Problems of Excretion

1
Problems of Excretion

• Management of Clients with Problems of the
  Renal/Urinary System

Jayson T. Valerio RN, MSN
2
The Urinary System
3
Important Concepts about Excretion

• Kidneys
• are two-bean shaped organs that are located
  behind the peritoneum
• receive 20-25 of the total cardiac output
• renal blood flow per minute is about
  6001300ml/min
• blood supply is delivered by a single renal artery

4
Important Concepts about Excretioncontinuation

• Neprhons are the functional units of the kidneys
• there are about 1 million nephrons in each kidney
  and each nephron makes urine from blood
• Each nephron is composed of glomerulus and a
  tubule
• The tubular component of the nephron begins with
  Bowmans capsule a sac-like structure that
  surrounds the glomerulus
• The tubular tissue of Bowmans capsule narrows
  into the proximal convoluted tubule ----loop of
  henle----distal convoluted tubule ---- collecting
  ducts

5
(No Transcript)
6
(No Transcript)
7
Important Concepts about Excretioncontinuation

• Renin
• is a hormone that helps regulate blood flow,
  glomerular filtration rate (GFR) and systemic
  blood pressure
• Is secreted when blood flow, blood pressure and
  sodium level are low resulting to
  Renin-Angiotensin and Aldosterone Mechanism

8
Important Concepts about Excretioncontinuation

• Functions of Kidneys
• Maintain body fluid volume and composition
• Filter waste products for elimination
• Regulate blood pressure
• Participate in acid-base balance
• Produce erythropoietin for RBC synthesis
• Metabolize vitamin D to an active form
• Therefore, kidneys have both regulatory functions
  (1,2,3,4) and hormonal functions (5,6).

9
Important Concepts about Excretioncontinuation

• The regulatory function of the kidneys is made
  possible thru the processes of glomerular
  filtration, tubular reabsorption and tubular
  secretion.
• Glomerular Filtration
• first process of urine formation
• normal GFR is 180 liters per day or 125 ml/min
• is related to BP and blood flow
• is controlled by selectively constricting and
  dilating afferent arterioles and efferent
  arterioles
• when afferent arteriole is constricted and/or
  efferent arteriole is dilated GFR decreases and
  vice versa

10
(No Transcript)
11
Important Concepts about Excretioncontinuation

• Tubular reabsorption
• indicates the movement of substances from the
  tubule (glomerular filtrate) to the blood in the
  peritubular capillaries
• keeps the normal urine output at 1 to 3 L per day
  and prevents dehydration
• second process of urine formation

12
Important Concepts about Excretioncontinuation

• Tubular secretion
• is a process by which substance may move from the
  blood into the tubular filtrate
• Potassium and hydrogen ions are some of the
  substances moved in this way to maintain
  acid-base balance

13
Important Concepts about ExcretioncontinuationTh
e kidneys produce

• Renin
• Prostaglandins
• Bradykinins
• Erythropoietin
• Activated Vitamin D

• ? BP
• Regulates intrarenal blood flow
• ? blood flow and vascular permeability
• Stimulates bone marrow to produce RBCs
• Promotes absorption of calcium in the GI tract

14
Important Concepts about ExcretioncontinuationHo
rmones that influence the kidney function

• Aldosterone
• Antidiuretic hormone (ADH)
• Natriuretic hormone

• Promotes Na reabsorption and K excretion in the
  DCT and CT
• Makes DCT and CT more permeable to water to
  maximize reabsorption and produce a concentrated
  urine
• Cause tubular secretion of sodium

15
Important Concepts about Excretioncontinuation

• Ureters
• each kidney has a single ureter
• Function
• move urine form the renal pelvis to the bladder
• Urinary bladder
• is a muscular sac
• total capacity is 1 liter of urine
• Function
• - provides a temporary storage of urine

• Urethra
• is a narrow tube like structure lines with mucous
  membrane and epithelial cells
• Male urethra 6-8 inches
• Female urethra 1-1.5 inches
• Function
• - for eliminating urine from the body

16
Urinary System Changes Associated with Aging

• Decreased GFR
• Nocturia
• Decreased bladder capacity
• Weakened urinary sphincter muscle sand shortened
  urethra in women
• Tendency to retain urine

17
Urinary AssessmentHistory

• - Demographic Data age, gender, and race
• Personal and Family History any previous
  renal/urologic disorders, medications, OTC drugs,
  patterns of elimination, recent travel, sexual
  contacts
• Diet History food and fluid intake taste
  discrimination
• Socioeconomic Status income capability,
  educational level, knowledge of different
  resources
• Current health problems

