The Urinary System Assessment & Disorders

1. The Urinary System Assessment & Disorders

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.

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

7. Assessment • Use simple language • Assess for incontinence (esp. muliparous) • Family history • Chief concern • Location and character of pain • Previous UTI, stones, urinary problems • Pattern or urination

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 • Chance of pregnancy • History of diabetes or other endocrine disorders • Unexplained anemia

10. Diagnostic Tests • Clean-catch urine • 24-hour urine collection • Culture and sensitivity • BUN, creatinine and creatinine clearance = {Vol. of urine (ML/hr) x urine creatine}/serum creatinine • IVP, Retrograde Pyelography

11. Diagnostic Tests • Cystography, voiding cystogram • CT scan, MRI • Renal scan • Ultrasound • X-ray (KUB) • Cystoscopy • Renal Angiography • Kidney biopsy (by needle or open procedure)

12. Glomerulonephritis • Inflammatory condition of glomerulus • Antigen–antibody complexes form in the blood and become trapped in the glomerular capillaries, inducing an inflammatory response. • Damages capillary membrane • Blood cells and proteins escape into filtrate • Hematuria, proteinuria, azotemia (increase BUN & Creatinin) • Acute or chronic

13. Acute Glomerulonephritis - Manifestations • Usually follows infection of group A beta-hemolytic Streptococcus • Affect children > 2 years • Manifestations develop abruptly • Hematuria (? Microscopic, or frank, urine is cola color), proteinuria, edema, azotemia (High BUN and Creatineine) hypertension, fatigue, hypoalbuminemia, hyperlipidemia • ? headache, malaise and flank pain

14. Glomerulonephritis

15. Glomerulonephritis – Diagnostic Tests ASO titer (anti streptolysine O) BUN Serum creatinine Serum electrolytes Urinalysis KUB x-ray Kidney scan or biopsy

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

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

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

19. Glomerulonephritis –Nursing Care Decrease protein and increase CHO to prevent protein breakdown. Accurate I & O (consider insensible loss)

20. Chronic Glomerulonephritis • Could be due to repeated episodes of acute glomerulonephritis, hypertensive nephrosclerosis, hyperlipidemia, glomerular sclerosis • Other causes include SLE, DM • Kidney size reduce to 1/5th of original size and many scar tissue formed leading to ESRF.

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

22. Medical Management • Control BP: Na & water restriction, antihypertensive drug • Monitor weight. • Diuretics. • Adequate CHO diet to spare protien • Treat UTI • ? Dialysis.

23. Nephrotic Syndrome • Is a cluster of clinical findings, including: • Marked increase in protein (particularly albumin) in the urine (proteinuria) • Decrease in albumin in the blood (hypoalbuminemia) • Edema (periorbital, ascites, and dependent edema) • High serum cholesterol and low-density lipoproteins (hyperlipidemia)

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

25. Nephrotic Syndrome

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

27. Acute Renal Failure • Persons at Risks • Major surgery • Major trauma • Receiving nephrotoxic medications • Elderly • ARF mostly occur within hospital settings

28. Causes of ARF • Prerenal Failure • Intrarenal Failure • Postrenal Failure

29. Prerenal Failure • Volume depletion resulting from: • Hemorrhage • Renal losses (diuretics, osmotic diuresis) • Gastrointestinal losses (vomiting, diarrhea, nasogastric suction) • Impaired cardiac efficiency resulting from: • Myocardial infarction • Heart failure • Dysrhythmias • Cardiogenic shock

30. Prerenal Failure • Vasodilation resulting from: • Sepsis • Anaphylaxis • Antihypertensive medications or other medications that cause vasodilation

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

32. Intrarenal Failure • Nephrotoxic agents such as: • Aminoglycoside antibiotics (gentamicin, tobramycin, amicacin) • Radiopaque contrast agents • Heavy metals (lead, mercury) • Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic) • Nonsteroidal anti-inflammatory drugs (NSAIDs) • Angiotensin-converting enzyme inhibitors (ACE inhibitors)

33. Intrarenal Failure • Infectious processes such as: • Acute pyelonephritis • Acute glomerulonephritis

34. Postrenal failure • Urinary tract obstruction, including: • Calculi (stones) • Tumors • Benign prostatic hyperplasia • Strictures • Blood clots

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

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

37. Acute Renal Failure • Diagnostic tests • BUN, creatinine, potassium increase. • pH • Hgb and Hct • Urine studies • US of kidneys • High phosphorus and low calcium.

38. Prevention of ARF • Provide adequate hydration • Prevent and treat shock promptly • Hourly urine output for critical patients • Continuosally assess renal function • Prevent and treat infections promptly • Monitor for effects of toxic drugs

39. Medical treatment of ARF • Objectives of treatment are to restore normal chemical balance and prevent complications until repair of renal tissue and restoration of renal function can occur. • Management includes • maintaining fluid balance, • avoiding fluid excesses, or • possibly performing dialysis.

40. Acute Renal Failure • Medical treatment • Treat the cause • Fluid and replacement or restrictions • Monitor for fluid overload • Diuretics • Maintain E-lytes • May need dialysis (especially with high K) • May need to stimulate production of urine with IV fluids, Dopomine, diuretics, etc.

41. Acute Renal Failure • Medical treatment • Hemodialysis • Subclavian approach • Femoral approach • Peritoneal dialysis • Nutritional Therapy • ? Decrease Protein (according to BUN level) • Increase CHO • Decrease potassium and phosphrous

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

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

44. Nursing interventions • Monitoring Fluid and Electrolyte Balance • Reducing Metabolic Rate • Promoting Pulmonary Function • Preventing Infection • Providing Skin Care

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

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

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

48. Chronic renal failure/ S&SCardiovascular: the most common cause of death • Hypertension • Pitting edema (feet, hands, sacrum) • Periorbital edema • Pericardial friction rub • Acidosis (kidney can’t excrete amonia, reabsorb bicarb, high phosphate) • Engorged neck veins • Pericarditis • Pericardial effusion • Pericardial tamponade • Hyperkalemia • Hyperlipidemia

49. Chronic renal failure/ S&S Neurologic • Weakness and fatigue • Confusion • Inability to concentrate • Disorientation • Tremors • Seizures • Asterixis • Restlessness of legs • Burning of soles of feet • Behavior changes

50. Chronic renal failure/ S&S Pulmonary Integumentary • Crackles • Thick, tenacious sputum • Depressed cough reflex • Pleuritic pain • Shortness of breath • Tachypnea • Kussmaul-type respirations • Uremic pneumonitis • Gray-bronze skin color • Dry, flaky (مُقشّر) skin • Pruritus • Ecchymosis • Purpura • Thin, brittle nails • Coarse, thinning hair