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Faculty of Nursing Ainshams University M-S Nursing Department Assessment, care, and management of chronic ill patient urology Prepared by Hagar Ali Ali Heba Abd-Alazeem 2nd Semester Doctorate Degree Under supervision of Prof. Dr Tahany El Senousy Professor/ Medical Surgical Nursing Department Faculty of Nursing Ainshams University 2010 Outlines Introduction Specific terminology related to urology disorders Anatomy and physiology of urinary tract system Functions of the urinary system Structures of the urinary system blood circulation of urinary system steps of urine formation General Assessment of urinary tract system Types of chronic disorders of urinary tract system 1. upper urinary tract disorders 2. lower urinary tract disorders Apply nursing care plan for urology disorders 6 Learning objectives At the end of this lecture the student will be able to: Introduction Define Specific terminology related to urological disorders Identify structure of the urinary system Explain Anatomy and physiology of urinary tract system Identify Functions of the urinary system Explain blood circulation of kidneys Explain steps of urine formation Explain General Assessment of urinary tract system List types of chronic disorders of urinary tract system Identify (definition – causes – clinical manifestation – complications – medical management – surgical management) for every disorder) Apply nursing care plan for urology disorders 6 Introduction Proper function of the urinary system is essential to life. Dysfunction of the kidneys and lower urinary tract is common and may occur at any age and with varying levels of severity. Assessment of upper and lower urinary tract function is part of every health examination and necessitates an understanding of the anatomy and physiology of the urinary system as well as of the effect of changes in the system on other physiologic functions. Disorders of the lower and upper urinary tracts range from easily treated infections to life-threatening disorders that necessitate organ replacement or long-term treatment with dialysis. Recent advances in phamacotherapeutics and technology have improved the diagnostic and treatment possibilities for these disorders. Additionally, many disorders that once required surgical intervention and prolonged recuperation can now be treated with noninvasive, nonsurgical techniques. (Bruner, 2009) Specific terminology: Uremia: is a syndrome of kidney failure characterized by elevated blood urea nitrogen (BUN) and creatinin levels Azotemia: is defined as increase in serum urea and creatinin levels Frequency : voiding more frequently than every 3 hours Urgency: The need to void immediately Hesistancy : Difficulty initiating voiding Oliguria: Urine output < 400ml/24hr Anuria: Urine output < 100ml/24hr urethrovesical reflux: backward flow of urine from the urethra into the bladder 6 Nephrotic syndrome: Is a set of clinical manifestations caused by protein wasting secondary to diffuse glomeruolar damage manifestation include (proteinuria , hypoalbunemia, and edema) Nephritic syndrome: refers to set of clinical manifestations that include hematuria and at least one of the following: oliguria, hypertension, elevated BUN or decreased GFR. urinary casts: protein plugs secreted by damaged kidney tubules specific gravity: reflects the weight of particles dissolved in the urine; expression of the degree of concentration of the urine I. Structure of the urinary system 1. Upper urinary tract that involves kidneys and ureters 2. Lower urinary tract involves the bladder and urethra 6 II. Anatomy and physiology of the urinary system An over view about anatomy and physiology of kidney The kidneys are bean shaped organ about the size of a fist they are located at the bottom of the rib cage at the back of the body "retroperitoneally". Represent about 0-5 of total weight of the body. Most people have two kidneys, but some people have only one it is possible to lead totally normal healthy life with just one kidney. Kidney receive 20-25% of total arterial blood pumped by heart. Each kidney is enclosed as fibrous capsule and is embedded in fatty tissue. It consist approximately 13millions nephrons. The kidney is anatomically divide into outer dark red portion called the cortex and inner height coloured section lying between cortex and pelvic. The medullary tissue is arranged in conical or pyramidal masses. The nephron: The nephron is a tube closed at one end, open at the other it consist of: Glomerulus: A capillary net work within the Bowman's capsule blood the glomerulus passes into second capillary network. Bowman's capsule: located at the closed end the wall of the nephron is pushed forming a double walled chamber. 6 Proximal convoluted tubule: Coiled and lined with microvilli and staffed with mitochondria. Loop of renle: It makes a hair pin and returns to DCT. Distal convoluted tubule: Which is also highly coiled and surrounded by capillaries. Collecting tubule: It leads to the pelvic of the kidney from where urine flows to the bladder and periodically on to outside the body. Renal pelvis: When the ureter joins the kidney it expands to form a funnel shaped receiving basin for ht eurine delivered by collecting tubules, it has projecting pouches "calyces". Blood supply: Renal artery to each kidney arises from the abdominal aorta. When the artery enter the kidney it progressively subdivides to become afferent arterioles. Each afferent arteriole enters nephrone to form glomerulus. The glomerular capillaries unite to form the efferent arterioles the blood is then collected into venules and eventually into renal veins that carries to inferior vena cava. Large volume of blood continuously circulated through the kidneys it is estimated that renal blood flow average about 100-1200 L per minutes about 23% from cardiac output. 2. Function of the kidney 1. Control of body fluid osmolarity to maintain the normal intra cellular fluid "ICF" and extracellular fluid volume "ECF including the blood volume. 2. Regulation of electrolyte balance K+ and Na+. 6 3. Regulation of acid base balance and blood PH. 4. Excretion of waste products, urea, uric acid and creatinine. 5. Excretion of drugs, chemicals. Toxins. 6. Secretion of hormones. a. Enythropoietin b. Renin c. Vitamin D3 d. Prostaglandins Ureters The ureters are two slender tubes that run from the sides of the kidneys to the bladder. Their function is to transport urine from the kidneys to the bladder. Peristalsis movement in ureters to propel urine from kidneys to bladder. Bladder The bladder is a muscular organ and serves as a reservoir for urine. Located just behind the pubic bone, it can extend well up into the abdominal cavity when full. Near the outlet of the bladder is a small muscle called the internal sphincter, which contract involuntarily to prevent the emptying of the bladder Urethra The urethra is a tube that extends from the bladder to the outside world. It is through this tube that urine is eliminated from the body The male urethra is about 20 cm long , but female urethra is 4 cm long 6 Prostate gland: Is a male reproductive gland Numerous prostatic ducts empty into urethra III. Functions of the urinary system The function of the urinary system is to: (1) removes waste products from the blood (2) eliminate them from the body. The principal waste products being eliminated are water, carbon dioxide and nitrogenous wastes including urea, uric acid and creatinine. Other functions of the urinary system include (3) regulation of the volume of body fluids (4) balance of pH and the electrolyte composition of these fluids Steps of urine formation Filtration occurs in Bowman's capsule Resorption occurs in the tubules and collecting duct Secretion occurs in the tubules and collecting duct Ultrafilteration: Is the process by which the fluid part of the urine is formed. Blood passes through the capillary bed of the glomerrulus, the pressure of plasma forces fluid across the semi permeable membrane (basement membrane) of the glomerulus into Bowman's capsule. Water and small molecules begins to be filtered out into Bowman's capsule through tiny pres in the capillary wall Blood cells and proteins are too large but urea is the correct size ti be filtered The volume of this glomerular filtrate approximates 180 L/Day. 6 99% Of This Total Volume Is Reabsorbed And Only 1% Is Secreted Clinically GFR is the amount of glomerular filtrate formed in 1 minute approximately(125ml/min) ( 7.5 L/ hr) Urine formation begins when blood enters the afferent arteriole of the nephron. it is in Bowman's capsule and the tubules that the ulrafilterate begins to be transformed into urine Resorption and secretion: The proximal convoluted tubules resorb 85% to 90% of the water in the ultrfilterate up to 80% of filtered sodium and most of the filtered potassium , bicarbonate , chloride, phosphate, glucose, and amino acids o The distal convoluted tubules and collecting tubule produce the final urine o Another mechanism that prevents water and electrolyte depletion is endocrine or hormonal response ADH or vasopressin is produced by the hypothalamus and stored and released by the pituitary glad in response to changes in plasma osmolarity o In both descending and ascending loops of the Henle the ultrafiilterate is further refined as more sodium , and water is desorbed and magnesium is reclaimed from the tubules o Final urine composition is made in the distal nephron which include distal convoluted tubules and collecting ducts o The final urine becomes concentrated and acidic as it moves from the proximal to the distal tubules and finally into the collecting duct o The average urine output in adult is 1-2 L/Day 6 Renal circulation: The renal circulation receives around 20% of the cardiac output. It branches from the abdominal aorta and returns blood to the ascending vena cava. It is the blood supply to the kidney, and contains many specialized blood vessels. General Assessment of the urinary system Assessment of the urinary system begins with 1. Health History 2. Physical examination 3. Diagnostic tests I. Health History: Health history focus on 1. assessment of predisposing factors of disorders 2. signs and symptoms of disorder 3. family history and surgical history When obtain health history about patient with urological disorders it's important to obtain information about: 1. Assess voiding pattern if thee is frequency , dysuria, hematuria urgency 2. Asses weight gain (fluid retention ) 3. History of nausea and vomiting 4. Assess if there is flank pain (lateral pain = loin pain) onset, duration , frequency , aggravating factors , if response to analgesic or not , associated signs and symptoms (nausea , vomiting ) 5. Assess if muscle weakness indicator to disturbance of calcium level 6 6. Assess level of consciousness indicator of ammonia accumulation and NH3 increased 7. Assess medication take , allergy 8. History of chronic illness (hypertension , DM liver disease, heart disease) indicator for prerenal causes of ARF 9. Assess if patient smoker or not 10.Assess drug abuse , alcoholism indicator to intrarenal causes of ARF 11.Change in bowel habits 12.Assess if there is family history of renal disorders 13.History of lethargy or fatigue 14.Assess surgical history if exposure to surgery and anesthesia II. Physical examination includes the following (inspection, auscultation, percussion, palpation) Obtaining clean catch urine specimen Inspect urine for color, odor, and clarity before sending it to the laboratory for analysis Obtain vital signs Inspect skin color and condition including looking for evidence of excessive dry skin or excoriation Inspect the face especially the periorbital area Palpate lower extremities for evidence of edema Expose the abdomen , and assess its contour and symmetry Auscultate bowel sounds palpate abdomen for tenderness including suprabupic region Peruses the kidney for tenderness Inspect the genital area and urinary meatus for redness swelling discharge or ulceration. 