Download Nursing Management

Disorders of the Renal
System
Mildred D. Fennal, PhD, RN, CNS
05/19/16
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ANATOMY
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Paired organs
Located in the dorsal part of the
abdomen.
Length 11cm long
Width 5.7 cm wide
Ply 2.5cm thick
Weight 145 grams (male) 135
grams (female)
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The left kidney is a fraction longer
and narrower than the right.
The lower border is at the third
lumbar vertebrae
The left kidney is a fraction higher
than the right kidney.
The kidney is covered by a fibrous
capsule
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The outer portion of the kidney is the
cortex
The middle portion of the kidney is
the medulla
The inner part of the kidney is the
sinus
The functional unit of the kidney is
the Nephron (appx. I million per
kidney).
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FUNCTIONS OF THE
KIDNEY
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Regulate water and electrolytes
Regulate blood pressure
Excretion of waste
Regulation of erythropoiesis
Metabolism of vitamin D
Synthesis of prostagladin
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REGULATION OF
WATER
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Responsible for maintenace of
volume and concentration of body
water via the thirst-neurohypophyseal renal axis
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REGULATION OF
BLOOD PRESSURE
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Decrease in the pressure to the
afferent arteriole, decrease in
glomerula filtration, release of
renin, goes to the liver where renin
becomes agiotensin I.
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Angiotensin I goes to the lungs to
receive a converter enzyme to
become angiotensin II. Agiotensin
II is a powerful vasoconstrictor,
which stimulates the adrenal
cortext to secrete aldosterone.
Aldosterone increases reasorption
of sodium and water, thereby
increasing the blood pressure.
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ELECTROLYTE
REGULATION
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Sodium
Aldosterone
Potassium
Calcium
Phosphate
Magnesium
Chloride
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GLOMERULA
FILTRATION
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Controlled by pressure (high) in the
capillaries in the glomerulus
(70mm Hg) elsewhere in the body
capillary pressure is 15 – 25 mm
hg.
25% of blood from each
contraction of the heart filters
through the kidneys
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Re-absorption occurs in the
tubules by active re-absorption,
passive diffusion and osmosis.
Secretion occurs from the tubular
cells. It is a chemical activity that
occurs in the opposite direction of
re-absorption.
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The kidneys regulate aldosterone
and sodium and potassium and
sodium.
The kidneys are the chief
regulators of PH in the body. This
occurs through the excretion of H+
(hydrogen ions). CO2 is
reabsorbed from the tubules and
excreted through the lungs.
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MECHANISM OF THE
KIDNEY
Clearance
Removal of end products, metabolic
waste from the blood and removal from
the body via the urine.
Countercurrent Mechanism
The method of concentrating and diluting
the urine. The ability to adjust the
osmolality of the urine.
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EXCRETION
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The primary role of renal function
is excretion of metabolic waste.
There are more than 200 metabolic
waste products excreted by the
kidneys.
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CREATININE
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A waste product of muscle
metabolism
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UREA
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A nitrogen waste product of protein
metabolism that is filtered and
reabsorbed along the entire
nephron.
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THE FORMATION OF
URINE
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Physiology
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Glomerular capillaries and
Bowman’s capsule: Filtration of
water electrolytes, creatinine,
sugars, nitrogenous waste (urea,
uric acid) bicarb and amino acid.
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PROXIMAL TUBULE
Sixty to seventy percent of
glomerula filtrate reabsorbed.
 Re-absorption of Na+, Cl-,K+,
Mg+, Ca++, HPO4-. Creatinine,
AA, sugars, some nitrogenous
waste, bicarb and water.
 Secretion of H+
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LOOP OF HENLE
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5% of glomerula filtrate reabsorbed
In the descending loop.
Re-absorption of water and
secretion of urea.
In the ascending loop
Re-absorption chloride, sodium,
potassium, magnesium and
calcium.
