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Kidney anatomy

The kidneys are responsible for removing wastes from the body,
regulating electrolyte balance and blood pressure,
and stimulating red blood cell production.
RENAL DISEASES
Terms:

*aldosterone *hematuria
*antidiuretic hormone *nocturia
*anuria *oliguria
*bacteriuria *proteinuria
*clearance *pyuria
*dysuria *Valsalva Leak Maneuver Point
*frequency *vesicoureteral reflux
*GFR

Test of Urine Specific Gravity:

1. Osmolality 2. Specific gravity


Illustration
Illustration
Kidneys

-retroperitoneal organs
-120 – 170g
-12cm long, 6cm wide and 2.5cm thick
-with 8 – 18 pyramids
-with 4 -13 minor calyces
-with 2 – 3 major calyces
-with protective structures:
a. Pararenal fat
b. Gerota’s fascia
c. Perirenal fat
d. Renal capsule
Nephron
-basic structural and functional unit of the kidney

3 Processes of Urine Formation


1. Glomerular Filtration
2. Tubular Reabsorption
3. Tubular Secretion
Renal function begins to decrease
at a rate of 1% each year at 30.
C. Acute Pyelonephritis

-bacterial infection of the renal pelvis, tubules and


interstitial tissue
-an ascending infection
-predisposing factors:
a. vesico-ureteral reflux
b. urinary tract obstruction
-enlarged kidney
-with abscess on the renal capsule and at the cortico-
medullary junction
SIGNS AND SYMPTOMS:
fever and chills costo-vertebral angle
leucocytosis tenderness
bacteriuria and pyuria dysuria
flank pain increase urinary frequency

DIAGNOSIS:
UTZ Nuclear scan
CT scan Urine Culture and Sensitivity
IVP Test
MEDICAL MANAGEMENT:

a. uncomplicated
-no dehydration, no nausea and vomiting, no sepsis
>2 weeks of oral antibiotics
Trimethoprim-Sulfamethoxazole
Ciprofloxacin
Gentamicin with or without Ampicillin
Third Generation Cephalosporins
>6 weeks of oral antibiotics if with relapse
*urine culture 2 weeks after antibiotic therapy
b. complicated
-pregnant patients
>hospitalization (antibiotics from IV to oral)
B. Chronic Pyelonephritis
-repeated acute pyelonephritis >> chronic
pyelonephritis
-no s/sx unless there’s an acute exacerbation
-kidneys scarred, contracted and non functional
SIGNS AND SYMPTOMS:
fatigue polyuria
headache excessive thirst
anorexia weight loss
DIAGNOSIS:
creatinine and BUN clearance
creatinine levels
intravenous pyelography
COMLICATIONS:
a. ESRD
b. hypertension
c. formation of renal stones
-may be due to the presence of urea
splitting microorganisms
MEDICAL MANAGEMENT:
a. urine culture and sensitivity guided antibiotic therapy
Nitrofurantoin
TMP-SMZ
NURSING MANAGEMENT:
a. monitoring
-I&O
b. oral fluids (3-4L/day)
c. symptomatic
-antipyretics
d. education
-advise bed rest
-prevention of UTI

C. Acute Glomerulonephritis
-primarily a disease of children older than 2 years old
-may affect any age
-causes:
>autoimmune
SLE
>streptococcal
Acute Post Streptococcal
Glomerulonephritis
Acute Post Streptococcal Glomerulonephritis
-2 to 3 weeks after
>impetigo
>sorethroat
SINGS AND SYMPTOMS:
hematuria hypertension
tea colored urine headache, malaise, flank pain
proteinuria (+) kidney punch
inc serum BUN and crea congestion
anemia confusion, somnolence
edema and seizures
Group A Beta-Hemolytic Streptococcal Infection

Antigen-Antibody Reaction

Deposition in the Glomerulus

Increased Production of Epithelial Cells in the

Glomerulus

WBC Infiltration

Thickening

Scarring

Decreased GFR
DIAGNOSIS:
a. kidney biopsy
b. electron microscopy
c. immunoflourescence analysis
d. Anti-Streptolysin O Titer
Anti-DNAse B Titer
e. Serum Complement Determination
-decreased
-will normalize in 2 – 8 weeks

