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Chapter 10
Care of the Patient with a
Urinary Disorder
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and
Physiology
• Functions of the urinary system
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
Excretion of waste products
Regulation of water (ADH), electrolytes, and acidbase balance (pH of blood)
• Kidneys (two)

Nephron: Functional unit of kidneys
• Urine composition and characteristics
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95% water; remainder is nitrogenous wastes and salts
• Urine abnormalities
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Albumin; glucose; erythrocytes; ketones; leukocytes
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Slide 2
Figure 10-2
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
Coronal section through right kidney.
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Slide 3
Figure 10-3
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
The nephron unit.
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Slide 4
Urine Formation
• 3 Phases of Urine Formation

Filtration
• Of water and blood products occurs in glomerulus of
Bowman’s capsule

Reabsorption
• Water, glucose, and necessary ions back into blood
(primarily done in proximal/distal convoluted tubules
and Henle’s loop)

Secretion
• Certain ions, nitrogenous waste and drugs (primarily
distal convoluted tubule); this is the reverse of
reabsorption; substances move from blood to filtrate
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Slide 5
Hormonal Influence
• Increased fluid loss (hemorrhage, vomiting, diarrhea,
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•
•
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etc.=hypotension
Decreases amount of filtrate produced by kidneys
Posterior pituitary releases ADH
ADH causes nephrons to increase rate of water
reabsorption
This causes water to return to bloodstream thus
raising BP and urine to be concentrated
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Slide 6
Overview of Anatomy and
Physiology
• Ureters (two)

Passageway for urine from the kidneys to the urinary
bladder
• Urinary bladder (one)

Temporary storage pouch for urine
• Urethra (one)

Carries urine by peristalsis from the urinary bladder
out to its external opening
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Slide 7
Figure 10-5
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
The male urinary bladder, cut to show the interior.
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Slide 8
Laboratory and Diagnostic
Examinations
• Urinalysis (most common urologic study)
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Blood urea nitrogen (BUN)
Blood creatinine
Creatinine clearance
Prostate-specific antigen (PSA)
Osmolality
Kidney-ureter-bladder radiography (KUB)
Intravenous pyelogram (IVP)
Retrograde pyelography
Voiding cystourethrography
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Slide 9
Laboratory and Diagnostic
Examinations
• Endoscopic procedures
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Renal angiography
Renal venogram
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Renal scan
Ultrasonography
Transrectal ultrasound
Renal biopsy
Urodynamic studies
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Slide 10
Medication Considerations
• Diuretics to enhance urinary output

Thiazide diuretics
 Loop (or high-ceiling) diuretics
 Potassium-sparing diuretics
 Osmotic diuretics
 Carbonic anhydrase inhibitor diuretics
• Medications for urinary tract infections
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Quinolone
Nitrofurantoin
Methenamine
Fluoroquinolone
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Slide 11
Maintaining Adequate Urinary
Drainage
• Types of catheters

Coudé catheter
 Foley catheter
 Malecot, Pezzer, or mushroom catheters
 Robinson catheter
 Ureteral catheters
 Whistle-tip catheter
 Cystostomy, vesicostomy, or suprapubic catheter
 External (Texas or condom) catheter
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Slide 12
Figure 10-6
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Different types of commonly used catheters.
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Slide 13
Disorders of the Urinary System
• Urinary retention

Etiology/pathophysiology
• The inability to void despite an urge to void

Clinical manifestations/assessment
• Distended bladder
• Discomfort in pelvic region
• Voiding frequent, small amounts
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Slide 14
Disorders of the Urinary System
• Urinary retention (continued)
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Medical management/nursing interventions
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Warm shower or sitz bath
Natural voiding position if possible
Urinary catheter
Surgical removal of obstruction
Analgesics
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Slide 15
Disorders of the Urinary System
• Urinary incontinence
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Etiology/pathophysiology
• Involuntary loss of urine from the bladder
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Total incontinence; dribbling; stress incontinence
• Secondary
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Infection; loss of sphincter control; sudden change in
pressure in the abdomen
• Permanent or temporary
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Slide 16
Disorders of the Urinary System
• Urinary incontinence (continued)

