Urinary system disorders.pptx1

Objectives:After 12 hrs. varied teaching learning activities, the students should:Review the anatomy and physiology of the urinary system.Explain the role of the urinary system in maintaining homeotasis.Identify abnormal findings that may indicate impairment of the urinary system.Implement appropriate nursing management techniques for patients with urinary and kidney problemUse the nursing process as framework, for the care of patients undergoing surgery.Demonstrate compassion when caring for patients with Urinary system problem

Anatomy of the KidneyCup-like that collects its urine

The NephronBasic structural and functional unit of kidney

AMOUNT AND COMPOSITION OF BODY FLUIDS60% of adult’s weight – fluids and electrolytes.FACTORS THAT INFLUENCE THE AMOUNT OF BODY FLUIDAge MedicationsSurgery StressIllness DietGenderBody FatClimate

2 FLUID COMPARTMENTSIntracellular – 2/3 of body fluids in the skeletal muscle massExtracellularIntravascular – contains plasma - 3L of the 6L of blood volumeInterstitial – fluids that surrounds the cell = 11–12 LTranscellular– contains approximately 1L of fluid. Ex. CSF, pericardial, synovial, intraocular, pleural, sweat

FLUID INTAKEFluid requirement/day- 2,500 mLAve. adult drinks 1,500 mL/dayRemaining 1,000 mL is preformed water.Thirst is triggered by:Intracellular dehydrationExcess angiotensin II (potent vasoconstrictor)Hemorrhage

ROUTES OF GAINS AND LOSESKidneys – 1-2 L daily urine volume - 1 mL urine/kg/hrSkin – 0-1,000 mL or more/hr (varies) - sensible -insensible – 600 mL/dayLungs – 400 mL/hr

GI tract – 100-200 mL/dayFLUID IMBALANCES2 BASIC TYPESIsotonic – occurs when water and electrolytes are lost and gained in equal proportionsOsmolar – loss or gain of only water4 CATEGORIES OF FLUID IMBALANCEIsotonic loss of water and electrolytes (Fluid volume deficit)Osmolar loss of only water (Dehydration)Isotonic gain of water and electrolytes (fluid volume excess)Osmolar gain of only water (Overhydration)

Formation of UrineTHREE PROCESSES IN URINE FORMATIONGlomerular FiltrationTubular reabsorptionTubular secretionGlomerular Filtration Rate- amount of fluid filtered from the blood into the capsule per minute.120-125 ml/min held constant by instrinsic controlMyogenicReninangiotensin mechanism

CHARACTERISTICS OF NORMAL URINEPale to deep yellow, clearOdor – AromaticSpecific Gravity – 1.001 – 1.030pH- 4.5-8.0Protein – Negative to traceGlucose – NegativeWBC – 0-5 hpfRBC – 0-5/hpfCasts – Negative to occasional

Defects of Genitourinary TractInguinal HerniaHydrocele- fluid in the scrotumPhimosis – narrowing or preputial opening of foreskinHypospadias – urethral opening located behind the glans penisEpispadiasChordee – ventral curvature of penis

UTIa bacterial infection that affects any part of the urinary tract.The most common type of UTI:bladder infection (cystitis).kidney infection (pyelonephritis)Risk FactorsFemale:Short, straight urethraProximity of urinary meatus to vagina and anusSexual intercourseUse of spermicidal compound for birth controlMale:UncircumcizedProstatic hypertrophyRectal intercourseBoth:AgingUrinary tract obstructionNeurogenic bladder dysfunctionVesicoureteral refluxGenetic factorsCatheterization

Symptoms & SignsFor bladder infectionFrequent urination along with the feeling of having to urinate even though there may be very little urine to pass. NocturiaUrethritis: Discomfort or pain at the urethral meatus or a burning sensation throughout the urethra with urination (dysuria). Pain in the midline suprapubic region. PyuriaHematuriaPyrexiaCloudy and foul-smelling urine Some urinary tract infections are asymptomatic

For Kidney InfectionsAforementioned symptoms. EmesisBack, side (flank) or groin pain. Abdominal pain or pressure. Shaking chills and high spiking fever. Night Sweats. Extreme Fatigue.

