Medical Surgical Nursing Care

1. Medical Surgical Nursing Care • The Urinary System Assessment & Disorders • Dr Ibrahim Bashayreh, RN, PhD

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

3. An illustration of the internal structures of the kidney.

4. The structure of the nephron and the processes of urine formation. (Source: Pearson Education/PH College)

5. Urine Formation • Glomerular filtration • Glomerular filtration rate • Tubular reabsorption • Include water and electrolytes • Tubular secretion • Urine concentration

6. Endocrine Function • Renin–angiotensin–aldosterone system • Role in blood pressure and sodium reabsorption • Erythropoietin • Role in RBC production • Vitamin D and calcium regulation • Acid–base balance

7. Age-Related Changes • Nephrons lost with aging • Reduces kidney mass and GFR • Less urine concentration • Risk for dehydration

8. Assessment • Color, clarity, amount of urine • Difficulty initiating urination or changes in stream • Changes in urinary pattern • Dysuria, nocturia, hematuria, pyuria

9. Assessment • History of urinary problems • Urinary or abdominal surgeries • Smoking, alcohol use, number of sexual partners and type of sexual relationship • Chance of pregnancy • History of diabetes or other endocrine disorders • History of kidney stones

10. Physical Assessment • Obtain clean-catch urine specimen • Color, odor, clarity • Vital signs and skin assessment

11. Diagnostic Tests • Clean-catch urine • 24-hour urine • Culture and sensitivity • BUN, creatinine and creatinine clearance • IVP • CT scan • Renal scan

12. Diagnostic Tests • Ultrasound • Bladder scan • Cystoscopy • Uroflowmetry

13. Renal FailureAcute and ChronicRenal Obstructive Disorder Medical Surgical Nursing Dr ibraheem Bashayreh, RN, PhD

14. Acute Renal Failure • Sudden interruption of kidney function resulting from obstruction, reduced circulation, or disease of the renal tissue • Results in retention of toxins, fluids, and end products of metabolism • Usually reversible with medical treatment • May progress to end stage renal disease, uremic syndrome, and death without treatment

15. Acute Renal Failure • Persons at Risks • Major surgery • Major trauma • Receiving nephrotoxic medications • Elderly

17. Acute Renal Failure • Causes • Prerenal • Hypovolemia, shock, blood loss, embolism, pooling of fluid d/t ascites or burns, cardiovascular disorders, sepsis • Intrarenal • Nephrotoxic agents, infections, ischemia and blockages, polycystic kidney disease • Postrenal • Stones, blood clots, BPH, urethral edema from invasive procedures

18. Acute Renal Failure • Stages • Onset – 1-3 days with ^ BUN and creatinine and possible decreased UOP • Oliguric – UOP < 400/d, ^BUN,Creat, Phos, K, may last up to 14 d • Diuretic – UOP ^ to as much as 4000 mL/d but no waste products, at end of this stage may begin to see improvement • Recovery – things go back to normal or may remain insufficient and become chronic

19. Acute Renal Failure • Subjective symptoms • Nausea • Loss of appetite • Headache • Lethargy • Tingling in extremities

20. Acute Renal Failure • Objective symptoms • Oliguric phase – • vomiting • disorientation, • edema, • ^K+ • decrease Na • ^ BUN and creatinine • Acidosis • uremic breath • CHF and pulmonary edema • hypertension caused by hypovolemia, anorexia • sudden drop in UOP • convulsions, coma • changes in bowels

21. Acute Renal Failure • Objective systoms • Diuretic phase • Increased UOP • Gradual decline in BUN and creatinine • Hypokalemia • Hyponaturmia • Tachycardia • Improved LOC

22. Acute Renal Failure • Diagnostic tests • H&P • BUN, creatinine, sodium, potassium. pH, bicarb. Hgb and Hct • Urine studies • US of kidneys • KUB • ABD and renal CT/MRI • Retrograde pyloegram: is a urologic procedure where the physician injects contrast into the ureter in order to visualize the ureter and kidney.

23. Acute Renal Failure • Medical treatment • Fluid and dietary restrictions • Maintain E-lytes • D/C or change cause • May need dialysis to jump start renal function • May need to stimulate production of urine with IV fluids, Dopomine, diuretics, etc.

24. Acute Renal Failure • Medical treatment • Hemodialysis • Subclavian approach • Femoral approach • Peritoneal dialysis • Continous renal replacement therapy (CRRT): The concept behind continuous renal replacement techniques is to dialyse patients in a more physiologic way, slowly, over 24 hours, just like the kidney • Can be done continuously • Does not require dialysate: the fluid and solutes in a dialysis process that flow through the dialyzer, do not pass through the membrane, and are discarded along with removed toxic substances after leaving the dialyzer.

25. Acute Renal Failure • Nursing Diagnosis- • imbalanced fluid volume= excess • Altered electrolyte balance • Altered cardiac output • Impaired tissue perfusion: renal • Anxiety • Imbalanced nutrition • Risk for infection • Fatigue • Knowledge deficit

26. Acute Renal Failure • Plan- • Promote recovery of optimal kidney function. • Maintain normal fluid and electrolyte balance. • Decrease anxiety. • Increase knowledge.

27. Acute Renal Failure • Nursing interventions • Monitor I/O, including all body fluids • Monitor lab results • Watch hyperkalemia symptoms: malaise, anorexia, or muscle weakness, EKG changes • watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions • Maintain nutrition • Safety measures • Mouth care • Daily weights • Assess for signs of heart failure • Skin integrity problems

28. Kidney failure causes hypoglycemia in three separate ways. The kidneys help to generate new glucose from amino acids (called gluconeogenesis). Gluconeogenesis is impaired in kidney failure. Also, insulin circulates for a longer period of time and is cleared slowly when kidney function is poor. The third important reason is that kidney failure reduces the appetite and consequently, oral intake of food.

