Renal System Disorders Nio C. Noveno, Noveno, RN RN,, MAN
The Human Kidney
Renal Disorders
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The Nephron
Renal Disorders
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Functions of the Renal System Excretion of waste Regulation of acid-base balance Formation of erythropoietin Regulation of fluid and electrolyte balance
(RAAS)
Regulation of phosphate and calcium Renal Disorders
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Classification of Renal Disorders Obstructive disorders Acute renal failure Chronic renal failure
Renal Disorders
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Obstructive disorders Can occur anywhere in the urinary
tract Signs and symptoms depend on the
site of location and size of obstruction
Renal Disorders
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Causes of urinary tract obstruction Lower urinary tract Bladder neoplasms Urethral strictures Calculi Tumors Benign prostatic hypertrophy
Renal Disorders
Ureteral obstruction Calculi Trauma Enlarged lymph nodes Congenital anomalies Kidney Calculi Polycystic kidney disease
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Renal stones Crystallization of minerals around an
organic matrix (blood, pus, devitalization tissue) Usually idiopathic:
– Infection
Renal Disorders
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SITES OF STONE FORMATION
Renal Disorders
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Composition of renal stones Calcium (oxalate and phosphate) Hypercalcemia Hyperthyroidism
Vitamin D intoxication Immobilization Tumors Renal tubular acidosis Intake of steroids
Renal Disorders
Uric acid High purine diet Gout Chemotherapy Cystine Genetic disorder Struvite Infection related
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Renal Stones Diagnostics Urinalysis KUB-UTZ KUB-IVP CT scan Cystoscopy BUN, Creatinine Clinical manifestations Pain Hematuria Renal Disorders
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Diagnostic Procedures
Renal Disorders
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Medical management Medications Pain medications Medications to Ca & PO4 content – Ascorbic acid Medications to uric acid formation – Sodium bicarbonate – Allopurinol Surgery Extracorporeal shockwave lithotripsy Percutaneous lithotripsy
Renal Disorders
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EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY
Renal Disorders
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Nursing management Administer medications as
ordered
Strain urine to detect passage
of stones
Monitor I & O Encourage to increase OFI
>3 L/day Instruct client on infection
prevention
Renal Disorders
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Bladder carcinoma Most common among 60-70 years old Males>females
Predisposing factors: – Cigarette smoking – Exposure to rubber dyes – Abuse of phenacetin-containing analgesics – Recurrent UTI – Recurrent nephrolithiasis Renal Disorders
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Bladder carcinoma Clinical manifestations – Gross painless hematuria – Dysuria – Frequent urination Diagnostics – Urinalysis – IVP – Cystoscopy with biopsy – CT scan Renal Disorders
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Bladder carcinoma Medical Management Surgical treatment Radiation Chemotherapy
Nursing management Encourage to:
– Increase OFI – Quit smoking Assess for presence
of UTI Renal Disorders
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Bladder carcinoma Care of the STOMA Immediate post-OP: Color of drainage is bright red/pink
Report: gray or black discoloration Position pouch at the side of
bed for drainage Monitor urine output daily Monitor for signs of peritonitis
Abdominal pain, distention, fever
Renal Disorders
Teach patient on stoma
care
Opening should be no more than 2-3 mm larger than the stoma Change every 3-5 days Report signs of UTI – Cloudy urine – Hematuria – Strong odor – Fever – Flank pain
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Benign Prostatic Hyperplasia (BPH) Most common
problem of adult male reproductive organ Cause is not
completely understood Not a predisposing
factor for prostatic carcinoma Renal Disorders
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Benign Prostatic Hyperplasia (BPH)
Clinical manifestations Dribbling Hesitancy Diminution in caliber and force of urinary stream Feeling of incomplete emptying Irritative symptoms
Renal Disorders
Diagnostics Digital rectal exam Urinalysis BUN/Creatinine Cystourethroscopy PSA
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Benign Prostatic Hyperplasia (BPH)
Renal Disorders
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Benign Prostatic Hyperplasia (BPH) Medical Management Pharmacologic treatment Anti-androgens – Finasteride – Alpha-adrenergic blockers – Terazosin
Non-surgical procedures Thermotherapy Prostatic balloon device Stents/coils TULIP (transurethral ultrasound-guided laser prostatectomy)
Surgical procedures Renal Disorders
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Benign Prostatic Hyperplasia (BPH) Nursing management: 1. Provide medications as ordered 2. Maintain patency of 3-way Foley • Observe aseptic technique • Irrigate with NSS (as ordered) 3. Control & treat bladder spasms • Short, frequent walks • Decrease frequency of bladder irrigation • Administer anti-cholinergics and antispasmodics Renal Disorders
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Benign Prostatic Hyperplasia (BPH) Prevent hemorrhage • Prevent straining (heavy lifting, constipation), prolonged periods of travel, sexual activity until doctor approves so. • Avoid rectal procedures. 5. Provide for bladder training after Foley catheter removal • Perineal exercise • Limit fluid intake in the evening • Restrict intake of caffeine-containing compounds • Withhold anti-cholinergics and antispasmodics if permitted 4.