6 III. Diagnostic tests include the following: 1. Blood tests 2. Urine tests 3. Imaging studies 1. Blood tests include the following: Blood teste Renal Concentration Tests Specific gravity( 1.010–1.025) Urine osmolality(300–900 mOsm/kg/24 h, 50–1,200 mOsm/kg random s) 24-Hour Urine Test Creatinine clearance Measured in mL/minute/1.73 m2 Age Male Female Under 30 88–146 81–134 30–40 82–140 75–128 40–50 75–133 69–122 50–60 68–126 64–116 60–70 61–120 58–110 70–80 55–113 52–105 Serum Tests Creatinine level( 0.6–1.2 mg/dL (50–110 μmol/L) Urea nitrogen (blood urea nitrogen 7–18 mg/dL BUN to creatinine ratioAbout( 10_1) 3. Imaging studies include the following : An abdominal X-rays (KBU) (Kidney , Ureter, And Bladder ) Intravenous pyelogram (IVP)to reveal renal arteries and blood circulation to kidney Retrograde pyelogram (used as an alternative to IVP) 6 Computed tomography (CT Scan) MRI (Magnetic resonance imaging) useful in kidney tumor or cancer to clear visualization of soft tissue Renal angiography is similar to IVP Ultrasound examination to determine size and texture of kidney and bladder Electromyography (EMG) involves the placement of electrodes in the pelvic floor musculature or over the area of the anal sphincter to evaluate the neuromuscular function of the lower tract. It is usually performed simultaneously with the CMG Nuclear scans require injection of a radioisotope (technetium 99m–labeled compound or iodine-131 hippurate) into the circulatory system; the isotope is then monitored as it moves through the blood vessels of the kidneys. A scintillation camera is placed behind the kidney with the patient in a supine, prone, or seated position. Nuclear scans are used to evaluate acute and chronic renal failure,renal masses, and blood flow before and after kidney transplantation. A cystometrogram (CMG) is a graphic recording of the pressures in the bladder during bladder filling and emptying. It is the major diagnostic portion of urodynamic testing. During the test, the amount of fluid instilled into the bladder and the patient’s sensations of bladder fullness and urge to void are recorded. These are then compared with the pressures measured in the bladder during bladder emptying Uroflowmetry (flow rate) is the record of the volume of urinepassing through the urethra per time unit (milliliters per second).The flow rate reflects the combined activity of the detrusor muscle And the bladder neck and the degree of relaxation of the urethral sphincter. 6 Urethral Pressure Profile measures the amount of urethral pressure along the length of the urethra needed to maintain continence. Gas or fluid is instilled through a catheter that is withdrawn while the pressures along the urethral wall are obtained. Types of chronic disorders in urinary system: 1-UPPER URINARY TRACT DISORDERS CHRONIC PYELONEPHRITIS CHRONIC GLOMERULONEPHRITIS NEPHROTIC SYNDROME CHRONIC RENAL FAILURE KIDENY CANCER POLYCYSTIC KIDENY 1-UPPER URINARY TRACT DISORDERS CHRONIC PYELONEPHRITIS Definition: Pyelonephritis is a serious bacterial infection of the kidney that can be acute or chronic. Chronic pyelonephritis is renal injury induced by recurrent or persistent renal infection. Causes: Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis Signs and Symptoms: no symptoms 6 Noticeable signs and symptoms may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss. Treatment: Treatment of chronic pyelonephritis requires correction of the underlying disorder as follow. The choice of antimicrobial agent is based on which pathogenis identified through urine culture. Impaired renal function alters the excretion of antimicrobial agents and necessitates careful monitoring of renal function, especially if the medications are potentially toxic to the kidneys. Complications ESRD (from progressive loss of nephrons secondary to chronic inflammation hypertension, formation kidney stones CHRONIC GLOMERULONEPHRITIS Definition: Chronic glomerulonephritis is the advanced stage of a group of kidney disorders, resulting in inflammation and slowly worsening destruction of internal kidney structures called glomeruli. Causes: repeated episodes of acute glomerulonephritis hypertensive nephrosclerosis hyperlipidemia, chronic tubulointerstitial glomerular sclerosis. 6 Symptoms The symptoms of chronic glomerulonephritis vary. Some patients with severe disease have no symptoms at all for many years.The first indication of disease may be a sudden, severe nosebleed, a stroke, or a seizure. Many patients report that their feet are slightly swollen at night. Most patients also have general symptoms, such as loss of weight and strength, increasing irritability, and an increased need to urinate at night (nocturia). Headaches, dizziness, and digestive disturbances are common. signs and symptoms of renal insufficiency and chronic renal failure may develop. The patient appears poorly nourished, with a yellow-gray pigmentation of the skin and periorbital and peripheral (dependent) edema. Blood pressure may be normal or severely elevated. Retinal findings include hemorrhage, exudate, narrowed tortuous arterioles, and papilledema. Mucous membranes are pale because of anemia. Cardiomegaly, a gallop rhythm, distended neck veins, and other signs and symptoms of heart failure may be present. Crackles can be heard in the lungs. Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occurs late in the disease. The patient becomes confused and demonstrates a limited attention span. Anadditional late finding includes evidence of pericarditis with a pericardial friction rub and pulsus paradoxus (difference in blood pressure during inspiration and expiration of greater than 10 mm Hg). Medical Management Symptomatic treatment as follow: The blood pressure is reduced with sodium and water restriction. Antihypertensive agents. Weight is monitored daily. Diuretic medications are prescribed 6 Proteins of high biologic value (dairy products, eggs, meats) are provided to promote good nutritional status. Adequate calories are also important to spare protein for tissue growth and repair. UTIs must be treated promptly to prevent further renal damage. Initiation of dialysis is considered early in the course of the disease to keep the patient in optimal physical condition Prevent fluid and electrolyte imbalances. Minimize the risk of complications of renal failure. NEPHROTIC SYNDROME Nephrotic syndrome is a primary glomerular disease characterized by the following: • Marked increase in protein in the urine (proteinuria) • Decrease in albumin in the blood (hypoalbuminemia) • Edema • High serum cholesterol and low-density lipoproteins (hyperlipidemia) 6 Pathophysiology of nephrotic syndrome Medical Management i. The objective of management is to preserve renal function. ii. Diuretic agents may be prescribed for the patient with severe edema; iii. angiotensin-converting enzyme (ACE) inhibitors in combination with diuretics often reduces the degree of proteinuria but may take 4 to 6 weeks to be effective. iv. antineoplastic agents (cyclophosphamide [Cytoxan]) 6 v. immunosuppressant medications (azathioprine [Imuran], chlorambucil vi. The patient may be placed on a low-sodium, liberal-potassium diet to enhance the sodium/potassium pump mechanism, thereby assisting in elimination of sodium to reduce edema. vii. Protein intake should be about 0.8 g/kg/day, with emphasis on high biologic proteins (dairy products, eggs, meats), and the diet should. 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 (retention of urea and other nitrogenous wastes in the blood). Causes and risk factors: systemic diseases, such as diabetes mellitus hypertension; chronic glomerulonephritis; pyelonephritis; obstruction of the urinary tract; hereditary lesions, as in polycystic kidney disease; vascular disorders; infections; medications or toxic agents. Autosomal dominant polycystic kidney disease accounts Environmental and occupational agents include lead, cadmium, mercury, and chromium. 