29. Chronic Renal Failure • Results form gradual, progressive loss of renal function • Occasionally results from rapid progression of acute renal failure • Symptoms occur when 75% of function is lost but considered cohrnic if 90-95% loss of function • Dialysis is necessary D/T accumulation or uremic toxins, which produce changes in major organs

30. Chronic Renal Failure • Subjective symptoms are relatively same as acute • Objective symptoms • Renal • Hyponaturmia • Dry mouth • Poor skin turgor • Confusion, salt overload, accumulation of K with muscle weakness • Fluid overload and metabolic acidosis • Proteinuria, glycosuria • Urine = RBC’s, WBC’s, and casts

31. Chronic Renal Failure • Objective symptoms • Cardiovascular • Hypertension • Arrythmias • Pericardial effusion • CHF • Peripheral edema • Neurological • Burning, pain, and itching, paresthesia • Motor nerve dysfunction • Muscle cramping • Shortened memory span • Apathy • Drowsy, confused, seizures, coma, EEG changes

32. Chronic Renal Failure • Objective symptoms • GI • Stomatitis • Ulcers • Pancreatitis • Uremic fetor (Ammonia breath odour) • Vomiting • constipation • Respiratory • ^ chance of infection • Pulmonary edema • Pleural friction rub and effusion • Dyspnea • Kussmaul’s respirations is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also renal failure.

33. Chronic Renal Failure • Objective symptoms • Endocrine • Stunted growth in children • Amenorrhea • Male impotence • ^ aldosterone secretion • Impaired glucose levels R/T impaired CHO metabolism • Thyroid and parathyroid abnormalities • Hemopoietic • Anemia • Decrease in RBC survival time • Blood loss from dialysis and GI bleed • Platelet deficits • Bleeding and clotting disorders – purpura and hemorrhage from body orifices , ecchymoses

34. Chronic Renal Failure • Objective symptoms • Skeletal • Muscle and bone pain • Bone demineralization • Pathological fractures • Blood vessel calcifications in myocardium, joints, eyes, and brain • Skin • Yellow-bronze skin with pallor • Puritus • Purpura • Uremic frost • Thin, brittle nails • Dry, brittle hair, and may have color changes and alopecia Uremic frost: A clinical finding in severe chronic renal failure, in which the concentration of urea is markedly increased in sweat, causing precipitation of crystallised urea in the skin

35. Chronic Renal Failure • Lab findings • BUN – indicator of glomerular filtration rate and is affected by the breakdown of protein. Normal is 10-20mg/dL. When reaches 70 = dialysis • Serum creatinine – waste product of skeletal muscle breakdown and is a better indicator of kidney function. Normal is 0.5-1.5 mg/dL. When reaches 10 x normal, it is time for dialysis • Creatinine clearance is best determent of kidney function (GFR). Must be a 12-24 hour urine collection. Normal is > 100 ml/min

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

37. Chronic Renal Failure • Ca • With disease in the kidney, the enzyme for utilization of Vit D is absent • Ca absorption depends upon Vit D • Body moves Ca out of the bone to compensate and with that Ca comes phosphate bound to it. • Normal Ca level is 4.5-5.5 mEq/L • Hypocalcemia = tetany • Treat with calcium with Vit D and phosphate • Avoid antacids with magnesium

38. Chronic Renal Failure • Other abnormal findings • Metabolic acidosis • Fluid imbalance • Insulin resistance • Anemia • Immunoligical problems

39. Chronic Renal Failure • Nursing diagnosis • Excess fluid volume • Imbalanced nutrition • Ineffective coping • Risk for infection • Risk for injury

40. Chronic Renal Failure • Nursing care • Frequent monitoring • Hydration and output • Cardiovascular function • Respiratory status • E-lytes • Nutrition • Mental status • Emotional well being • Ensure proper medication regimen • Skin care • Bleeding problems • Care of the shunt • Education to client and family

41. Chronic Renal Failure Treatment

42. Chronic Renal Failure • Medical treatment • IV glucose and insulin • Na bicarb, Ca, Vit D, phosphate binders • Fluid restriction, diuretics • Iron supplements, blood, erythropoietin • High carbs, low protein • Dialysis - After all other methods have failed

43. Dialysis • ½ of patients with CRF eventually require dialysis • Diffuse harmful waste out of body • Control BP • Keep safe level of chemicals in body • 2 types • Hemodialysis • Peritoneal dialysis

44. Dialysis • Peritoneal dialysis • Semipermeable membrane • Catheter inserted through abdominal wall into peritoneal cavity • Cost less • Fewer restrictions • Can be done at home • Risk of peritonitis • 3 phases – inflow, dwell and outflow • Automated peritoneal dialysis • Done at home at night • Maybe 6-7 times /week • CAPD • Continous ambulatory peritoneal dialysis • Done as outpatient • Usually 4 X/d

45. Peritoneal Dialysis • Abdominal lining filters blood • 3 types • Continuous ambulatory • Continuous cyclical • Intermittent

46. Hemodialysis • 3-4 times a week • Takes 2-4 hours • Machine filters blood and returns it to body

47. Chronic Renal Failure • Hemodialysis • Vascular access • Temporary – subclavian or femoral • Permanent – shunt, in arm • Care post insertion • Can be done rapidly • Takes about 4 hours • Done 3 x a week

48. Types of Access • Temporary site: subclavian or femoral • Permanent: shunt, in arm • AV fistula • Surgeon constructs by combining an artery and a vein • 3 to 6 months to mature • AV graft • Man-made tube inserted by a surgeon to connect artery and vein • 2 to 6 weeks to mature

49. Temporary Catheter

50. AV Fistula & Graft