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,Crest, 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, parenthesia, 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 • GCS and Denny Brown • Skin integrity problems

28. 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

29. 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

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

31. Chronic Renal Failure • Objective symptoms • GI • Stomatitis • Ulcers • Pancreatitis • Uremic fetor • Vomiting • consitpation • 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.

32. 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

33. 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

34. 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

35. 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.

36. 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

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

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

39. 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

40. Chronic Renal Failure Treatment

41. 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

42. 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

43. 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

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

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

46. 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

47. 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

48. Temporary Catheter

49. AV Fistula & Graft

50. What This Means For You • No BP on same arm as fistula • Protect arm from injury • Control obvious hemorrhage • Bleeding will be arterial • Maintain direct pressure • No IV on same arm as fistula • A thrill will be felt – this is normal