Introduction:
• Anatomy of the Urinary
System:

Introduction:
•
– Kidneys:
• Two kidneys - a pair of purplish-brown organs located below the ribs toward the middle of the back.
• Their function is to remove liquid waste from the blood in the form of urine; keep a stable balance of salts and other substances in the blood; and produce erythropoietin, a hormone that aids the formation of red blood cells.
• The kidneys remove urea from the blood through tiny filtering units called nephrons.

Introduction:
•
– Kidneys:
• The nephron is the functional unit of the kidney
• Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule.
• Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.

Introduction:
•
– Ureters:
• Two ureters - narrow tubes that carry urine from the kidneys to the bladder.
• Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys.
• About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters.

Introduction:
•
– Bladder:
• bladder - a triangle-shaped, hollow organ located in the lower abdomen.
• It is held in place by ligaments that are attached to other organs and the pelvic bones.
• The bladder's walls relax and expand to store urine, and contract and flatten to empty urine through the urethra.
• The typical healthy adult bladder can store up to two cups of urine for two to five hours.

Introduction:
•
– Sphincter:
• Two sphincter muscles - circular muscles that help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder.
– Nerves:
• Nerves in the bladder - alert a person when it is time to urinate, or empty the bladder.

Introduction:
•
– Urethra:
• Urethra - the tube that allows urine to pass outside the body. The brain signals the bladder muscles to tighten, which squeezes urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax to let urine exit the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs.

Introduction:
• Facts about urine:
– Adults pass about a quart and a half of urine each day, depending on the fluids and foods consumed.
– The volume of urine formed at night is about half that formed in the daytime.
– Normal urine is sterile. It contains fluids, salts and waste products, but it is free of bacteria, viruses and fungi.
– The tissues of the bladder are isolated from urine and toxic substances by a coating that discourages bacteria from attaching and growing on the bladder wall.

Introduction:
• Functions of the kidneys:
– The chief physiologic functions of the kidneys are regulatory and hormonal. The function of the renal system as a whole is to maintain homeostasis.
– Regulatory Functions:
• Water balance, includes fluid and electrolyte balance.
• Waste product formation and elimination:
– Glomerular filtration.
– Tubular reabsorption.
– Tubular secretion.
• Acid-base balance.

Introduction:
•
– Hormone Synthesis:
• Erythropoietin production:
– Stimulates RBC production.
• Renin:
– Blood pressure regulation
• Vitamin D activation:
– Critical in regulation of calcium balance.
• Prostaglandin production:
– Regulate glomerular filtration, kidney vascular resistance, and renin production.
• Bradykinin production:
– Maintains kidney blood flow and tubular function.

Introduction:
•
– Reduced renal blood flow.
– Thickened glomerular and tubular basement membrane.
– Decreased tubule length.
– Decreased GFR.
– Nocturnal polyuria and risk for dehydration.

Renal Assessment:
•
– Nursing history:
• Assess for history of renal problems, chronic disease, and family history for any disease.
• Assess life style including eating (diet, drinks, smoking), exercise and activity.
• Assess for common signs and symptoms: pain, hematuria, and hesitancy, decreased force of urine stream, urinary frequency, nocturia, burning sensation, and urgency to voiding.

Renal Assessment:
•
– Nursing history:
• Assess for weight changes.
• Ask about urine output.
• Assess for history of using of drugs.

Renal Assessment:
•
– Nursing Physical Examination:
• Skin and mucosal membrane: indicate fluid and electrolytes disturbances. Examine skin turgor and mucosal membrane.
• Kidney: percussion of the costovertebral angel for pain and auscultation for renal artery bruits (narrow artery).
Palpate kidney for size, shape, and position.

Renal Assessment:
•
– Nursing Physical Examination:
• Bladder: examine for bladder for distension between the umbilicus and symphysis pubis (when it is distended). Normally it is rests below the symphysis pubis. It is rounded and smooth on palpation and is dull on percussion.
• Urethral meatus: assess for discharge, inflammation\n, and lesions.

Diagnostic Tests:
•
– Chemistry:
• Serum Creatinine (0.5 – 1.2 mg/dl).
• Blood Urea Nitrogen (10-20 mg/dl).
• BUN/Creatinine Ratio (12:1 to 20:1 mass).
• Serum electrolytes.
– Hematological:
• Hb.
• Plantlets count.
• Prothrombin time.

Diagnostic Tests:
•
– Urinalysis:
• Color: cloudy (infection), bloody, darker or concentrated (dehydration).
• Protein, ketones, blood, pH, Specific gravity.
– Urine for C&S.
– Composite (e.g., 24hr) urine collections.
– Creatinine Clearance Test.
– Urine Electrolytes.

Diagnostic Tests:
•
– Tubular function: osmolality. Early morning urine sample.
– Glomerular filtration rate: especially Creatinine clearance test:
• Keep client to maintain normal live except vigorous exercises and avoidance of excessive tea, coffee, and meat for 24 hours before the test.
• 24 hours urine collection and blood sample taken.
• Normal 1.2-1.7 gm/24 hours.