Renal Disorders
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Benign Prostatic Hyperplasia (BPH) 5.
Provide health teaching on: • Increasing OFI • Signs of UTI and report once noted • Avoidance of heavy lifting, straining and prolonged travel. • Possible impotence
Renal Disorders
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Prostate cancer Highest incidence in African-American over
age 60 Adenocarcinoma; growth related to presence of androgens Clinical manifestations: – Same as BPH – Hard, nodular, fixed mass upon rectal exam Laboratory diagnostics: – Elevated PSA, acid & alkaline phosphatase – Bone scan Renal Disorders
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Prostate cancer
Renal Disorders
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Prostate cancer Medical management: Drug therapy: Estrogens, chemotherapeutic agents Radiation therapy Surgery: Perineal prostatectomy
Renal Disorders
Nursing interventions: 1. Administer prescribed medications 2. If with radiotherapy: • Double flush the toilet after use. • Advise to avoid placing children on their lap. • Avoid sexual intercourse for the whole duration of therapy. 3. Provide care postprostatectomy
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Acute renal failure (ARF) Sudden cessation of kidney function; reversible
Renal Disorders
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Acute renal failure (ARF) Sudden cessation of kidney function; reversible Causes: 1. Ischemic (pre-renal) • Dehydration • Blood loss (surgery, trauma) • Cardiac failure • Shock 2.
Toxic substance (renal) • Solvents (carbon tetrachloride, methanol, ethylene glycol) • Heavy metals (lead, arsenic, mercury) • Antibiotics (aminoglycosides, amphotericin B) • Pesticides • Mushrooms
Renal Disorders
3.
Obstruction (post-renal) • Stones • Tumors • Strictures/stenosis
4.
Other causes: • Acute glomerulonephritis • Malignant hypertension • Hemolysis
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Physiologic effect
Oliguric
Findings
Symptoms
↑ BUN, Crea
Drowsiness, Confusion, Coma GI bleeding Asterixis Pericarditis
Inability to excrete wastes
↑ K+, ↓ Na+, acidosis Inability to regulate electrolytes
Cardiac dysrhythmias Kusmaull’s breathing Coma
Inability to excrete fluid loads
CHF Pulmonary edema Hypertension
Diuretic
Urine output of 4-5 L/day Hypotension Tachycardia Improving mental alertness Weight loss Dry mucous membranes Muscle weakness Constipation
Fluid overload
Recovery Renal Disorders
Hypovolemia ↓ Na+ ↓ K+
Return to normal
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Nursing management: Medical management: Supportive Dialysis Nursing management: 1. Maintain F & E balance • Accurate I & O • Weigh daily • Maintain fluid restrictions • Assess for signs of fluid overload 2. Maintain nutrition • Moderate CHON, low K+, high CHO, high fat • Measures to relieve nausea Renal Disorders
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Nursing management: 3.
Maintain rest-activity balance • Provide assistance in ADL • Maintain strict bed rest in acute phase
4.
Prevent injury • Keep side rails elevated (pad if necessary) • Protect from bleeding
5.
Prevent infection • Maintain asepsis • Reverse isolate • Turn frequently • Meticulous skin care • Relieve pruritus
Renal Disorders
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Chronic renal failure (CRF) Causes: Chronic systemic disease DM, HTN Polycystic kidney disease Long standing obstruction Chronic glomerulonephritis Recurrent infections
Renal Disorders
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Stages of CRF 1.
2.
3.
