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GUT

LORD IZON O. SANTOS, M.D., R.N. SCOPE Anatomy and Physiology Assessment Procedures Diagnostic and Laboratory Exams Disorders

RENAL CIRCULATION DESCENDING AORTA RENAL ARTERY INTERLOBAR ARTERY ARCUATE ARTERY INTERLOBULAR ARTERY AFFERENT ARTERIOLE GLOMERULUS EFFERENT ARTERIOLE VASA RECTA THEN BACK TO THE HEART

CIRCULATION at KIDNEY TUBULES (URINE) BOWMAN’S/GLOMERULAR CAPSULE PROXIMALCONVOLUTED TUBULE NEPHRON LOOP DESCENDING LIMB ASCENDING LIMB DISTAL CONVOLUTED TUBULE COLLECTING DUCT MAJOR CALICES MINOR CALICES RENAL PELVIS URETERS URINARY BLADDER URETHRA OUT OF THE BODY

Kidney Function Excretory and Reabsorption

Tubular

–Water –Electrolytes –Wastes

Secretory –Active Vitamin D –Renin –Erythropoietin

ADH Regulation ADH is produced by the Hypothalamus ADH is stored and secreted by the posterior pituitary gland With less water in the plasma ADH is secreted, to conserve water by reducing urine output With fluid overload in the plasma ADH secretion stops, to excrete fluid in the kidneys by increasing urine output

ADH Disorder SIADH

–Abnormally high ADH concentration –urine output is reduced (oliguria) –water retention (fluid overload) –Urine SG is high (normal: 1.005 – 1.030) –Hct is low (43-48%)

DI –Abnormally low ADH –urine output is increased (polyuria) –water loss (fluid deficit) –Urine SG is low –Hct is high

Aldosterone Disorders Addison’sDisease (autoimmune process, hemorrhage into the adrenal gland, adrenalectomy, TB of the adrenals) –Abnormally low aldosterone –Serum Na is low, serum potassium is high –FVD Cushing’s Disease (Adrenal hyperplasia, Adrenal Neoplasms, Lung and Pancreatic Tumor releasing ACTH) –Abnormally high aldosterone –Serum Na is high, serum potassium is low –FVE

NOTE: Functional unit of the kidneys are the glomerulus, vasa recta and kidney tubules (nephron (nephron)) Only the renal tubules can regenerate Acidosis—increases hydrogen Acidosis—increases secretion (kidney tubules)— increases HCO3 reabsorption Alkalosis—decreases Alkalosis—decreases hydrogen secretion—decreases HCO3 reabsorption

ASSESSMENT IRRITATION Dysuria Frequency Urgency Nocturia Strangury

OBSTRUCTION Weak Stream Hesitancy Terminal Dribbling Incomplete emptying Nocturia

PAIN Flank or lumbar Inguinal or iliac Initiation of voiding End of voiding Painless hematuria

Incontinence Stress Urge Overflow Total Mixed Enuresis

URINE CHANGES Pneumaturia Proteinuria Ketonuria Glucosuria Hematuria Pyuria Fecaluria

PROCEDURES & Dx Urine specimen collection Urinalysis Catheterization Urinary diversion Serum BUN and CREA Serum electrolytes CBC Renal biopsy

MRI (with injection of contrast media) Renal Angiography Intravenous Pyelography IVP or Excretory Urography Retrograde Urography Collection of Urine Specimen Random urine sample Clean catch urine, Mid stream catch urine Urine straining 24-hour Double catch Diversionary Method –Catheter Insertion

URINALYSIS

Appearance - clear Odor - faint aromatic odor Color - clear yellow or amber Normal pH is around 6 (acid) or 4.67.5 SG Normal range is from 1.0101.025 Normal range is from 300-1090 mOsm/L

Types of Catheterization Foley, Indwelling Straight, Intermittent Diversion: Cystostomy Tube Ureterostomy Tube Nephrostomy Tube

Surgical Urinary Diversion Cutaneous Ureterostomy Cutaneous Vesicostomy Ileal Conduit Colon Conduit

Lab and Diagnostic There is no single test for renal function Best results are obtained by combining a number of clinical tests Renal function is variable from time to time Renal function may be within normal limits until >50% of renal function is lost

Blood Studies

Blood Urea Nitrogen or serum BUN Specific for kidney disease normal value = 20-30 mg/dl Serum Creatinine is more specific for renal function test is not affected by dietary intake or hydration status can not be reabsorbed by the kidney tubules normal value 0.5-1.5 mg/dl