Clinical manifestations/assessment
• Involuntary loss of urine
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Leaking with coughing, sneezing, or lifting
Medical management/nursing interventions
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Treat underlying cause
Surgical repair of bladder
Temporary or permanent catheter
Bladder training
Kegel exercises
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Slide 17
Disorders of the Urinary System
• Neurogenic bladder
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Etiology/pathophysiology
• Loss of voluntary voiding control
• Results in urinary retention or incontinence
• Lesion of the nervous system that interferes with normal
nerve conduction to the urinary bladder
• Two types
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Spastic
Flaccid
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Slide 18
Disorders of the Urinary System
• Neurogenic bladder (continued)
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Clinical manifestations/assessment
• Infrequent voiding
• Incontinence
• Diaphoresis, flushing, nausea prior to reflex
incontinence
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Medical management/nursing interventions
• Antibiotics; urecholine
• Intermittent catheterization
• Bladder training
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Slide 19
Disorders of the Urinary System
• Urinary tract infections
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Etiology/pathophysiology
• Type depends on location
• Pathogens enter the urinary tract
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Nosocomial infection
Bladder obstruction
Insufficient bladder emptying
Decreased bactericidal secretions of the prostate
Perineal soiling in females
Sexual intercourse
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Slide 20
Disorders of the Urinary System
• Urinary tract infections (continued)
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Clinical manifestations/assessment
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Urgency; frequency; burning on urination
Nocturia
Abdominal discomfort; perineal or back pain
Cloudy or blood-tinged urine
Medical management/nursing interventions
• Pharmacological management
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Antibiotics; urinary antiseptics/analgesics
• Encourage fluids
• Perineal care
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Slide 21
Obstructive Disorders of the
Urinary System
• Urinary obstruction
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Etiology/pathophysiology
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Strictures; kinks
Cysts; tumors
Calculi
Prostatic hypertrophy
Clinical manifestations/assessment
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Continuous need to void
Voiding small amounts frequently
Pain
Nausea
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Slide 22
Obstructive Disorders of the
Urinary System
• Urinary obstruction (continued)
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Medical management/nursing interventions
• Establish urinary drainage
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Indwelling catheter
Suprapubic cystostomy
Ureterostomy
Nephrostomy
• Pharmacological management
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Pain relief
o Narcotics
o Anticholinergics
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Slide 23
Obstructive Disorders of the
Urinary System
• Hydronephrosis
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Etiology/pathophysiology
• Dilation of the renal pelvis and calyces
• Unilateral or bilateral
• Obstruction of the urinary tract
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Clinical manifestations/assessment
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•
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Dull flank pain (slow onset)
Severe stabbing pain (sudden onset)
Nausea and vomiting
Frequency, dribbling, burning, and difficulty starting
urination
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Slide 24
Obstructive Disorders of the
Urinary System
• Hydronephrosis (continued)
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Medical management/nursing interventions
• Pharmacological management
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Antibiotics
Narcotic analgesics
• Surgery to relieve obstruction
• Nephrectomy
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Severely damaged kidney
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Slide 25
Obstructive Disorders of the
Urinary System
• Urolithiasis
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Etiology/pathophysiology
• Formation of urinary calculi (stones)
• Develops from minerals
• Identified according to location
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Nephrolithiasis; ureterolithiasis; cystolithiasis
Clinical manifestations/assessment
• Flank or pelvic pain
• Nausea and vomiting
• Hematuria
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Slide 26
Obstructive Disorders of the
Urinary System
• Urolithiasis (continued)
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Medical management/nursing interventions
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Antibiotics
Encourage fluids
Ambulate
STRAIN ALL URINE
Surgical procedures