EpidemiologyMost common in sexually active womenDiabetesanatomical malformations of the urinary tract.AllergiesUse of urinary catheters as bladder wall is coated with various mannosylated proteins, such as Tamm-Horsfall proteins (THP), which interfere with the binding of bacteria to the uroepithelium

CYSTITISPYELONEPHRITISIs inflammation of the urinary bladderTypesbacterial cystitis most often caused by coliform bacteria being transferred from the bowel through the urethra into the bladder interstitial cystitis (IC) is considered more of an injury to the bladder resulting in constant irritation and rarely involves the presence of infectionradiation cystitis often occurs in patients undergoing radiation for the treatment of cancer. inflammation of the renal pelvis, and kidney tissues.Acute- bacterial “ascending infection”Chronic-non bacterial and inflammatory processes

Causes, incidence and risk factorssexually active women ages 20 to 50 but may also occur in those who are not sexually active or in young girls.escherichia coli ("E. coli“)Sexual intercourseinsertion of instruments into the urinary tractobstruction of the bladder or urethra with resultant stagnation of urine

Diagnosisurine culture and sensitivityurinalysis.IVPCystoscopyManual prostate and pelvic examTreatmentoral antibiotics such as trimethoprim-sulfamethoxazole (TMP-SMZ), cephalosporins, nitrofurantoin, or a fluoroquinolone (e.g. ciprofloxacin, levofloxacin).

Nursing Managementincreased water-intakefrequent voidingavoidance of sugars and sugary foodsAvoid caffeinated drinksdrinking unsweetened cranberry juiceas well as taking vitamin C with the last meal of the dayPreventionCleaning the urethral meatus after intercourseurinating within 15 minutes of sexual intercourse to allow the flow of urine to expel the bacteria before specialized extensions anchor the bacteria to the walls of the urethra. Having adequate fluid intake, especially water. Not resisting the urge to urinate. Bathing in warm water without soap, bath foams, etc. Practicing good hygiene, including wiping from the front to the back to avoid contamination of the urinary tract by fecal pathogens.

URINARY RETENTIONalso known as ischuria is a lack of ability to urinateSigns and Symptomspoor urinary stream with intermittencestraining, a sense of incomplete voiding and urgency

Causes:BPHProstatic CancerDamage to the bladderObstruction in the urethra

Diagnostic testsUroflowmetry may aid in establishing the type of micturition abnormality. A post-void residual scan may show the amount of urine retained. Serum prostate-specific antigen (PSA) may aid in diagnosing or ruling out prostate cancer. Urea and creatinine determinations may be necessary to rule out backflow kidney damage.

obstruction of the urinary tract may cause:Bladder stonesHydronephrosisDiverticula

TreatmentACUTE :urinary catheterization suprapubiccystostomyCHRONIC:transurethral resection of the prostate, TURP

Benign prostatic hyperplasiaincrease in size of the prostate in middle-aged and elderly menSymptoms:urinary hesitancy, frequent urination, increased risk of urinary tract infections and urinary retention.results in: stasis of bacteria in the bladder residue and an increased risk of urinary tract infections. Urinary bladder stones, Urinary retention

DiagnosisRectal examinationblood tests are performed to rule out prostatic malignancy: elevated prostate specific antigen (PSA) levelstransrectalultrasonographyUltrasound examination of the testicles, prostate and kidneys

TreatmentLifestylePatients should decrease fluid intake before bedtime, moderate the consumption of alcohol and caffeine-containing products, and follow timed voiding schedules.MedicationsAlpha blockers (α1-adrenergic receptorantagonists) provide symptomatic relief of BPH symptoms. Available drugs include doxazosin, terazosin, alfuzosin and tamsulosin. Alpha-blockers relax smooth muscle in the prostate and the bladder neck, and decrease the degree of blockage of urine flow. The 5α-reductase inhibitors (finasteride and dutasteride) are another treatment option. When used together with alpha blockers a reduction of BPH progression to acute urinary retention and surgery has been noted in patients with larger prostates.

SurgeryIf medical treatment fails, transurethral resection of prostate (TURP)Transurethral electrovaporization of the prostate (TVP), laser TURP, visual laser ablation (VLAP), TransUrethral Microwave ThermoTherapy (TUMT), TransUrethral Needle Ablation (TUNA), ethanol injection

KIDNEY STONE ALSO CALLED RENAL CALCULIare solid concretions (crystal aggregations) of dissolved minerals in urinenephrolithiasis and urolithiasisat least 2-3 millimeters can cause obstruction of the ureter.severe episodic pain, most commonly felt in the flank, lower abdomen and groin a condition called renal colicHematuriaStaghorn calculus (struvite stone)Star shaped bladder urolith

Kidney StonesCalcium oxalate stones -consumption of low-calcium diets Other types of kidney stones are composed of struvite(magnesium, ammonium and phosphate) are always associated with urinary tract infectionsuric acid is associated with conditions that cause high blood uric acid levels, such as gout, leukemias; calcium phosphate is associated with conditions such as hyperparathyroidism and renal tubular acidosis.cystine.