IgA Nephropathy
-most common type of primary
glomerulonephritis
-Inc IgA; with normal serum complement
-complications:
a. Hypertensive Encephalopathy
b. Heart Failure
c. Pulmonary Edema
Rapidly Progressive Glomerulonephritis
-patient deteriorates in weeks to months
-course is more severe and more rapid

Management To Glomerulonephritis
Goals:
1. Treat symptoms
2. Preserve renal function
3. Treat complications
a. antibiotics d. protein restriction
b. steroids e. sodium restriction
c. cytotoxic agents f. diuretics
g. dialysis
D. Chronic Glomerulonephritis
-components:
repeated acute glomerulonephritis
hypertensive nephrosclerosis
hyperlipidemia
chronic tubulo-interstitial injury
hemodynamically mediated glomerular sclerosis
-contraction of the kidneys to 1/5 of its original size
-deformed kidneys
-may result to ESRD

SIGNS AND SYMPTOMS:


may be asymptomatic hypertension
inc BUN and Crea bipedal edema
retinal hemorrhages
ophthalmoscopy
papilledema
weight loss
weakness and irritability
nocturia
GIT disturbances
anemia
heart failure
peripheral neuropathy, decreased DTR
pulsus paradosus

DIAGNOSIS:
1. Urinalysis- fixed sp. Gravity at 1.010
proteinuria; urinary casts
2. serum chemistry
-hyperkalemia
- hypoalbuminemia
-hyperphosphatemia
-hypocalcemia
-hypermagnesemia
3. CBC
-anemia
4. Chest X-Ray
-cardiomegaly
-pulmonary edema
5. ECG
-left ventricular hypertrophy
MANAGEMENT:
1. treatment of hypertension
2. weight monitoring
3. give proteins of high biologic value
4. adequate calories
5. dialysis

NURSING MANAGEMENT:
1. monitoring

E. Nephrotic Syndrome
-components:
proteinuria hyperlipidemia
hypoalbuminemia
CAUSES:
a. chronic glomerulonephritis
b. diabetes mellitus
c. amyloidosis
d. SLE
e. multiple myeloma
f. renal vein thrombosis
SIGNS AND SYMPTOMS:
edema (soft and pitting)
-eyes, dependent area and abdomen
malaise irritability
headache fatigue
DIAGNOSIS:
1. Urinalysis
-proteinuria (3-3.5g/day)
-inc WBC
2. Protein Electrophoresis
Immunoelectrophoresis
3. Biopsy
4. AntiC1q antibodies (SLE)

COMPLICATIONS:
a. infection d. acute RF
b. thromboembolism e. accelerated
atherosclerosis
c. pulmonary emboli
MANAGEMENT:

1. diuretics
2. ACE inhibitors
3. immunosuppressants
4. steroids
5. hypolipidemic agents
6. sodium restriction
7. CHON intake of 0.8g/kg/day
low saturated fats
 Urolithiasis
-stones or calculi in the urinary tract
-supersaturation of substances such as calcium
oxalate, calcium phosphate and uric acid
SIGNS AND SYMPTOMPS:
>depends on
*the site of obstruction *edema
*infection
ASSESSMENT AND DIAGNOSIS:
>IVP, Intravenous Urography
>Retrograde Pyelography
>UTZ
>serum chemistries and 24 urine tests
deficiency of citrate, mg
nephrocalcin & uropontin

dehydration

infection
Urolithiasis
urinary stasis

periods of immobility

hypercalciuria and hypercalcemia


Causes of hypercalcemia and hypercalciuria:

a. hyperparathyroidism
b. renal tubular acidosis
c. cancers
d. granulomatous disease
e. excessive intake of Vitamin D
f. excessive intake of milk and alkali
g. myeloproliferative disease
-substances other than calcium that may precipitate
and form stones
a. uric acid
-5%-10% of renal stones
-gout, myeloproliferative disorders
b. struvite
-15% of renal stones
-in persistently alkaline and ammonia rich urine
(caused by urease-splitting bacteria)
-in neurogenic bladder, foreign bodies and
recurrent UTI
c. cystine
-1%-2% of renal stones
-hereditary defect in the renal absorption
-medicines that increases the risk of urolithiasis

