Interferences with Urinary Elimination Renal Calculi

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Interferences with Urinary Elimination
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Urinary Elimination

• Bones can break, muscles can atrophy, glands can
  loaf, even the brain can go to sleep without
  immediate danger to survival. But should the
  kidneys fail.neither bone, muscle, gland, nor
  brain could carry on.

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Urinary System
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KidneysMacrostructure

• Paired, reddish, brown bean-shaped organs
• Location
• Retroperitoneal on either side of the vertebral
  column
• 12th thoracic vertebrae to 3rd Lumbar
• Left kidney is 1.5 to 2 cm higher than right
• Weight 115 175 gms (4-6 ounces)
• Adrenal Gland lies on top of each kidney

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KidneysMicrostructure

• Nephron -- Functional unit of kidney, forms urine
• Each kidney has 1 million nephrons
• Each Nephron is composed of
• Cortex glomerulus, Bowmans capsule, proximal
  convoluted tubule, distal convoluted tubule
• Medulla The loop of Henle and collecting ducts

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KidneysMicrostructure

• Glomerulus selective filtration
• Bowmans Capsule semipermeable membrane /
  hydrostatic pressure changes
• Proximal tubule Active transport
• Reabsorption of 80 of electrolytes water
• Reabsorption of all glucose amino acids
• Reabsorption of HCO3- Acid-Base Balance
• Reabsorption of Creatinine
• Loop of Henle
• Reabsorption of Na Cl- in ascending limb
• Reabsorption of water in descending loop
• Concentration of filtrate

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KidneysMicrostructure

• Distal Tubule
• Secretion of K, H, ammonia
• Reabsorption of water (regulated by ADH)
• Reabsorption of HCO3- -- Acid-Base Balance
• Regulation of Ca and PO4- by parathyroid
  hormone
• Regulation of NA K by aldosterone
• Collecting Duct
• Reabsorption of water (ADH required)

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Blood Supply

• Blood reaches kidney via renal artery
• 20-25 of cardiac output
• 1200 ml per minute
• TO KIDNEY Aorta renal artery kidney hilus
• Renal artery divides into secondary branches,
  then into smaller braches to afferent arteriole
• Capillary network Glomerulus
• FROM KIDNEY Efferent arteriole Peritubular
  capillaries Renal vein inferior vena cava

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Nephron FunctionPhysiology of Urine Formation

• Normal glomerular function- Urine formation
  starts at glomerulus where blood is filtered
• GFR-(Glomerular filtration rate)- amt of blood
  filtered by glomeruli in a given time
• Normal GFR- 125ml/minute, however only 1 ml per
  minute becomes urine, most is reabsorbed

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Nephron Function
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Renal Function
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Other Kidney FunctionsHormone Production

• Erythropoietin
• In response to hypoxia decreased renal blood
  flow
• Stimulates RBC production in the bone marrow
• Deficiencies lead to anemia in renal failure
• Renin
• Released from juxtaglomerular apparatus of the
  nephron
• In response to lt arterial BP, renal ischemia, gt
  NA concentration
• Splits angiotensinogen into angiotensin I
  angiotensin II
• Stimulates aldosterone from the adrenal cortex
  water NA retention peripheral
  vasoconstriction

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Renin-angiotensin-aldosterone System
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Other Kidney FunctionsHormone Production

• Prostaglandins (PGs)
• Kidney medulla
• Vasodilating action increases renal blood flow
  and promotes NA excretion
• Counteracts the vasoconstrictor effect of
  angiotensin and norepinephrine
• Lowers arterial BP by decreasing systemic
  vascular resistance
• Active metabolite of Vitamin D second step in
  activating Vitamin D after action of ultraviolet
  radiation on cholesterol in the skin

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Nursing ProcessAlterations in Urinary Function

• Assessment Patient history
• Physical Assessment
• inspection, percussion, palpation
• Assessment of Urine color, clarity, odor
• Urine testing specimen collection
• Urinalysis, CS, Composite urine collection
• Creatinine Clearance 85-135ml/min
• Diagnostic tests KUB (kidney, ureter, bladder)
  renal ultrasound, renal CT scan
• Invasive IVP, Cystoscopy, arteriogram,
  urodymanics

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Upper Urinary Tract Infections

• Acute Pyelonephritis
• Chronic Pyelonephritis
• Acute Glomerulonephritis
• Acute Poststreptococcal Glomerulonephritis
• Chronic Glomerulonephritis