Medical Managementnon-invasive Extracorporeal Shock Wave Lithotripsy or (ESWL) Ureteral (double-J) stents

HYDRONEPHROSISis distention and dilation of the renal pelvis, usually caused by obstruction of the free flow of urine from the kidney.Ultrasound picture of hydronephrosis caused by a left ureteral stone.

EtiologyThe obstruction may be either partial or complete and can occur anywhere from the urethral meatus to the calyces of the renal pelvis.The obstruction may arise from either inside or outside the urinary tract or may come from the wall of the urinary tract itself. Intrinsic obstructions (those that occur within the tract) include blood clots, stones, sloughed papilla along with tumours of the kidney, ureter and bladder. Extrinsic obstructions (those that are caused by factors outside of the urinary tract) include pelvic or abdominal tumours or masses, retroperitoneal fibrosis or neurologicaldeficits. Strictures of the ureters (congenital or acquired), neuromuscular dysfunctions or schistosomiasis are other causes which originate from the wall of the urinary tract.

Acute renal failureis a rapid loss of renal function due to damage to the kidneys, resulting in retention of nitrogenous (urea and creatinine) and non-nitrogenous waste products that are normally excreted by the kidney. Characteristics1. Abrupt onset2. Lead toa.Azotemia = accumulation of nitrogenous wastes in the bloodb. Oliguria = < 400 ml per 24 hours; 40% of failure is nonoliguric or anuriaCausesAcute Renal FailurePre-renal FunctionalPost-renal Obstructive Renal Structurala. decrease in renal perfusion pressure; no kidney pathologya. Any obstruction to excretion of normal urinea. Acute parenchymal changes that damage nephronsb. Intrarenal = uric acid crystals and methotrexate toxicityb. Specifically: acute glomerulonephritis, vascular disease, interstitial nephritis, acute tubular necrosisb. Hepatorenal syndrome from hemorrhage, dehydration, excessive diuresis or massive paracentesis]c. Extrarenal = BPH, renal calculi, and obstruction to flow (more common)

Comparing Categories of Acute Renal Failure

Pre-renal (causes in the blood supply): Hypovolemia, usually from shock or dehydrationfluid loss or excessive diuretics use.hepatorenal syndrome in which renal perfusion is compromised in liver failure vascular problems, such as atheroembolic disease and renal vein thrombosis (which can occur as a complication of the nephrotic syndrome)

Renal (damage to the kidney itself):infection usually sepsis (systemic inflammation due to infection),rarely of the kidney itself, termed pyelonephritis toxins medication (e.g. some NSAIDs, aminoglycoside antibiotics, iodinated contrast, lithium) rhabdomyolysis (breakdown of muscle tissue) - the resultant release of myoglobin in the blood affects the kidney; it can be caused by injury (especially crush injury and extensive blunt trauma), statins, stimulants and some other drugs hemolysis - the hemoglobin damages the tubules; it may be caused by various conditions such as sickle-cell disease

Post-renal (obstructive causes in the urinary tract)due to: medication interfering with normal bladder emptying. benign prostatic hypertrophy or prostate cancer. kidney stones. due to abdominal malignancy (e.g. ovarian cancer, colorectal cancer). obstructed urinary catheter.