Cystoscopy; ureterolithotomy; pyelolithotomy;
nephrolithotomy
• Lithotripsy
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Slide 27
Figure 10-7
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)
Location and methods of removing renal calculi from upper urinary tract.
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Slide 28
Renal Tumors
• Etiology/pathophysiology
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Adenocarcinomas that develop unilaterally
Renal cell carcinomas arise from cells of the proximal
convoluted tubules
• Clinical manifestations/assessment
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Early: Intermittent painless hematuria
Late
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Weight loss
Dull flank pain
Palpable mass in flank area
Gross hematuria
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Slide 29
Renal Tumors
• Medical management/nursing interventions
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Radical nephrectomy
Radiation
Chemotherapy
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Slide 30
Renal Cysts
• Etiology/pathophysiology
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Cysts form in the kidneys
Polycystic kidney disease
• Cysts cause pressure on the kidney structures and
compromise function
• Clinical manifestations/assessment
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Abdominal and flank pain
Voiding disturbances
Recurrent UTIs
Hematuria
Hypertension
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Slide 31
Renal Cysts
• Medical management/nursing interventions
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No specific treatment
Pharmacological management
• Analgesics
• Antibiotics
• Antihypertensives
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Relieve pain
Heat (unless bleeding)
Dialysis
Renal transplant
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Slide 32
Tumors of the Urinary Bladder
• Etiology/pathophysiology
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Most common site of cancer in the urinary tract
Range from benign papillomas to invasive carcinoma
• Clinical manifestations/assessment
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Painless intermittent hematuria
Changes in voiding patterns
• Medical management/nursing interventions
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Localized—remove tissue by burning
Invasive lesions—partial or total cystectomy
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Slide 33
Conditions Affecting the Prostate
Gland
• Benign prostatic hypertrophy
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Etiology/pathophysiology
• Enlargement of the prostate gland
• Common in men 50 years old and older
• Cause is unknown
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Slide 34
Conditions Affecting the Prostate
Gland
• Benign prostatic hypertrophy (continued)
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Clinical manifestations/assessment
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Frequent urination
Difficulty starting urination
Dysuria
Frequent UTIs
Hematuria
Oliguria
Nocturia
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Slide 35
Conditions Affecting the Prostate
Gland
• Benign prostatic hypertrophy (continued)
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Medical management/nursing interventions
• Relieve obstruction—Foley catheter
• Prostatectomy
• Postoperative
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TURP
o Bladder irrigations
o Urine will be pink to cherry red
Suprapubic or abdominal
o Assess dressings
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Slide 36
Conditions Affecting the Prostate
Gland
• Cancer of the prostate
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Etiology/pathophysiology
• Malignant tumor of the prostate gland
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Clinical manifestations/assessment
• Initially
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No symptoms
• Advanced stages
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Urinary obstruction
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Slide 37
Conditions Affecting the Prostate
Gland
• Cancer of the prostate (continued)
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Medical management/nursing interventions
• Localized: radiation and/or surgery
• Men over 70 years old: Radiation and hormone therapy
• Advanced
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Estrogen therapy
Orchiectomy
Radiation therapy
Chemotherapy
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Slide 38
Urethral Strictures
• Etiology/pathophysiology
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Narrowing of the lumen of the urethra that interferes
with urine flow; congenital or acquired
• Clinical manifestations/assessment
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Dysuria; nocturia
Weak urinary stream
Pain with bladder distention
• Medical management/nursing interventions
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Correction of stricture
Analgesics
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Slide 39
Urinary Tract Trauma
• Urinary tract trauma
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Etiology and pathophysiology
• Injury to the urinary tract may result from accidents,
surgical intervention, and fractures
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Clinical manifestations
• Hematuria
• Abdominal pain and tenderness
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Medical management/nursing interventions
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Slide 40
Immunological Disorders of the
Kidney
• Nephrotic syndrome
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Etiology/pathophysiology
• Physiologic changes of the glomeruli interfere with
selective permeability
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Clinical manifestations/assessment
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Proteinuria; hypoalbuminemia
Generalized edema
Anorexia
Fatigue
Oliguria
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Slide 41
Immunological Disorders of the
Kidney
• Nephrotic syndrome (continued)
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Medical management/nursing interventions
• Pharmacological management
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Corticosteroids
Diuretics
• Diet
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Low sodium
High protein
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Slide 42
Immunological Disorders of the
Kidney
• Nephritis (acute glomerulonephritis)
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Etiology/pathophysiology
• Previous infection with β-hemolytic streptococcus
(2-3 weeks prior)
• Preexisting multisystem diseases
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Slide 43
Immunological Disorders of the
Kidney
• Nephritis (acute glomerulonephritis) (continued)