Diagnostic Tests:
•
– Kidney Ureter Bladder (KUB) X- ray:
• It is normal x-ray for the renal system.
– No preparations are required unless other information ordered by physician

Diagnostic Tests:
•
– Used to detect size and structure of the kidney and in determine kidney position in biopsy.
– Keep client NPO or as hospital policy.
– Full bladder may be needed (according to the physician prescription) and client examined before and after voiding for residual volume.

Diagnostic Tests:
• Intravenous pylography (IVP) or Intravenous urography:
– These procedures use the radio- opaque substances. These substances excreted by the kidney.
– Radiographs are taken for kidney(pylography) and bladder
(urography).
– Fluid restricted for 4 h before the procedure.
– Some laxatives may be used at the night before the procedure.

Diagnostic Tests:
•
– Cyctoscopy is the passage and visualization of the
Cyctoscope through the urethra into the bladder.
– Fine catheter may be inserted in both kidneys and urine sample form the kidney may be collected.
– Injection of radio- opaque iodine may injected into the renal pelvis to visualize pelvis and ureters (taking radiographs). This procedure is called retrograde pyelography.

Diagnostic Tests:
•
– Perpetrations and nursing care:
• Explain the procedure.
• Get the consent form.
• Local anesthesia may be used.
• Keep client NPO for 6-8 h.
• Administer IV fluid as prescribed.
• Keep client in bed rest for few hours.
• Encourage fluid intake after procedure and measure intake and output and observe for haematuria
(especially bright blood).

Diagnostic Tests:
•
– Used to detect tumors and cysts.
– Keep client NPO for 4 h before the procedure.

Diagnostic Tests:
•
– Visualization of the renal blood vessels by X- rays after injection of radio-opaque substances.
– Used in cases of renal artery stenosis and to differentiate renal masses (tumors and cysts).

Diagnostic Tests:
•
– Nursing Care:
• Radio-opaque sensitivity and preparations of client as in Intravenous urography.
• After the procedure observe the site of the catheter insertion (femoral artery) for infection, redness, swelling, tenderness, temperature, and hemorrhage.
• Apply firm dressing.
• Check circulation (pulses) below the site of insertion.
• Keep client in bed rest.

Diagnostic Tests:
•
– The perpetrations and nursing care as other MRI.
•
– To identify the underlying pathology of the renal dysfunction.
– Risk for hemorrhage.

Diagnostic Tests:
•
– Contraindicate indicated in the following cases:
• HTN.
• Bleeding tendency.
• Only one kidney.
• Suspected perirenal abscess.

Diagnostic Tests:
•
– Procedure and nursing responsibility:
• Determination of the location of the kidney and indicate it in the skin.
• Cleaning the skin and infiltration of local anesthesia.
• Instruct client to hold breath during the needle insertion.
• Apply pressure at the site of the needle after removing it for several minutes.
• Fill the laboratory form and send the sample to the lab.
• Check client vital signs after procedure every 15 minutes for
1 hour then 30 minutes for 2 h then every 4 h.

Diagnostic Tests:
•
– Procedure and nursing responsibility:
• Check for sings and symptoms of bleeding and shock.
• Check urine for haematuria.
• Keep client in bed rest for the prescribed period in dorsal recumbent position (supine position with knee flexed).
• Keep below under client (kidney elevator) for the prescribed period to prevent hemorrhage.

Urinary Tract Infection (UTI):
•
– Upper UTIs are known as Pylonephritis,
Glomerulonephritis.
– Lower UTIs: Ureteritis, Cystitis, Urethritis.
• Women develop UTI more than men because their shorter urethras.

Urinary Tract Infection (UTI):
•
– Sexual intercourse.
– Indwelling catheter.
– Urine stasis.
– Urinary tract instrumentation.
– Metabolic disorders.

Urinary Tract Infection (UTI):
•
– Clinical Manifestations:
• Back pain.
• Blood in the urine (hematuria).
• Cloudy urine.
• Inability to urinate despite the urge.
• Fever.
• Frequent need to urinate.
• General discomfort (malaise).
• Painful urination (dysuria).

Urinary Tract Infection (UTI):
•
– Diagnostic tests:
• Urine analysis.
• Urine culture.
• WBCs.

Urinary Tract Infection (UTI):
•
– Avoid products that may irritate the urethra (e.g., bubble bath, scented feminine products).
– Cleanse the genital area before sexual intercourse.
– Change soiled diapers in infants and toddlers promptly.
– Drink plenty of water to remove bacteria from the urinary tract.

Urinary Tract Infection (UTI):
•
– Do not routinely resist the urge to urinate.
– Take showers instead of baths.
– Urinate after sexual intercourse.
– Women and girls should wipe from front to back after voiding to prevent contaminating the urethra with bacteria from the anal area.

Pylonephritis:
• Pylonephritis is bacterial infection of the kidney or its parts.
• Bacteria (mainly Escherichia Coli) enter through ureter, blood, and lymph.
• Pylonephritis may cause high blood pressure and chronic renal failure.
• Clinical manifestation:
– Cloudy urine containing pus (pyuria), blood and mucus.
– Urgency in urination.

