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KIDNEY
• Bean-shaped organ
• Highly vascular
• Has exocrine and endocrine functions
• Weight: 150 g
• Length: 4.5 inches (11.4 cm)
• Width: 2.5 inches (6.4 cm)
• Location: Retroperitoneal
• Supine: T12-L3
• Trendelenburg: 10th-11th ICS
• Standing: Down the iliac crest
• 1 contains about million nephrons.
NEPHRON
2 sections:
1. Bowman's capsules - outer cortex region
2. Renal tubules - from the cortex into the darker medulla.
Filtration:
Blood flows to the glomerulus (from the renal artery)
Pressure in the glomerulus forces: water, glucose, urea, salts through the capillary wall and tubule
(Protein & blood cells remain)
Glucose, most of the water and salts are absorbed back into the blood in the nearby capillaries. (TRR –
124 cc/min)
They pass down the tubule and eventually reach the bladder.
(Blood flows out of the kidney to the renal vein.)
URETERS
• Length: 10-12 inches (25-30 cm)
• Diameter: 2-8 mm
• Major function: Channel urine down to the bladder by peristaltic waves (1-5x/min)
• Ureterovesical valve – prevents reflux of urine
URINARY BLADDER
• Hollow, spherical, muscular organ
• Anterior and inferior to the pelvic cavity
• Posterior to Symphysis Pubis
• Elastic as it stores urine
a. First Urge: 200-300 cc
b. Moderately full: 500-600 cc
c. Maximum capacity: 1000-1800 cc (Rises up to the Symphisis Pubis
Lester R. L. Lintao, RN
Page 1 of 14
• Effects of:
a. Parasympathetic Nerves: Contract
b. Sympathetic Nerves: Relax
URETHRA
• Anterior to the vagina (female) – behind symphisis pubis
• Length
a.Female: 3-5 cm
b.Male: 20 cm
ROUTINE URINALYSIS
Blood Tests:
BUN : 10-20 mg/dL
Serum Creatinine : .4-1.2 mg/dL
Serum Uric Acid : 2.5-8 mg/dL
Albumin : 3.2-5.5 mg/dL
RBC : 4.5-5.5 mg/dL
Hematocrit : 38-54 vol%
Serum Electrolytes:
Potassium : 3.5-5 mEq/L
Sodium : 135-145 mEq/L
Calcium : 4.5-5.5 mEq/L
Magnesium : 1.5-2.5 mEq/L
Phosphorus : 3.5-5.5 mEq/L
Chloride : 98-108 mEq/L
DIAGNOSTIC STUDIES
CYSTOSCOPY
• Provides a means of direct visualization of the urethra, bladder, and urethral orifices
• The Cystoscope (an instrument with lighted lens) is inserted into the urethra
• Biopsy specimens, lesions, small stones and small foreign bodies can be removed by this means.
Lester R. L. Lintao, RN
Page 2 of 14
After Cystoscopy:
• BR until VS are stable
• Blood-tinged (pink) witihin 24-48 hours is normal
• Due to irritation:
a. Dysuria c. Hematuria
b. Frequency
• Assess for:
a. Urinary retention c. Prolonged / excessive hematuria
b. Signs of infection
• Monitor VS and I&O
• Force fluids
Before IVP . . .
• Secure written consent
• NPO 6-8 hours
• Bowel preparation
• Check for hypersensitivity to iodine (sea foods)
• Emergency drug: Epinephrine (for possible anaphylactic shock)
• Inform: warm flushing sensation on IV injection site is normal
Before RPG:
• Written consent
• Check for iodine / dye allergy
• Inform: discomfort of the procedure
• Emergency drug: Epinephrine (for possible anaphylactic shock)
After RPG:
• Monitor VS
• Increase fluid intake flush the dye
• Inform: Burning sensation during urination may be experienced
• Assess: Late allergic reactions
Lester R. L. Lintao, RN
Page 3 of 14
VOIDING CYSTOURETHROGRAM FILM
• Provides visualization in 3 phases:
• Before voiding: Outlines bladder wall
• During voiding: Outlines urethra and reflux of urine into ureters
• After voiding: demonstrates if bladder is emptied completely
• Contrast medium as instilled into the bladder by the use of cystoscope
• Nursing responsibilities: Same as of RPG
RENAL ARTERIOGRAM
• Provides x-ray pictures of the blood vessels supplying the kidney.
• Introduction of a radiopaque dye directly into the renal artery.
• Most common site is the femoral artery
• Used in evaluating persons suspected of having renal artery stenosis, abnormalities on the renal
blood vessels or vascular damages.
