Assessment of Renal and Urinary Tract Function (Chap. 43)

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Assessment of Renal and Urinary Tract Function
(Chap. 43)
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Functions of the Kidneys

1. Urine formation
2. Excretion of water products
3. Regulation of electrolytes
4. Regulation of acid-base balance
5. Regulation of water balance
6. Control of blood pressure
7. Renal clearance ( the ability of the kidneys to
   clear solutes from the plasma
8. Regulation of red blood cell production
9. Synthesis of vit.D to active form
10. Secretion of prostaglandins (PGE2) (
    vasodilatation effect and maintaining renal flow

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Assessment

• Health history
• Patient chief concern
• Pain ( characteristic, location, duration,. Etc)
• Dysuria, Hesitancy, urine incontinence, urinary
  frequency, Hematuria, Nocturia, polyuria,
  oliguria (less than 400/day), and anuria ( urine
  less than 50 ml/day)
• The present of renal calculi
• History of GI symptoms
• History of UTI

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Cont

• History of sexual transmitted disease
• Habits smoking, alcohol, drugs
• Medication
• History of any renal diagnostic test (
  catheterization)
• Any risk factors ( DM, Hypertension, Sickle cell
  anemia, Benign prostatic hypertrophy, spinal cord
  injury, immobilization

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Physical examination
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Diagnostic Evaluation

• Urine analysis urine color (light yellow), Urine
  clarity ( clear and translucent), urine odor (
  arometic), urine PH ( acidic 6.0 or 4.6-8),
  urine specific gravity, detect protein, glucose
  and ketone bodies in the urine, microscopic
  examination of the urine sediments to detect
  RBCs, WBCs, casts, crystals, pus (pyuria), and
  bacteria
• Urine Culture and sensitivity
• Renal function test (KFT) Renal concentrate test
  (Specific gravity, and urine osmolarity)
  creatinine clearance test ( 24-hour urine
  collection test), serum creatinine, BUN, and
  serum electrolyte level

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Continue

• X-Ray film and other Imaging modalities
• KUB studies to detect size, shape, location and
  position of the kidneys, to reveal stone,
  hydronephrosis ( distention of the kidney
  pelvis), Cysts, tumors, and any surrounding
  tissue abnormalities.
• CT scan and MRI cross section view of the kidney
  and urinary tract metal objects should be
  removed, sedative or certain contrasts may given,
  contraindicated in patient has pacemaker,
  surgical clips, or any metal objects

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Cont

• 3. General Ultrasonography assess fluid
  accumulation, masses, congenital malformation,
  changes in size, shape, or any obstruction, fluid
  intake should be encouraged before the procedure
• 4. Bladder Ultrasonography to measure fluid
  volume in the bladder, indicated for urinary
  frequency, inability to void after removal of FC
  or postoperative, measuring residual volume of
  urine after voiding

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Cont.

• Intravenous urography intravenous pyelography
  (IVP) or intravenous urogram (IVU). History of
  iodine or any contrast allergy should be obtained
  before the procedure. Patient should be
  instructed he may have temporary feeling of
  wormth, flushing of the face and unusual flavor
  (seafood) in the mouth. Monitor the patient
  closely for any allergic reaction.

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Cont.

• 6. Retrograde pyelography catheter induced
  through ureters to the kidney pelvis by means of
  cystoscopy. Provide direct visualization of the
  kidney.
• Cystography direct visualization of the bladder
  walls. Assessing vesicoureteral reflux ( back
  flow of urine from the bladder to one or both of
  the ureters), bladder injury
• 8. Renal Angiography provide an image of the
  renal arteries preparation done same as Cardiac
  cathetarization

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Cont

• 9. Urologic Endoscopic Procedure ( Endourology)
• through Cystoscope inserted via urethra or
  percataneously.
• Direct visualization of the system,
• removal of stone,
• obtaining urine specimen from the kidney.
• Sedation or anesthesia may performed, patient
  should be kept NPO.
• Post- procedure
• moist heat to the lower abdomen and warm sitz
  bath are helpful in relieving pain and relaxing
  the muscles,
• monitor the patient with prostatic hyperplasia
  for urine retention,
• intermittent catheterization may needed for few
  hours
• monitor for S/S of UTI, monitor for signs of
  retention