Pylonephritis:
•
– Pain during urination.
– Renal colic, severe pain in the kidney (below the ribs) that radiates to the groin.
– Tenderness on one or both sides of the lower back.
– Fever, chills
– Nausea, vomiting, malaise.

Pylonephritis:
•
– Intravenous Pylogram.
– Urine analysis with culture and sensitivity.
– Blood urea nitrogen, serum creatinine, and CBC.

Pylonephritis:
•
– Medical and Pharmacological:
• Administration of antimicrobials (ciprofloxacin or bactrim).
• Administration of antipyretics (decrease fever) and analgesia.
– Diet:
• Light diet and increase fluid.

Pylonephritis:
•
– Administer medication.
– Assessment of the vital signs and urine out put.
– Record intake and output.
– Provide the prescribed diet and increase fluid intake
(3000 mL per day) as ordered.
– Take nursing responsibility in diagnostic test.
– Educate client and family about the disease and treatments and assure them to decrease their anxiety level.
– Teach or reinforce the hygiene measure of cleansing the perineum from front to back.

Pylonephritis:
•
– Encourage the client to empty the bladder frequently.
– Promote rest periods, which aid the healing process.
– Inform the client to call the physician immediately if there is a decrease in urine output or signs of infection.
– Teach client to weigh daily and report sudden weight gain to the physician.
– Teach the client the importance of long-term treatment and monitoring for chronic pyelonephritis.

Acute Glomerulonephritis:
• Glomerulonephritis is the inflammation of glomerulus within the nephrons unit.
•
– Bacterial and viral infection→ autoimmune response
→inflammation → reduce ability of the glomeruli to function.
•
– Chronic Glomerulonephritis.
– Renal Failure.

Acute Glomerulonephritis:
•
– Some clients are asymptomatic.
• Facial edema may have been the first sign noticed. The edema will progress to dependent areas (the sacral area and the legs), abdomen (Ascites), and lungs
(pulmonary edema).
• The glomeruli become more permeable, resulting in the loss of red blood cells and protein from the blood to the urine.

Acute Glomerulonephritis:
•
• Decrease in the amount of urine (oliguria).
• Headache and flank pain.
• Impaired vision.
• Increase in body temperature and blood pressure.
• Increase weight.
• Client may develop congestive heart failure.
– Most clients develop symptoms 1 to 3 weeks after an upper respiratory infection (tonsillitis or pharyngitis) or skin infection.

Acute Glomerulonephritis:
•
– Blood (BUN, creatinine, CBC, and potassium)
– Urine test.
– Kidney Ureter and Bladder (KUB) X- ray.
•
– The client is not considered to be free from the disease until the urine tests negative for protein and red blood cells for 6 months.

Acute Glomerulonephritis:
•
– Pharmacological:
• Antimicrobial therapy (penicillin).
• Diuretic and antihypertensive medication.
• Corticosteroids, chemotherapeutic drugs.
• Immunosuppressive drugs such as Imuran.
• Plasmapheresis may be indicated if there is no response from other treatments.

Acute Glomerulonephritis:
•
– Diet:
• Fluid restriction (according to the client's intake and output record and daily weight).
• Protein may be restricted.
• Sodium Restriction.
– Activity:
• Physical and emotional rest.

Acute Glomerulonephritis:
•
– Strict intake and output.
– Observation for and treat clinical manifestation.
– Administer medication.
– Encourage the client to discuss fears.
– Explain the importance of protecting the client from other infections.
– Allow no one with an upper respiratory infection to visit the client.
– Discuss the importance of compliance with medications, bed rest, and diet to prevent permanent damage to the kidneys.

Acute Glomerulonephritis:
•
– Emphasize the importance of keeping the followup visits to the laboratory for tests and to the physician's office.
– Provide client and family with ongoing support and understanding.
– Fluids restricted (900 mL / day).
– Daily body weight.
– Provide eye care with normal saline to promote comfort from the edema.

Acute Glomerulonephritis:
•
– If hematuria and/or proteinuria are present, provide a diet with mild to moderate protein restriction to rest the kidney tissue.
– Provide low-sodium diet.
– Before discharge, teach client and family about diet, fluids, and activity restrictions and measuring fluid intake and urine output.

Chronic Glomerulonephritis:
• Chronic Glomerulonephritis leads to permanent kidney damage (It may take up to 30 years for the signs of renal insufficiency to develop).
• Nephrons lose their ability to:
– Filter nitrogenous wastes from the blood.
– Protein (albumin) and red blood cells escape into the urine.
– The serum level of creatinine increases.
– Anemia may be developed.

Chronic Glomerulonephritis:
•
– Medical:
• Medical treatment is to limit further destruction of the glomerular tissue.
– Blood transfusion may be required for severe anemia.
– Dialysis.
– Exposure of the client to infection of any kind must be avoided.
– Pharmacological:
• Diuretic and antihypertensive medications.
• Antimicrobial therapy is generally given prophylactically.