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DISTAL TUBULE
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5% of glomerula filtrate reabsorbed
Re-absorption of Na+ (controlled
by aldosterone), Cl-, and Ca++ and
phosphate (controlled by
parathyroid hormone). Magnesium
and bicard.
Secretion of K+ (controlled by
aldosterone) H+ and NH3
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COLLECTING DUCT
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19 % of glomerula filtrate is reabsorbed.
Re-absorption of water (controlled
by aldosterone)
Reabsorption and secretion of
urea, Na+, ClFormation of urine
125ml of filtrate will yield 1cc of
urine.
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Assessment of the
Renal System
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Physical Assessment
24 hour urine
Clean catch/Midstream
Specific Gravity
Creatinine clearance
Osmolality
Serum Creatinine
Blood, urea, nitrogen (BUN)
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KUB
CT Scan
MRI
Renal Angiography
IVP
Cystoscopic exam
Biopsy
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Urinary/Renal Calculi
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Definition: Urolithiasis, or the
development of urinary stones.
Masses of of crystals composed of
substances that are normally
excreted in the urine
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Etiology
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May occur from dehydration,
immobility, excess dietary intake of
calcium, oxalate or protein, gout,
hyperparathyroidism, and repeated
urinary tract infections.
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Incidence
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Males are more affected than
females (four time more affected)
Affects 720,000 people in the
United states each year.
Most common cause of urinary
tract obstruction.
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75 – 80% of stone are composed
of calcium
15% are composed of magnesium
ammonium phosphate and are
called sturvite stones.
5 – 10 % are made from uric acid
or cystine.
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Pathophysiology
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The development of these stones
involve the precipitation of a salt
around a mucoprotein to from a
crystalline structure. High ingestion
of minerals plus elevated salt in the
urine allows stone to form and
progressively enlarge. The acidity
or alkalinity of the urine will also
contribute to the development of
stone.
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Signs and Symptoms
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Renal Calculi in the Calyces and
the pelvis of the kidney may have
few symptoms other than dull,
aching flank pain.
Bladder calculi may produce dull
suprapubic pain with exercise or
after voiding. Gross hematuria may
be present.
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Uretheral stones produce a severe
intermittent pain in the flank and
upper outer abdominal quadrant
on the affected side. This is known
as Renal Colic.
Decrease Urinary output
UTI
Nausea, vomiting, pallor, cool
clammy skin.
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Medical Management
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Urinalysis
Urine Calcium
Uric Acid
KUB
Flat plate of the abdomen
IVP
Renal ultrasound
CT/MRI
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Narcotic Analgesic (morphine or
demerol)
Indomethacin, atropine, ditropan,
banthine, and a thiazide diuretic.
2 ½ - 3 liters of fluid per day
For calcium stones, limit
substances that contain vitamin D
and calcium. Administer an
Alkaline Ash Diet
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For uric acid stone limit foods high
in purines (sardines, organ meats).
Surgery: Stones larger than 5mm.
Stones in the bladder
 Stones in the renal pelvis
(percutaneous nephrostomy)
 Lithotripsy
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Nursing Management
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Assessment
Relieve the pain
Assist with procedures
Distraction techniques
Strict I&O
Straining all urine
Management of fluid volume
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Teaching
Nursing diagnosis
Acute Pain
 At risk for complications of
immobility
 Ineffective coping
 At risk for injury
 Anxiety
 Risk for Fluid volume excess
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Tumors of the Bladder
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Definition: Squamous cell
carcinoma of the bladder.
Papillomas (70%),
Incidence: 50,000 people per year
in the United States.
Fifth most common malignancy
Occur most often in the fifth
decade.
Affect men more than women
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Etiology
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Cigarette smoke
Chemicals and dyes used in
plastics, rubber, cable industries,
leather finishers, spray paints, hair
dressing, petroleum products.
Frequent urinary calculi
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Pathophysiology
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A cell that mutates begin to form a
papillary transitional cell
carcinoma. 70% of bladder
cancers are papillomas.