6 Signs and symptoms: Causes Signs and symptoms Assessment parameter 1. Hematological system Decreases erythropoietin Decreased survival time of RBCs Blood loss during dialysis Anemia Fatigue Defects in platelets functions Decreased hamatocrit 1. . Haematocrit 2. . Hemoglobin 3. . Bleeding time 2. Cardiovascular system Fluid overload Chronic hypertension Rennin angiogenesis mechanism Hypervolemia Hypertension Tachycardia Dysrrythmias Congestive heart failure 1. Vital signs – body weight 2. ECG 3. Heart sounds 4.Monitor electrolytes 3. Respiratory system Compensatory mechanism of metabolic acidosis Uremic toxemia Fluid overload Tachypnea Pain with coughing Elevated temperature Pulmonary edema 1. Respiratory assessment 2. ABGs 3. Vital signs 4. Pulse oximeter 4. GIT system Change in platelets activity Serum uremic toxins Electrolyte imbalance Anorexia Abdominal distension GIT Bleeding 6 1. Monitor intake , output 2. Hematocrit 3. Hemoglobin Nausea , vomiting 1. Assess abdominal pain , quality of stools 5. Neurological system Uremic toxins Electrolyte imbalance Cerebra swelling from fluid shifting Confusion Convulsions Muscle irritability Sleep disturbance 1. Assess level of consciousness 2. Assess reflexes 3. - Electrolyte levels 6. Skeletal system Decreased calcium absorption Decreased phosphate excretion Joint pain Muscle pain Retarded growth 1. Serum phosphors 2. Serum calcium 3. - Parathyroid hormone level 7. Skin Anemia Pigmented retained Dry skin Decreased size of sweat glands 8. Genitourinary system Damaged nephrons Pallor Pigmentation Pruritis Decreased urine output Proteinuria Casts and cells in urine - Assess color of skin - Assess integrity of skin - Observe for bruising - Monitor intake , output - Serum creatinin , BUN - Urine electrolytes - Serum electrolytes 6 Stages of chronic renal failure: Stage 1 Reduced renal reserve, characterized by a 40% to 75% loss of nephron function. The patient usually does not have symptoms because the remaining nephrons are able to carry out the normal functions of the kidney. Stage 2 Renal insufficiency occurs when 75% to 90% of nephron function is lost. At this point, the serum creatinine and blood urea nitrogen rise, the kidney loses its ability to concentrate urine and anemia develops. The patient may report polyuria and nocturia. Stage 3 End-stage renal disease (ESRD), the final stage of chronic renal failure, occurs when there is less than 10% nephron function remaining. All of the normal regulatory, excretory, and hormonal functions of the kidney are severely impaired. ESRD is evidenced by elevated creatinine and blood urea nitrogen levels as well as electrolyte imbalances. Once the patient reaches this point, dialysis is usually indicated. Many of the symptoms of uremia are reversible with dialysis. Complications of Chronic Renal failure: Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet, medications, fluids) Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis Hypertension due to sodium and water retention and malfunction of the renin–angiotensin–aldosterone system 6 Anemia due to decreased erythropoietin production, decreased RBC life span, bleeding in the GI tract from irritating toxins, and blood loss during hemodialysis Bone disease and metastatic calcifications due to retention of phosphorus, low serum calcium levels, abnormal vitamin metabolism, and elevated aluminum levels Medical Management: Medical Management The goal of management is to maintain kidney function and homeostasis for as long as possible through: Pharmacological therapy diet therapy dialysis PHARMACOLOGIC THERAPY Complications can be prevented or delayed by administering prescribed antihypertensives, erythropoietin (Epogen), iron supplements, phosphate-binding agents, and calcium supplements. DIET THERPAY Dietary intervention is necessary and includes careful regulation of protein intake. Protein is restricted sodium intake to balance sodium losses and some restriction of potassium. caloric intake and vitamin supplementation must be ensured. the fluid allowance is 500 to 600 mL more than the previous day’s 24-hour urine output. Calories are supplied by carbohydrates and fat to prevent wasting. Vitamin supplementation is necessary because a protein-restricted diet does not provide the necessary complement of vitamins 6 Type of dialysis a) Introduction - In UK, approximately half on dialysis are treated by haemodialysis and other half by peritoneal dialysis. Both method are effective and in fact many patient with experience both types of dialysis during their life with kidney failure. - Your clinical condition may determine which treatment will be the most suitable, but often you have choice. - This choice is an important one find out as much as you can about the different treatment options and discuss them with your renal health care team and with your family. Dialysis: Is an artificial process which replace some of work of the kidneys. It clears the waste products from the blood and removes excess water. Dialysis thus performs the two main functions of the kidneys. Toxins clearance and maintaining fluid balance. b) Purposes of dialysis 1. Remove waste products of proteins metabolism 2. Remove toxins from blood 3. remove excess water 4. Maintain proper level of electrolytes 5. Maintain acid base balance. c) How dialysis work Waste products are cleared from the blood by process diffusion. 6 called Excess water is removed from the blood by process called ultrafiltration. Wastes and water pass into special liquid called the dialysis fluid or dialysate for removal from the body. A thin layer of tissue or plastic, known as the dialysis membrane. 5. Haemodialysis Haemo is a greek word for blood and dialysis mean a filtrating process. Therefore haemodialysis refer to the process of filtrating blood. With haemodialysis, the dialysis process takes place out side the body in machine. The dialysis membrane is an artificial one, called dialyser the dialyser removes the extra. Fluid and waste from the blood. The clean blood is then returned to the body. Definition: An extracorporeal flow of the patients blood is separated from specifically dialysate membrane. Water and some solutes may move to or from the blood. Purpose from haemodialysis Haemodialysis cleans and filters your blood using machine to temporary rid your blood of harmful wastes, extrawater, haemodialysis helps control blood pressure and help your body keep balance of important chemicals such s potassium, sodium, calcium and bicarbonate. Haemodialysis is the more efficient method of dialysis but is more complex procedure. Then peritoneal dialysis and requires more sophisticated equipment. 6 In haemodialysis, the blood from an artery is directed extracorporeally. Through an exchange unit and is returned to vein. The components of the exchange unit include porous tube through which. The blood flows and a compartment containing a dialysiate. A second essential unit is the dialysate supply system which mixes and delivers the solutions to exchange unit. The membrane like tube which transports the blood requires priming with blood or prescribed intervenous solution to exclude all air before being connected to the patient artery and vein. Heparine is added to the blood as it enters. The dialysis machine to prevent coagulation. Dialyzing fluid (DF) Concentration of Na+, Cl- in the DF are equal their conc. In normal plasma. Concentration of waste products of metabolism, urea, creatinine, uric acid, phosphate and phosphate are zero in the DF (to help rapid transfere of these substances from plasma of the patient to DF). Concentration of Hco-3, Ca2+ and glucose are higher in the DF than in uremic their levels in the patient's plasma. Dialyzing period: usually 3-6 hours, 3 times a weak. Advantages and disadvantages of haemodialysis Advantages Disadvantage Rapid fluid removal Vascular access problems Rapid removal of urea and creatinine Dietary and fluid restrictions 6 Heparinization may e necessary Effective potassium removal Extensive equipment necessary Less protein loss Hypotension during dialysis Lowering of serum triglycerides Added blood loss that contributes tot anemia Home dialysis possible Specially trained personnel necessary Temporary access can be placed at Surgery for permanent access placement bedside Self-image problems with permanent access Vascular access Before beginning of hemodialysis treatment, a person need an access to their blood stream called vascular access. The access allows the patient's blood to travel to and from the dialysis machine at long volume and high speed so that toxins, waste and extra-fluid can be removed from the body. - Types of vascular access. - There are three types of vascular access a) Arteriovenous fistula "AV fistula" b) Arteriovenous graft "AV graft" c) Control venous catheter or internal port device. Each access is created surgically. There are limited number of places of body where an access can be placed (arm-neck-eg-chest). Fistula and graft are considered to permanent accesses because they are placed under the skin with plants use them for many years. 6 When patient find out they are in advanced stags of chronic kidney disease and will besterting dialysis in the future, their nephrologists will advice them to get fistula or graft. When the patient suddenly discover they have kidney fistula a catheter may be placed to allow for mediate dialysis treatment. The catheter will be used until fistula or graft has time to mature. 1. AV fistula: is created by directly connecting person's artery and vein. Usually in arm. This procedure performed as an outpatient operating using local anesthetic, blood flows to the vein from the newly connected artery the vein grow longer and stronger. It can provide good blood flow for many years of haemodialysis. Research studies have proven patients with fistula have the fewest complications, such as infection or clotting compared to all other access choice. The fistula is considered the "gold standard" access because it: Has a lower risk of infection than other access type. Has lower risk of forming clots than other access type. Performs better than other accesses. Allow for greater blood flow Lasts longer than other access type Can last many years even decades, when well we is cared for. Some issues people may have with fistulas includes: 1. The appearance of bulging veins at the access site. 2. Taking several month for new one to mature. 3. not maturing at all in some case. Not every one may be able to have fistula due to weak arteries. 6 2. AV graft o AV graft is similar to fistula in that also under the skin of an artery and vein, except that with graft a man made tubing connects the artery and vein the soft plastic like tube is about one half inch in diameter and is mad from Teflon material. Transplanted human vessel may also be used as grafts to connect an artery and vein. o Graft don't require as much time to mature as fistula because the graft does not need time to enlarge before using in most cases a graft can be used two to six weeks after placement. o AV graft have more problems then fistulas due to clotting and infections graft may not last as long as fistula and could need to be repaired or replaced each year. Caring for fistula or graft Taking good care for fistula or graft will help keep it working properly. There are a few things you can do to help prevent infection, clotting and damage to your access. a) Cleanliness is important to keep out infections. - Keep your access area clean and free of any trauma. - Look for signs of infection including pain, tenderness swelling or redness around your access area. - Also a ware of any fever and flu-like symptoms if patients have sign of infection proper antibiotic should be used. b) Protect your access form any restriction or trauma by: 6 - Avoiding tight clothes, jewelry or any thing that may put pressure on your access . - Not sleeping on top of or resting on your access area. - Don't carries, bags or heavy items across your access area. - Always requesting that blood be drown from your access area. - Always measuring blood pressure from non access area. - Learn patient to feel of thrill or vibration. c) Good needle sticks cannulation help keep access working well 3. Catheters and internal port devices Catheter: is narrow tube that is placed into large central vein, usually in patient's neck, chest or groin. Placement of the catheter usually takes less then a half hour. Usually two tubes, extend out of the body from the catheter one allows blood out of the body and one allows blood back to the body. Internal port devices are special access systems which are placed under the skin and connected to very large venous catheters to provide access to remove blood out of the body for cleaning and then back into the body. Catheter and internal port devices can be used for dialysis immediately after placement. Care for catheter and internal port devices - Cleanliness helps prevent infections - We should always keep it clean and dry especially during showers keep in healed catheter exit sit wet. - You will be taught importance of making sure your catheter clamps are clamped and end caps are on securely. 