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Cont

• 10. Kidney biopsy
• Indications
• Unexplained acute renal failure,
• persistent proteinuria or hematuria,
• transplant rejection,
• and glomerulopathies.
• Contraindications
• Serious bleeding disorders,
• excessive obesity, and sever hypertension.
• It is usually performed percataneously with a
  biopsy needle

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Procedure for kidney biopsy include

• Place patient in prone position with a sandbag
  under the abdomin
• The skin site of biopsy is infiltrated with local
  anesthesia
• The needle biopsy is inserted just inside the
  renal capsule
• The patient is instructed to breath in and hold
  the breath to immobile the kidney during
  insertion of the needle
• Nursing diagnosis for the patient undergoing
  assessment of urinary or renal function include
  the following
• Knowledge deficit regarding the procedure and
  diagnostic test
• Acute pain related to renal invasive diagnostic
  procedure
• Fear related to possible procedure or serious
  illness

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Chapter 44 45 (1514-1607)

• Management of patients with Urinary Disorders

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Dysfunctional Voiding pattern (1578)

• Urinary Retention
• Is the inability to empty the bladder completely
  during attempt to void. Residual urine is the
  urine remain in the bladder
• Causes
• DM,
• prostatic enlargement,
• urethral pathology ( infection , tumor,
  calculus),
• trauma,
• pregnancy,
• Neurological disorder,
• some medication ( anti-cholinergic agent,
  tricyclic antidepressant, alpha-adrenergic,
  beta-adrenergic blockers, and estrogens
• .

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Complication

• may lead to chronic infection which may lead to
  calculi formation,
• polynephritis,
• sepsis,
• back flow of urine lead to deterioration of the
  kidney,
• leakage of the urine may lead to peripheral skin
  damage

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Nursing Management

• Promote normal urinary elimination
• Provide privacy, ensure the environment and
  position is conducive to voiding, assisting the
  patient to use bathroom, and offering reassurance
• Applying warmth to relax sphincter
• Simple trigger techniques, such as turning on the
  water while voiding attempt, stroking the abd or
  inner thigh, tapping above the pubic area
• After surgery the prescribed analgesia should be
  given

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Cont

• Promote urinary elimination Catheterization is
  used to prevent overdistention of the bladder
• Promote home and community-based care
• Provide easy, safe access to the bathroom
• Installing support bars in the bathroom
• Placing a bedpan or urinal within easy reach
• Leaving a light on the bedroom, and bathroom
• Wearing clothing that is easy to remove

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Chart 45-8 (Strategies for promoting Urinary
Continence
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II. Urinary Incontinence

• Is the involuntary or uncontrolled loss of urine
  from the bladder
• Types of Incontinence
• Stress incontinence as a result of a sudden
  increase in intra-abdominal pressure (sneezing,
  coughing, or changing position
• Urge Incontinence associated with a strong urge
  to void that can not be suppressed.
• predominantly medications

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Cont

• 3. Reflex incontinence due to hyperflexia in the
  absence of normal sensation usually associated
  with voiding.
• 4. Overflow incontinence due to overdistention
  of the bladder
• 5. Functional incontinence lower urinary tract
  function is intact but other factors such as
  sever cognitive impairment, or physical
  impairment
• 6. Latrogenic incontinence due to extrinsic
  medical factors,

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Medical management

• Behavioral intervention
• Fluid management encourage fluid intake of
  1500-1600ml daily between breakfast and evening
• Standardized voiding frequency voiding on a
  schedule
• Time voiding, promote voiding ( in patient has
  cognitive difficulties), Habit retraining, pelvic
  muscle exercise (PME) (Kegel exercise) to
  strengthen the voluntary muscles ( gently
  tightening the same muscle used to stop the
  stream of urine 5-10 sec. follow by 10 sec
  resting phase.

