RENAL GUD I slide power point presentation

Urinary system

1. REVIEW OF A & P OF URINARY SYSTEM

2. Urinary system is main excretory system Consists up of: 2 kidneys, which secrete urine 2 ureters transport urine U rinary bladder, collects & stores urine Urethra excretes urine

3. Functions of the kidneys Formation of urine Maintaining water, electrolyte & acid–base balance Excretion of waste products Production and secretion of erythropoietin Production and secretion of renin

4. Kidney Lie on the posterior abdominal wall , Extends from T12 to L13 Right kidney slightly lower than left S urrounding by a fibrous capsule Has a cortex & inner medulla Hilum concave medial border

5. End of renal pyramids are renal papilla M inor calyces merge into major calyx Major calyces forms renal pelvis Renal pelvis, narrows to become ureter Blood supply renal artery, drainage renal vein

6. Functions of the urine Formation of urine Water and electrolyte balance Excretion of waste products Regulation of acid base balance Regulation of BP Regulation of RBC production

7. RENAL GENITO URINARY SYSTEM ASSESSMENT

8. Objectives By the end of this module the leaner should: Perform assessment of the renal system Manage disorders of the kidney using the nursing process Manage the disorders of the ureters, urinary bladder and urethra using the nursing process

9. Assessment of renal system History taking Chief complains History of presenting complains Past medical history Family social history Gynecological history

10. Ct… Physical examination Inspection Auscultation Percussion Palpation

11. Diagnostic evaluation Urinalysis & urine culture Culture & sensitivity Colour & clarity Odor PH Specific gravity

12. Presence of glucose, protein,WBCS pus Microscopic examination of sediments Osmolality Renal function test Evaluates the severity of the disease Status of kidney function

13. Lab studies on blood Detects kidney disorders They include: Serum creatinine levels Serum osmolality Calcium levels

14. Phosphorus levels Magnesium levels Albumin levels Tissue studies – Renal biopsy Radiological studies KUB (Kidney, Ureter, Bladder studies) – X-ray

15. Renal Ultrasonography, CT scan, & MRI Retrograde pyelogram Renal angiography/arteriography Intravenous pyelography Anterograde pyelogram

16. CONDITIONS OF GUD

17. Common Signs & Symptoms ■ Pain ■ Enuresis ■ Urgency ■ Nocturia ■ Hesitancy ■ Oliguria ■ Incontinence ■ Hematuria ■ Frequency of micturition

18. GLOMERULONEPHRITIS Definition Its inflammation of the glomerular capillary membranes as a result of antigen-antibody reaction

19. Classified as acute and chronic Acute glomerulonephritis Causes Streptococcal infections Hepatitis B, mumps Varicella zoster virus, HIV

20. Drugs Foreign serum Immunologic reaction - Kidney tissue itself Acute viral infections like; URTI

21. Pathophysiology Antigen antibody complexes deposition in glomerulus Activation of immune system Macrophages are released Lysozyme released damages capillaries ↑ permeability leakage of large substances With healing fibrosis occur

22. Clinical features History of preceding episode of pharyngitis or tonsillitis Hematuria Edema pitting, puffiness of the face Proteinuria Reduced glomerular filtration rate(GFR) Back pain, Flank pain

23. Azotemia Hypertension Malaise & Headache In severe cases Hypoproteinemia , Convulsions Hyperlipidemia , Decreased urinary output

24. Diagnosis History taking; PE Urinalysis – RBCS, increased WBC, proteinuria Blood urea and nitrogen - elevated Throat swab to r/o streptococcus infection Renal ultra-sound scan Renal biopsy – for definite diagnosis

25. Management Aim of management To preserve kidney functions Treat symptoms Treat complications

26. Admit patient in ward Offer bed rest Dietary therapy Vital sign monitored especially BP Daily weight intake Input output monitoring

27. Educate patient on disease process Ensure proper hygiene Medical management Antibiotic ,penicillin Corticosteroids; Immunosuppressant Loop diuretics; Antihypertensive

28. Complications Heart failure Pulmonary edema End stage renal failure

29. Chronic glomerulonephritis Repeated attacks of acute glomerulonephritis Pathophysiology Repeated attacks – arteriole hardening Kidney reduce to 1/5 normal size Kidney surface becomes rough & irregular Severe glomerular damage – ESRD

30. Clinical manifestations Hypertension Increased BUN & Creatinine level Cardiomegaly Distended neck veins Dx. hard ECG

31. Management Hypertension Mx. Initiation of dialysis Proteins of ↑ biologic value Complications Hypertension, ESRD Formation of kidney stones

32. Nephrotic syndrome

33. Nephrotic ct…… Definition A disorder that seriously impairs the glomerular capillary membrane resulting in increased permeability to protein/albumin with no altered kidney function