6 - Check site of catheter for sign of infection as redness, swelling, pain, pus or fever, Complications of haemodialysis The cannula can fall out the client might bleed to death. More severe bleeding also can occur because the cannula is heparinized. The membrane within the dialysis machine can rupture, causing hemorrhage. If the chemical agents used are the wrong ones or if the chemistry workup is incorrect, the client's electrolyte balance will be disrupted even further. Because most clients on dialysis have high blood pressure (caused by renal damage), they may go into shock when connected to the machine. The blood in the machine must be warm, or the client can suffer cardiac arrest from the shock of cold blood. Infection or septicemia is always a possibility. Because this client has especially low resistance, infection can be dangerous. Blood can clot in the cannula and cause phlebitis. Male clients often become impotent, although this problem may correct itself as the condition is stabilized. Excesses in alcohol or food intake will not be excreted between dialysis runs. Nursing intervention in haemodialysis patient a) Pre dialysis 6 Patient and family receive a simple explanation of the purpose of dialysis and what to expect during the procedures. Using prepared brochures and audiovisual programs to provide information and reinforce verbal explanations and instructions. Position the patient comfortably in bed or reclining chair with limb with the AV fistula or graft exposed and supported. Measures and record for patient weight and vital signs. Blood specimens are obtained when the needles are introduced for laboratory determinations of haematocrit, electrolytes (Na+, K+), blood urea and creatinine levels and clotting time. The vascular access site is examined for signs of a haematoma or infection. Observations are made of the patient colour and condition of skin (dryness, turgor, abrasions) and for oedema. Compare for patient his weight and his weight in last dialysis sessions, and difference in weight. During dialysis - During dialysis the patient is monitored continuously for indications of the effectiveness of treatment and signs of complications. - Observing and recording for vital signs on schedule manner. - Monitoring for temperature of dialysate, heparinization and blood clotting time. - Observing for signs of dehydration or overhydration. - Blood analysis for potassium and sodium levels may be repeated. 6 - The first dialysis should be short (2+-3 hours) to allow gentele clearance of nitrogen waste. This prevents complication of cerebral oedema associated with disequilibrium syndrome (disorientation or convulsion) - Fluid are given, often in excess of dialysis allowance. To give the patient a little more freedom and extra fluid may removed through out the dialysis. - Allow patient free diet at least for first two hours of dialysis. This still adequate time for metabolites to be dialyzed out safely before the end of dialysis. - The temperature of dialysate is monitored and automatically controlled. - The dialyzer has alarm to alert attending staff of malfunction - The length of time the patient is kept on dialyser varies with patient condition. Average range is (4-6 hours). C) Post dialysis 1. The arterial line is clamped after completion 2. Try as possible blood in dialyzing circuit lines is returned to the patient. 3. Dressing is applied and area observed until ether is no evidence of bleeding. 4. Apply pressure for brief period. 5. The patient weight, blood pressure, lying and standing pulse and temperature are taken sudden change in blood pressure, rapid work, pulse, headache, disorientations and disrobed level of conscious. 6. Inspection for possible leakage around tube. 7. Mild abdominal discomfort may be alleviated by slowing the rate of inflow. 6 8. Restriction for food and fluid. 9. Put patient in his comfortable position. 10. Activity is encouraged as much as possible Post dialysis 1. We must record the following a. Times that the flow is commenced and completed b. Coloure and volume of the fluid (negative and positive balance). c. Patient weight on completion of dialysis 2. The catheter is cupped and an antiseptic or sterile occlusive dressing may be applied. 3. Check patient vital signs. 6 6. Peritoneal Dialysis Uses a natural membrane inside the body called peritoneal membrane for dialysis this membrane has tiny boles in it and act as filter allowing waste products and fluid from the blood to pass across peritoneal dialysis may be used for most patient with symptomatic renal failure and have a healthy peritoneal surface area. How peritoneal dialysis occur? - Dialysate is introduced into peritoneal cavity. The peritoneum consist of two membranes, the parietal and visceral potential space between this two layer form peritoneal cavity normally this cavity normally small amount of serous fluid. - Transfer of solutes and fluid across these layers take space by diffusion and osmosis. Peritoneal catheter - A permanent peritoneal catheter used with patient who has chronic renal failure. Catheter with several openings in the tip such as tenck off catheter or modifications of it. Is inserted into peritoneal cavity. - Tissue cell fibroblasts subcutaneous section of grow into the two dacrom cuffs on the catheter in 2-3 weeks. Stabilizing the catheter position and decrease the incidence of infection and escape of fluid. - The procedure is done in operating theater and local or general anaesthetic. Dialysis solution: are available commercially in one or two liters in plastic bag and provide various options of glucose concentrations of 6 1.5%-2.5% and 4.25%s. the plasma composition is similar to that of plasma. Phases of peritoneal dialysis a) Inflow phase: Prescribed amount of solution 2 liter, is infused through an established catheter over about 10 minutes after solution has been infused. The inflow clamp is closed before air enters tube. b) Dwell phase: Equilibration: during this phase diffusion and osmosis occur between the patient's blood and peritoneal cavity. This phase last about 20-30 minutes. c) Drain phase: drain for solution it takes about 15-30 minutes and may be facilitated gently by massaging the abdomen or changing position. Methods of peritoneal dialysis a) Automated peritoneal dialysis An automated device called a cycler is used to delive the dialysate for APD. The automated cycler times and controls the fill dwell and drain phases. The machine cycles four or more exchange per night 1-2 hour per exchange. The patient disconnect from machine in morning and usually leaves fluid in the abdomen during the day. One to two manual exchange may be also prescribed to ensure adequate dialysis. b) Continuous ambulatory peritoneal dialysis (CAPD) Continuous because the process does not end constantly cleans the blood as long as there is dialysis fluid in peritoneal cavity. With CAPD, dialysis is taking place 24 hours a day 7 day per week. 6 Ambulatory: ambulate means to walk because patient not attached to machine. The dialysis is happening all the time day and night during activities and while the patient sleeps. CAPD: Involves performing an exchange of dialysis fluid exchange are usually carried out by patient themselves. CAPD can be performed in any clean and convenient place at home, at work at school or an holiday 6 Advantages and disadvantages of PD Advantages Disadvantages Immediate initiation in almost any Bacterial or chemical peritonitis hospital Protein loss into dialysate Exit site and tunnel infections Less complicated than hemodialysis Self-image problems with catheter placement Fewer dietary restrictions Hyperglycemia Relatively short training time Aggravated hypyerlipidemia Usable in the patient with vascular access Surgery for catheter placement problems Contraindication in the patient with Less cardiovascular stress multiple abdominal surgeries, trauma, Home dialysis possible unrepaired hernia Specially trained personnel needed Preferable for the diabetic patient Catheter can migrate Complications of PD 1. Peritonitis: This is a major complication of peritoneal dialysis due to sudden increase of organism by contamination of equipment or dialysate fluid. 2. Catheter complications as follow: Leakage around the catheter obstruction of catheter. 3. Pain: This may be due to the tip of catheter pressing on viscra or overheating from dialysate. 4. Protein catabolism and anorexia: break down of tissue protein may occur due to loss of protein in dialysate. Anorexia may occur due to feeling of fullness. 5. Electrolytes imbalance. 6 6. Disequilibrium syndrome: Rapid removal of nitrogenous wastes from blood can produce a complication in which cerebral oedema develops causing seven headache restlessness and disorientation "very rare complication nursing care for patient with peritoneal dialysis Nursing care for patient with peritoneal dialysis Predialysis 1. Preparation of the patient by: a. Evaluation the patient understanding of dialysis b. Explanation of procedure and patient purpose. 2. Assessment for patient include a. Vital signs (temp. pulse, Bl. p, respiratory). b. Laboratory investigation and serum electrolytes, blood urea nitrogen, serum creatinine. c. Assess for signs of over load, respiratory distress and dehydration. 