SerumElectrolytes Evaluation All electrolytes are elevated in CRF except calcium and HCO3 Diuretics may alter serum electrolytes

CBC

Erythropoietin activity RBC – significantly low in CRF WBC Platelets

Radiology and Imaging Radiology and Imaging UTZ

Intravenous Pyelography IVP or Excretory Urography Retrograde Urography MRI (with injection of contrast media) Renal Angiography

Renal Biopsy

Supine position Hold breath when

the kidney is about to puncture Bleeding time must be checked before the test Prone position after the test Avoid palpation and manipulation on the area Avoid strenuous activity 2-3 weeks after the test Monitor complications: Colicky pain = clot in the ureter/s Flank pain = bleeding in the muscle Evaluate hematuria = collect serial urine specimen

DIURETICS

Thiazide blocks Na reabsorption in the distal CT Na and K are excreted (HPN, edema, CHF) Hyponatremia and Hypokalemia taken early AM report sore throat Chlorthiazide (Diuril) Chlorthalidone (Hygroton) Loop Diuretics Inhibits Na, Cl and K reabsorption at the proximal portion of ascending Loop of Henle Hypokalemia Use: HPN, PE, CHF, Cirrhosis Furosemide (Lasix) Potassium Sparer

Blocks Aldosterone receptors in the kidneys H20 and Na loss, K retention (hyperkalemia) Use: Hyperaldosteronism, HPN, edema Taken with food, 2-3 days to take effect Avoid high K diet Spironolactone (Aldactone) Carbonic Anhydrase Inhibitors Decreases the rate of Carbonic Acid and H ion production in the kidneys Increases the excretion of solute and H20 Used in treating Open-angle Glaucoma Acetazolamide (Diamox) Osmotic Diuretics Acts by increasing the osmotic pressure of GFR, reducing the rate of tubular reabsorption while increasing the rate of urine output Used in increased ICP tx, drug overdose IV filter must be used for infusing the solution (above 15% solution) Mannitol (Osmitrol)

Disorders

UTI Ureteritis = inflammation of ureter (maybe caused by stone in the ureter) Cystitis = inflammation of bladder (caused by ascending bacterial infection usually E. coli) Urethritis = inflammation of urethra (may lead to prostatitis and epididymitis)

FACTORS THAT CONTRIBUTE TO UTI FEMALE (PROXIMITY TO THE ANUS, SHORTER URETHRA) POOR HYGIENE UNSAFE SEXUAL PRACTICES BACK TO FRONT STROKE HIGH pH URINARY STASIS KIDNEY STONES OBSTRUCTION OF URINE OUTFLOW

S/Sx: PAIN assessment Pain during and after urination = cystitis Pain after urination = urethritis Inguinal pain = ureteritis Flank pain = pyelonephritis Inflammatory manifestations fever and chills

Cx: Ascending infection Obstruction (stones/calculi)

Management E. coli (most common C.A.) Increase fluids Warm sitz bath EMPTY the bladder Good hygiene Observe safe sexual practice Front to back stroke Acidify urine (cranberry juice, prune, plums) C/S test before giving antibiotics For urosepsis give aminoglycosides Observe complications

LITHIASIS

Nephrolithiasis = kidney stone Ureterolithiasis = ureter stone Cystolithiasis = bladder stone Urethrolithiasis = stone at the urethra The stone is usually calcium phosphate/oxalate and uric acid –Struvite = acid ash diet is recommended –Staghorn = large stone FACTORS THAT CONTRIBUTE TO STONE FORMATION HYPERURICEMIA (GA) HYPERCALCEMIA (PARATHYROIDISM) DEHYDRATION PROLONGED IMMOBILITY HEREDITARY

s/sx Pain assessment will be dependent on the site of stone Flank pain = kidney or ureter Groin pain = ureter Watchout for obstruction (bladder distention) Descending stone may scratch the membrane irritating the membrane leading to inflammation, bleeding may occur also Adhesions may follow after healing

CALCULI(Stones)

MANAGEMENT Increase fluid intake 3-4L/day Determine the CAUSE and type of stone (calcium or uric acid) Encourage ambulation If its calcium give cranberry (acid ash diet) or ascorbic acid If its uric acid give dairy products (alkali ash diet) or Allopurinol Antibiotics prophylactically

I & O, strain urine (stone must be submitted to lab to identify the type of stone) Drugs: –Sodium cellulose phosphate (GI abs. is decreased) –Thiazide (inc. tub. Reabs., decreasing calculi formation in the kidney tubules) –Cholestyramine (binds oxalates in the feces) –Allopurinol (decreased uric acid formation) –Antibiotics (chronic UTI is a precursor to calculi formation) –Narcotics and NSAID for pain management –Antispasmodic (Probanthine) –Rowatinex to dissolve stone