a. acetazolamide d. laxatives
b. Vitamin D e. high doses of aspirin
c. antacids
MANAGEMENT:
a. eradicate the stone
b. determine the stone type
c. prevent nephron destruction
d. control infection
e. relieve any obstruction
>Opioid Analgesics
NSAIDs
>Hot Baths and Moist Heat to the flank area
>Advise to increase oral fluid intake
(urine output of >2L/day is advisable)
SPECIFIC MANAGEMENT:
1. Calcium stones
-restrict proteins and sodium in the diet
-acidify the urine using Ammonium chloride
or Acetohydroxamic Acid
-Cellulose sodium phosphate
(binds calcium from food)
-thiazide diuretics (if caused by inc PTH)
2. Uric Acid Stones
-low purine diet (shellfish, mushrooms,
asparagus, organ meats)
-Allopurinol
-alkalinize the urine
3. Cystine
-low protein diet
-penicillamine (to decrease excretion
through the urine)
4. Oxalate
-dilute the urine
-limit oxalate containing foods
(spinach, strawberries, rhubarb, tea,
bran)
SURGICAL MANAGEMENT:
a. Ureteroscopy
b. Extracorporeal Shock Wave Lithotripsy
c. Percutaneous Nephrostomy or Nephrolithotomy
ACUTE RENAL FAILURE
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Acute kidney failure occurs when the kidneys suddenly stop working.
This may occur after surgery or due to an injury. It can also occur due to the
use of certain drugs. People with acute renal failure may regain their kidney function
depending on the cause of the damage.
 Acute Renal Failure

-sudden and almost complete loss of renal function


-s/sx:
*oliguria *normal urine output
*anuria *rising serum creatinine and

BUN
1. Prerenal
-shock
2. Intrarenal
-the result of actual parenchymal damage
-use of nephrotoxic drugs (NSAIDs and ACE inh)
3. Postrenal
-the result of an obstruction in the distal urinary tract
Acute Renal Failure

ACUTE RENAL FAILURE

PRE-RENAL INTRA-RENAL POST-RENAL


Four Clinical Phases of ARF
1. Initiation
-begins with the initial insult and ends when oliguria develops
2. Oliguria
-rise in the serum of waste products of metabolism
-rise in serum potassium and magnesium
3. Diuresis
-with gradually increasing urine output
-renal function may still be markedly abnormal
4. Recovery Period
-improvement of renal function
-may take 3-12 months
-with normal laboratory values
-with permanent 1-3% reduction in GFR
Characteristics
Prerenal Intrarenal Postrenal
Etiology hypoperfusion parenchymal obstruction
damage

BUN value increased increased Increased


Creatinine increased increased Increased
value

Urine output decreased varies, often varies, may be


decreased decreased or
anuria
Urine sodium Decreased, Increased, Varies, often
<20mEq/L >40mEq/L <20mEq/L

Urinary Normal, few Abnormal casts Usually normal


Sediment hyaline casts
Characteristics Prerenal Intrarenal Postrenal
Urine Increased to Abnormal casts Usually normal
osmolality 500mOms and debris

Urine specific Increased Low normal, Varies


gravity 1.010
ASSOCIATED PROBLEMS:
*metabolic acidosis
*hyperphophatemia and hypocalcemia
*anemia

PREVENTION:
*prevention of exposure to nephrotoxic drugs
-aminoglycosides, cyclosporine, amphotericin B
*serum BUN and creatinine monitoring

MANAGEMENT:
a. restore chemical balance and prevent complications
b. identification and treatment of the underlying cause
c. maintain fluid balance
-BP, CVP, serum and urine elect., fluid loses
d. monitoring for over hydration
-dyspnea, crackles, distended neck veins
-Furosemide, Ethacrynic Acid
e. dialysis
-to prevent serious complications
*hyperkalemia
*severe metabolic acidosis
*pericarditis
*pulmonary edema
f. pharmacologic
-cation exchange resin
(sodium polystyrene sulfonate-kayexalate)
-retention enema
-diuretic therapy
-low dopamine dose (1-3g/kg)
-phosphate binding agents (AlOH)
g. nutritional therapy
-give additional proteins (1g/kg/day during the
oliguric phase)
-high potassium and phosphate foods are
restricted (banana, citrus and coffee)
-potassium restricted to 20-40mEq/day
-sodium restricted to 2g/day
-may require parenteral nutrition
NURSING MANAGEMENT:

a. monitoring fluid and electrolyte balance


b. reducing metabolic rate
-bed rest, prevention of fever and infection
c. promoting pulmonary function
-assistance in changing positions
-advise to cough and deep breath
d. preventing infection
-asepsis
-avoid inserting an indwelling urinary catheter
e. providing skin care
f. providing support
CHRONIC RENAL FAILURE
Patients with kidney dysfunction
(i.e. Renal Failure) are typically
identified by the increased blood
levels of Cr and BUN on routine bloo
lab testing. By definition we separat
kidney failure into ACUTE vs.
CHRONIC.
 Chronic Renal Failure
-is a progressive irreversible deterioration in renal
function
-with uremia or azotemia (severity of build up will be
proportional to the severity of s/sx)
-prognosis will be determined by the presence or
absence of hypertension and proteinuria