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Acute Pyelonephritis

• Inflammation of the renal parenchyma and
  collecting system
• Most common cause bacterial (E.coli, Proteus,
  Klebsiella, Enterobacter species)
• Pre-existing factor vesicoureteral reflux
• Commonly begins in the renal medulla and spreads
  to the adjacent cortex
• Recurring episodes may lead to chronic
  pyelonephritis
• Urosepsis bacteriuria and bacteremia

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Acute Pyelonephritis

• Clinical Manifestations sudden chills, fever,
  vomiting, malaise, flank pain, and lower UTI
  symptoms of cystitis
• Diagnostics
• Urinalysis pyruia, bacteriuia, hematuria
• Imaging Studies IVP, CT Scan, Ultrasonography
  of the urinary system

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Acute Pyelonephritis

• Medical Management for Mild Symptoms
• Short hosp stay for IV antibiotic or OP oral
  antibiotics
• Empiric broad spectrum (Ampicillin / Vancomycin)
  combined with aminoglycoside
• Change to sensitivity-guided therapy when culture
  results are available for 14-21 days
• SulfaBactrim / Cipro / Floxin
• Adequate fluid intake
• Nonsteroidal antiinflammatory drugs
• Antipyretic drugs
• Urinary analgesics Pyridium
• Follow-up cultures imaging studies
• Relapse may occur treated with 6-week course of
  antibiotics
• Antibiotic prophylaxis

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Acute Pyelonephritis

• Medical Management for Severe Symptoms
• Hospitalization
• Parenteral antibiotics
• Broad-spectrum switch to sensitivity specific
• Followed by oral antibiotics 7-21 days
• Adequate fluid intake parenteral until symptoms
  of N/V, dehydration subside
• Relieve pain
• Treat fever
• Urinary antiseptics
• Follow-up culture imaging studies

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Chronic Pyelonephritis

• Term used to describe a kidney that has lost
  function due to scarring and fibrosis
• Result of chronic upper urinary tract infections
• Other names interstitial nephritis, chronic
  atrophic pyelonephritis, reflux nephropathy
• Level of renal function depends on
• whether one or both kidneys are affected
• magnitude of scarring
• the presence of co-existing infection
• Progresses to end-stage renal disease when both
  kidneys are affected

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Acute Glomerulonephritis

• Immunologic process resulting in inflammation of
  the glomeruli
• Usually affects both kidneys equally
• Tubular, interstitial, and vascular changes occur
• Etiology
• Two types
• Antibodies have specificity for antigens within
  the glomerular basement membrane (GBM) produce
  autoantibodies to ones own tissue -- mechanism
  unknown
• Antibodies react with circulating nonglomerular
  antigens and are randomly deposited as immune
  complexes along the GBM
• End result glomerular injury as a result of
  inflammation

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Acute Glomerulonephritis

• Clinical Manifestations
• Varying degrees of hematuria
• Varying degrees of urinary excretion of WBC and
  casts
• Proteinuria
• Elevated BUN and Creatinine and Albumin
• renal biopsy
• Medical Management
• Rest
• Sodium and fluid restriction
• Diuretics
• Antihypertensive therapy
• Decreased dietary protein

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Glomerulonephritis
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Chronic Glomerulonephritis

• Syndrome end-stage glomerular inflammatory
  disease
• Proteinuria, hematuria, slow development of
  uremic syndrome decreased renal function
• Slow course toward renal failure over a few to as
  many as 30 years
• Often found coincidentally with abnormal UA or
  elevated blood pressure
• Confirmed with ultrasound and CT scan Renal Bx
• Medical Management
• Treat HTN
• Treat UTIs
• Protein and Phosphate restriction

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Acute Poststreptococcal Glomerulonephritis

• Most common in children young adults
• 5-21 days after a streptococcal sore throat or
  impetigo
• Nephrotoxic strains of group A B-hemolytic
  streptococci
• Antibodies are produced to the strept antigen
• Unknown mechanism the antigen-antibody
  complexes are deposited in the glomeruli leads
  to decreased glomerular filtration
  inflammation

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Acute Poststreptococcal Glomerulonephritis

• Clinical Manifestation
• Generalized body edema, hypertension, oliguria,
  hematuria, oliguria, proteinuria, fluid
  retention, edema in low-pressure tissues
  periorbital edema abdominal or flank pain
• Patient may be asymptomatic UA finding
• Diagnostics
• Antistreptolysin O (ASO) titers
• Renal biopsy
• Erythroycte casts
• Elevated BUN and Creatinine

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Acute Poststreptococcal Glomerulonephritis