Clinical manifestations/assessment
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Edema of the face
Pallor
Malaise
Anorexia
Dyspnea with exertion
Hematuria
Changes in voiding patterns
Oliguria; dysuria
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Slide 44
Immunological Disorders of the
Kidney
• Nephritis (acute glomerulonephritis) (continued)
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Medical management/nursing interventions
• Pharmacological management
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Antibiotics
Diuretics
Antihypertensives
• Supportive management
• Diet
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
Protein and sodium restrictions
Increase calories
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Slide 45
Immunological Disorders of the
Kidney
• Nephritis (chronic glomerulonephritis)
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Etiology/pathophysiology
• Slow, progressive destruction of glomeruli
• Commonly caused by other chronic illnesses
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
Diabetes mellitus
Systemic lupus erythematosus
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Slide 46
Immunological Disorders of the
Kidney
• Nephritis (chronic glomerulonephritis) (continued)
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Clinical manifestations/assessment
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Malaise; morning headaches
Dyspnea with exertion
Visual and digestive disturbances
Generalized edema
Weight loss
Fatigue
Hypertension
Anemia
Proteinuria
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Slide 47
Immunological Disorders of the
Kidney
• Nephritis (chronic glomerulonephritis) (continued)

Medical management/nursing interventions
• Same as acute glomerulonephritis
• Renal dialysis
• Kidney transplant
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Slide 48
Renal Failure
• Acute renal failure
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Etiology/pathophysiology
• Kidney function altered
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Interference with ability to filter blood
Decrease in blood flow to the kidney
• Three phases
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Oliguric phase
Diuretic phase
Recovery phase
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Slide 49
Renal Failure
• Acute renal failure (continued)

Clinical manifestations/assessment
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Anorexia
Nausea
Vomiting
Edema
Dry mucous membranes
Poor skin turgor
Urine output less than 400 mL/24 hours (oliguric phase)
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Slide 50
Renal Failure
• Acute renal failure (continued)

Medical management/nursing interventions
• Pharmacological management
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•
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Diuretics
Antibiotics
Kayexalate
Administer fluids
Assess for and treat electrolyte imbalances
Dialysis
Diet: High in carbohydrates; low in protein, potassium,
and sodium
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Slide 51
Renal Failure
• Chronic renal failure

Etiology/pathophysiology
•
•
•
•
End-stage renal failure
Kidneys are unable to regain normal function
Develops slowly over an extended period of time
Result of kidney disease or other disease process that
compromises renal blood flow
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Slide 52
Renal Failure
• Chronic renal failure (continued)

Clinical manifestations/assessment
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Headache
Lethargy; decreased strength
Anorexia
Pruritus
Anuria
Muscle cramps or twitching
Dusky yellow-tan or gray skin color
Disorientation and mental lapses
Anemia
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Slide 53
Renal Failure
• Chronic renal failure (continued)

Medical management/nursing interventions
•
•
•
•
Dialysis
Renal transplant
Medications to treat symptoms
Diet: High in calories; restricted protein,
potassium, and sodium
• Restricted fluids

300 to 600 mL above urine output
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Slide 54
Care of the Patient Requiring
Dialysis
• A medical procedure for the removal of certain
elements from the blood through a semi-permeable
membrane (external or peritoneum)
• Mimics kidney function
• Two types
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
Hemodialysis
Peritoneal dialysis
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Slide 55
Surgical Procedures for Urinary
Disorders
•
•
•
•
Nephrectomy
Nephrostomy
Kidney transplantation
Urinary diversion