34. Etiology Chronic glomerulonephritis S ystemic disease Drugs Allergy Renal vein thrombosis Diabetes emlitus

35. Pathophysiology Damaged glomerular capillary membrane Loss of plasma proteins Hypoalbuminemia – decreased oncotic pressure Stimulates lipoprotein synthesis – hyperlipidemia Generalized edema sets in Activation of renin–angiotensin system

36. Clinical manifestations Soft and pitting edema Hyperlipidemia Acute renal failure Headache Fatigue & Malaise Ascites

37. Diagnosis Urinalysis Urea and electrolytes Serum cholesterol Full hemogram Needle biopsy of the kidney Renal U/S

38. Management Nursing Management Early stages Mx as AGN Worse condition Mx. as CRF Reduce proteins & cholesterol Spironolactone 25-200mg daily ACE inhibitors

39. Complications Infection – due to low immunity Thromboembolism – especially renal vein Pulmonary embolism Acute renal failure due to hypovolemia Accelerated atherosclerosis due to hyperlipidemia

40. RENAL FAILURE

41. Renal failure Definition It’s a condition which results when the kidneys cannot remove the body’s metabolic wastes or perform their regulatory functions

42. There is acute and chronic RF Acute renal failure/Acute kidney injury Definition It’s a reversible condition where there is s udden and almost complete loss of kidney function for hours or days

43. Cause/Classification of ARF Pre-renal causes impaired blood flow Prompt reversal, improves kidney function Hypoperfusion is caused by: Severe bleeding GIT losses (D &V)

44. Impaired cardiac performance Severe burns Vasodilation (sepsis or anaphylaxis ) Renal loses (diuretics) Intrarenal causes Due to parenchymal damage

45. Intrarenal ARF results from: Burns Crush injuries, trauma Severe transfusion reactions Medications

46. Post renal causes of ARF Obstruction distal to the kidney Obstruction may be caused by: Calculi ( Tumors; Benign prostatic hyperplasia Strictures; Blood clots; Blocked catheter Neurogenic bladder; Trauma

47. Phases of acute renal failure There are four clinical phases of ARF Initiation/onset phase Begins with the initial insult ↓ Renal blood flow & tissue oxygenation ↓ Urinary output

48. Oliguric/ anuric phase ↑ Serum concentration of substances Urinary output below400ml/day Electrolyte imbalance, acidosis Hyperkalemia & fluid overload Lasts for 10-20 days

49. Diuretic phase Gradual ↑ in urinary output Kidney function still abnormal Observe pt. for dehydration Recovery phase Decreased edema

50. Normalization of fluid and electrolyte balance Return of GFR to normal Lab values return to normal Takes 3-12 months

51. Pathophysiology Reduction in blood flow Reduction in o2 &nutrients supply Ischemia results Antiregulatory mechanisms of the kidney Ischemia leads to cell necrosis Cells slough off, blocks tubules

52. Clinical Manifestations Persistent N,V, and diarrhea CNS - drowsiness, headache, muscle twitching, & seizures Oliguria (0.5-1ml/kg/ hr ) Anuria (<1ml/kg/day ) Pallor Edema

53. Hypertension Uremic encephalopathy Fluid overload - CCF, pulmonary edema Hyperkalemia Metabolic acidosis Increased respiration

54. Assessment and diagnosis Urinalysis – low specific gravity Ultrasonography, MRI or CT scan BUN & creatinine – Elevated Blood analysis Blood sugar

55. Management Medical Mx. Adjust medication dosages If well hydrated give furosemide Bicarbonate 1-2 mmol /l over 1 hour Antihypertensive

56. Erythropoietin 2,000-4,000 IU twice a week Iron supplements Calcium supplements Antidepressant agents

57. Nursing management Weigh the patient daily High biological value proteins Restrict diet containing K & P Manage fever and infection Skin care Dialysis & Psychological therapy

58. Chronic renal failure (End-Stage Renal Disease) Definition 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

59. Causes Systemic diseases, such as; DM - leading cause) Hypertension Chronic glomerulonephritis Pyelonephritis Obstruction of the urinary tract

60. Hereditary lesions, as in polycystic kidney disease Vascular disorders Infections Medications; or toxic agents Environmental and occupational agents

61. Clinical manifestations Acidosis Hyperkaliemia E levated blood urea E levated serum creatinine P ulmonary edema Hypertension

62. Pericarditis and cardiac tamponade Heart failure E ncephalopathy A nemia

63. Stages of Chronic Renal Disease Stage I: Reduced renal reserve 40% to 75% loss of nephron function No symptoms Stage 2: Renal insufficiency 75% to 90% of nephron function is lost ↑ Serum creatinine & BUN

64. Inability to concentrate urine Polyuria and nocturia sets in Stage 3 End-stage renal disease (ESRD ) < 10 % nephron function remaining Kidney functions severely impaired D ialysis is usually indicated

65. Management Goal is to maintain kidney function & homeostasis Nursing management Nutritional therapy Protein restricted Restriction of potassium Calories are supplied