18
Urinary AssessmentcontinuationPhysical
Assessment

• Assessment of the Kidneys, Ureters and Bladder
• performed in conjunction with abdominal
  assessment
• Inspection position supine and sitting
• Auscultation note for bruits
• Palpation position supine right kidney is
  more palpable than the left kidney
• Percussion dull sounds over the bladder
  indicates distention
• Assessment of the Urethra
• - note for any discharges

19
Urinary Assessmentcontinuation

• Psychosocial Assessment
• Diagnostic Assessment
• Serum Creatinine
• is the measurement of end product of muscle and
  protein metabolism
• Normal Value 0.6 1.2 mg/dl
• Interpretation Increase renal impairment
• Decrease decrease muscle mass

20
Urinary AssessmentcontinuationDiagnostic
Assessment

• Blood Urea Nitrogen (BUN)
• is a by-product of protein metabolism in the
  liver
• Is not the most reliable indicator of kidney
  impairment
• Normal Value 10-20 mg/dl
• Interpretation Increase renal/hepatic
  disease, dehydration, a high protein diet,
  infection, stress, steroids use
• Decrease malnutrition, fluid volume
  excess or severe hepatic damage

21
Urinary AssessmentcontinuationDiagnostic
Assessment

• BUN/Creatinine Ratio
• determines whether factors such as dehydration or
  lack of renal perfusion are causing the elevated
  BUN level
• Normal Value Mass ratio 121
• Interpretation Increase ratio fluid volume
  deficit, obstructive uropathy, catabolic
  state
• Decrease fluid volume excess
• No change in ration renal impairment

22
Urinary AssessmentcontinuationDiagnostic
Assessment

• Urinalysis
• Color pale yellow
• Odor aromatic
• Turbidity clear
• Specific Gravity 1.000-1.030
• pH 4.6-8 average is 6
• Glucose lt0.5 g/day
• Ketones none
• Protein 8-18 mg/day
• Bilirubin none
• RBC 0-2 HPF
• WBC 0-5 HPF
• Casts none or few
• Crystals none
• Bacteria lt1000 colonies/ml
• Parasites none
• Nitrates none

23
Urinary AssessmentcontinuationDiagnostic
Assessment

• Urinalysis
• ideal is the first mornings voiding
• Several techniques
• Voided urine
• Celan-catch specimen
• Catheterized specimen
• 24-Hour Urine Collection

24
Urinary AssessmentcontinuationRadiographic
Assessment

• Kidney, Ureter and Bladder (KUB)X-ray
• CT Scan
• requires bowel preparation
• assess allergies
• Ultrasonography

25
(No Transcript)
26
Renal Failure Abnormalities

• Fluid volume excess
• Electrolyte and acid-base abnormalities
• Accumulated nitrogenous wastes
• Hormonal inadequacies

27
Chronic Renal Failure End-Stage Renal Disease
(ESRD

• Progressive, irreversible kidney injury
• Azotemia
• Uremia
• Uremic syndrome
• Stages
• Diminished renal reserve
• Renal insufficiency
• End-stage renal disease

28
Respiratory -uremic halitosis -tachypnea -kussmaul
respirations -SOB -pleural effusion -crackles -ur
emic pneumonitis -depressed cough reflex

• Neurologic
• lethargy
• decreased attention span
• -slurred speech
• ataxia
• paresthesias
• coma
• seizures

• Metabolic Alteration
• urea and creatinine
• sodium
• potassium
• acid-base balance
• Ca and phosphate

Hematologic -anemia -bruising -bleeding
A client with CRF
Urinary -polyuria,nocturia -oliguira,
anuria -proteinuria -hematruia
Gastrointestinal -anorexia -nausea -vomiting- -met
allic taste in the mouth -changes in taste
sensation -uremic colitis -uremic
gastritis -uremic fetor -stomatitis
Integumentary -decreased skin turgor -dry
skin -pruritus -purpura -ecchymosis -uremic
frost -soft tissue calcifications
Musculoskeletal -muscle weakness -bone
pain -pathologic fractures -renalosteodystrophy
Reproductive -decreased libido -infrequent/absent
menses -decreased fertility -impotence
29
Chronic Renal Failure-Nursing Diagnosis

• Imbalanced nutrition
• Excess fluid volume
• Decreased cardiac output
• Risk for infection
• Risk for injury
• Fatigue
• Anxiety

30
Chronic Renal Failure-Interventions

• Nutrition therapy
• Drug therapy
• Fluid restriction
• Renal replacement therapies
• Hemodialysis
• Peritoneal dialysis
• Renal transplantation

31
Placement of a transplanted kidney in the right
iliac fossa
32
Chronic Renal Failure-Nutrition Therapy

• Protein restriction
• Sodium restriction
• Potassium restriction
• Phosphorus restriction
• Vitamin supplementation
• Individualization of diet