Chronic Glomerulonephritis:
•
– Diet:
• Fluid intake is adjusted according to urinary output.
• Protein allowed in the diet will be according to the BUN and the creatinine blood levels (if these levels increase, protein will be restricted to decrease the nitrogenous wastes).
• Sodium and potassium restrictions will be determined by the serum electrolyte levels.
• Carbohydrates are usually increased in the diet to provide adequate energy.
– Activity:
• Bed rest is indicated when the client has hematuria or albuminuria.

Chronic Glomerulonephritis:
•
– Observation of V/S and S&S of the diseases.
– Assess skin (color, presence of rash, dryness) and mental functioning (irritability, tremors).
– Assessment for edema.
– Assess and document the color and consistency of the urine.
– Weigh client daily.
– Maintain fluid intake at restricted amount.
– Assist client to express concerns about the possible treatment (dialysis), Facial edema, and blurring of vision.

Chronic Glomerulonephritis:
•
– Arrange for a dialysis with the kidney dialysis unit.
– Assist patient in performing ADLs.
– Lung sounds need to be assessed every shift for crackles (a sign of fluid retention).
– Take responsibility in monitoring of laboratory tests (BUN, Protein (albumin), CBC, serum creatinine, and electrolytes).

Chronic Glomerulonephritis:
•
– Measure urine output hourly, or every 4 or 8 hours as ordered.
– Take nursing responsibility in providing medical care such as blood transfusion and dialysis.
– Protect client from infection.
– Administer medication and observe for their side effects and report them to the physician immediately.

Renal Stones (Urolithiasis):
• Urolithiasis is the process of forming stones in the kidney, bladder, and/or urethra (urinary tract).
• Renal stones are a solid mass of minerals salts occurring within the kidney (mainly in renal pelvis).

Renal Stones (Urolithiasis):
•
– Immobility.
– Hyperparathyroidism, hypercalcemia.
– Recurrent UTI.
– Diet.
– Urine stasis.
– Fractures

Renal Stones (Urolithiasis):
• S&S:
– Renal colic, pain in the back below the ribs nears to the spine.
– Nausea and vomiting accompanying severe pain
– Obstruction of the passage of the urine → urine retention → enlarged kidney (hydronephrosis).
– Other urinary symptoms such as increase frequency, burning sensation, urgency to voiding, and hematuria.
– Fever and chills.

Renal Stones (Urolithiasis):
•
– X-rays or KUB.
– Intravenous Pylogram.
– Ultrasound.
– Urine analysis (may be normal or contains crystals).

Renal Stones (Urolithiasis):
•
– Medical:
• Small stones may be flushed with fluid (urine).
• Drainage of urine be using of small catheter
(temporary).
• Extracorporeal shock wave lithotripsy (ESWL): breakdown of the stones by ultrasonic waves (may cause hematuria).

Renal Stones (Urolithiasis):
•
– Surgical:
• Nephroscopic removal
(percutaneous nephrolithotomy).
• Pyelolithtomy, removal through the renal pelvis.
• Nephrolithotomy, removal through incision into the kidney.
• Ureterolithotomy, removal through the ureter (for ureter stones).

Renal Stones (Urolithiasis):
•
– Diet:
• Increase fluid intake up to 4000ml/day if not contraindicated.
• Decrease intake of calcium (mainly dairy products) or uric acid (meat, fish, and poultry).
– Activity:
• Perform regular exercise help in the stones movement out of the body and prevent formation of other stones.

Renal Stones (Urolithiasis):
•
– Pharmacological treatment:
• Antispasmodics.
• Analgesia.
• Prophylactic antibiotics.
• Uracil: wash the urinary tract.
• Drugs specified to composition of stones: Calcibind.

Renal Stones (Urolithiasis):
• Nursing care:
– Administer medication.
– Use analgesia and other methods for pain relief.
– Monitor urine for amount and color.
– Encourage client to increase fluid intake.
– Encourage client to ambulate if able.
– Monitor intake and output.
– Assist in diagnostic procedures.

Renal Stones (Urolithiasis):
• Nursing care:
– Consult dietitian for providing the ordered diet and to educate patient and family (low protein, low calcium)
– Assess client for complication.
– Provide support and encourage patient to express his feeling.
– Prepare client if ordered for surgery or other treatment modalities.

Acute Renal Failure (ARF):
• Acute renal failure (ARF) is the reversible rapid deterioration of the renal function with raising of the urea and nitrogen wastes (azotemia) and inability to regulate body fluids and acid-base balance.

Acute Renal Failure (ARF):
• Predisposing factors:
– Kidney infection.
– Acute Glomerulonephritis.
– Decrease cardiac output.
– Trauma.
– Hemorrhage.
– Drugs side effect (dye, antibiotic, and NSAIDs).

Acute Renal Failure (ARF):
• Diagnostic Evaluation:
– Serum creatinine level—the most reliable measure of the GFR, found to be rising.
– Radionuclide studies to evaluate GFR and renal blood flow and distribution.
– Urinalysis—reveals proteinuria, hematuria, casts.
– Ultrasonography to determine anatomic abnormalities.