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Cont

• Pharmacological therapy
• Anticholinergic agents (oxybutynin, dicyclomic)
  which inhibit bladder contraction, first line
  medication for urge incontinence
• Tricyclic antidepressant (impramine) decrease
  bladder contraction as well as strengthen bladder
  neck resistance
• Estrogen restoring the mucosal integrity,
  vascular, and muscular integrity of the urethra
• III.Surgical management surgical correction of
  the bladder and urethra if the patient not
  responding to the previous management

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III. Neurogenic Bladder

• Is a dysfunction of the bladder due to a lesion
  of the nervous system caused by spinal injury,
  spinal tumor, herniated vertebral disk, multiple
  sclerosis, infection, congenital anomalies, and
  DM.
• Pathophysiology
• Spastic (or reflex) bladder is the most common
  type and is caused by any spinal cord injury
  above the voiding reflex arc ( Upper motor neuron
  lesion).
• The result is a loss of conscious sensation and
  cerebral motor control.
• A spastic bladder empties on reflex, with
  minimal or no controlling influence to regulate
  its activity

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Cont..

• 2. Flaccid bladder caused by lower motor neuron
  lesion, commonly result from trauma.
• Mainly recognized in DM Pt..
• The bladder continues to fill and becomes greatly
  distended, and overflow incontinence occurs. The
  bladder is not contracted forcefully at any time.
  Because of sensory loss the patient feels no
  discomfort.

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Medical management

• Prevention of overdistention of the bladder
• Emptying the bladder frequently and completely
• Maintaining urine sterility with no stone
  formation
• Maintain adequate bladder capacity without reflux
• Pharmacological therapy Parasympathomimetic
  medication (Urecholine)
• Surgical management to correct bladder neck
  contractures or vesicoureteral reflux, perfoming
  some type of urinary diversions procedures

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Catheterization (1585)

• Is the introduction of the catheter through the
  urethra into the bladder for the purpose of
  withdrawing urine.
• Indications
• relieve urinary tract retention,
• monitor accurate urine output in critically ill
  patients,
• promote urinary drainage,
• prevent urinary leakage in patient with advance
  pressure ulcer,
• obtain a sterile urine specimen,
• emptying the bladder before, during, after
  surgery and before certain diagnostic procedure.

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Types of catheters

• Indwelling urethral catheter (Follys catheter)
  is remains in the place for continuous drainage .
  Types (Double and triple lumen catheter).
• Intermittent catheter is used to drain the
  bladder for short time (5-10 min)
• Suprapubic catheter it is surgical inserted into
  the bladder through a small incision above the
  pubic area.

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Nursing Management during catheterization

1. Assessing the patient and the system
2. Assessing for age-related complication
   infection, elderly patient doesnt exhibit the
   S/S of infection but any physical and mental
   changes should be considered and reported.
3. Minimizing trauma using proper size, use
   lubricate, proper technique, and securing the
   catheter

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Cont.

• 4. Bladder retraining after indwelling
  catheterization chart 45-10).
• place patient on timed voiding schedule usually
  every 2-3 hours
• the patient instructed to void as scheduled
• scan the bladder for residual urine
• if more equal or more than100 ml straight
  catheter may inserted for complete bladder
  emptying.
• 5. Assisting with intermittent self
  catheterization every 4-6 hours and at bed time
  (or when ever needed)

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Cont..

• 5. Prevent infection in the catheterized patient
• Use aseptic technique during insertion of the
  catheter
• Use sterile closed urinary drainage system
• Prevent contamination of the closed system never
  disconnect the tubing, the drainage bag should
  not touch the floor
• The bag and collecting tubing are changed if
  contamination occurs, if urine flow become
  obstructed, if tubing start to leak.
• Clamp the urine drainage if you raised the system
  above the kidneys level
• Ensure free flow of urine

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Cont

• Empty the collection bag frequently
• Never irrigate the catheter routinely
• Never disconnect the tubing to collect urine
  sample
• Avoid routine catheter changes
• Wash the perineal area with soap and water at
  least twice a day
• Monitor the patients voiding when the catheter
  is removed. The patient must void within 8 hours
• Instruct the patient to drink measure fluid fro 8
  am- 10 pm and stop drinking after 10pm

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Dialysis

• Is the process used to remove fluid and uremic
  waste products from the body when the kidneys are
  unable to do so.
• Indications
• Acute dialysis is indicated when there is a high
  and rising level of serum potassium, fluid
  overload, impeding pulmonary edema, increased
  acidosis, pericarditis, and sever confusion. May
  also used to remove toxin from the blood.
• Chronic or maintenance dialysis is indicated in
  ESRD, in the presence of uremic signs and
  symptoms affecting all the body systems ( nausea,
  vomiting, sever anorexia, increasing lethargy,
  mental confusion). Hyperkalemia, fluid overload
  not responsive to diuretics and fluid restriction.