3. Examination for abdominal distention and tenderness, observe for area around the catheter for redness, drainage and infection. During dialysis 1. Apply aseptic technique during handling the catheter tubing and dialysate. 2. Warming for dialysate solution. 3. Record for amount, type of dialysate and its time for instillation. 4. Observation for patient psychological and physiological reactions. 6 5. Observing for unwanted sign and symptoms, such as abdominal pain, nausea vomiting. 7. General Care for the Client Receiving Dialysis Always wear gloves (rationale: you will be exposed directly to the client's blood. Many people double glove). Check the shunt every 2 to 4 hours for vibration (thrill), which you can feel. Listen with a stethoscope for the whooshing sound of blood moving through the shunt (bruit). Record the sound as follows: RAG (right arm gortex)++. (The ++ indicates that you can both feel and hear the blood movement. Notify the physician immediately if you detect a change in the intensity of these sounds or sensations or if they are absent (rationale: this could be life threatening). Keep two clamps on the dressing over the external cannula at all times. (rationale: in case of cannula separation). Do not draw blood on the arm with a cannula or fistula. (Rational: to avoid disturbing the shunt). You may need to take the client's blood pressure with an electronic device. (rationale: you may be unable to hear it with a stethoscope). If an arteriovenous fistula bleeds, apply pressure until the bleeding stops (Rationale: bleeding can be a life threatening emergency). Usually, you will not flush the port (Rational: it is not likely to clot and you want to avoid further possibility of injection). Many clients on dialysis are diabetic and require insulin. These clients usually will not void (rationale: they do not produce urine because of lack of kidney functioning). Do not give these clients orange juice. Give apple or grape juice instead. (Rationale: orange juice is high in potassium. Elevated 6 potassium is common in these clients and is dangerous. Hyperkalemia (elevated potassium) can cause fluid overload, shortness of breath, and irregular hearbeat, which can lead to cardiac arrest). Blood for potassium and other electrolyte level tests is usually drawn daily. (Rational: to determine what should be included in the next run). Follow medication times exactly. (rationale: to maintain therapeutic blood levels and to avoid overload). Measure the client's daily weight (Rationale: to evaluate fluid retention). The client's blood pressure may be elevated (rationale: monitor blood pressure carefully). Guaiac all stools is often ordered (rationale: to check for internal bleeding from the vascular kidney). Teach the client and family about care of the cannula or fistula and other aspects. (Rational: they must understand that disconnection of these devices is an emergency, requiring immediate attention). Carefully and completely document all teaching. Assessment also includes careful observation for any indication of excessive bleeding. Hemorrhage can easily occur after surgery for renal calculi because the kidneys are so vascular. 6 Surgical Management - Kidney transplantation Definition: Kidney transplantation is a surgical procedure to remove a healthy, functioning kidney from a living or brain-dead donor and implant it into a patient with nonfunctioning kidneys Purpose Kidney transplantation is performed on patients with chronic kidney failure, or end-stage renal disease (ESRD). Description Kidney transplantation involves surgically attaching a functioning kidney, or graft, from a brain-dead organ donor (a cadaver transplant) or from a living donor to a patient with ESRD. Living donors may be related or unrelated to the patient, but a related donor has a better chance of having a kidney that is a stronger biological match for the patient. Preoperative care: Emotional support Monitor vital signs The patient is fasting 6-8 hours Increase fluid intake to ensure adequate excretion of waste products Explain the procedure for patient and relative Ensure adequate investigation especially kidney functions tests Postoperative care: 6 A typical hospital stay for a transplant recipient is about five days. Both kidney donors and recipients will experience some discomfort in the area of the incision after surgery. Pain relievers are administered following the transplant operation. Patients may also experience numbness, caused by severed nerves, near or on the incision. A regimen of immunosuppressive, or anti-rejection, medication is prescribed to prevent the body's immune system from rejecting the new kidney. Common immunosuppressants include cyclosporine, prednisone, tacrolimus, mycophenolate mofetil, sirolimus, baxsiliximab, daclizumab, and azathioprine. The kidney recipient will be required to take a course of immunosuppressant drugs for the lifespan of the new kidney. Intravenous antibodies may also be administered after transplant surgery and during rejection episodes. Because the patient's immune system is suppressed, he or she is at an increased risk for infection. The incision area should be kept clean, and the transplant recipient should avoid contact with people who have colds, viruses, or similar illnesses. If the patient has pets, he or she should not handle animal waste. The transplant team will provide detailed instructions on what should be avoided posttransplant. After recovery, the patient will still have to be vigilant about exposure to viruses and other environmental dangers. Transplant recipients may need to adjust their dietary habits. Certain immunosuppressive medications cause increased appetite or sodium and protein retention, and the patient may have to adjust his or her intake of calories, salt, and protein to compensate. 6 Complications: 1. Infection and bleeding (hemorrhage). 2. A transplanted kidney may be rejected by the patient 3. Atelectasis 4. Pneumonia 5. Thromboembolism Normal results The new kidney may start functioning immediately, or may take several weeks to begin producing urine. Living donor kidneys are more likely to begin functioning earlier than cadaver kidneys, which frequently suffer some reversible damage during the kidney transplant and storage procedure. Patients may have to undergo dialysis for several weeks while their new kidney establishes an acceptable level of functioning. Studies have shown that after they recover from surgery, kidney donors typically have no long-term complications from the loss of one kidney, and their remaining kidney will increase its functioning to compensate for the loss of the other. Morbidity and mortality rates A new study describes the psychological profile of adolescents who have received kidney transplants and compares them to those of healthy peers. The findings reveal a significantly higher prevalence of psychiatric conditions (depression, phobia, ADHD), educational impairment and social isolation among adolescents who had undergone a transplant. (Science Daily, 2009) Chronic kidney tumor 6 Definition: It is formation of tumor in the kidney Causes and risk factors 1. The cause of kidney cancer is unknown 2. Gender affects men more than women 3. Tobacco use - Occupational exposure to industrial chemicals such as petroleum products , heavy metals, asbestos 4. Obesity - Unopposed estrogen therapy 5. Polycystic kidney disease Pathophysisology Because the kidneys are deeply protected in the body tumors can become quit large before causing symptoms As the tumor enlarges it occupies space extending into adjacent renal structures and interfering with urine flow. Tumor cells tend to metastases by way of the renal vein and vena cava to the lungs, bones lymph nodes, liver, and brain. The majority of renal cell carcinoma starts in the proximal convoluted tubules There are five cell types (clear cell, papillary, chromophobe, collecting duct, unclassified clear cell type ) Renal cell carcinoma is staged using the TMN system or the Robson system TMN T = tumor- M = metastasis - N= Lymph nodes nvolvement 6 The Robson system includes the following: Stage I: The Tumor Is Well Defined Encapsulated , Compress On The Renal Parenchyma Stage II: Tumor Invade the Fat Surrounding Kidney Stage III: Local metastases through direct extension or vein or lymph nodes Stage IV: Distant metastases I the lung, liver , spleen Treatment: Radiation therapy - Chemotherapy - Immunotherapy Surgical therapy (open nephrectomy – laparoscopic procedure) ) 1. Open nephrectomy The surgical procedure to remove a kidney from a living donor is called a nephrectomy. 2. Laparoscopic nephrectomy: Laparoscopic nephrectomy is a form of minimally invasive surgery using instruments on long, narrow rods to view, cut, and remove the donor kidney Outcome of the nephrectomy or heminephrectomy 1. Reduce pain and haematuria caused by the tumor 2. The hospital stay is typically 4-6 days 3. Return to the work within 4-8 days 4. With laparoscopic surgery (fewer analgesic- early dischargedearly rerun to work- ) Polycystic kidney 6 Definition: It is formation of one or more fluid- filled cavities within the kidneys. Causes: Hereditary causes - Acquired after birth Signs & symptoms Abdominal and flank pain – Haematuria - Infection due to rupture of cysts - Chronic renal failure - Hypertension in 50% of patients Management: 1. health history 2. Ultrasound 3. CT – MRI 4. Hypertension should be controlled 5. Diets limited in protein 6. Antibiotics to control infection 7. Analgesics to control pain 8. Patient Is Instructed Signs and Symptoms Of Infection To Avoid Incidence Of CKD Surgical Management: Surgical aspiration - laparoscopic decompression of cysts 2.LOWER URINARY TRACT DISORDERS 1. Bladder cancer 2. Ureteral stricture 3. Urethral stricture 4. voiding disorders 1. Bladder Cancer 6 Definition: Cancer that forms in tissues of the bladder Types of bladder cancer: There are three types of bladder cancer that begin in cells in the lining of the bladder. These cancers are named for the type of cells that become malignant (cancerous): 1. Transitional cell carcinoma: Cancer that begins in cells in the innermost tissue layer of the bladder. These cells are able to stretch when the bladder is full and shrink when it is emptied. Most bladder cancers begin in the transitional cells. 2. Squamous cell carcinoma: Cancer that begins in squamous cells, which are thin, flat cells that may form in the bladder after longterm infection or irritation. 