• Medical Management
• Rest until signs of glomerular inflammation
  subside (proteinuria hematuria)
• Treat hypertension
• Restrict sodium fluid intake
• Antibiotics only if streptococcal infection is
  still present
• Prevention Early diagnosis treatment of sore
  throats and skin lesions good personal hygiene,
  patient adherence to antibiotic therapy

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Renal Conditions

• Polycystic Kidney
• Renal Artery Stenosis
• Renal Tuberculosis
• HIVassociated Nephropathy
• Nephrotic Syndrome

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Polycystic Kidney

• One of the most common genetic diseases
• Two forms
• Childhood manifestation rare autosomal
  recessive disorder with rapid progression
• Adult manifestation autosomal dominant disorder
  latent 30-40 years of age
• Involves both kidneys
• Cortex medulla are filled with thin-walled
  cysts that are several mm cm in diameter
• Cysts enlarge contain blood and pus - destroy
  surrounding tissue

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Polycystic Kidney

• Clinical Manifestation
• Symptoms appear when the cysts begin to enlarge
• Abdominal and/or flank pain
• Palpable enlarged kidneys
• Hematuria
• UTI
• Hypertension
• Diagnosis
• Family History, IVP, ultrasound, CT scan
• Usually progresses to end-stage renal failure

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Renal Artery Stenosis

• Partial occlusion of one or both renal arteries
• Atherosclerotic narrowing or fibromuscular
  hyperplasia
• 1-2 of hypertension
• Diagnosis Renal arteriogram
• Therapy Goal
• Control hypertension
• Restore kidney perfusion
• Percutaneous transluminal renal angioplasty
• Surgical revascularization (splenic artery or
  aorta)

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Renal Artery Stenosis
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Renal Tuberculosis

• Rarely a primary lesion
• Onset 5-8 years after primary pulmonary TB
• Initially asymptomatic
• Low grade fever, when infection descends to
  bladder polyuria, dysuria, epididymitis in men
• Diagnosis TB in Urine IVP
• Long Term scarring of renal parenchyma
  ureteral strictures
• Earlier the treatment less likely renal failure
  will occur
• Five drugs Isoniazid (INH), rifampin,
  pyrazinamide, streptomycin, ethambutol

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HIVassociated Nephropathy

• Range from mild fluid electrolyte abnormalities
  to progressive renal impairment and renal failure
• 10 incidence highest among IV drug users
• Clinical Manifestations
• Proteinuria nephrotic syndrome
• Progressive azotemia, enlarged kidney, rapid
  progression to end-stage renal failure
• Acute renal failure most commonly seen in
  patients with AIDS who is critically ill with
  HIV-related infection or malignancy
• Treatment Depends on treatment of primary
  disease - Dialysis

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Nephrotic Syndrome

• Decreased urine output
• Proteinuria
• Volume overload
• CHF
• Dysrhythmias
• N/V
• Uremic frost
• Anemia

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Vascular Tubular Pathogenesis
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Nephrotic Syndrome

• Increase in nitrogen waste in blood
• Fluid and electrolyte disturbance
• Treatment either conservative or aggressive

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Renal Disease Assessment - Labs

• Elevated BUN
• Elevated creatinine
• Elevated potassium
• Elevated phosphate
• Decreased calcium
• Decreased HCO3 and pH

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Renal Disease Treatment

• Conservative
• Medication, diet fluid restriction
• Aggressive
• Renal Replacement Therapies
• Dialysis (Peritoneal or Hemo)
• Organ transplantation

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Acute Renal Failure
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4 Pitting Edema
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Renal DiseaseNursing Process

• Assess comprehensive pain assessment monitor
  urinary outputcolor, frequency, consistency,
  volume, odor neuro, CVwt, edema, respiratory,
  skin integrity GI-abd girth
• Nsg Action Admin medspain relief, antibiotics,
  treat HTN, fluid restriction versus hydration IV
  po hygiene prepare for testing, procedures,
  surgery
• Pt Education Meds nutrition, fluid
  restriction, hygiene pathology strategies to
  promote adherence

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Peritoneal Dialysis
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Hemodialysis
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Renal Transplant
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Ureters

• Renal pelvis holds 3-5 ml of urine
• Kidney damage may result from backflow of more
  than that amount of urine REFLUX
• UVJ (Ureteropelvic junction) closes based on
  the ureters angle of bladder penetration and
  muscle fiber attachments to prevent backflow
• During coughing or voiding muscle fibers
  contract to promote ureteral lumen closure
• The bladder then contracts to further close the
  UVJ and prevent urine from moving back through