Ileal conduit
Continent ileal urinary reservoir or Kock pouch
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Slide 56
Figure 10-12
(From Belcher, A.E. [1992]. Cancer nursing. St. Louis: Mosby.)
Renal transplantation.
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Slide 57
Figure 10-13
Ileal conduit or ileal loop.
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Slide 58
Figure 10-14
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. (13th ed.). St. Louis: Mosby.)
Kock pouch.
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Slide 59
Nursing Process
• Nursing diagnoses
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Urinary elimination, impaired
Tissue perfusion: renal, ineffective
Pain, acute and chronic
Infection, risk for
Fluid volume excess
Sexuality patterns, ineffective
Knowledge, deficient
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Slide 60
Chapter 15
Cardiovascular and Renal Medications
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
61
Chapter 15
Lesson 15.1
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
62
Learning Objectives



Identify the approved way to give different
forms of antianginal therapy
Discuss the uses and general actions of
cardiac drugs used to treat dysrhythmias
Describe the common treatment for various
types of lipoprotein disorders
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
63
Urinary System
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
64
Chapter 15
Lesson 15.2
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
65
Learning Objectives



List the general uses and actions of
cardiotonic drugs
Explain the actions of different categories of
drugs used to treat hypertension
Identify indications for electrolyte replacement
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
66
Antihypertensives, Diuretics, and Other
Drugs Affecting the Urinary Tract
Diuretics
 Indirectly reduce blood pressure by producing
sodium and water loss and lowering the tone
or rigidity of the arteries
 Types



Thiazide and sulfonamide diuretics
Loop diuretics
Potassium-sparing diuretics
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
67
Antihypertensives, Diuretics, and Other
Drugs Affecting the Urinary Tract (cont.)
Adrenergic Inhibitors
 Beta-adrenergic blockers



Central adrenergic inhibitors


Nonselective; block beta1 and beta2 sites
Selective; block beta1 sites
Cause vascular relaxation and lower blood
pressure
Peripheral adrenergic antagonists

Limit norepinephrine release, prevent
vasoconstriction
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68
Antihypertensives, Diuretics, and Other
Drugs Affecting the Urinary Tract (cont.)

Alpha1-adrenergic inhibitors


Lower peripheral resistance and blood pressure
Combined alpha- and beta-adrenergic blockers
Angiotensin-Related Agents


Angiotensin-converting enzyme inhibitors
Angiotensin II receptor antagonists
Vasodilators
Calcium Channel Blocking Agents
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69
High Blood Pressure



Stage I: Lifestyle Changes
Stage II: Drug Therapy
Adverse Reactions


Drug specific
Drug Interactions
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70
Drugs Useful in Treating Urinary
Problems

Urinary incontinence


Benign prostatic hyperplasia


Treatment: anticholinergics/antispasmodics, alphaadrenergic agonists, estrogens, cholinergic agonists,
and alpha-adrenergic antagonists
Treatment: alpha1-adrenergic receptor blockers
Analgesia

Treatment: phenazopyridine
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71
Williams' Basic Nutrition & Diet
Therapy
14th Edition
Chapter 21
Kidney Disease
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72
Lesson 21.1: Kidney Anatomy,
Physiology, and Disease


Kidney disease interferes with the normal capacity of
nephrons to filter waste products of metabolism.
Short-term kidney disease requires basic nutrition
support for healing rather than dietary restriction.
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73
Introduction (p. 425)





100,000 Americans diagnosed with end-stage renal
disease each year
84,000 die per year
Reduced kidney function often undiagnosed
Requires extensive medical nutrition therapy
Dialysis extends lives but carries high costs
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74
Basic Structure and Function of
the Kidneys (p. 425)


Kidneys filter about 1.2 L of fluid per minute
Structures

Nephron
• Glomurulus: cluster of capillaries filters the blood
• Tubules: carries filtered fluid to kidney medulla
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75
Basic Structure and Function of
the Kidneys (cont’d) (p. 427)
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76
Tubules (p. 426)




Proximal tubule: reabsorbs needed nutrients and
returns them to blood
Loop of Henle: exchanges sodium, chloride, water
Distal tubule: secretes hydrogen ions as needed
Collecting tubule: produces concentrated urine
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77
Function (p. 427)