D. Pathogenesis1. Loss of renal autoregulation (altered renal blood flow)2. Initially renal blood flow decrease, but then GFR decreases out of proportion to renal flow3. Tubular obstruction may cause tubular reabsorption and (tubular obstruction)4. Decreased GFR because of hydrostatic pressure (back leak theory)E. Clinical picture1. Severe decrease GFR2. Oliguria or anuria (30-50% no oliguria)3. Increased BUN & creatinine

Type of acute renal failureAcute tubular necrosis = ARF caused by destruction of tubular epithelial cells1. ATN = most common cause of ARF2. Common causes a.Ischemiaresulting from shock, hemolysis or skeletal muscle breakdown; patchy damage to tubules with blocking of tubule by cell casts & dilation of Bowman's capsule.b. Nephrotoxicagents from hemolysis, intravascular coagulation, precipitation of oxalate and uric acid crystals, and tissue hypoxia; more damage to & casts in distal tubules and necrosis in all nephrons.Aging with decrease in nephrons or dehydration can increase toxicityMany antibiotics (tetracyclines, aminoglycosides cephalosporins, ampho-B) and contrast materials with iodineF. Stages of ARF1. Initiation = inciting event causing tubular necrosis & altered blood flow2. Maintenance stage (1-3 weeks)a. Oliguriab. Electrolyte imbalancesc. Urine specific gravity at 1.010 which = plasma specific gravityd. Renal blood flow down which = decrease GFRe. Water excess with dilutional hyponatremiaf. Hyperkalemia from decreased excretion and excessive muscle breakdown; also increased creatinine, phosphate, and ureag. Metabolic acidosis

h. Anemiabecausesuppressederythropoietini. Progressiveazotemia3. Recovery (begins >24 hrs post onset)a.Diuresis; gradual increase in output asmuchas 6L/dayb. Tubular function still altered because large amounts of Na+ and K+ still lost in urinec. Dehydration, hypokalemiad. Increased RBC productione. Continues over 6-12 months; 30% never fully recover renal function

G. Treatment principles correcting fluid and electrolyte disturbances

drugs and metabolites aren't excretedII. Chronic renal failure= slowly progressive loss of nephrons and damage to glomeruli characterized by irreversible reduction in the GFR. Affects all functions normally carried out by the kidneys.A. Causes:1. Glomerulopathies2. Tubulo-interstitial renal diseases3. Hereditary diseases4. Vascular diseases:5. Obstructive nephropathy

B. Problems created by CRF1. Fluid imbalanceUnable to concentrate urine early so excess H20 lossUntil 25% loss of function maintains solute, then once past threshold osmotic diuresis with dehydrationAs progresses, inability to dilute urine so isosthenuria (urine and plasma have same, fixed specific gravity 1.010)2. Na+ imbalancea. Intact nephrons receive more Na+ so...b. Osmotic diuresis, so...c. Reduction in blood volume and GFR

3. K+ imbalancea. If water balance is maintained and acidosis controlled, not a problemb. Hyperkalemia if increased acidosis or hyponatremia or catabolismc. Hypokalemia if diuretic therapy, vomiting, renal tubular disease that prevents reabsorption.4. Acid-base imbalancea. Metabolic acidosis because kidneys can't excrete enough H+b. Renal tubule dysfunction leads to progressive inability toe excrete H+c. H+ excretion is proportional to GFRd. Acids are continuously formed, but glomerulus cannot filer as effectively, production of ammonia decreases, and tubular damage

5. Anemia - Hct. proportionate to azotemiaa. Short life span of RBCs because of altered plasmab. Increased loss of RBCs because of GI ulceration, dialysis, and lab drawsc. Reduced erythropoietin because of decreased renal formation and inhibition from uremiad. Folate deficiency if dialysise. Iron deficiencyf. Elevated parathyroid which stimulates fibrous replacement of bone marrow6. Bleeding disordersa.Thrombocytopenia or platelet dysfunctionb.Nitrogenous wastes increase risk of hemorrhage

7. Urea and creatinine alterations (renal function studies)a.BUN increases (also increases with shock, protein intake, infection, gout) b.Creatinine - excretion=productionc.BUN up with nonrenal; hepatorenal then BUN lowF. Uremic syndrome= symptomatic renal failure associated with metabolic events and multi-organ complications 1. Cardiovasculara. Fluid and Na+ retentionb. Accelerated atherosclerosisc. Pericarditis increased without dialysisd. Heart Failure

Uremia = decrease RBC life span

Uremia = inability of cells to pump out Na+ so swelling and hemolysis

Immunosuppression from reduction of lymphocytes

Platelet defects = bleeding3. DermatologicPallor from anemia and retention of pigmented urochromes

Dehydration and atrophy of the sweat glands

Uremic itching = (?) skin deposits, peripheral neuropathy

Uremic frost = urea deposits from sweat

Soft tissue calcification from hyperparathyroidism 4. GI - retention of metabolic acids and waste productsa. N&V (nausea and vomiting)b. Hiccupsc. Anorexiad. Irritation, inflammation, ulceration of GI tract - mouth to colone. Uremic fetor when urea broken down to ammonia5. Reproductive - Amenorrhea, infertility, decreased libido, decreased testosterone6. Endocrineb. Hypothyroidisma. Hyperparathyroidism