3. Adenocarcinoma: Cancer that begins in glandular (secretory) cells that may form in the bladder after long-term irritation and inflammation. NB: Cancer that is confined to the lining of the bladder is called superficial bladder cancer (papillary lesions). Cancer that begins in the transitional cells may spread through the lining of the bladder and invade the muscle wall of the bladder or spread to nearby organs and lymph nodes; this is called invasive bladder cancer (non-papillary lesions). Causes: Cause of bladder cancer is unknown cause Risk factors: Smoking. Being exposed to certain substances at work, such as rubber, certain dyes and textiles, paint, and hairdressing supplies. A diet high in fried meats and fat 6 Being older, male Having an infection caused by a certain parasite. Certain drugs such as cyclophosphamide and phenacetin are known to predispose to bladder Transitional cell carcinoma (TCC) Family history Signs and symptoms Painless haematuria. this may be visible to the naked eye (frank hematuria) or detectable only by microscope (microscopic hematuria) pain during urination, frequent urination (Polyuria) Feeling the need to urinate without results. Fatigue Shortness of breathing Anemia Stages of bladder cancer: The following stages are used to classify the location, size, and spread of the cancer, according to the TNM (tumor, lymph node, and metastasis) staging system: Stage 0: Cancer cells are found only on the inner lining of the bladder. Stage I: Cancer cells have proliferated to the layer beyond the inner lining of the urinary bladder but not to the muscles of the urinary bladder. 6 Stage II: Cancer cells have proliferated to the muscles in the bladder wall but not to the fatty tissue that surrounds the urinary bladder. Stage III: Cancer cells have proliferated to the fatty tissue surrounding the urinary bladder and to the prostate gland, vagina, or uterus, but not to the lymph nodes or other organs. Stage IV: Cancer cells have proliferated to the lymph nodes, pelvic or abdominal wall, and/or other organs. Recurrent: Cancer has recurred in the urinary bladder or in another nearby organ after having been treated. Diagnosis: 1. (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. 2. Urinalysis: A test to check the color of urine and its contents, such as sugar, protein, red blood cells, and white blood cells. 3. Internal exam: An exam of the vagina and/or rectum. The doctor inserts gloved fingers into the vagina and/or rectum to feel for lumps. 4. Intravenous pyelogram (IVP): A series of x-rays of the kidneys, ureters, and bladder to find out if cancer is present in these organs. A contrast dye is injected into a vein. As the contrast dye moves 6 through the kidneys, ureters, and bladder, x-rays are taken to see if there are any blockages. 5. Cystoscopy: A procedure to look inside the bladder and urethra to check for abnormal areas. A cystoscope is inserted through the urethra into the bladder. A cystoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer. 6. Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. A biopsy for bladder cancer is usually done during cystoscopy. It may be possible to remove the entire tumor during biopsy. 7. Urine cytology: Examination of urine under a microscope to check for abnormal cells. Medical management: The treatment of bladder cancer depends on how deep the tumor invades into the bladder wall: 1. Superficial tumors : by elecrocautary – and cystoscopy 2. Immunotherapy as BCG anti-inflammatory and prevent recurrence of superficial tumors 3. Chemotherapy as alternative of BCG 4. Radiation therapy Surgical management: Determine type of surgery according to stage of cancer Radical Cystectomy by urinary diversion in late stage of tumor Nursing implications for bladder cancer surgeries: 6 Procedure 1. Transurethral resection of bladder tumor(TURBT) Description Tumor removal via cystoscope inserted into urethra Nursing considerations - Maintain continuous bladder irrigations ordered - Ensure catheter patency - Monitor for excessive bleeding - Encourage fluids up to 2.500- 3.000 ml/day 2. Partial cystectomy 3.Complete or radical cystectomy - Give stool softeners to prevent straining Resection of the tumor - Maintain urethral and and a portion of the suprapubic catheter bladder wall patency to reduce pressure on suture lines Removal of the entire urinary bladder and surrounding tissues - Monitor for excessive bleeding - Permanent urinary diversion required - Maintain stent position and patency 4. Cutanous ureterostomy One or both ureters brought to abdominal wall urine drains via stoma - May have urethral catheter to drain pelvic cavity -Requires urinary drainage appliance - Small stoma may make tight seal difficult - Risk for irritation from direct contact 6 with urine 5.Ileal conduit 6.Continent internal ileal reservoir or continent ileal bladder conduit (Kock`s pouch ) - Increased risk for UTI due to direct access from skin to kidney - Continuous urine drainage requires appliance Portion of ileum formed into pouch ureters inserted into pouch and open end is brought to surface to - Risk for infection is significant form stoma Pouch created from ileum - Good skin care is vital due to constant contact with urine Drainage –collection device is not necessary 2. Ureteral stricture: Definition: The ureters are tubes that normally carry urine from the kidneys to the bladder. A ureteral stricture is a narrowing of the ureter that results in an obstruction in the flow of urine. Causes and risk factors 1. They may develop after treatment for another urologic condition. 2. Individuals who have undergone ureteroscopic or percutaneous kidney treatment for stones or tumors 6 3. Pelvic radiation therapy or urinary diversion surgery may develop ureteral strictures. After these procedures, scar tissue may obstruct the ureter 4. Gynecologic or vascular surgery procedures. 5. External traumatic injury can cause strictures. Symptoms and diagnosis Include flank and/or abdominal pain, nausea, vomiting, fever, infection, or sometimes an overall sensation of not feeling well. A variety of diagnostic tests to clarify different causes of stricture. X-rays, ureteroscopy, retrograde pyelogram or nephrostogram, ultrasound, CT scan, or MRI. Treatment: After determining the cause and location ureteral stricture, develop an individualized treatment strategy, we focus on minimally invasive treatments for ureteral strictures whenever possible. For strictures that develop shortly after external injury or after surgical injury, surgery may be the first choice of treatment. During surgery doctor will remove scar tissue and may surgically reconstruct ureter in a different location and reconnect it to the kidney. Surgery may be open, laparoscopic or robotic. If the stricture is extensive, then tissue from another part of the body, such as the small intestine, may be used to help reconstruct the ureter. For less severe or chronic strictures, endoscopy may be recommended. Here, a flexible tube is passed through the urethral 6 opening and threaded up through the bladder into the ureters. The doctor then uses specialized surgical instruments or lasers to cut through the blockage. In some cases, a balloon may be used to dilate the ureter. A stent (a hollow tube) may be inserted to keep the ureter open after treatment for several weeks. Because an obstructed ureter may lead to fluid retention in the kidneys (hydronephrosis), your doctor may need to drain the fluid through a procedure known as percutaneous nephrostomy, in which a needle is inserted through the back into the kidney to drain excess urine. A ureteral stent may also be put in place; this device can help drain urine directly from the kidney to the bladder, bypassing the point of obstruction or stricture 3. Urethral stricture: A urethral stricture most commonly results from previous infection or injury. A less forceful urinary stream or a double stream usually occurs with mild strictures. Severe strictures may completely block the stream of urine. The buildup of pressure behind the stricture may cause the formation of passages from the urethra into the surrounding tissues (diverticula). By decreasing the frequency or completeness of urination, strictures often lead to urinary tract infections. A urologist diagnoses a stricture by looking directly into the urethra through a flexible viewing tube (cystoscope) after administering a lubricant containing a local anesthetic. To widen the urethra, a urologist may dilate or cut (urethrotomy) the stricture. Urethral strictures can recur and may require excision of 6 the scar and surgical reconstruction of the urethra, sometimes with a skin graft Voiding disorders Types of voiding disorders 1. Chronic Urine retention 2. Chronic Urine incontinence Chronic Urine retention: Urinary retention also known as ischuria is a lack of ability to urinate. It is a common complication of benign prostatic hypertrophy (also known as benign prostatic hyperplasia or BPH), although anticholinergics may also play a role, and requires a catheter or Prostatic stent. Various medications (e.g. some antidepressants) and recreational use of amphetamines and opiates are notorious for this. Signs and symptoms: Urinary retention is characterised by poor urinary stream with intermittent flow, straining, Incomplete voiding - hesitancy (a delay between trying to urinate and the flow actually beginning). -Incontinencenocturia (need to urinate at night) and Chronic urine retention causes obstruction of the urinary tract: Bladder stones Loss of detrusor muscle tone (atonic bladder is an extreme form) Hydronephrosis (congestion of the kidneys) Hypertrophy of detrusor muscle Diverticula in the bladder wall (leads to stones and infection 6 Causes: In the bladder: Detrusor sphincter dyssynergia Neurogenic bladder (commonly saccral nerve damage, demyelinating diseases or Parkinson's disease) Iatrogenic scarring of the bladder neck (commonly from removal of indwelling catheters or cystoscopy operations) Damage to the bladder In the prostate Benign prostatic hyperplasia Prostate cancer and other pelvic malignancies Prostatitis Penile urethra Congenital urethral valves Phimosis or pinhole meatus Circumcision Obstruction in the urethra, for example a metastasis or a precipitated pseudogout crystal in the urine STD lesions (gonorrhoea causes numerous strictures, leading to a "rosary bead" appearance, whereas chlamydia usually causes a single stricture) Others: Consumption of some psychoactive substances, mainly stimulants, such as Ecstasy. 