Excretory and regulatory functions




Filtration: removes most particles from blood
except proteins and RBCs
Reabsorption: substances body needs are
reabsorbed and returned to blood
Secretion: additional hydrogen ions secreted as
needed to maintain acid-base balance
Excretion: waste materials excreted in
concentrated urine
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78
Endocrine Functions (p. 428)



Renin secretion: maintains hormonal control of body
water balance
Erythropoietin secretion: stimulate RBC production
within bone marrow
Vitamin D activation: converts inactive form to final
active vitamin D
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79
Disease Process and Dietary
Considerations (p. 428)

General causes of kidney disease




Infection and obstruction: bladder infections,
kidney stones
Damage from other diseases: diabetes mellitus,
hypertension
Toxins: environmental agents, animal venom,
certain plants, heavy metals, drugs
Genetic or congenital defects: cystic diseases,
congenital abnormalities
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80
General Causes of Kidney
Disease (p. 428)

Risk factors



Diabetes, hypertension, CVD
Older than 60, smoke, obese
Family history of kidney disease
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81
Case Study

Mrs. Hendricks is a 65-year-old female who has poor
glycemic control with her Type 2 diabetes of 32
years, hypertension, and smokes 1 pack of cigarettes
per day. Her most recent glomerular filtration rate is
22 mL/min.
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82
Case Study (cont’d)

What are Mrs. Hendrick’s risk factors for chronic
kidney disease (CKD)?
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83
Case Study (cont’d)

What clinical assessment parameters would be
useful to find out from Mrs. Hendricks?
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84
Medical Nutrition Therapy in
Kidney Disease (p. 429)

Based on the nature of the disease process
and individual responses



Length of disease: acute or chronic
• Long term: more specific nutrient modifications
Degree of impaired renal function
• Extensive: extensive nutrition therapy required
Individual clinical symptoms
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85
Nephron Diseases (p. 429)

Acute glomerulonephritis or nephritic
syndrome



Disease process: affects glomeruli
Clinical symptoms: hematuria, proteinuria,
possible edema, mild hypertension
Medical nutrition therapy: diet modifications
usually not crucial
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86
Nephrotic Syndrome (Nephrosis)
(p. 430)


Disease process: nephron tissue damage allows
protein to pass into tubule
Clinical symptoms: hypoalbuminemia, edema,
ascites, distended abdomen, reduced plasma protein
level
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87
Nephrotic Syndrome (Nephrosis)
(cont’d) (p. 430)

Medical nutrition therapy:

Protein: moderate
 Energy: adequate to support nutrition status
 Sodium, potassium: restricted and monitored
 Calcium, phosphorus: 1 to 1.5 g/day calcium,
maximum 12 mg/day phosphorus
 Fluid: restricted according to output and losses
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88
Lesson 21.2: Treatment of
Kidney Disease


The progressive degeneration of chronic kidney
disease requires dialysis treatment and nutrient
modification according to individual disease status.
Current therapy for kidney stones depends more on
basic nutrition and health support for medical
treatment than on major food and nutrient
restrictions.
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89
Kidney Failure (p. 431)

Acute kidney injury

Disease process
• Prerenal: inadequate blood flow to kidneys and
subsequent reduced GFR
• Intrinsic: damage to a part of the kidney
• Postrenal obstruction: obstruction of urine flow
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90
Acute Kidney Injury (p. 431)

Clinical symptoms: RIFLE classification
system assesses severity of:

Risk
 Injury
 Failure
 Loss
 End-stage kidney disease
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91
Acute Kidney Injury (cont’d)
(p. 431)

Medical nutrition therapy


Basic objective: improve or maintain nutrition
status
Principle: prevent protein catabolism, electrolyte
and hydration disturbance, acidosis, uremic
toxicity
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92
Chronic Kidney Disease (CKD)
(p. 432)

Disease process:


Progressive breakdown of kidney tissue
Most often results from
• Primary glomerular disease
• Metabolic diseases with kidney involvement
• Inherited diseases
• Other causes: immune diseases, obstruction, infection,
hypertension
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93
Clinical Symptoms (p. 433)






Water balance: large amounts of dilute urine
Electrolyte balance: metabolic acidosis
Nitrogen retention
Anemia
Hypertension
Azotemia
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94
General Signs and Symptoms
(p. 433)