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Signs and Symptoms
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Painless hematuria
UTI
Colicky pain
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Medical Management
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Urinalysis
IVP
CT
Cystoscopy
Chemo therapy (Thiotepa)
Radiation
Surgery
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Nursing Management
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Post operative care
Comfort measures
Psychological support
Administration of drugs
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Nursing Diagnosis
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Altered pattern of urination
Risk for impaired skin integrity
Risk for infection
Body image disturbance
Risk for ineffective coping
Knowledge deficit
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RENAL FAILURE
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Pre-renal: physiologic states that
lead to diminished perfusion to the
kidney without renal tubular
damage.
Intra-renal: cortical involvement of
vascular, infectious, or
immunologic processes.
Post renal: associated with
obstruction of the collecting
system.
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ACUTE RENAL FAILURE
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Definition: A syndrome of varying
etiologies, sub-classified into prerenal, intra-renal and post renal
conditions, resulting in an acute
deterioration of renal function.
Less than 400 cc of urine in 24
hours.
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ETIOLOGY
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Caused by numerous clinical
conditions, i.e. pre-renal azotemia,
precipitated by fluid volume loss,
extracellular sequestration (third
spacing), inadequate cardiac
output, or vasoconstriction of the
renal blood vessels.
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INTRARENAL FAILURE
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Acute tubular necrosis
Infection
Cortical necrosis
Systemic Lupus
Goodpasture’s syndrome
Endocarditis
Abruptio placenta
Malignant hypertension
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Antibiotics
Carbon tetrachloride
Heavy metals
Pesticides and fungicides
X-Ray contrast media
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Massive injury
Transfusion reaction
Septic or cardiogenic shock
Major trauma and crushing injuries
Post surgical hypotension
Postpartum hemorrhage of
pregnancy.
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POST RENAL FAILURE
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Urethral obstruction
Prostatic hypertrophy
Bladder cancer
Renal calculi
Abdominal tumor
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INCIDENCE
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5% of all hospitalized patients
30% of all critically ill patients
High in the elderly and in patients
taking nephrotoxic drugs
10,000 people per year in the
United states.
Mortality 90%
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PATHOPHYSIOLOGY
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Physiologic states leading to
diminished perfusion of the kidney,
decrease glomerular filtration
and/or obstruction.
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MEDICAL
MANAGEMENT
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Blood work especially BUN and
Creatinine
Daily weights
Intake and output
Radiologic exam (KUB)
Ultrasound
IVP
CT
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Renal angiography
Renal scan
Renal biopsy
Dialysis (peritoneal or hemo)
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NURSING
MANAGEMENT
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Management of fluid volume
Monitor for infection
Skin integrity
Nutrition balance
Management of anxiety
Drug administration
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NURSING DIAGNOSIS
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Fluid volume excess
Risk for infection
Altered role performance
Ineffective coping
Altered nutrition
Knowledge deficit
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CHRONIC RENAL
FAILURE
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Definition: A slowly progressive
renal disorder culminating in endstage renal disease.
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ETIOLOGY
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Progressive deterioration of
glomerula filtration, tubular
secretion and tubular reabsorption.
Related to: Diabetic nephropathy,
hypertension, glomerulonephritis,
and cystic kidney disease The
degree of decline in function is
correlated with nephron lost.
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INCIDENCE
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Occurs more often in older adults
More frequent in Native-Americans
and African-Americans
(hypertension 40% of cases)
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PATHOPHYSIOLOGY
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Destruction of Nephrons
Scaring of tissue
Inability to filter
Uremia
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MEDICAL
MANAGEMENT
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Prevention of further deterioration
Correction of fluid balance
Diuretics
Anti-hypertensive agents
Kayexalate
Folic acid and iron
Dialysis
Renal transplant
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NURSING
MANAGEMENT
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Management of fluid restriction
Management of nutrition status
Management of skin integrity
Monitoring for infection
Monitoring for heart failure
Management of dialysis
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RENAL DIALYSIS
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Definition: removes waste products
from the body when the kidneys
can no longer filter.