Before RA
• Cleanse bowel(Laxative)
• Shave catheter insertion site
• After RA
• VS until stable
• Cold puncture on the puncture site
• Check for swelling / edema
• Assess peripheral pulses
• Check for color and temperature of the skin
• Bedrest for 24 hours, no sitting
• Measure I and O
ULTRASOUND
• Detects tumors, cyst obstructions and abscesses
Nursing Interventions:
• Cleanse the bowel
• Force fluids
• Withhold voiding
RENAL BIOPSY
• To determine malignancies
• Nursing Interventions
• NPO 6-8 hours
• Check PTT, PT (Bleeding is usual)
• Mild Sedation
• Local anesthesia
• Hold breath during insertion of needle
• UTZ to locate kidneys
Lester R. L. Lintao, RN
Page 4 of 14
• A reversible condition characterized by a sudden reduction or cessation of renal function
retention of waste compounds increase in urea and creatinine
a. Etiology:
Prerenal
• Prolonged deficit in renal blood (renal artery disease , hypovolemia, aortic stenosis, hypotension)
Intrarenal
• Damage to the renal parenchyma (glomerulonephritis, acute tubular necrosis [ATN], diabetic
nephropathy, pyelonephritis, drug induced).
• Diagnostic tests requiring the use of dye (nephrotoxic.)
Postrenal
• Obstruction to urine outflow (renal stones, tumors, ureteral kinks, instrumentation).
Lester R. L. Lintao, RN
Page 5 of 14
Assessment of CRF:
1. Inability of the kidneys to excrete metabolic waste products of protein through urine formation
• Oliguria
• Increased BUN, s. creatinine (AZOTEMIA)
• Uriniferous odor of breath
• Stomatitis and G.I. Bleeding – urea is converted back into ammonia which
• irritates mucous membrane
• Destruction of rbc, wbc, platelets
• Renal encepalopathy
• Uremic frost (pruritis and dryness of skin)
• Decreased libido, impotence, infertility (hormonal imbalances)
2. Inability of the kidneys to maintain fluid – electrolyte, acid – base balance.
• Edema
• Hyperkalemia
• Hypo / hypernatremia
• Hypermagnesemia
• Metabolic acidosis
3. Inability of the kidneys to secrete Erythropoietin (Renal Erythropoetic Factor) Anemia
4. Inability of the kidneys to metabolize Vitamin D.
• Hypocalcemima
• Hyperphosphatemia
• Renal osteodystrophy
5. Altered biochemical environment
• Glucose intolerance
1. Conservative Management
• Fluid Control
• Electrolyte Control
• Hyperkalemia
• Metabolic acidosis
• Hypocalcemia / hyperphosphatemia
• Dietary Control
2. Treatment of intercurrent Disorders
• Anemia
• Gastrointestinal Disturbance
• Hypertension, CHF, pulmonary edema, hypocalcemia, hyperphosphatemia, etc.
Guidelines for the Care of the Person with Chronic Renal Failure
Lester R. L. Lintao, RN
Page 6 of 14
• Protect person from exposure to infectious agents.
• Maintain good medical / surgical asepsis during treatments and procedures.
• Avoid aspirin products.
• Encourage use of soft toothbrush.
3. Promote comfort
• Medicate patient as needed for pain.
• Antipruritics, control environmental temperature to relieve pruritis.
• Use of damp cloth to keep lips moist; give good oral hygiene.
• Rest for fatigue; however, encourage self – care as tolerated.
MEDICAL MANAGEMENT:
Hemodialysis
• Alternates to the excretory but not on the endocrine function of the kidneys
• Practice ARM PRECAUTION
• Assess for patency: auscultate for bruit, palpate for thrill
• Tourniquet be always available if A – V shunts is present.
•A – V shunt may be used immediately
•A – V fistula may be used after 4-6 weeks wait for healing. It can be used for 3-4 years.
• Vascular access:
•Arteriovenous fistula.
•Arteriovenous graft.
•External arteriovenous shunt.
•Femoral vein catheterization.
•Subclavian vein catheterization.
Peritoneal Dialysis
Advantages:
• Steady state of blood chemistries.
• Patient can dialyze alone in any location without need for machinery.
• Patient can readily be taught the process.
• Patient has few dietary restrictions; because of loss of CHON in daily dialysate, the patient is
usually placed on a high CHON diet.
• Patient has much more control over daily life.
Lester R. L. Lintao, RN
Page 7 of 14
• Peritoneal dialysis can be used for patients that are hemodynamically unstable.
a. Etiology
• Bacteria, usually E. Coli.
