for signs of hyperkalemia
52Renal Disorders
severe infections
Manifestations:
� Headache, nausea and vomiting
� Signs of hyperkalemia
� Seizures, coma, hyperventilation
� Provide alkaline mouthwash
� Lubricate lips to prevent dryness
� I & O
� Institute seizure precaution
� Monitor ABG & electrolyte losses
Causes of Acid-Base DisordersCauses of Acid-Base Disorders
Metabolic alkalosis
Causes:
� Severe vomiting, NGT suctioning, diuretic therapy, excessive
Nursing management:
� Decreased respirations
� Replace fluids nad
53Renal Disorders
therapy, excessive ingestion of NaHCO3, biliary drainage
Manifestations:
� Nausea and vomiting
� Signs and symptoms of hypokalemia
� Replace fluids nad electrolytes losses
� I & O
� Assess for signs of hypokalemia
� Monitor ABG & electrolytes
Causes of Acid-Base DisordersCauses of Acid-Base DisordersRespiratory acidosis
Causes:
� Hypoventilation: COPD, barbiturate or sedative overdose, acute airway obstruction,
Nursing management:
� Semi-Fowler’s
� Patent airway
54Renal Disorders
obstruction, neuromuscular disorders
Manifestations:
� Headache, weakness, visual disturbances, rapid respirations, confusion, drowsiness, tachycardia, coma
� Patent airway
� Turn, cough, deep-
breath
� Administer fluids
� O2 therapy
� Monitor ABG
Causes of Acid-Base DisordersCauses of Acid-Base Disorders
Respiratory alkalosis
Causes:
� Hyperventilation, mechanical overventilation, encephalitis
Nursing management:
� Offer reassurance
� Encourage breathing into a paper bag
55Renal Disorders
encephalitis
Manifestations:
� Numbness and tingling of mouth and extremities
� Inability to concentrate
� Rapid respirations, dry mouth, coma
into a paper bag
� Provide sedation as ordered
� Monitor mechanical ventilation and ABG
Interpretation Interpretation
UC PC FC
pH ↓ or ↑ ↓ or ↑ normal
56Renal Disorders
pH ↓ or ↑ ↓ or ↑ normal
HCO3-
↓ or ↑
normal↓ or ↑ ↓ or ↑
Paco2
↓ or ↑
normal↓ or ↑ ↓ or ↑
Renal System DisordersRenal System DisordersRenal System DisordersRenal System DisordersNio C. Noveno, USRN, MANNio C. Noveno, USRN, MAN