CAUSES:
*diabetes mellitus- most common
*hypertension
*chronic glomerulonephritis
*obstruction of the urinary tract
*polycystic kidney disease
*infections
*nephrotoxic medications
STAGES:
Stage 1
-Reduced Renal Reserve
-40%-75% loss of nephron function
-usually asymptomatic
Stage 2
-Renal Insufficiency
-75%-90% loss of nephron function
-increase in serum BUN and creatinine
-inability to concentrate urine
-anemia may develop
-with polyuria and nocturia
Stage 3
-End Stage Renal Disease
-<10% of nephron function remaining
-regulatory, excretory and hormonal functions
are lost
-requires dialysis
SIGNS AND SYMPTOMS

cardiovascular
*hypertension *pulmonary edema
*heart failure *pericarditis
dermatologic
*pruritus
*uremic frost (deposit of urea crystals)
GI and Neurologic s&sx
ASSESSMENT AND DIAGNOSIS:
a. glomerular filtration rate
creatinine clearance
b. serum electrolytes
c. ABG
d. CBC
COMPLICATIONS:
a. Hyperkalemia
b. Pericarditis, Pleural Effusion and Cardiac
Tamponade
c. Hypertension
d. Anemia
e. Bone Disease
MEDICAL MANAGEMENT:
a. maintain kidney function and homeostasis
b. treat the underlying cause and contributory
factors
>medications >dialysis
>diet therapy
1. Pharmacologic Therapy
a. antihypertensives
> includes intravascular volume control
*fluid restriction
*sodium restriction
b. sodium bicarbonate
c. erythropoietin
>will achieve a Hct of 33%-38%
>IV or SC 3x a week
>takes 2-6 weeks to increase Hct
>A/R:
*hypertension
*increased clotting of vascular access
sites

*seizures
*depletion of body iron stores
d. iron supplementation
e. antiseizure agents
>Diazepam
>Phenytoin
f. antacids
>aluminum based antacids
neurologic symptoms
osteomalacia
>calcium carbonate
2. Nutritional Therapy
-regulation of protein intake
-regulation of fluid intake
(500-600ml more than the previous day’s 24 hour
UO)
-regulation of sodium intake
-regulation of potassium
-adequate calories and vitamins
3. Dialysis
-to prevent hyperkalemia
NURSING MANAGEMENT:
a. avoid the complications of reduced renal
function
b. assess fluid status
c. identify potential sources of the imbalance
d. implement a dietary program
e. encourage self care and independence
ADPIE
Assessment
 Subjective: Dysuria and Frequent
urination
 Objective: Hyperthermia Urinary
incontinence or retention
Nursing Diagnosis
-Impaired urinary elimination r/t renal
problems as evidenced by urinary
incontinence.
-Hyperthermia r/t kidney infections.
-Acute pain r/t damaged kidney.
ADPIE
Planning
 STG: After an hour of nursing intervention the patient’s body temperature
will decreased and the pain will be verbalized as tolerable.
 LTG: Within hospital stay the patient will maintain normal body
temperature, verbalizes pain not occurring and will maintain normal
urinary elimination.
Intervention
 -TSB
-Provide teachings of safety measures
 -Explain patient’s condition
 -Monitor VS to know any alteration
 -Assess patient’s pain tolerance
 -Administer medications as prescribed
 -Monitor I and O
Evaluation
 STG: After an hour of nursing intervention the patient’s body temperature
has reduced and the patient verbalizes pain as tolerable.
 LTG: Within hospital stay the patient has maintain normal body
temperature, verbalizes pain not occurring and has maintained normal
urinary elimination.
REFERENCES
 Brunner and Suddarth’s Textbook of
Medical and Surgical Nursing
 10th Edition, Suzanne C.
Smeltzer; Brenda Bare
 www.google.com
END!!!

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