Decreased renal reserve (renal 4. End-stage renal disease impairment) • GFR: <10% • GFR: 40-50% • BUN & crea severely • BUN & crea are normal increased • Asymptomaitc • Signs of CHF Renal insufficiency • Hypocalcemia, • GFR: 20-40% hyperphosphatemia, • BUN & crea begins to rise hyperkalemia, hyponatremia • Mild anemia, mild azotemia • Fractures, joint pains • Polyuria, nocturia • Infertility, amenorrhea Renal failure • Uremia • GFR: 10-20% • BUN & crea increase • Anemia, azotemia, metabolic acidosis
Renal Disorders
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Stages of CRF Decreased renal reserve Renal insufficiency Renal failure End-stage renal disease Renal Disorders
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Renal Disorders
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Chronic renal failure (CRF) Diagnostics: Blood chemistry Urinalysis KUB-TUZ Medical management: Conservative TX Fluid and electrolyte control – Hyperkalemia Diet Dialysis Exchange resins – Hypocalcemia/ hyperphosphatemia Phosphate binders Diet Vitamin D Renal Disorders
Anemia – Epoieitin alfa – Iron – Folate and Vitamin B12 – Blood transfusion Hypertension
Dialysis Renal transplant
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Renal Disorders
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Peritoneal Dialysis
Renal Disorders
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Peritoneal Dialysis Intermittent: 8-12 H x 3-5x/week Ambulatory: 3-5 passes/day Continuous cycling: 3-7x during sleep Renal Disorders
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Peritoneal dialysis Must consider:
(+) pink-tinged effluent
– Explaining procedure
or presence of small strings is normal
– Monitor VS (+ weight)
Blood is normal for
– Note for signs of infection
With ascites from other
several days
source, substitute a lower concentration of dialysate
– Assess skin integrity Renal Disorders
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Hemodialysis AV Fistulas – Internal AVF – Internal Graft AVF – Internal AV Graft with external access device Complications – Thrombosis – Local infections – Aneurysms – Steal syndrome Renal Disorders
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Hemodialysis
Renal Disorders
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HEMODIALYSIS
PERITONEAL DIALYSIS
ACCESS
AVF Subclavian vein Arteriovenous graft
Peritoneum
DURATION
2-4 H
36 H
COMPLICATIONS
Disequilibrium syndrome Hypotension Bleeding Sepsis Hepatitis
Exit site infection Peritonitis Hernias Pulmonary complications Protein loss
Weigh before and after HD VS q 15 mins Monitor I & O, signs of DE WOF signs of bleeding Do NOT use the AVF other than for dialysis Provide diversional activities
Monitor for VS and changes in behavior Check patency of catheter May procaine HCl in the dialysate to minimize discomfort Observe for signs of peritonitis Maintain aseptic technique during insertion of trochanter. 46
NURSING INTERVENTIONS
Renal Disorders
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Chronic renal failure (CRF) Nursing management: Maintain F & E balance – I & O q 80 – Weigh daily – Assess edema Auscultate breath sounds V/S q 80 Assess LOC q 80 High CHO diet, within prescribed Na+, K+, and CHON limits Administer medications as ordered Renal Disorders
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Renal Transplant
Renal Disorders
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Renal Transplant
Renal Disorders
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Chronic renal failure (CRF) Nursing management cont…:
Prevent infection and injury
– – – – – –
Promote meticulous skin care Protect from infectious agent Protect confused person Maintain asepsis Avoid aspirin products Encourage use of soft bristle toothbrush
Promote comfort
– Give anti-pruritics – Use emolient baths, keep skin moist – Provide good oral hygiene Renal Disorders
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ACID-BASE DISORDERS Disorder
Clinical manifestation
Compensation
Respiratory acidosis
↑Paco2, ↑ or normal HCO3-, ↓ pH
Kidneys eliminate H+ and retain HCO3-
Respiratory alkalosis
↓ Paco2, ↓ or normal HCO3-, ↑ pH
Kidneys conserve H+ and eliminate HCO3-
Metabolic acidosis
↓ or normal Paco2, ↓HCO3-, ↓ pH
Lungs eliminate CO2 and conserve HCO3-
↑ or normal Paco2, ↑HCO3-, ↑ pH
Lungs hypoventilate to ↑ Paco2, kidneys conserve H+ excrete HCO3-
Metabolic alkalosis
Renal Disorders
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Causes of Acid-Base Disorders Nursing management: Metabolic acidosis Administer sodium Causes: bicarbonate DKA, uremia, Monitor for signs of starvation, diarrhea, hyperkalemia severe infections Provide alkaline mouthwash Manifestations: Lubricate lips to prevent Headache, nausea and vomiting dryness Signs of hyperkalemia I & O Seizures, coma, Institute seizure precaution hyperventilation Monitor ABG & electrolyte losses Renal Disorders
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Causes of Acid-Base Disorders Metabolic alkalosis Causes: Severe vomiting, NGT suctioning, diuretic therapy, excessive ingestion of NaHCO3, biliary drainage Manifestations: Nausea and vomiting Signs and symptoms of hypokalemia Renal Disorders
Nursing management: Decreased respirations Replace fluids nad electrolytes losses I&O Assess for signs of hypokalemia Monitor ABG & electrolytes
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Causes of Acid-Base Disorders Respiratory acidosis Causes: Hypoventilation: COPD, barbiturate or sedative overdose, acute airway obstruction, neuromuscular disorders Manifestations: Headache, weakness, visual disturbances, rapid respirations, confusion, drowsiness, tachycardia, coma Renal Disorders
Nursing management: Semi-Fowler’s Patent airway Turn, cough, deepbreath Administer fluids O2 therapy Monitor ABG
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Causes of Acid-Base Disorders Respiratory alkalosis Causes: Hyperventilation, mechanical overventilation, encephalitis Manifestations: Numbness and tingling of mouth and extremities Inability to concentrate Rapid respirations, dry mouth, coma
Renal Disorders
Nursing management: Offer reassurance Encourage breathing into a paper bag Provide sedation as ordered Monitor mechanical ventilation and ABG
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Interpretation UC
PC
FC
pH
↓ or ↑
↓ or ↑
normal
HCO3-
↓ or ↑ normal
↓ or ↑
↓ or ↑
Paco2
↓ or ↑ normal
↓ or ↑
↓ or ↑
Renal Disorders
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Renal System Disorders Nio C. Noveno, USRN, MAN