• Pyelonephritis spread of bacteria into the bloodstream, urinary reflux, obstruction or
ascending UTI.
• Cystitis:
a. BPH
b. Occurs more commonly in women
c. Uretheritis - bacterial and viral infections
• Other factors include:
a. Stasis
b. Urinary retention and bladder distention.
c. Instrumentation
d. Poor hygiene
e. Fecal incontinence
f. Sexual transmission of bacteria
c. Nursing interventions:
• C AND S before antibiotic therapy
• Fluid intake (3 – 5 L/day)
• Acidity
• Hot Sitz bath
• 3 W’s: wash, wear, wipe
• Empty bladder every 2-3hours
• Empty bladder immediately after sexual intercourse
• Analgesic: PYRIDIUM (Phenazopyridine) - Causes red – orange discoloration of body
secretions
• Urinary Antiseptic
Cinoxacin (Cinobac)
Nalidixic (Noroxin)
Lester R. L. Lintao, RN
Page 8 of 14
Nitrofurantoin (Macrodatin)
Metheranime Mandelate (mandelamine)
• Sulfonamides
Co-trimoxazole (Bactrim)
Sulfisoxazole (Gantrisin)
• Cholinergics (to relieve urinary retention)
Bethanechol chloride (Urecholine)
• Anticholinergics (to decrease bladder muscle spasms)
Propantheline Bromide (Pro-Banthine)
• Antibiotics
Ciprofloxacin (Cipro)
Cephalexin (Keflex)
a. Etiology
• Urinary pH influences stone formation
• Low calcium and phosphate stone formation
• High uric acid stone formation
• Other factors are:
• Excessive calcium and protein intake
• Urinary stasis
• Dehydration
c. Nursing Interventions
• Increase fluid intake 1 to 3 L daily
• Strain urine to determine type of stone
• Encourage patient to ambulate to facilitate passage of stones.
• Administer analgesics for pain
• Provide dietary counseling to prevent recurrent stone formation:
a. Acid-ash diet for calcium and phosphate stones
b. Alkaline ash and low purine diet for uric acid stones
• Prepare for surgery for stone removal:
a. Nephrolithotomy – kidney stone
b. Pyelolithotomy – renal pelvis
c. Ureterolithotomy – ureters
d. Cystostomy – bladder calculi
• Institute postop care.
BLADDER CANCER
• More common in males
• Cause: unknown
a. Risks Factors
• Exposure to cigarette smoke
• Pelvic radiation
• Use of cyclophosphamide
• Chronic cystitis
Lester R. L. Lintao, RN
Page 9 of 14
• Bladder calculi
• Schistosomiasis
b. Assessment
• Painless hematuria (first sign)
• Dysuria
• Gross hematuria
• Obstruction to urine flow
• Development of fistula (urine from the vagina, fecal material in the urine)
c. Collaborative Management
• Chemotherapy
Thiotepa
Mitomycin C
Doxorubicin (Adriamycin)
Cyclophosphamide (cytoxan)
Cisplatin (Platinol)
Methotrexate
• Radiation
• Surgery - Urinary Diversion Surgeries
a. Ileal Conduit
• For CA Bladder
• Adult Neurogenic Bladder
• Insterstitial Cystitis
• Irreparable Trauma
Important!
• External collection device needed
• Proper fitting to prevent urine leak to the skin
• Skin care with warm water and mild soap
Complications:
• Obstruction to the urine flow via small intestines secondary to edema
• Infection
• Stoma prolapse
• Calculi
• Electrolyte imbalances
b. Ureterostomy
• Either or both ureters are out to the abdominal wall
• Ureteral stoma is created
• External collection device is needed
• Infection is a potential hazard
• Increase fluid intake
c. Nephrostomy
• To drain the urine while ureteral inflammation from trauma or calculus is present
Complications:
• Infection (Pyelonephritis)
• Blockage of the catheter
Important!
• DO NOT IRRIGATE!!!
Lester R. L. Lintao, RN
Page 10 of 14
d. Ureterosigmoidostomy
• No external collection device
• Passage of flatus includes leak of urine
• Infection is possible
c. Assessment
• Rectal Examination (Digital Examination)
• Cystoscopy
• Nocturia
• Hesitancy
• Residual urine
• Hematuria
• UTI
d. Management
1. TURP (Transurethral Resection of the Prostate)
• No incision
• Continuous bladder irrigation (CBI) or dystoclysis I done postpop
• This is to irrigate the bladder and remove blood clots
• No incontenence, no impotence postop.