33
Chronic Renal Failure-Hemodialysis

• Principles
• Diffusion passive transfer of toxins
• Movement from an area of ? concentration to an
  area of ? concentration
• Osmosis removal of excess water
• Components of hemodialysis system
• Dialyzer
• Dialysate
• Vascular access routes
• Hemodialysis machine

34
SUBCLAVIAN CATHETERS
35
Options for long-term vascular access for
hemodialysis
36
An arteriovenous shunt in the forearm
37
Artificial kidney (dialyzer) used in dialysis
38
Hemodialysis Circuit
39
Peritoneal Dialysis

• Surgical replacement of abdominal catheter is
  required
• Slow process
• Correction of fluid and electrolyte is slow
• Does not cause blood loss
• Protein is lost in dialysate
• Nursing Implications
• Heparinization is not required
• Simple to perform
• Easy to use at home
• Dialysate is similar to IV fluid
• Complications bowel and bladder perforation,
  infection and peritonitis

40
Chronic Renal Failure-Peritoneal Dialysis

• Client selection
• Principles
• Takes place within the peritoneal cavity
• Slower than HD
• Diffusion and osmosis across the semipermeable
  peritoneal membrane
• Medication additives
• Heparin
• Potassium chloride
• Antibiotics

41
Manual peritoneal dialysis via an implanted
abdominal catheter (Tenckhoff catheter)
42
Chronic Renal Failure-Peritoneal Dialysis

• Complications
• Peritonitis
• Pain
• Exit site and tunnel infection
• Insufficient flow of dialysate
• Dialysate leakage
• Other complications

43
Urolithiasis

• is the presence of calculi (stones) in the
  urinary tract
• are generally asymptomatic but when they pass
  into the lower tract, they can cause pain
• the cause is unknown however 90
• of clients have metabolic risk factors
• like hypercalcemia, hyperuricemia, and
  hyperoxaluria

44
UrolithiasisClinical Manifestations

• Renal colic
• Hematuria
• Flank pain suggest that the stone is in the
  kidney and upper ureter
• Frequency and dysuria when stone reaches the
  bladder
• Oliguria or anuria suggests obstruction and
  requires emergency surgery
• Positive RBCs, WBCs and bacteria

45
NDX Acute pain Goal Focus on pain management
and prevention of infection and obstruction

• Pain relief Non Surgical Management
• Drug therapy Opioid analgesic
• NSAID
• Spasmolytics
• gt Complementary and Alternative
  Therapyrelaxation techniques imagery
  hypnosistherapeutic touch acupuncture
• gt Other Management Techniques Extra Corporeal
  Shockwave Lithotripsy (ESWL)

46
UrolithiasisInterventions Focus on pain
management and prevention of infection and
obstructioncontinuation

• Pain relief Surgical Management

47
(No Transcript)
48
Infectious DisordersUrinary Tract Infections
(UTIs)

• Accounts for more than 6.5 million health care
  visits annually in the USA
• 1.5 million hospital discharges involve a
  diagnosis of UTI
• The most prevalent nosocomial infection
• Total direct and indirect costs for urologic
  disorders are estimated at nearly 200 million
  dollars each year

49
Classifications of UTI

• Upper UTI infection of the kidney and kidney
  pelvis known as pyelonephritis
• Lower UTI infection of the urethra
  (urethritis), bladder (cystitis), prostate gland
  (prostatitis).

50
Predisposing Factors

• Renal scarring from previous UTI
• 2. Diminished ureteral peristalsis
• 3. Compression of growing uterus against ureters
• 4. Urinary retention
• 5. Presence of foreign object.
• 6. Immunodeficiency
• 7. Shorter urethra in females
• 8. Diabetes Mellitus
• 9. Neurogenic Bladder

51
Etiology and Pathophysiology

• It can be cause by invasion of microorganism
• It is estimated that 90 of UTIs are caused by
  E-coli
• Microroganisms may originate from the GI tract,
  perineal area, instrumentation, irritation or
  trauma
• Microrganisms may travel into the urethra
  bladder-ureters- kidneys

52
Key Features of UTI

• Frequency
• Urgency
• Dysuria
• Hesitancy
• Low back pain
• Nocturia
• Incontinence
• Retention
• Suprapubic tenderness or dullness
• Feeling on incomplete emptying of the bladder

53
Interventions Prevention

• For nurses Know the best practice for minimizing
  catheter-related infection
• For clients Know the client education guide for
  preventing UTI

54
InterventionsNon-surgical Management

• Drug therapy
• - urinary antispetics
• - antibiotics
• - analgesics
• - antispasmodics
• Diet therapy
• Other pain relief measures

55
InterventionsSurgical Management

• Removal of obstructions
• Repair of vesicoureteral reflux
• Treatment of calculi
• Cystoscopy