MANAGEMENT

Medical and Surgical Intervention Nephrolithotomy Ureterolithotomy Cystolithotomy PUL percutaneous ultrasonic lithotripsy Nephroscope is inserted to kidney, an ultrasonic waves disintegrates stones followed by suction and irrigation Laser lithotripsy = non invasive procedure –Post nsg care = increase fluids, encourage ambulation, strain urine and watchout for obstruction and bleeding ESWL extra corporeal shock wave lithotripsy Client is immersed to water, slow waves disintegrate stones (non invasive) –Post nsg care = increase fluids, encourage ambulation, strain

urine and watchout obstruction and bleeding

for

Benign Prostatic Hyperplasia

Male Reproductive Organ Testes are formed in the abdominal cavity near the kidney During last month of fetal life they descend into the groin (spermatic cord) Internal inguinal canal to the scrotum Testes descend into the scrotum Testes are encased by the scrotum (slightly lower temperature than the rest of the body to facilitate spermatogenesis)

Male Reproductive Organ Seminiferous tubules (sperm) Leydig’s cells (testosterone) Prostate gland (alkaline fluid) Bulbourethral glands, Cowper’s Glands (alkaline fluid) Seminal vesicle (nutrients: fructose)

Lobules of the testes

seminiferous tubules (sperm) stored at the epididymis vas deferens sperm plus secretions from seminal vesicle will drain into the ejaculatory duct plus drainage of fluids coming from P.G. and B.G. together with the sperm will now move towards the direction of urethra (seminal fluid) 3-5ml/ejaculation (50-130 million/ml 300-500 million/ejaculation

Surgical incision at the perineum area (may lead to impotence)

BPH

Benign Prostatic Hyperplasia Slow enlargement of the prostate Men over 40 year (prostate gland enlargement begins) On the latent phase it will constrict the urethra which interferes in urination

SIGNS/SYMPTOMS SUBJECTIVE Frequency Urgency Difficulty initiating stream Incomplete emptying of bladder after urination

Post-resection of the Prostate Following this procedure CBI (continuous bladder irrigation) must be instituted for the sole purpose of preventing clot formation that may obstruct urine outflow.

Pediatric Renal Disorders Acute Glomerulonephritis Chronic Glomerulonephritis Nephrotic Syndrome the

OBJECTIVE Nocturia Hematuria Weak stream Urinary retention Biopsy reveals hyperplasia Rectal Examination

Management Urinary obstruction (divert urine by catheter, cystostomy) Finasteride (can stop glandular hyperplasia) Medical and Surgical Intervention

Prostate Resection TURP transurethral resection of the prostate Resectoscope or laser is inserted to urethra to resect prostate Supra pubic prostatectomy Surgical incision at the pubis Perineal prostatectomy

AGN acute glomerulonephritis Infection of kidney due to immune response Previous infection from group A beta hemolytic streptococcus S/Sx – proteinuria, hematuria, oliguria, edema and HPN CGNchronic glomerulonephritis slowly developing disease S/Sx – same with AGN NephroticSyndrome Severely damaged glomerular activity that leads to increased capillary permeability S/Sx – proteinuria, hypoalbuminemia, edema and hyperlipidemia Caused by CGN, DM and SLE

AGN Bilateral infection of the glomeruli Caused by: –Post infection (GABS) COMMON

–Systemic

diseases (SLE, goodpasture’s syndrome or glomerular deposits) –Idiopathic Common in boys ages 3-7 Pathophysiology Acute poststreptococcal infection ANTIGEN stimulates formation of ANTIBODIES ANTIGEN-ANTIBODY-COMPLEXES are lodged in the glomerular capillaries Increasing capillary permeability

AGN S/sx: –proteinuria, periorbital edema, hematuria, oliguria, azotemia and HPN –smoky or coffee-colored urine, bibasilar crackles, nausea and malaise Dx Tests: –Elevation of BUN and crea –Serum protein levels are reduced –Hb count is also reduced –ASO titers are elevated –KUB (bilateral enlargement) –UA (postive RBC, WBC, and protein) Management: –Treat the underlying cause –Antibiotics 7-10 days –Diuretics to reduce fluid overload –DIET restrictions: sodium and electrolytes, CHON is restricted in severe AZOTEMIA –Fluids restriction –Strict I and O –Vasodilators to control HPN –Steroids to reduce inflammation