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Nephrolithiasis

• 500,000 people in US annually
• 20-55 years of age
• More common in men than women
• Except for struvite stones associated with UTI
• No single theory can account for stone formation
• Urinary pH, solute load, urinary stasis, urinary
  infection with urea-splitting bacteria
• Five major categories
• Calcium phosphate
• Calcium oxalate
• Uric acid
• Cystine
• Struvite

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Risk Factors for the Development of Renal Calculi

• Metabolic
• Increased urine levels of calcium, oxaluric acid,
  uric acid, citric acid
• Climate
• Warm climates cause increase fluid loss, low
  urine volume, and increased solute concentration
  in urine
• Diet
• Proteins that increase uric acid excretion
• Excessive amounts of tea or fruit juices that
  elevate urinary oxalate level
• Large intake of calcium and oxalate
• Low fluid intake
• Genetic Factors
• Family history of stone formation, cystinuria,
  gout, renal acidosis
• Lifestyle
• Sedentary occupation, immobility

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Types of Renal Calculi
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Renal Calculi

• Clinical Manifestation
• Abdominal or flank pain
• Hematuria
• Renal Colic passing into the ureter
• Nausea vomiting
• Chills, fever
• Diagnosis
• UA, Urine CS, IVP, retrograde pyelogram,
  ultrasound, cystoscopy
• Renal function BUN, Serum Creatinine

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Renal Calculi

• Medical Management
• Acute treat pain, infection, obstruction
• Narcotics, for fluidsIV and po, strain urine
• Evaluate cause of stone formation history, stone
  analysis
• Adequate hydration, dietary NA restriction,
  dietary changes, medication
• Treatment of struvite stones control of
  infection

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Renal CalculiRemoval

• Indications for Endourologic, lithotripsy or open
  surgical stone removal
• Stones too large for spontaneous passage
• Stones associated with bacteriuria or symptomatic
  infection
• Stones causing impaired renal function
• Stones causing persistent pain, nausea, or ileus
• Inability of patient to be treated medically
• Patient with one kidney

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Renal CalculiRemoval

• Endourological Procedures
• Cystoscopy remove stones from bladder
• Cystolitholapaxy cysto with lithotrite (stone
  crusher) then flushed out of bladder
• Cystoscopic lithotripsy cysto with pulverize
  stones
• Flexible ureteroscopes remove stones from
  ureter, kidney pelvis may be used with
  ultrasound, electrohydraulic, or laser
  lithotripsy
• Percutaneous nephrolithotomy -- nephrostomy tube
  left in place for a period of time

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Percutaneous Nephrostomy
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Renal Stents
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Incisions for Kidney Surgery
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Renal CalculiRemoval

• Invasive Lithotripsy
• Percutaneous ultrasonic lithotripsy via
  percutaneous nephroscope
• Electrohydraulic lithotripsy percutaneous
• Laser lithotripsy probes lower ureteral and
  large bladder stones
• Non-invasive - Extracorporeal shock-wave
  lithotripsy
• Patient is anesthetized
• High-energy acoustic shock waves shatter stone
  without damaging surrounding tissue

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Lithotripsy
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Renal CalculiNursing Diagnoses

• Acute pain
• Anxiety r/t uncertain outcome
• Ineffective therapeutic regimen management
• Impaired urinary elimination
• Risk for infection

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Renal CalculiNursing Management

• Assess Painguarding, pain scale,
  occurrencecolic versus ongoing, tenderness on
  palpation History recent/chronic UTI,
  immobility, gout, hyperparathyroidism, prostatic
  hyperplasia family history of calculi urine
  output oliguria, hematuria labsBUN, CR, UA,
  Urine CS, Increased uric acid, calcium
• Action Relieve pain Treat UTI Admin meds
  Force fluids PO - gt2L/day Maintain IV patency
  strain urine position of comfort
• Pt Education Rationale for treatment Measures
  to prevent future recurrence (once calculi origin
  is determined)dietary restrictions (purine,
  calcium, oxalates

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Renal CalculiNutritional Therapy

• Foods high in purine, calcium, or oxalate
• Purine
• High Sardines, herring, mussels, liver, kidney,
  goose, venison, meat soups sweetbreads
• Moderate Chicken, salmon, crab, veal, mutton,
  bacon, pork, beef, ham
• Calcium milk, cheese, ice cream, yogurt, sauces
  containing milk, all beans (except green beans),
  lentils, fish with fine bones (sardines, kippers
  herring, salmon) dried fruits, nuts, chocolate,
  cocoa, Ovaltine
• Oxalate spinach, rhubarb, asparagus, cabbage,
  tomatoes, beets, nuts, celery, parsley, runner
  beans, chocolate, cocoa, instant coffee,
  Ovaltine, tea Worcestershire sauce