Acute dialysis used when there is a
sudden onset of failure with rising
levels of potassium, pulmonary
edema, increasing acidosis and
fluid volume overload.
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Chronic dialysis or maintenance
dialysis is used when the failure is
irreversible and/or in end stage
renal disease.
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PERITONEAL DIALYSIS
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Continuous peritoneal dialysis
(CAPD)
Continuous cyclic peritoneal
dialysis (CCPD)
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COMPLICATIONS OF
PERITONEAL DIALYSIS
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Peritonitis
Bleeding
Abdominal hernias
Pulmonary edema
Congestive heart failure
Perforation of bowel
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HEMODIALYSIS
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The most commonly used form of
dialysis.
120,000 patients on dialysis in the
United States
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COMPLICATIONS OF
HEMODIALYSIS
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Hypotension
Muscle cramping
Air embolis
Chest pain
Dialysis disequilibrium
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Urinary Incontinence
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Definition: Involuntary loss of urine
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Etiology
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Injury, fistulas, infection, age,
dehydration, urinary retention,
fecal impaction, urinary tract
infection
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Incidence
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More common in women than men. After
age 35, more than 10 percent of women
experience some degree of
incontinence, with men there is a 2-7 %
increase after age 35. The prevalance in
individuals over sixty five range from
30% for seniors who experience
independent living to 50-70% for seniors
who are institutionalized
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Types of Incontinence
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True or total incontinence
Stress incontinence
Urgency Incontinence
Paradoxical Incontinence
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Pathophysiology
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True Incontinence
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Constant leakage, usually
produced by injury to the urethral
sphincter
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May be caused by a vesicovaginal
fistula in the female, occurring
secondary to pregnancy, surgical
radiation or neurological disease.
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Urinary tract fistulas result in urine
leaving the body in un-natural
ways such as through he vagina.
Fistulas are abnormal openings
between two organs and the skin
that allow passage of secretions
and other substances.
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Stress Incontinence is a sudden
increase in intra abdominal
pressure as with sneezing severe
coughing, laughing, or straining.
Usually occurs from pelvic
relaxation, loss of tissue tone and
aging
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Urgency: the pathology may be
calculi, diverticuli, foreign bodies,
tumors, CNS disorders such as
stroke, dementia and multiple
sclerosis.
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Paradoxal incontinence occurs
when the bladder is flaccid and
there is intermittent loss of urine.
Usually caused by urinary
retention. May be a sign of benign
prostate hypertrophy
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Medical Management
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Kegal Exercises
Triamenic
Sudafed
Estrogen replacement
Marshall-Marchetti-Krantz
procedure
Catherterization
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Nursing Management
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Acknowledge of the patients
embarrassment
Patient Teaching
Weight reduction
 Avoid constipation
 Kegel exercises
 Bladder training programs
 Encourage the use of velcro
enclosures vs. zippers and buttons
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Protection of the skin
Post operative care when surgery
is the treatment
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Urinary Retention
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Definition: Retention of urine after
it has been produced by the
Kidneys. The inability of the
bladder to empty
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Etiology
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Obstruction that is either
mechanical or functional
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Incidence
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After surgery
Certain medications
Anxiety
Neurological diseases
Prolong use of urinary cathether
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Pathophysiology
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In acute urinary retention there is
no permanent damage to the
bladder. With chronic urinary
retention, the detrusor muscle
becomes hyperactive, causing
frequency, urgency, and nocturia,
which leads to muscle hypertrophy.
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The thicken bladder wall is more
rigid and less easy to stretch
normally.
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Signs and Symptoms
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Absence of voided urine
Distended bladder
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Medical Management
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Catheter
Dilatation of urethra
Supra-pubic catheters
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Nursing Management
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Encourage activity as soon as
possible after surgery
Encourage relaxation
Run water
Monitor for bladder distention
Catheterization
Comfort measures after dilation
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