Acute Renal Failure (ARF):
• Forms of ARF:
– It can be classified according to underlying cause.
– Postrenal ARF:
• Caused by obstruction after the kidney caused by calculi, blood clots, tumors, prostate hypertrophy, and pregnancy.
• Catheterization and removal of the obstruction are required.

Acute Renal Failure (ARF):
• Forms of ARF:
– Prerenal ARF:
• Related to decrease renal perfusion such as in heart failure, hypovolemia, and vasodilatation.
• Signs and symptoms:
– Pale, cool skin.
– Orthostatic hypotension.
– Oliguria.
– Blood urea nitrogen: creatinine raised from 10:1 to 20:1.
– Low sodium in the urine (< 20 mEq/L).
– High osmolality (> 500 mosm/L) and specific gravity (> 1.020).

Acute Renal Failure (ARF):
• Forms of ARF:
– Prerenal ARF:
• Treatment:
– Intravenous fluids.
– Albumin, plasma, or blood.
– Inotropic agents: increase the muscle contraction such as dobutamine.

Acute Renal Failure (ARF):
• Forms of ARF:
– Intrarenal ARF:
• Damaged to the glomeruli and/or tubules. Increase blood urea nitrogen (BUN) (may reach 70 mg/dl) and creatinine (may reach 7mg/dl).
• Signs and symptoms are the same as chronic renal failure addressed below in the next topic.

Acute Renal Failure (ARF):
• Forms of ARF:
– Intrarenal ARF:
• Phases of damaged:
– Oliguric /nonoliguric phase: urine <400 ml/24h. last for 1-2 weeks.
– Diuretic phase: rarely seen.
– Recovery phase: all test and function of the kidney return closer to the normal limits. May last for several months. Some client may recover completely while others need long-term dialysis.

Acute Renal Failure (ARF):
• Forms of ARF:
– Intrarenal ARF:
• Management:
– Medical:
» Treat metabolic acidosis, fluid volume overload,
Correction and control of fluid and electrolyte imbalances and infection.
» Dialysis.
– Surgical:
» Remove the obstruction surgically.(Correction of any reversable cause).

Acute Renal Failure (ARF):
• Forms of ARF:
– Intrarenal ARF:
• Management:
– Pharmacological:
» Diuretics.
» Antihypertensive.
» Electrolytes replacement.
» Potassium lowering agents.
» Phosphate-binding acids.
» Inotropic agents.

Acute Renal Failure (ARF):
• Forms of ARF:
– Intrarenal ARF:
• Management:
– Diet:
» Sodium, protein, phosphate, potassium, and fluid restriction.
» Increase amount of fat and carbohydrates.
– Activity:
» Activity mainly is restricted at the initial phase because client is weak.

Acute Renal Failure (ARF):
• Nursing care:
– Assess and treat signs and symptoms in coordination with health team members.
– Provide psychological support.
– Allow client to express his feelings and answer his questions.
– Educate client about the disease, diagnostic tests, and treatment.

Acute Renal Failure (ARF):
• Nursing care:
– Assess vital signs.
– Assess for the presences of the cause of the disease and try other complications related to the cause.
– Strict intake and output (May be hourly) and observe characteristic of the urine output.
– Follow the lab and diagnostic test results and inform the physician about the results.

Acute Renal Failure (ARF):
• Nursing care:
– Help in diagnostic test and treatment procedures.
– Administer medication, fluids, blood as ordered.
– Wight client daily.
– Assess skin status and lung sounds.

Chronic Renal Failure (CRF):
• Chronic Renal Failure (CRF): is a slow, progressive condition in which the kidney's ability to function ultimately decline
(irreversible).
• Signs and symptoms:
– The effects of chronic renal failure on body systems.
System
Urinary
Blood
Effect
Oliguria from renal insufficiency.
Azotemia (nitrogen component poisoning).
Anemia from decreased RBC production (decreases rythropoietin).
Decreased platelet activity, causing bleeding tendency.

Chronic Renal Failure (CRF):
• Signs and symptoms:
Cardiovascular
Respiratory
GI
System skin
Effect
Hypervolemia and tachycardia. Hypertension and dysrhythmias from hyperkalemia.
Dyspnea, pulmonary edema. Hyperventilation from metabolic acidosis.
Gastrointestinal Urea in the blood is converted to ammonia.
Hiccups, anorexia, and nausea (RT edema within the gastrointestinal tract).
Dry Skin with pruritis from uremic frost (excretion of urea through the skin with an odor of urine). Pallor with anemia.

Chronic Renal Failure (CRF):
• Signs and symptoms:
System
Nervous
Effect
Lethargy, headaches, confusion, impaired concentration with disorientation, depression, decreased level of consciousness, sleep disturbances, and uremic encephalopathy resulting in seizures and coma.
Sensory
Reproductive
Immune
Peripheral neuropathy with numbness and tingling of extremities
Decrease in libido. Decreased sperm count. Amenorrhea,
Impotence. Delayed puberty.
Decrease in antibody production

Chronic Renal Failure (CRF):
• Main causes of ESRD (End Stage Renal Disease):
– Diabetes mellitus 34%
– Hypertension 25%
– Glomerulonephritis l6%
– Cystic kidney 4%.
– Nephrotoxic drugs.
– ARF

Chronic Renal Failure (CRF):
• Stages of chronic renal failure:
– Reduced renal reserve:
• Symptoms are not apparent until more than 40% of the nephrons fail.
• A prolonged urine concentration test or a decline in glomerular filtration rate (GFR) may be the only evidence of reduced renal reserve.