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Hemodialysis

• The objective of Hemodialysis are
• to extract toxic nitrogenous substances from the
  blood
• and to remove excess water.
• Indicated for
• the patient who are acutely ill and require
  short-term dialysis (day to weak)
• and for patient with ESRD who require long-term
  or permanent therapy.
• A dialyzer or artificial kidney serves as a
  synthetic, semipermeable membrane.

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Principles of Hemodialysis

• Diffusion principle dialysate ( is a solution
  made up of all the important electrolytes in
  their ideal Extracellular concentrate.
• Osmosis principle
• Ultrafiltration principle

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Hemodialysis System
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Preprocedure

• A predialysis assessment include patients
  history and clinical findings, response to
  previous dialysis treatment, and laboratory
  results
• Evaluates fluid balance before dialysis treatment
  so that corrective measures may be initiated at
  the beginning of the procedure blood pressure,
  pulse, Wt, intake and output, tissue turgor, dry
  Wt or ideal WT

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Procedure..

• Check the equipment
• Access to the circulation is gained by inserting
  two large gauge needles to a graft or fistula
• Blood being to flow through the tubing, assisted
  by the blood pump
• A clamped saline bag always is attached to the
  circuit, just before the blood pump to use it if
  hypotension occurred
• Heparin infusion can be attached to the circuit

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Cont

• Blood flows into the compartment of the dialyzer,
  where exchange of fluid and waste products takes
  place
• Blood leaving the dialyzer passes through an air
  detector that shuts down the blood pump if any
  air is detected
• After the located time finished, dialysis is
  terminated by clamping off blood from the
  patient, opening the saline line, and rinsing the
  circuit to return the patients blood
• The nurse should monitor, support, assessing, and
  educating the patients.

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Vascular Access

• Subclavian, internal Juglar, and femoral catheter
  (venous catheter)
• Arteriovenous Fistula created surgically,
  provide long-term access for hemodialysis, the
  fistula takes 4-6 weeks to mature before it is
  ready for use, the patient instructed to perform
  exercise to increase the size of these vessels,
  venipunctures is contraindicated in the arm with
  fistula, assess for the thrill.

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3. Synthetic graft

• An arteriovenous graft can be created by
  subcutaneously interposing a biological,
  semibiologic, or synthetic graft material between
  an artery and vein
• The graft is created when the patients vessels
  are not suitable for a fistula ( DM)
• Graft usualy placed in the forearm, upper arm, or
  upper thigh
• Complication such as thrombosis, infection,
  aneurysm formation and stenosis at the site of
  anastomosis are more frequent than fistula

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Hemodialysis Catheter
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Internal Arteriovenous Fistula and Graft
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Complication of Hemodialysis

1. Atherosclerotic cardiovascular disease an, Angina
   and fatigue
2. Disturbance of lipid metabolism
   (hypertriglyceridemia)
3. Stroke
4. Peripheral vascular insufficiency
5. Gastric ulcer
6. Disturbed calcium metabolism that lead to bone
   pain and fractures

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Cont

• Sleep problem
• Fluid overload, malnutrition, infection,
  neuropathy and pruritis
• Hypotension, nausea, vomiting, Dysrhythmias,
  chest pain
• Painful muscle cramping
• Air embolism
• Dialysis disequilibrium result from cerebral
  fluid shift ( headache, nausea, vomiting,
  restlessness, decrease level of consciousness and
  seizures

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Long term management for Hemodialysis

• Pharmacologic therapy the dosage of medications
  need to adjust for patient undergoing
  hemodialysis and monitored closely to ensure that
  blood and tissue levels of these medications are
  maintained without toxic accumulation.
• Example are antihypertensive medication which
  should not be taking at the day of dialysis to
  prevent hypotension.
• II. Nutritional and fluid therapy
• To minimize uremic symptoms and fluid and
  electrolyte imbalances.
• To maintain good nutrition status through
  adequate protein calories, vitamin, and minerals
  intake

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Cont..