7. NeurologicEncephalopathy - fatigue, decreased concentration, irritability, depression, drowsiness, insomnia, personality changes, seizures, and deathPeripheral neuropathy - burning, numbness, delayed sensory and motor responsesDiagnosisCreatinine or blood urea nitrogen testsUrinalysisBlood testMedical ultrasonography of the tract ( is essential to rule out obstruction of the urinary tract)

TreatmentThere are several modalities of renal replacement therapy (RRT) for patients with acute renal failure: Intermittent hemodialysis Continuous hemodialysis (used in critically ill patients)

DIALYSISIs used to substitute some kidney functions during renal failure.

It is used to remove fluid and uremic waste products from the body when the kidneys are unable to do so.

It may be indicated to treat patients with edema that do not respond to treatment.

Acute dialysis is indicated when there is a high and increasing level of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis and severe confusion. It may also be used to certain medications or other toxins in the blood.DIALYSISChronic or maintenance dialysis is indicated in ESRD in the following instances:Presence of uremic signs and symptoms affecting all body systems (nausea and vomiting, severe anorexia, increasing lethargy, mental confusion)Hyperkalemia and fluid overload not responsive to diuretics and fluid restriction.General lack of well-being. An urgent indication for dialysis in patients with CRF is pericardial friction rub.

PERITONEAL DIALYSISTYPES:Intermittent peritoneal dialysis = acute or chronic renal failureContinuous ambulatory peritoneal dialysis = chronic renal failureContinuous cycling peritoneal dialysis = prolonged dwelling time

PERITONEAL DIALYSISIndwelling catheter is implanted into the peritoneum.A connecting tube is attached to the external end of peritoneal catheter T –tube. Plastic bag of dialysate solution is inserted to the end of T-tube; the other end is recap.Dialysate bag is raised to shoulder level and infused by gravity in the peritoneal cavityInfusion time = 10 minutes/2 liters; dwelling time is 4-6 hours depending on doctor’s order.At the end of dwelling time, dialysis fluid is drained from the peritoneal cavity by gravityDraining time is 10-20 minutes/2 liters Then repeat the procedure when necessary

Peritoneal DialysisUsually for patients with absolutely no other options of dialysisOr as a temporary measure until options of dialysis sorted out

Pre and post operative care for Tenckhoff catheter insertionPre operative careFast for 8 hoursAllow essential medicationsBowel preparation not necessaryRemoval of body hair limited to that necessary to facilitate performance of procedureEmpty bladderSingle dose of prophylactic antibioticOperating room or well equipped procedure room

Pre and post operative care for Tenckhoff catheter insertionPost operative careCatheter irrigation with 1 L of heparinized saline performed as an in-and-out flush within 72 hours following surgery and weekly thereafter until PD initiatedDelay PD for a min of 2 weeks to allow wound healingChange dressings weekly for 2 weeksThen patient should begin a routine of daily exit-site cleansing with antibacterial soapShowering only permitted after 1 month if wound healing uncomplicatedAvoid catheter movement at the exit siteUse sterile gauze dressing over exit siteNo tub bathing and swimming

PERITONEAL DIALYSISNURSING CONSIDERATIONS:Dialysate must be room-warmed before use ( for better absorption)Drugs (heparin, potassium and antibiotics) must be added in advance.Allow the solution to remain in the peritoneal cavity for the prescribed time.Check outflow for cloudiness, blood and fibrin (early peritonitis).NEVER PUSH THE CATHETER IN.Monitor the VS regularly.Keep a record of patient’s fluid balance (daily weighing)Monitor blood chemistryTurn the patient side to side if drainage stopObserve for abdominal pain (cold solution), dialysate leakage (prevent infection)Intake must be equal to output.

HEMODIALYSISIs the process of cleansing the blood of accumulated waste productsPatient’s access is prepared and cannulated surgically One needle is inserted to the artery (brachial) then blood flow is directed to dialyzer (dialysis machine)The machine is equipped with semi-permeable membrane surrounded with dialysis solution

Urinary system disorders.pptx1

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Urinary system disorders.pptx1