Chronic Renal Failure (CRF):
• Stages of chronic renal failure:
– Renal insufficiency:
• When 75% of the nephrons stop functioning, renal insufficiency occurs.
• BUN and creatinine are above normal, and the client may have nocturia and polyuria.

Chronic Renal Failure (CRF):
• Stages of chronic renal failure:
– End-stage renal disease (ESRD):
• The onset of ESRD occurs when at least 90% of the nephrons fail.
• BUN and creatinine levels rise, polyuria changes to oliguria, and severe fluid and electrolyte imbalances.

Chronic Renal Failure (CRF):
• Diagnosis:
– The diagnosis is confirmed when the BUN is at least 50 mg/dL and the serum creatinine level is greater than 5 mg/dL.
– Kidney Ultrasound: small kidney.

Chronic Renal Failure (CRF):
• Complications:
– Azotemia/uremia—nitrogen waste products accumulating in blood. Toxic levels manifest themselves in many ways such as coma, headache, gastrointestinal disturbances, neuromuscular disturbances.
– Metabolic acidosis—as a result of decreasing GFR.
– Electrolyte imbalance.
– Severe anemia—kidneys unable to stimulate erythropoietin; uremic toxins deplete erythrocytes; nutritional deficiencies.
– Hypertension—renal ischemia stimulates renin– angiotensin system.
– Congestive heart failure

Chronic Renal Failure (CRF):
• Treatment:
– Medical: Dialysis:
• Goals of Medical management:
– Preserve the remaining kidney function for as long as possible.
– Prevent complications (Fluid retention increases the risk of complications such as edema (ascites), hypertension, and congestive heart failure).

Chronic Renal Failure (CRF):
• Treatment:
– Pharmacological:
• Antihypertensives such as Aldomet and Inderal.
• Diuretics such as Lasix are used for treatment of fluid retention.
• Anticonvulsants: phenytoin (Dilantin) to control seizure.
• Antiemetics: to control vomiting.
• Antipruritics: antihistamines (Periactin): to control itching.
• Calcium acetate is used to lower the phosphate level in the blood.
• epoetin alpha (Epogen): treat anemia.
• An iron supplement.
• Multivitamins with folic acid are used because dialysis promotes the loss of water-soluble vitamins.

Chronic Renal Failure (CRF):
• Treatment:
– Diet:
• Sodium, potassium, phosphorus, and protein are restricted.
• Fluids are also limited.
– Activity:
• The client is encouraged to participate in activities of daily living.
• Safety becomes a significant factor during periods when the client has weakness, fatigue, or mental confusion.
– Kidney transplantation.

Chronic Renal Failure (CRF):
• Nursing care:
– Assess vital signs frequently.
– Monitor electrolytes level.
– Assess client for the effects of chronic renal failure on body systems and report any sings for physician for treating or decreasing it.
– Monitor daily weight, intake and output (may be hourly), skin turgor, edema, blood pressure, respirations, and lung sounds.
– Provide prescribed amounts of fluids.
– Teach client to plan nutritional and fluid intake within the prescribed amounts.

Chronic Renal Failure (CRF):
• Nursing care:
– Monitor laboratory reports for serum albumin level and serum electrolyte levels.
– Monitor client for changes in neurological status such as reduced alertness and awareness should be noted.
– Ensuring safety:
• Protect the patient from the effects of decreased level of consciousness and involuntary movements by maintaining crib or bed side rails up and padded, as necessary.
• Monitor for any seizure activity and have airway or tongue blade and suction equipment on hand.
– Administer medication as ordered and antiemetics 30 minutes before meals to control nausea.

Chronic Renal Failure (CRF):
• Nursing care:
– Bathe skin frequently.
– Administer antihistamines.
– Encourage the client to discuss feelings about longterm lifestyle changes.
– Teach client and family about the diet, rest, medications, fluid restrictions, intake and output, activities, dialysis, required lab tests, and frequent visits to the physician.
– Complete referrals before discharge.
– Provide psychological support for the client and his family.

Benign prostatic hyperplasia (BPH):
• Benign prostatic hyperplasia (BPH) is a progressive enlargement of the prostate gland that occurs with aging. BPH cause obstruction of the urine outflow.
• More than 50% of men over the age of 50 and
75% of men over the age of 70 demonstrate some increase in the size of the prostate gland.

Benign prostatic hyperplasia (BPH):
•
– Hesitancy: difficulty initiating the urinary stream.
– Decreased force of urine stream.
– Urinary frequency.
– Nocturia (awakening at night to void).
– Inability to completely empty the bladder when voiding (post void residual→ urinary alkalosis
(↑urine pH) a perfect environment for bacterial growth → urinary tract infection (UTI).