• 3. To enable patient to eat a palatable and
  enjoyable diet.
• Protein intake should be restricted to about 1
  g/kg ideal body wt/day, High biologic quality
  protein ( contain essential amino acids) should
  be taken ( eggs, milk, meat, poultry, and fish)
• Sodium is usually restricted to 2-3 g/day
• Fluids are restricted to amount equal to the
  urine output plus 500ml to keep interdialytic wt
  gain under 1.5 kg.
• Potassium restriction ( Average 1.5 to 2.5 g/day).

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Nursing Management of the Hospitalized Patient on
Dialysis

• Protect vascular access assess site for patency
  and signs of potential infection, and do not use
  it for blood pressure or blood draws
• Monitor fluid balance indicators and monitor IV
  therapy carefully keep accurate IO and IV
  administration pump records
• Assess for signs and symptoms of uremia and
  electrolyte imbalance regularly check lab data
• Monitor cardiac and respiratory status carefully
• Monitor blood pressure antihypertensive agents
  must be held on dialysis days to avoid
  hypotension

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Cont..

• Monitor all medications and medication dosages
  carefully avoid medications containing potassium
  and magnesium
• Address pain and discomfort
• Implement stringent infection control measures
• Monitor dietary sodium, potassium, protein, and
  fluid address individual nutritional needs
• Provide skin care prevent pruritus keep skin
  clean and well moisturized trim nails and avoid
  scratching

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Nursing Management

• I. Meeting psychosocial needs Give the patient
  and their Families the opportunity to express
  feelings of anger and concern over the
  limitations that disease and treatment impose.
• Treatment of depression with antidepressant
  agents
• Referring the pt and family to clinical nurse
  specialists, and psychologist
• Assess noncompliant pt for the impact of renal
  failure and its treatment on the pt and family
  and the coping strategies that may use
• Helps pt to identify safe, effective coping
  strategies to cope with ever-present problems and
  fears

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Cont

• II. Teaching patient self care
• III. Teaching patient about Hemodialysis
• IV. Continuing care.
• The five Es Bridges to Renal rehabilitation
• Encouragement,
• Education,
• Exercise,
• Employment, and
• Evaluation

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Peritoneal Dialysis

• The goals are to remove toxic substances and
  metabolic wastes and to reestablish normal fluid
  and electrolyte balance.
• May be treatment of choice for
• Patient with renal failure who are unable or
  unwilling to undergo hemodialysis or renal
  transplantation.
• An initial treatment for renal failure while
  patient is being evaluated for a hemodialysis
  program, or when access to the blood stream is
  not possible

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Cont

• 3. Patient who are susceptible to the rapid
  fluid, electrolyte, and metabolic changes that
  occur during hemodialysis ( pt with DM,
  Cardiovascular diseases, older patients, and
  those who may be at risk for adverse effects of
  systemic heparin).
• 4. Pt with sever hypertension, congestive heart
  failure, and pulmonary edema ( not responsive to
  usual treatment regimens)

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Peritoneal Dialysis
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Peritoneal Dialysis (cont.)
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Principles underlying peritoneal dialysis

• In peritoneal dialysis, the peritoneal serves as
  the semi permeable membrane ( provide about
  22,000 square cm surface area)
• Sterile dialysate fluid is introduced into the
  peritoneal cavity through an abdominal catheter
  at intervals.
• Urea, creatinine, metabolic end products are
  cleared from the body by diffusion and osmosis

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Cont

• It is usually takes 36-48 hours to achieve with
  peritoneal dialysis what hemodialysis achieve in
  6-8 hours
• Urea is cleared at rate of 15-20 ml/min where
  creatinine is removed more slowly
• Ultrafiltration (water removal) occurs in
  peritoneal dialysis through an osmotic gradient
  created by using a dialysate fluid with dextrose
  concentration.

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Preprocedure

• Prepare the patient for catheter insertion and
  the dialysis procedure by giving a thorough
  explanation of the procedure
• Consent form may be signed according to hospital
  policy
• Assess the pts anxiety, and provide support
  instruction
• Take the pats history, identifying abdominal
  surgery or trauma
• Examine the abdomen before the catheter is
  inserted.
• Ask the patient to empty the bladder and bowel
  just before the procedure to avoid accidental
  puncture with the trocar
• Give a preoperative medication, as ordered, to
  enhance relaxation during the procedure

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Cont..