2. Suprapublic Prostatectomy
• Incision over lower abdomen and bladder
• With cystostomy tube and 2-way foley chatter postop
• No incontenence, no impotence post
3. Retropublic Prostatectomy
• Incision over the abdomen
• No incontenence, no impotence postop
Postoperative Care
Client Teaching
• After removal of catheter: observe for urinary retention/dribbling
• Dribbling: KEGEL’s exercise to strengthen pubococcygeal muscle and help regain control
voiding
• Avoid the following
1. Vigorous exercise
Lester R. L. Lintao, RN
Page 11 of 14
2. Having lifting sexual intercourse 3 weeks after the discharge
3. Driving 2 weeks after discharge
4. Straining with defection
5. Prolonged sitting / standing
6. Crossing the legs
7. Long trips
PROSTATE CANCER
• Most common male cancer
• Androgen – dependent adenocarcinomas
a. Predisposing Factors
• 50 years of age
• Genetic tendency
• Hormonal factors
• Late puberty
• High frequency of sexual experience
• History of multiple sexual partners
• High fertility
• Diet
• ↑fat (alters cholesterol and steroid metabolism)
• Chemical carcinogens
• Air pollution
• Occupation-related; industries – fertilizer, rubber, textile; batteries containing Cadmium
• Viruses
b. Assessment
• Hesistancy
• Hematuria
• Urinary retention
• Stool changes
• Pain radiating down hips and legs
• Cytitis
• Dribbling
• Nocturia
• Hard, enlarged prostate
• Pain on defaction
• High level of acid phospatase
• Pain on defection
• Elevated PSA (Prostatic Specific Antigen)
c. Nursing Interventions
• Early detection of tumor
• Ultrasound
• MRI
• X-ray
• CT Scan
• Radiation therapy
• Endocrine therapy - DES (diethylstilbestrol) decreases testosterome level)
• Surgery: Prostatectomy
NEPHROTIC SYNDROME
• A group of symptoms associated with the protein loss that occurs with various renal disorders.
a. Etiology:
Lester R. L. Lintao, RN
Page 12 of 14
• Presence of other primary diseases, such as diabetes, and systemic lupus erythematosus
(SLE).
c. Nursing interventions:
1. Provide the patient with a high-protein, low-salt, diet.
2. Administer diuretics, as ordered.
3. Observe carefully for signs of hypovolemia and hypokalemia.
4. Observe for and treat symptoms of renal failure.
GLOMERULONEPHRITIS
• Glomerulonephritis is an inflammatory disorder involving the glomerulus.
• Types of glomerulonephritis include:
a. Acute poststreptococcal: Onset is abrupt, typically occurring 7 to 10 days after a streptococcal
throat or skin infection.
b. Chronic glomerulonephritis: Occurs when glomerular disease leads to chronic renal failure
c. Glomerular lesions may assume any shape or form; the type of lesions present often
determines the course and severity of the disease.
a. Etiology:
• Glomerulonephritis is caused by an immune reaction to the presence of an infectious organism,
usually group A beta-hemolytic Streptococcus.
Manifestations include:
• Acute onset of hematuria
• Red blood cell casts
• Proteinuria
• Decreased (GFR)
• Oliguria
• Edema
• Hypertension
Lester R. L. Lintao, RN
Page 13 of 14
c. Nursing interventions:
1. Assess and monitor renal functions - serum creatinine (BUN) tests.
2. Observe for signs and symptoms of infection; avoid exposing the patient to persons with infections.
3. Limit sodium, potassium, fluid, and protein intake.
4. Prepare for dialysis, as indicated.
PYELONEPHRITIS
• Infection of the kidney tissue and pelvis that occurs from several sources; may be acute or chronic.
a. Etiology:
1. Typically is caused by bacteria, but may result from fungi or viruses.
2. Acute pyelonephritis results
• From bacterial contamination by way of the urethra or from instrumentation.
• Bacterial hematogenous spread
3. Chronic pyelonephritis may:
• Be idiopathic
• May occur in association with obstruction or reflux due to kidney stones or neurogenic
bladder
c. Nursing interventions:
1. Administer antimicrobial agents, as ordered.
2. Avoid exposing the patient to persons with infections.
3. High normal fluid intake, 2 to 3 L daily
4. CBR to reduce the metabolic rate and rest the kidneys.
5. Analgesics PRN
6. Monitor I & O, weight, temperature, PR, and BP to assess volume status.
Lester R. L. Lintao, RN
Page 14 of 14