6 Use of drugs with anticholinergic properties. Stones or metastases can theoretically appear anywhere along the urinary tract, but vary in frequency depending on anatomy Diagnostic tests: Urine flow tests may aid in establishing the type of micturition abnormality. Common findings include a slow rate of flow, intermittent flow and a large post void residual, determined by ultrasound of the bladder. In chronic retention, ultrasound of the bladder may show massive increase in bladder capacity (normal capacity being 400-600 ml). Determination of the serum prostate-specific antigen (PSA) may aid in diagnosing or ruling out prostate cancer, though this is also raised in BPH and prostatitis. A TRUS biopsy of the prostate (trans-rectal ultra-sound guided) can distinguish between these prostate conditions. Serum urea and creatinine determinations may be necessary to rule out backflow kidney damage. Cystoscopy may be needed to explore the urinary passage and rule out blockages Treatment: In acute urinary retention, urinary catheterization, placement of a Prostatic stent or suprapubic cystostomy instantly relieves the retention. In the longer term, treatment depends on the cause. Benign prostatic hypertrophy may respond to alpha blocker and 5-alpha-reductase inhibitor therapy, or surgically with prostatectomy or transurethral resection of the prostate (TURP). 6 Chronic Urinary incontinence Definition: Urinary incontinence — the loss of bladder control — is a common and often embarrassing problem. The severity of urinary incontinence ranges from occasionally leaking urine when you cough or sneeze to having sudden, unpredictable episodes of strong urinary urgency. Symptoms: Urinary incontinence is the inability to control the release of urine from your bladder. The problem has varying degrees of severity. Some people experience only occasional, minor leaks — or dribbles — of urine. Others wet their clothes frequently. For a few, incontinence means both urinary and fecal incontinence — the uncontrollable loss of stools. Types of urinary incontinence include: Stress incontinence. This is loss of urine when you exert pressure — stress — on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy Urge incontinence. This is a sudden, intense urge to urinate, followed by an involuntary loss of urine. Your bladder muscle contracts and may give you a warning of only a few seconds to a minute to reach a toilet. With urge incontinence, you may also need to urinate often. Overflow incontinence. If you frequently or constantly dribble urine, you may have overflow incontinence. This is an inability to empty your bladder, leading to overflow. With overflow incontinence, sometimes you may feel as if you never completely empty your bladder. 6 Mixed incontinence. If you experience symptoms of more than one type of urinary incontinence, such as stress incontinence and urge incontinence, you have mixed incontinence. Functional incontinence. Many older adults, especially people in nursing homes, experience incontinence simply because a physical or mental impairment keeps them from making it to the toilet in time. For example, a person with severe arthritis may not be able to unbutton his or her pants quickly enough. Someone with Alzheimer's disease may not plan well enough to make a timely trip to the toilet. This type of incontinence is called functional incontinence. Gross total incontinence. This term is sometimes used to describe continuous leaking of urine, day and night, or periodic large volumes of urine and uncontrollable leaking. The bladder has no storage capacity. Some people have this type of incontinence because they were born with an anatomical defect. It can be caused by a spinal cord injury or by injury to the urinary system from surgery. Causes: Causes of persistent urinary incontinence Urinary incontinence can also be a persistent condition caused by some underlying physical problem — weakened pelvic floor or bladder muscles, neurological diseases, or an obstruction in your urinary tract. Factors that can lead to chronic incontinence include: Pregnancy and childbirth. Pregnant women may experience stress incontinence because of hormonal changes and the increased 6 weight of an enlarging uterus. In addition, the stress of a vaginal delivery can weaken the pelvic floor muscles and the ring of muscles that surrounds the urethra (urinary sphincter). Changes with aging. Aging of the bladder muscle affects both men and women, leading to a decrease in the bladder's capacity to store urine and an increase in overactive bladder symptoms. Women produce less of the hormone estrogen after menopause, a decrease that can contribute to incontinence. Estrogen helps keep the lining of the bladder and urethra healthy. With less estrogen, these tissues lose some of their ability to close — meaning that your urethra can't hold back urine as easily as before. Hysterectomy. In women, the bladder and uterus (womb) lie close to one another and are supported by the same muscles and ligaments. Any surgery that involves a woman's reproductive system — for example, removal of the uterus (hysterectomy) — runs the risk of damaging the supporting pelvic floor muscles, which can lead to incontinence. Painful bladder syndrome (interstitial cystitis). This rare, chronic condition can be associated with an inflammation of the bladder wall. It occasionally causes urinary incontinence, as well as painful and frequent urination. Interstitial cystitis affects women more often than men, and its cause isn't clear. Prostatitis. Loss of bladder control isn't a typical sign of prostatitis, or inflammation of the prostate gland — a walnut-sized organ located just below the male bladder. Even so, urinary incontinence sometimes occurs with this extremely common 6 condition. The prostate actually surrounds the urethra, so inflammation of the prostate occasionally swells and constricts the urethra, blocking normal urine flow and leading to urinary urgency and frequency. Rarely, this also causes incontinence. Enlarged prostate. In older men, incontinence often stems from enlargement of the prostate gland, a condition also known as benign prostatic hyperplasia (BPH). The prostate begins to enlarge in many men after about age 40. As the gland enlarges, it can constrict the urethra and block the flow of urine. For some men, this problem results in urge or overflow incontinence. Prostate cancer. In men, stress incontinence or urge incontinence can be associated with untreated prostate cancer. However, more often, incontinence is a side effect of treatments — surgery or radiation — for prostate cancer. Bladder cancer or bladder stones. Incontinence, urinary urgency and burning with urination can be signs and symptoms of bladder cancer and also of bladder stones. Other signs and symptoms include blood in the urine and pelvic pain. Neurological disorders. Multiple sclerosis, Parkinson's disease, stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control, causing urinary incontinence. Obstruction. A tumor anywhere along your urinary tract can obstruct the normal flow of urine and cause incontinence, usually overflow incontinence. Urinary stones — hard, stone-like masses that can form in the bladder — may be to blame for urine leakage. Urinary obstruction can also occur after overcorrection during a 6 surgical procedure to correct urinary incontinence, leading to more urine leakage. Diagnostic tests: Complete medical exam. A complete physical examination, focusing on your abdomen and genitals, also may give clues to your incontinence. Your doctor will look for reasons for your incontinence, such as a urinary tract infection, mass or compacted stool. If the cause of your incontinence is harder to find, your doctor may want to do some tests. Common tests: Common tests for urinary incontinence include: Bladder diary. Your doctor may go over a bladder diary that he or she has asked you to complete at home over several days. You record how much you drink, when you urinate, the amount of urine you produce, whether you had an urge to urinate and the number of incontinence episodes. To measure your urine, your doctor may give you a pan that fits over your toilet rim. The pan has markings like a measuring cup. Keeping a bladder diary can be tedious, but it gives your doctor important information. Urinalysis. A sample of your urine is sent to a laboratory, where it's checked for signs of infection, traces of blood or other abnormalities. For the sample to be collected, you're asked to urinate into a container. A urine culture is a lab test that specifically checks for signs of infection in your urine. A urine cytology involves a check of your urine for cancer cells. 6 Blood test. Your doctor may have a sample of your blood drawn and sent to a laboratory for analysis. Your blood is checked for various chemicals and substances related to causes of incontinence. Specialized tests: If further testing is needed, you'll likely be referred to a doctor who specializes in urinary disorders (urologist). Women might be referred to a doctor who focuses on urological problems in women (urogynecologist). At the specialist's office, you may undergo additional testing such as: Postvoid residual (PVR) measurement. This test helps your doctor determine whether you have difficulty emptying your bladder. For the procedure, you're asked to urinate (void) into a funnel-like container that allows your doctor to measure your urine output. Then your doctor checks the amount of residual urine in your bladder using a catheter — a thin, soft tube that's inserted into your urethra and bladder to drain any remaining urine — or an ultrasound device. For the ultrasound test, a wand-like device is placed over your abdomen. The device sends sound waves through your pelvic area. A computer transforms these sound waves into an image of your bladder, so your doctor can see how full or empty it is. A large amount of leftover (residual) urine in your bladder may mean that you have an obstruction in your urinary tract or a problem with your bladder nerves or muscles. Pelvic ultrasound. Ultrasound also may be used to view other parts of your urinary tract or genitals to check for abnormalities. Stress test. For this test, you're asked to cough vigorously or bear down as your doctor examines you and watches for loss of urine. 