• Broad spectrum antibiotic agent may be given to
  prevent infection
• Take and record baseline vital signs and body wt
• Warm the dialyzing fluid to body temperature or
  slightly warmer to prevent hypothermia, increase
  urea clearance, prevent abd pain, and dilate the
  vessels of the peritoneum.
• Prepare the proper concentration of dialysate and
  the medication to be added ( Heparin, Potassium
  chloride, antibiotic, and insulin may be added)
  as doctor order

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Cont

• Immediately before initiating the dialysis, the
  nurse assembles the administrating set and
  tubing. The tube is filled with the prepared
  dialysate to reduce the amount of air entering
  the peritoneal cavity.
• Preparation of equipment
• Peritoneal dialysis administration set,
• peritoneal dialysis catheter set,
• Trocar set, and
• medication such as heparin, local anesthesia,
  KCL, and broad spectrum antibiotics

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Performing the exchange

• Peritoneal dialysis involves a series of
  exchanges or cycles. This cycle is repeated
  through the course of the dialysis which varies
  from 12-36 hours
• 1. Infusion phase the dialysate is infused by
  gravity into the peritoneum. Period about 5-10
  min is usually required to infuse 2 L of fluid.
• 2. Dwell or equilibrium phase is the time allows
  diffusion and osmosis to occur.
• 3. Drainage phase the tube is unclamped and the
  solution drains from the peritoneal cavity by
  gravity through closed system. Usually completed
  in 10-30 min. the drainage fluid is normally
  colorless or straw-colored and should not be
  cloudy

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Cont

• The entire cycle (exchange) takes 1 to 4 hours,
  depending on the prescribed dwell time
• The removal of excess water is achieved by using
  a hypertonic dialysate with a high dextrose
  concentration that creates an osmotic gradient
  (1.5, 2.5 and 4.25 are available in several
  volumes from 500-3000ml).

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Postprocedure

• Maintain accurate records of intake and output,
  and weight
• Monitor BP and pulse frequently. Orthostatic
  blood pressure changes, and increased pulse rate
  are valuable clues that help the nurse evaluate
  the pts volume status
• Detect S/S of peritonitis early ( low-grade
  fever, diffuse abd pain, rebound tenderness, and
  cloudy peritoneal fluid)
• Maintain sterility of the peritoneal system
• Detect and correct technical difficulties early

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Cont.

• Prevent constipation which decreases the
  clearance of waste product and cause the patient
  more discomfort
• Assess for the presence of complications
• Peritonitis ( inflammation of the peritoneum)
  most common
• Leakage
• Bleeding
• Long-term complications abdominal hernia,
  hypertriglyceridemia, cardiovascular diseases,
  low back pain, and anorexia

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Management of patients with urinary disorders
(Chap.45)
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Infection of the urinary Tract (UTI)

• Caused by pathogenic microorganism in the urinary
  tract.
• Lower tract infection ( Urethritis, prostatitis,
  and Cystitis)
• Upper tract infection (pyelonephritis,
  interstitial nephritis and renal abscesses)
• Other classification Complicated and
  uncomplicated lower or upper tract infection

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Lower Urinary tract infections

• Pathophysiology for infection to occur
• bacteria must gain access to the bladder,
• attach to and colonize the epithelium of the
  urinary tract to avoid being washed out with
  voiding,
• evade host defense mechanisms, and initiate
  inflammation
• Most UTIs results from
• fecal organism
• Reflux Urethrovesical reflux ( backward flow of
  urine from the urethra into the bladder

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Cont

• Uropathogenic bacteria Bacteriuria is generally
  defined as more than 100,000 colonies of bacteria
  per ml of urine
• Most frequent bacteria responsible for UTI are
  those normally found in the lower GI tract such
  as E.coli , and lees common staphylococcus.