Benign prostatic hyperplasia (BPH):
•
• The physician will perform a digital rectal examination in order to identify any enlargement or nodular lumps on the surface of the prostate gland.
– Diagnostic tests:
• Prostate-specific antigen (PSA).
• Measurement of residual urine.
• Cystoscopy.
• Intravenous pyelogram.
• Ultrasonography.

Benign prostatic hyperplasia (BPH):
•
– Medical:
• Balloon dilation of the prostate.
• Urethral Stent
• Prostate urethral stent, as shown in the figure below. It used to provide support to the urethra, which is being compressed by the prostate.

Benign prostatic hyperplasia (BPH):
•
– Surgical:
• Transurethral resection of the prostate (TURP):
– Surgery is performed via a resectoscope (an instrument that includes a cutting and cauterization device, see figure below) under general or a spinal anesthetic.
– The resectoscope is passed through the urethra for the purpose of removing small pieces of prostate tissue while controlling bleeding.

Benign prostatic hyperplasia (BPH):
•
– Surgical:
• Transurethral resection of the prostate (TURP):
The bladder is continuously irrigated with normal saline or another solution during the procedure. This irrigation is continued during the postoperative period to reduce clot formation that would interfere with urinary drainage.

Benign prostatic hyperplasia (BPH):
•
– Surgical:
• Prostatectomy:
– Removal of the prostate tissue.
– Postoperative complications can cause danger to or seriously affect the quality of a man's life:
» Hemorrhage.
» Infection.
» Thrombosis.
» Damage to surrounding structures, sexual dysfunction, and urinary incontinence.
• Laser prostatectomy.

Benign prostatic hyperplasia (BPH):
•
– Pharmacological:
Alpha blockers:
– Relax the smooth muscles along the urinary tract without compromising normal urinary control reflexes.
– Examples of alpha blockers includes example: terazosin and
Cardura.
– These drugs are also used to treat hypertension→ hypotension.
• Belladonna and opium (B & 0) suppositories:
– Are used to reduce postoperative bladder spasms.

Surgery to Correct Renal Disorders:
•
– Urinary patterns: the presence of urinary frequency, hesitancy, dribbling, number of times client gets up at night to void, and the force of the urinary stream.
– History of chronic urinary tract infections.
– Assess for pain.
– Emotional Assessment.
– After a TURP, the client will have a three-way Foley catheter and continuous bladder irrigation for at least
24 hours.
– Record intake and output, noting the amount, color, and presence of clots.

Surgery to Correct Renal Disorders:
• Nursing care for post-TURP:
– Monitor the client's urinary output, after 24 hours of TURP, the urine should be a light pink color.
– Encourage a fluid intake of 2500 to 3000 mL/day.
– After the catheter is removed, assess for loss of urinary control and palpating the abdomen for bladder distention.
– Assess for water intoxication (the result of absorbing irrigating fluid in addition to the IV fluids). Symptoms of water intoxication are changes in the client's mental status
(agitation, confusion Early symptom) and, later, convulsions. Slow pulse and increase in systolic and decrease in diastolic blood pressure.

Surgery to Correct Renal Disorders:
•
– Assess for incisional pain.
– Do a dressing check, being careful to also check the linens underneath the client's back for drainage.
– If the urine has clots, a darker color, or decreased output, Increase rate of flow of the bladder irrigation.
– Administer analgesics as ordered. Teach deep breathing, relaxation techniques.

Kidney Transplantation:
• Transplants are either from a live donor
(usually a relative) or from a cadaver.
• Before the transplantation:
– Tissue compatibility.
– Blood-typed compatibility.

Kidney Transplantation:
• Steps of Surgery:
– Lower abdominal incision will be done, and then the surgeon attaches the donor kidney to the client's blood supply.
– The donor kidney is usually placed in the iliac fossa anterior to the iliac crest.
– The donor ureter is anastomosed (surgical connection) to the client's ureter or surgically implanted into the client's urinary bladder.
– The client's nonfunctioning kidney is left in place to reduce the postoperative risk of hemorrhage.

Kidney Transplantation:
• Complications of renal transplantation:
– Infection.
– Rejection.
– Hemorrhage.

Kidney Transplantation:
• Nursing care:
– 2 days of bed rest then client allowed increasing activities and discharged in 1 to 3 weeks (if no complication).
– Monitor urine output, blood tests, vital signs, and level of consciousness.
– Encourage coughing and deep breathing.
– Assess the incision is to ensure that wound closures
– Assess for rejection and other complication.
– Client education about dietary restriction and prevention and observation of complication.

Kidney Transplantation:
• Organ Rejection:
– The body recognizes the implanted kidney as a foreign body and rejects it.
– May be after months or years.
– Signs of rejection:
• Generalized edema or edema on extremities or eyes.
• Tenderness over the graft site.
• Fever.
• Decreased urine output, oliguria or anuria.
• Hematuria.
• Weight gain.
• Elevated BUN and creatinine.