–Plasmapheresis to circulating antibodies –Dialysis or transplantation

reduce kidney

CGN The unfortunate outcome of AGN Most common cause of ESRD s/sx: same with AGN –HPN and OLIGURIA are the dominant clinical features Microscopic hematuria is usually present than GROSS hematuria Prognosis is POOR Management: same with AGN DIALYSIS and KIDNEY transplant

NEPHROTIC SYNDROME Clinical complex Acute onset Caused

by: SLE, AGN, CGN and DM Dx: same with AGN S/sx: same with AGN (↑ (↑ capillary permeability) –Hypoalbuminemia –Edema (anasarca) –Hyperlipidemia (due to catabolism and ↓COP) Management: same with AGN –Increase CALORIE to stop catabolism –Give plasma expanders to control edema MASSIVE PROTEINURIA RENAL FAILURE Pre renal decreased renal tissue perfusion from: –DM (most common) –Hypovolemia –Shock –Hemorrhage

–Burns –Impaired cardiac output –Diuretic therapy Post-renal due to obstruction or disruption to urine flow anywhere along the urinary tract: –Cystitis –Urethritis –Pyelonephritis –Urolithiasis –Injuries to the bladder and urethra –Cancer of the bladder –Prostatitis –BPH Intra-renal AGN acute glomerulonephritis Infection of kidney due to immune response Previous infection from group A beta hemolytic streptococcus S/Sx – proteinuria, hematuria, oliguria, edema and HPN CGN chronic glomerulonephritis slowly developing disease S/Sx – same with AGN Nephrotic Syndrome Severely damaged glomerular activity that leads to increased capillary permeability S/Sx – proteinuria, hypoalbuminemia, edema and hyperlipidemia Caused by CGN, DM and SLE

Acute Renal Failure Sudden decline in renal function, usually associated with increased in BUN, creatinine & elec. Causes: intra, pre and post RENAL

Reversible

Clinical Course: Oliguric-anuricPhase may last 7-14 days Non-oliguric or high output RF yet nitrogenous waste products are still high in the blood. DiuresisPhase return to normal urine output RecoveryPeriod may take 6 months to 1 year from the initial onset

Chronic Renal Failure Progressive deterioration of renal function which end fatally in uremia Dialysis or kidney transplant is necessary Irreversible Clinical Course: Decreased Renal Reserve 4070 GFR Renal Insufficiency 2040 GFR Renal Failure 1020 GFR End-Stage Renal Disease ↓ 10 GFR Both kidneys are severely affected and renal function is absent

SIMILARITIES in ARF and CRF ↓ waste product excretion  chaotic acid and base regulation  elevation of electrolytes  water retention ↓ production of erythropoietin ↓ active vitamin D secretions ↑ renin activation

s/sx Na and water retention – inc BVedema – HPN – CHF - ascites ↓ RP – renin activation – angiotensin and aldosterone production – inc BV – inc BP ↓ H ion excretion – metabolic acidosis ↓ nitrogenous excretion – azotemia – toxic to CNS – CHANGES IN LOC ↓ formation of active vit D – hypocalcemia ↓ secretion of erythropoietin – anemia ↓ electrolyte excretion – elevation of electrolytes in the blood

Let’s Diagnose! Serum crea – elevated (normal 0.5-1.5 mg/dl) Serum BUN – elevated (normal 20-30 mg/dl) Serum electrolytes – all electrolytes are elevated except for HCO3 and Calcium CBC – anemia (due to reduced erythropoietin production) Renal Ultrasonography – to estimate renal size and obstruction Other tests that may help in detecting the cause

Nursing Diagnosis FVE related to decreased GFR and sodium retention Risk for infection related to reduced host defenses Altered Nutrition related to catabolic state, anorexia Risk for internal bleeding related to stress ulcer Altered thought processes related to effects of uremic toxins to CNS Fluids and electrolytes imbalance

Impaired skin integrity related to uremic frost Constipation related to fluid restriction and phosphate binding agent administration High risk for injury (fracture) related to osteoclast activity Non compliance to therapeutic regimen related to restrictions imposed by CRF and its treatment

ARF Management I&O Weighing Infection monitoring Examine gross and occult blood Diet (CHON moderate, increase CHO) Electrolyte management (Pls refer to Fluids and Electrolytes Study Guide by Sonny M. Moreno) Neurologic assessment

CRF Management Restrict water and sodium intake ABG monitoring and NaHCO3 administration Neurologic assessment Dialysis Diet (CHON restriction, inc CHO) Give vit D and calcium supplement Give synthetic erythropoietin (Epogen) Manage electrolyte imbalance