6 Urodynamic testing. These tests measure pressure in your bladder both at rest and when filling. A doctor or nurse inserts a catheter into your urethra and bladder. The catheter is used to fill your bladder with water while a pressure monitor measures and records the pressure within your bladder. Normally, pressure increases by only very small amounts during filling. This test helps your doctor measure the strength of your bladder muscle and the health of your urinary sphincter. Cystogram. In this X-ray of your bladder, a catheter is inserted into your urethra and bladder. Through the catheter, your doctor injects a fluid containing a special dye. As you urinate and expel this fluid, images show up on a series of X-rays. These images help reveal problems with your urinary tract. Cystoscopy. In this procedure, a thin tube with a tiny lens (cystoscope) is inserted into your urethra. With the aid of this device, your doctor can check for — and potentially remove — abnormalities in your urinary tract. Once the tests are complete, your doctor can explain the results and discuss treatment options with you. Treatment: Treatment for urinary incontinence depends on: 1. The type of incontinence, 2. The severity of your problem and the underlying cause. Treatment options for urinary incontinence fall into four broad categories: 1. behavioral techniques 6 2. medications 3. devices 4. Surgery. 1. Behavioral techniques Behavioral techniques and lifestyle changes work well for certain types of urinary incontinence. They may be the only treatment you need. Pelvic floor muscle exercises. These exercises strengthen your urinary sphincter and pelvic floor muscles — the muscles that help control urination. Your doctor may recommend that you do these exercises frequently to treat your incontinence. They are especially effective for stress incontinence, but may also help urge incontinence. To do pelvic floor muscle exercises (Kegels), imagine that you're trying to stop your urine flow. Squeeze the muscles you would use and hold for a count of three. Relax, count to three again, then repeat. You can do these exercises almost anywhere — while you're driving, watching television or sitting at your desk at work. With Kegels, it can be difficult to know whether you're contracting the right muscles and in the right manner. In general, if you sense a pulling-up feeling when you squeeze, you're using the right muscles. Men may feel their penises pull in slightly toward their bodies. To double-check that you're contracting the right muscles, try the exercises in front of a mirror. Your abdominal, buttock or leg muscles shouldn't tighten if you're isolating the muscles of the pelvic floor. Another way to be sure you're doing Kegels correctly is a simple finger test. Place a finger in your anus or vagina. Then 6 squeeze around your finger. The muscles you contract are your pelvic floor muscles. If you're still not sure whether you're contracting the right muscles, ask your doctor for help. Your doctor can refer you to a physical therapist for biofeedback techniques that will help you identify and contract the right muscles. After several months of doing pelvic floor muscle exercises correctly, you should notice improvement in your urinary control. Contract your pelvic muscles to control leakage when you have an urge to urinate or when you cough or sneeze. Bladder training. Your doctor may recommend bladder training — alone or in combination with other therapies — to control urge and other types of incontinence. Bladder training involves learning to delay urination after you get the urge to go. You may start by trying to hold off for 10 minutes every time you feel an urge to urinate. Then try increasing the waiting period to 20 minutes. The goal is to lengthen the time between trips to the toilet until you're urinating every two to four hours. Scheduled toilet trips. This means timed urination — going to the toilet according to the clock rather than waiting for the need to go. Following this technique, you go to the toilet on a routine, planned basis — usually every two to four hours. Scheduled toilet trips In some cases, you can simply modify your daily habits to regain control of your bladder. You may need to cut back on or avoid alcohol or caffeine, if either causes you incontinence. If acidic foods irritate your bladder, cutting back on 6 such triggers may rid you of your problem. For some people, reducing liquid consumption before bedtime is all that's needed. Losing weight also may eliminate the problem. 2. Medications Many times, urinary incontinence can be corrected with the help of medication. Often, medications are used in conjunction with behavioral techniques. Drugs commonly used to treat incontinence include: Anticholinergic (antispasmodic) drugs. These prescription medications calm an overactive bladder, so they may be helpful for urge incontinence. As (Detrol), Antidepressant drugs may occasionally be used in combination with other medications to treat incontinence. Antibiotics. If your incontinence is due to a urinary tract infection or an inflamed prostate gland (prostatitis), your doctor can successfully treat the problem with antibiotics. Electrical stimulation in this procedure, electrodes are temporarily inserted into your rectum or vagina to stimulate and strengthen pelvic floor muscles. Gentle electrical stimulation can be effective for stress incontinence and urge incontinence, but it takes several months and multiple treatments to work. And it can cause side effects, such as abdominal cramps, diarrhea and bleeding. Electrical stimulation is usually reserved for people with severe urge incontinence who don't respond to behavioral techniques or medications. 6 3. Medical devices several medical devices are available to help treat incontinence. They're designed specifically for women and include: Urethral inserts. These are small, tampon-like disposable devices or plugs that a woman inserts into her urethra — the tube where urine exits the body — to prevent urine from leaking out. Urethral inserts aren't for everyday use. They work best for women who have predictable incontinence during certain activities, such as playing tennis. Pessary (PES-uh-re). Your doctor may prescribe a pessary — a stiff ring that you insert into your vagina and wear all day. The device helps hold up your bladder, which lies near the vagina, to prevent urine leakage. You need to regularly remove the device to clean it. You may benefit from a pessary if you have incontinence due to a dropped (prolapsed) bladder or uterus. 4. Surgery If other treatments aren't working, several surgical procedures have been developed to fix problems that cause urinary incontinence. In men, surgery may be necessary to remove the obstructive part of an enlarged prostate gland. If your bladder or uterus has slipped out of position, a surgeon can put it back in place with a variety of techniques. Rarely, surgery to treat urinary incontinence may involve enlarging the bladder or correcting a birth defect. Or surgery may be needed to bolster weakened urinary sphincter muscles. Some of the more common procedures include: 6 Artificial urinary sphincter. This small device is particularly helpful for men who have weakened urinary sphincters from treatment of prostate cancer or an enlarged prostate gland, and it's used rarely in women with stress incontinence. Shaped like a doughnut, the device is implanted around the neck of your bladder. The fluid-filled ring keeps your urinary sphincter shut tight until you're ready to urinate. To urinate, you press a valve implanted under your skin that causes the ring to deflate and allows urine from your bladder to be released. This surgery is the most effective procedure for male incontinence. Complications include malfunction of the device — which means the surgery will need to be repeated — and infection, but both are uncommon. Bulking material injections. Some women and men with stress incontinence benefit from urethral injections of bulking agents. This procedure involves injecting bulking materials — which may be cow-derived collagen, carbon particle beads or synthetic sugars — into the tissue surrounding the urethra or the skin next to the urinary sphincter. The injection tightens the seal of the sphincter by bulking up the surrounding tissue. The procedure is done with minimal anesthesia and typically takes about two to three minutes. It usually needs to be repeated after several months, because the effect can be lost over time. There is a risk of rejection or infection. Sacral nerve stimulator. This small device acts on nerves that control bladder and pelvic floor contractions. The device, which resembles a pacemaker, is implanted under the skin in your abdomen. A wire from the device is connected to a sacral nerve an important nerve in bladder control that runs from your lower spinal cord to your bladder. Through the wire, the device emits electrical pulses that 6 stimulate the nerve and help control the bladder. The pulse doesn't cause pain and provides relief from heavy leaking in many cases. Possible complications include infection, but the device can be removed. Sling procedure. The most popular and common surgery for women with stress incontinence is the sling procedure. During this procedure, a surgeon removes a strip of abdominal tissue and places it under the urethra. Or the surgeon may use a strip of synthetic mesh material or a strip of tissue from a donor (xenograft) or cadaver. The strip acts like a hammock, compressing the urethra to prevent leaks that occur with the activities of daily living. Sling procedures improve or cure incontinence in most cases. There are varying techniques for the sling procedure, so talk with your doctor about what procedure is planned and why. Bladder neck suspension. In this procedure, your surgeon makes a 3- to 5-inch incision in your lower abdomen. Through this incision, he or she places stitches (sutures) in the tissue near the bladder neck and secures the stitches to a ligament near your pubic bone (Burch procedure) or in the cartilage of the pubic bone itself (Marshall-Marchetti-Krantz, or MMK, procedure). This has the effect of bolstering your urethra and bladder neck so that they don't sag. The downside of this procedure is that it involves major abdominal surgery. It's done under general anesthesia and usually takes about an hour. Recovery takes about six weeks, and you'll likely need to use a catheter until you can urinate normally. Absorbent pads and catheters If medical treatments can't completely eliminate your incontinence 6 or you need help until a treatment starts to take effect — you can try products that help ease the discomfort and inconvenience of leaking urine. Pads and protective garments. Various absorbent pads are available to help you manage urine loss. Most products are no more bulky than normal underwear, and you can wear them easily under everyday clothing. Men who have problems with dribbles of urine can use a drip collector — a small pocket of absorbent padding that's worn over the penis and held in place by closefitting underwear. Catheter. 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