Kidney Transplantation:
• Organ Rejection:
– Immunosuppressive drug therapy may decrease the chance of organ rejection:
• Imuran.
• Cytoxan.
• Cyclosporine (Sandimmune).
• Corticosteroids such as prednisone.

Renal surgery:
• Nursing care:
– Preoperative care:
• Preparation of the client as other operations focusing in the diagnostic test and investigation done.
• Get consent form.
• Monitor kidney function test, vital signs, heart and lung sounds, and bleeding susceptibility.
• Monitor skin and fluid status.

Renal surgery:
• Nursing care:
– Post operative care:
• Check for hemorrhage (internal and external) by frequent checking of vital sings (especially pulse and
BP), skin condition, and mental status.
• Check for signs of infection and apply dressing as prescribed.
• Client postoperatively mainly received with drain
(observe the color, amount, & smell of drainage & record these amounts in the client file).
• Strict intake and output measurement.

Renal surgery:
• Nursing care:
– Post operative care:
• Provide diet and fluid prescribed for client.
• Assess client for pain frequently and administer analgesia as prescribed.
• Administer other medication that includes antibiotics.
• Monitor electrolytes and other tests required postoperatively.
• Educate client about result of operation and action required from client to follow the treatment plan.

Medical Therapies to Treat Renal Disorders:
• Dialysis:
– Is a mechanical method of removing nitrogenous waste from the blood by imitating the function of the nephrons.
– It involves filtration and diffusion of wastes, drugs, and excess electrolytes and/or osmosis of water .
– Dialysate, a solution designed to approximate the normal electrolyte structure of plasma and extracellular fluid (according to the client's needs).
– Types of dialysis:
• Hemodialysis
• Peritoneal dialysis.

Medical Therapies to Treat Renal Disorders:
•
– Hemodialysis is performed by a machine with an artificial semipermeable membrane (artificial kidney) used for the filtration of the blood.
– Steps:
• Before hemodialysis a graft or fistula is surgically prepared to access the client's circulatory system.

Medical Therapies to Treat Renal Disorders:
•
– Steps:
• The client's blood is circulated through the semipermeable membrane.
•
• Excess fluids are removed by osmosis and by-products of protein metabolism, especially urea and uric acid, as well as creatinine, drugs, and excess electrolytes, are removed from the blood by diffusion or filtration.
• In return, the client receives fluids, electrolytes, and blood products, as necessary. The solution (dialysate) is especially prescribed to meet the client's metabolic needs.
• Hemodialysis is usually performed 3 times a week and takes
3 to 6 hours each time.

Medical Therapies to Treat Renal Disorders:
•
– Notes:
• All health care personnel should be aware of the location of the hemodialysis access site.
• Blood pressure and blood draws should never be done on the extremity where the graft or fistula is placed.
• Restraints or intravenous solutions should never be applied to or inserted into that extremity.

Medical Therapies to Treat Renal Disorders:
•
– Notes:
• The graft or fistula site requires strict aseptic care and must be assessed for signs of infection (redness, swelling, or drainage).
• Pulses peripheral to the graft site must be assessed.
• Weighed the client before and after each dialysis session to determine if fluid is being retained.
• To decrease client discomfort, the dialysate should be at body temperature and not instilled too rapidly.

Medical Therapies to Treat Renal Disorders:
•
– Possible complications:
• Hemorrhage.
• Infection.
• Emboli formation.

Medical Therapies to Treat Renal Disorders:
•
– Peritoneal dialysis uses the peritoneal lining of the abdominal cavity as the membrane through which diffusion and osmosis occur instead of the artificial kidney machine.

Medical Therapies to Treat Renal Disorders:
•
– It is usually performed 4 times a day 7 days a week.
– Complication:
• The main complication of peritoneal dialysis is infection.

Medical Therapies to Treat Renal Disorders:
•
– Procedure of peritoneal dialysis and nursing intervention:
• A Tenckhoff or a flanged-collar catheter is placed by the physician, under aseptic conditions, into the client's peritoneal space.
• The client must void just before catheter insertion to prevent accidental puncture of the bladder.
• The client should be weighed before and after each dialysis session.
• Check bowel sounds.
• The dialysate (held within a sterile soft container similar to an IV bag), is instilled aseptically through the catheter into the abdominal cavity.

Medical Therapies to Treat Renal Disorders:
•
– Procedure of peritoneal dialysis and nursing intervention:
• The dialysate should be at body temperature and not instilled too rapidly. Severe pain shouldn't be experienced.
• Keep the container connected to the catheter when the amount prescribed administered and close the infusion set.
• Allow the dialysate remains in the abdominal cavity for a specified length of time (The client is free to ambulate during this time).
• The container is then opened and lowered below the abdominal cavity to allow the dialysate to drain (by gravity) back into the container.

Medical Therapies to Treat Renal Disorders:
•
– Procedure of peritoneal dialysis and nursing intervention:
• The dialysate now contains excess fluids, nitrogenous waste, and other excess materials.
• Inspect the outflow of dialysate for color, sediments, and amount. Normally light yellow and clear.
• If the outflow does not at least equal the inflow, ask client is to turn from side to side to increase the outflow.