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Routes of infection

• Up the urethra ascending infection ( most common
  route)
• Through the blood stream (hematogenous spread).
• By means of a fistula from the intestine ( direct
  extension)
• Risk factors
• Inability or failure to empty the bladder
  completely
• Obstructed urinary flow
• Decrease natural host defense or
  immunosuppression
• Instrumentation of the urinary tract
• Inflammation or abrasion of the urethral mucosa
• Contributing conditions DM, pregnancy,
  neurological disorders, gout.

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Clinical manifestations

• about half patient with Bacteriuria have no
  symptoms.
• Uncomplicated
• pain and burning on urination,
• frequency,
• urgency, nocturia, incontinence,
• Suprapubic or pelvic pain,
• and Hematuria with low back pain may presented
• Complicated UTI manifestations may range from
  asymptomatic bacteriuria to a gram-negative
  sepsis with shock

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Assessment and Diagnostic findings

1. Colony count at least 100,000 colony per ml of
   urine on a clean catch midstream or cathetarized
   specimen is a major criterion for infection
2. Cellular studies microscopic hematuria ( greater
   than 4 RBCs per high power field, Pyuria (
   greater than 4 WBCs per high power field)
3. Urine culture urine culture remains the gold
   standard in documenting a UTI and can Identify
   the specific organism present

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Medical management

• 1. A cute pharmacologic therapy
• single dose administration, short course (3-4
  days) medication regimen, or 7-10 day therapeutic
  course used in treating uncomplicated lower UTI.
• 2. Long term pharmacologic therapy
• If infection reoccurs within 2 weeks after
  completing antimicrobial therapy, another short
  course of full-dose antimicrobial therapy,
  followed by a regular bedtime dose of an
  antimicrobial agent be prescribed
• If there is no recurrence, medication may taken
  every other night for 6-7 months

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Cont

• Patient education include
• 1. Hygiene (shower rather than bathe tube
• 2. Fluid intake drink enough fluid, avoid
  coffee, tea, colas, alcohol
• 3. Voiding Habits void every 2-3 hours, void
  immediately after sexual intercourse
• 4. therapy take medication exactly as
  prescribed, if recurrence take long term
  treatment

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Upper UTI

• Acute pyelonephritis is bacterial infection of
  the renal pelvis, tubules, and interstitial
  tissue of one or both kidneys
• Upper UTI is associated with the antibody coating
  of the bacteria in the urine
• Pathophysiology
• Ascending of bacteria from the urethra, then to
  bladder to reach the kidney
• Rarely from the blood ( less than 3)
• Ureterovesical reflux
• Urinary tract obstruction, bladder tumor,
  strictures, benign prostatic hyperplasia, and
  urinary stones

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Cont..

• Usually these pt has enlarged kidneys with
  interstitial infiltration of inflammatory cells
  which may lead to destruction and atrophy of the
  kidney
• Clinical manifestation
• Acutely ill with chills and fever,
• leukocytosis,
• Bacteriuria and Pyuria,
• Flank pain.
• Dysuria and frequency may associated.
• Assessment and Diagnostic findings US, CT scan
  to locate any obstruction, urine culture and
  sensitivity may performed

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Medical management

• patient usually treated as outpatient if they are
  not dehydrated, not experiencing nausea or
  vomiting and not showing S/S of sepsis
• For outpatient, a 2-weeks course of antibiotic is
  recommended , 6 weeks therapy may needed if
  relapse is seen, follow up urine culture is done
  2 weeks after completion of antibiotic therapy

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2. Chronic pyelonephritis

• Repeated of a cute pyelonephritis may lead to
  chronic pyelonephritis
• Clinical manifestations usually no symptoms of
  infection, S/S may include fatigue, headache,
  poor appetite, polyuria, excessive thirst, and
  weight loss
• Persistent and recurring infection may produce
  progressive scaring of the kidney, with renal
  failure as the end result
• Assessment and diagnostic findings Intravenous
  urogram, Measurement of creatinine clearance, BUN
  and creatinine levels, and urine culture

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Complication

• ESRF, hypertension, and formation of kidney
  stones
• Medical management Antibiotics depends on U/C,
  careful monitoring of renal function is important
  while giving medication due to the alteration of
  kidney function
• Nursing Management Monitor IO, encourage
  fluid(3-4 L/day) unless contraindicated, Assess
  Temp. every 4 hrs, administer antibiotic as
  prescribed,Teach the pt the preventive measures
  of UTI

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Acute Renal Failure

• Is a sudden and almost complete loss of kidney
  function ( decreased GFR)
• Mnifestations
• Oligurea
• Anurea
• normal urine volume.
• Categories of ARF
• Prerenal as a result of impaired blood flow to
  the kidney
• Interrenal as a result of actual parenchymal
  damage to the glomeruli and kidney tubule.
• Post renal as a result of obstruction somewhere
  distal to the kidney, such as Ureterovesical
  reflux.