Dialysis Hemodialysis PeritonealDialysis CVVH (removes water from blood) EMERGENCY DIALYSIS ARTERIOVENOUS FISTULA

Kidney Transplant

Rejection and Infection Donor and Recipient Preparation HLA test, ABO, Rh test Donor Living = anemia, prone to infection,bleeding,Cadaveric Recipient Stages of Rejection (HA, AA, A, C)

Drugs (Immunosuppresive Antibiotics, prophylactically Isolation (Reverse)

and

KIDNEY SURGERY THE TRANSPLANTED KIDNEY KIDNEY TRANSPLANT URETERAL STENTING

Short Quiz 1. Priority during dwelling time? A. respiratory B. pain C. bowel movement D. all 2. palpate for? A. bruit B. thrill 3. auscultate for? A. bruit B. thrill 4. and 5. Two types of donor in kidney transplant? 6. Dialysis work in what process or mechanism? 7. 8. 9. Common problem encountered by first timer in hemodialysis? 10. Action of an immunosuppressive drug? WHAT IS THE COMMON AGENT OF UTI? PRESENCE OF STONE IN THE ENTIRE GU TRACT? COMMON TYPE OF STONE IN urolithiasis? IMPORTANT FINDINGS THAT MUST BE REPORTED FOLLOWING EXTRA CORPOREAL SHOCK WAVE LITHOTRIPSY? BPH ONSET? (AGE) DRUG THAT IS ABLE TO STOP GLANDULAR (PROSTATE) ENLARGEMENT? COMMON AGENT IN AGN DEVELOPMENT? DIFFERENCE BETWEEN AGN AND NEPHROTIC SYNDROME (S/SX) MAIN PURPOSE OF CYSTOCLYSIS? EXAMPLE OF AN ACID ASH DIET AND ALKALI ASH DIET?

Common type of kidney stone? Drug that is able to reduce the size of renal stone? Early diagnostic exam to determine BPH? Common agent that leads to UTI? Type of catheter inserted following prostate resection?

Nursing instruction following laser lithotripsy? Nursing instruction to decreased pH of urine? Nursing instruction to prevent UTI development? Example of an alkali ash diet? Interruption of sleep due to increase in frequency? What is the primary reason of edema formation in Glomerulonephritis? Edema is more severe in A. AGN B. CGN C. NS Azotemia is more pronounce in A. AGN B. CGN C. NS What is the common cause of AGN development? What is the early sign of renal failure? ARF is irreversible? TRUE or FALSE CRF is bilateral involvement of the kidneys? TRUE or FALSE What is the common cause of death in RF? What is the common prerenal condition that leads to ARF? NURSING Dx in FVE? Nursing Dx in hyperkalemia? Drug of choice to reduce potassium? Drug of choice to reduce PO4? Problem and nsg action in ↓RBC? Early sign of Type of isolation in RF management? Best DIURETIC for RF? ELEVATION of NH3 in the blood would lead to? High in CHON and low in CHO is the DIET of choice to spare protein in RF? TRUE or FALSE? Uremic frost is an accumulation of? A. NWP in the skin B. NWP in the blood C. waste in the joints D. drug metabolites

Board Questions A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the clamp is opened to allow the dialysate to drain. The nurse notes that drainage has stopped and only 500 ml has drained, the amount of dialysate instilled was 1,500 ml. Which of the following interventions would be done first? a. check the client’s position b. call the physician c. check the catheter for kinks or obstruction d. clamp the catheter and instill more dialysate at the next exchange time

The most significant complication in clients undergoing peritoneal dialysis, is a. pulmonary embolism b. hypotension

c. dyspnea d. peritonitis

A client returns to the room with CBI continuous bladder irrigation following TURP, the client reports bladder pain, what should the nurse do first? A. notify the physician B. give Meperidine 50 mg IM as prescribed C. assess patency of the drainage system D. increase the flow rate

The nurse is caring for a client in acute renal failure, the nurse should expect hypertonic glucose insulin infusion to treat: A. hypernatremia B. cerebral edema C. hyperkalemia D. hyperglycemia A client requires hemodialysis. Which of the following drug drugs should be withheld before this procedure? A. cardiac glycosides B. insulin C. antibiotics D. phosphate binders

A client with GUT problem is being examined in the ER, the nurse should keep in mind the anatomical fact that: A. left kidney is lower than the right B. adrenal glands are situated on top of the kidneys C. kidneys lie between 12th thoracic and 3rd lumbar vertebrae D. the average kidney measures 2.5 cm thick, 5 cm wide and 11 cm long