66. Regulation of fluid intake Vitamin supplementation Monitor urine output Treat hypertension Patient teaching

67. Medical management Antihypertensive Erythropoietin 2,000-4,000 IU twice a week Iron supplements Phosphate-binding agents Calcium supplements

68. Dialysis Definition It’s the procedure used to correct fluid and electrolyte imbalances and remove waste product

69. Indications R ising level of serum potassium Fluid overload Impending pulmonary edema Increasing acidosis Pericarditis Severe confusion

70. To remove certain medications Uremic convulsions Persistent dyspnea V omiting and restlessness

71. Methods of therapy include: Hemodialysis C ontinuous renal replacement therapy ( CRRT) P eritoneal dialysis

72. Hemodialysis Consists of : Dialyzer – A rtificial kidney Dialysate – solution with all

73. Principles of hemodialysis Diffusion Removes toxins & wastes from blood Move from ↑ conce. to ↓ concentration Large molecules do not pass

74. Osmosis Removes excess water from blood Water moves from ↑ s olute concentration to ↓ Ultrafiltration Water moving from ↑ pressure to ↓ pressure N egative pressure or suctioning force is required

75. Anticoagulant heparin is administered Hemodialysis requires 5 things Access to patient’s circulation (via fistula) Access to dialysis machine The appropriate solution (dialysate bath) Time – 12 hours each week

76. Place – at home or at a dialysate center Hemodialysis requirements Dialyzer/artificial kidney Its an artificial kidney Act as semi-permeable membrane Blood & dialysate flow in opposite direction

77. Cleansed blood is returned to the body Dialysate Solution used to clean blood Consists of electrolytes Vascular access Allows blood to be removed

78. C leansed and returned Types of access Venous catheter Tube is inserted in the veins Double-lumen catheter is inserted Removed when necessary

79. Not ideal for long-term use Fistula M ore permanent access J oin an artery to a vein Takes 4 to 6 weeks to mature

80. Graft S ynthetic graft material inserted btn an artery & vein Indications Patient’s vessels not suitable

81. Process of hemodialysis Patients circulation is accessed H eparin is administered Arterial blood pumped to dialyzer F lows through semipermeable membrane Dialysate flows in & around the tubules W aste products in blood diffuse into dialysate

82. Solute waste is discarded Ultrafiltration removes excess water

83. Continuous renal replacement therapies Does not require dialysis machines A hemofilter is used Continuous Arteriovenous Hemofiltration (CAVH ) Blood flows from an artery to a hemofilter F emoral and venous arteries are used filtered blood returns through venous catheter

84. Administer IV fluids Ultrafiltrate collected measured & discarded Continuous Arteriovenous Hemodialysis (CAVHD) As CAVH though concentration gradient needed Continuous Venovenous Hemofiltration (CVVH) Blood pumped from double-lumen venous catheter

85. N o arterial access is required Continuous Venovenous Hemodialysis (CVVHD)

86. Nursing care before hemodialysis Explain procedure to the patient Obtain an Informed consent Ask the patient to void Check cannula & fistula for patency Reassure the patient Assess patients weight

87. Take vital signs Withhold drugs that pass through dialysis membrane Withhold antihypertensive Restricting dietary protein Restrict fluid intake restrict potassium and sodium -rich food

88. Allow expression of feelings Care after dialysis Check and record vital signs, weight Record the condition of the patient Give medication as ordered Inform on next appointment date

89. Health education for a patient on hemodialysis Care of vascular access Detection of complications Diet

90. Complications of hemodialysis Infection (septicemia) Catheter clotting Central venous thrombosis Stenosis Development of aneurysm Hypotension Muscle cramps Hepatitis

91. Peritoneal dialysis Definition It involves repeated cycles of instilling dialyzing solution into the peritoneal cavity through a catheter

92. Indications Patients: Unable/unwilling to undergo hemodialysis R isk for adverse effects of systemic heparin Lack of vascular access To perform dialysis at home

93. P eritoneal membrane serves as semi permeable membrane Two types of peritoneal dialysis: CAPD (Continuous ambulatory peritoneal dialysis) APD (Automated peritoneal dialysis )

94. CAPD Happens throughout the day 1.5 – 3 liters is used in each session (4) No machine is required APD Dialysate is changed by a machine

95. It takes 8-12 hours 10-15 liters of dialysate is connected Care before peritoneal dialysis Discuss with the physician on the: Concentration of dialysate Medications to be added

96. Process of peritoneal dialysis Dialysate infused by gravity – peritoneal cavity Drainage complete in 10 - 30 minutes Drainage completed in 10 - 0 minutes Drainage fluid is normally colorless E ntire exchange takes 1 to 4 hours

97. Complications of peritoneal dialysis Exit site infection Peritonitis Abdominal pain Low back pain Protein loss Atelectasis & pneumonia Leakage Bleeding Abdominal hernias