Progressive weakness
Shortness of breath
General lethargy
Fatigue
Possible thirst, anorexia, weight loss, diarrhea,
vomiting
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95
Medical Nutrition Therapy
(p. 433)


Basic objectives: monitor at regular intervals
Principles






Protein: generally limited to .0 to 0.8 g/kg body weight
Energy: 35 kcal/day for those under 60 with GFR less than
25 ml/min
Sodium/potassium: may be restricted
Phosphorus/calcium: phosphorus may be restricted, calcium
1.0 to 1.5 g/day
Vitamins/minerals: help patients meet needs for B-complex
vitamins and vitamin C
Fluid: intake balanced with output
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96
Case Study (cont’d)

Mrs. Hendricks is in what stage of chronic kidney
disease?
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97
Case Study (cont’d)

Outline appropriate medical nutrition therapy plan of
care for Mrs. Hendricks.
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98
End-Stage Renal Disease
(p. 434)

Disease process



Patient, family, physician face life-support
decisions
Irreversible damage to majority of nephrons
Options are long-term dialysis for kidney
transplant
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99
Hemodialysis (p. 434)



Artificial kidney machine removes toxins and
restores metabolites and nutrients
Three to six treatments per week
Medical nutrition therapy





Protein: major concern of patients on dialysis
Energy: 35 kcal/day for patients <60 years
Sodium/potassium: may be restricted
Phosphorus/calcium: monitored and limited
Vitamins/minerals: achieve the DRI
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100
Peritoneal Dialysis (p. 437)



About 6% of patients
Exchange of fluids occurs within the body,
allows mobility
Medical nutrition therapy




Protein: increased slightly
Energy: maintain lean body weight
Sodium/potassium: intake slightly more liberal
Phosphorus/calcium, vitamins/minerals: same as
for hemodialysis
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101
Peritoneal Dialysis (cont’d)
(p. 437)
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102
Transplantation (p. 438)




Improves quality of life and survival
More cost effective than maintenance dialysis
Waiting lists can be long
Donor matches difficult to find
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103
Transplantation (cont’d) (p. 439)

Transplantation


Complications: bone disorders, malnutrition,
anemia, hormonal and blood pressure
imbalances, depression, reduced quality of life
Nutrition support: enteral or parenteral feedings
customized to dialysis
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104
Transplantation (cont’d) (p. 439)

Osteodystrophy



Bone disease and disorders common with CKD
Decreased activation of vitamin D has cascade
effect
Neuropathy


Central and peripheral disturbances common at
initiation of dialysis
Patients should be periodically assessed
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105
Kidney Stone Disease (p. 442)




Basic cause is unknown
Factors relating to urine or urinary tract
environment contribute to formation
Present in 5% of U.S. women and 12% of
U.S. men
Major stones are formed from one of three
substances:

Calcium
 Struvite
 Uric acid
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106
Calcium Stones (p. 442)




Most common type: 80% of cases
High levels of urinary oxalate
Long-term megadosing of vitamin C
Dietary calcium intake inversely related to stones
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107
Struvite Stones (p. 442)




10% of all stones
Caused primarily by urinary tract infection
No diet therapy
Usually surgically removed
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108
Uric Acid Stones (p. 443)



Caused by impairment of purine metabolism
with some diseases
Account for 9% of stones
Other stones

Due to inherited disorders or complications of
medications
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109
Clinical Symptoms and Medical
Nutrition Therapy (p. 443)

Clinical symptoms




Severe pain
Urinary symptoms
Weakness, fever
Medical nutrition therapy






Protein: no more than DRI
Calcium: normal calcium intake
Sodium: no more than 2300 to 3450 mg/day
Oxalates: avoid
Vitamins/minerals: limit to DRI
Fluid: high intake
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110
Objectives Specific to Type of
Stone (p. 444)



Calcium stones: reduce dietary intake of stone
constituents, consider fiber intake
Uric acid stones: raise urinary pH, maintain healthy
weight, limit animal protein
Cystine stones: reduce intake of cystine and dilute
urine
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111