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Phases of ARF

• Initial period begins with initial insult
• The oliguria period( less than 400ml/day)
  Characterized by increase serum urea, creatinine,
  K, uric acid, organic acids, and magnesium. The
  uremic symptoms first appears which is
  life-threatening such as Hyperkalemia.
• The diuresis period gradually increasing urine
  output, lab values stop rising and start to
  decrease
• The recovery period signals the improvement of
  renal function and may take 3-12 months, lab
  results return to the normal levels

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Clinical manifestations

• Oliguria, anuria (less than 50 ml/day), or normal
  urine output are not as common.
• Increased serum creatinine, and BUN level
• Pt may appear critically ill and lethargic, with
  nausea, vomiting, and diarrhea.
• Skin and mucous membrane are dry from dehydration
  and the breath may have the odor of the urine
  (uremic fetor)
• Drowsiness, headache, muscle twitching, and
  seizures

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Assessment and diagnostic findings

• Changes in the urine
• Changes in the kidney contour ( ultrasound)
• Increase BUN and creatinine levels
• Hyperkalemia, hypocalcemia, hyperphosphoremia
• Anemia
• Metabolic acidosis

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Medical management

• Manage fluid and electrolyte imbalance
• Diuretics may be given
• Adequate blood flow to the kidney ( by low doses
  of dopamine 1-3 microgram/kg)
• Dialysis may be initiated to prevent serious
  complications of ARF
• Treat Hyperkalemia
• administer Kayexalate ( orally or by retention
  edema)
• intravenouse glucose and insulin or calcium
  gluconate
• sodium bicharbonate to elevate plasma PH which
  cause potassium to move into the cell.
• Finally decrease the dietary intake of potassium
• Correction of Acidosis and elevated phosphorus
  level ( by aluminum hydroxide---- phosphate
  binding agent)
• Nutritional therapy

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Nursing Management

• Monitor fluid and electrolyte balance
• Reduce metabolic rate
• Promote pulmonary function
• Prevent infection
• Provide skin care
• Provide support

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Chronic renal failure

• Or ESRD is a progressive irreversible
  deterioration in renal function in which the
  bodys ability to maintain metabolic and fluid
  and electrolyte balance fails, resulting in
  uremia or azotemia ( retention of urea and other
  nitrogenous wastes in the blood)
• May caused by systemic disease such as DM,
  hypertension, chronic glomerulonephritis etc

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Clinical manifestations

• Neurologic Weakness, fatigue, confusion,
  inability to concentrate, tremors, seizures,
  behavior changes
• Integumentary gray-bronze color skin, dry,
  pruritis, ecchymosis, thin brittle nails
• Cardiovascular hypertension, pitting edema,
  periorbital edema, pericardial friction rub,
  engorged neck veins, pericarditis, pericardial
  effusion, hyperkalemia, hyperlipidemia
• Pulmonary signs of pulmonary edema
• Gastrointestinal Ammonia odor to breath, mouth
  ulceration and bleeding, anorexia, constipation
  or diarrhea
• Hematology anemia
• Musculoskeletal muscle cramps, loss of muscle
  strength, bone pain, bone fracture

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Assessment and diagnostic findings

• GFR by obtaining a 24 hr urine collection for
  creatinine clearance.
• Na and water retention
• Acidosis
• Anemia
• Ca and Ph imbalance
• Complications
• Hyperkalemia
• Hypertension
• anemia, Bone disease

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Medical management

• Antacids To treat hyperphosphatemia and
  hypocalcemia (Aluminum-based antiacide bind with
  phosphorus in the GI tract)
• antihypertensive cardiovascular agents
• Antiseizure agents
• Erythropoietin
• Nutritional therapy
• Dialysis