GENITO-URINARY SYSTEM
DISORDER
Outline
Overview of the renal system
 Urinary tract infections (UTI)
 Nephrotic syndrome
 Renal failure (acute and chronic)

Overview of anatomy and physiology
–
The renal and urinary systems
include:
the kidneys
 ureters
 bladder
 urethra

–
Urine is formed by the kidney
and flows through the other
structures to be eliminated from
the body.
–
Kidneys
A pair of bean-shaped, brownish-red structures located retroperitoneally on
the posterior wall of the abdomen.
 Average adult ~113 to 170g, 10 to 12 cm long, 6 cm wide, 2.5 cm thick
 The right kidney is slightly lower than the left.
 Each kidney has 1 million nephrons responsible for urine formation

–
Blood Supply to the Kidneys

Receive 20% to 25% of the total cardiac output.
Ureters, Bladder, and Urethra
–
Ureters:


–
Urinary bladder:



–
Long, narrow fibromuscular tubes that receive urine form renal pelvis and pass to the
bladder.
It is 24 to 30 cm long, originate at the lower portion of the renal pelvis and terminate in
the trigone of bladder wall.
Is a muscular, hollow sac located just behind the pubic bone.
Capacity of the adult bladder is 400 to 500 mL
It has two inlets (the ureters) and one outlet (the urethra)
Urethra:



Arises from the base of the bladder
Male: passes through the penis surrounded by prostate
Female: it opens just anterior to the vagina
–
Function of the renal and urinary systems
Is essential to life
 The primary purpose is:

 to
maintain the body’ s state of homeostasis by:
 regulating fluid and electrolytes,
 removing wastes,
 providing other functions
–
Dysfunction of the kidneys and lower urinary tract is common and may
occur at any age with varying degrees of severity.
–
Functions of the Kidney


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
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Urine formation
Excretion of waste products
Regulation of electrolytes
Regulation of acid– base balance
Control of water balance
Control of blood pressure
Renal clearance
Regulation of red blood cell
production



Synthesis of vitamin D to active
form
Secretion of prostaglandins
Regulates calcium and phosphorus
balance
Assessment of urinary system
Assessment of the disorder of urinary system is performed

By Subjective finding


patient health history
By Objective finding

Physical examination: Observation; Palpation; Percussion and Auscultation
8
Physical Examination

Weighing patient

Look for skin turgor, Scratch, Color, Edema, Genital area for infection.

Inspect and palpate bladder

Palpate kidney at CVA

Fist percussion at flank area for tenderness

Check fluid overload on lung by auscultation
10
Diagnostic Evaluation
–
–
–
Comprehensive health history and physical
–
examination
Urinalysis and Urine Culture:
 Urine color
 Urine clarity and odor
 Urine pH, Osmolality and specific gravity
 Tests to detect protein, glucose, and ketone
bodies
 Microscopic examination
RFT: renal concentration tests, creatinine clearance,
serum creatinine, BUN, serum electrolyte levels
Imaging: x-ray,
Ultrasonography, CT scans, MRI,
Intravenous Urography,
Retrograde Pyelography,
Cystography, Angiography,
Urologic Endoscopic Procedures
URINARY TRACT INFECTION
–
–
–
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Urinary tract infections (UTIs)
are infections of the urinary
tract.
They are the most common
outpatient infection.
Escherichia coli is the most
common pathogen causing a
UTI.
Fungal and parasitic infections
sometimes cause UTIs.
Classification of Urinary Tract Infection
–
–
UTIs can be classified based on its location
as
 an upper or
 lower UTI
 We use specific terms to describe the
location of a UTI.
For example,
 pyelonephritis implies inflammation (usually
caused by infection) of the renal parenchyma and
collecting system.
 Cystitis is an inflammation of the bladder.
 Urethritis is an inflammation of the urethra.
–
We also classify a UTI as

Uncomplicated UTIs
 occur
in an otherwise normal urinary tract.
 They usually only involve the bladder.

Complicated UTIs
 occur
in a person with an underlying disease or with a structural or functional
problem in the urinary tract.
• Examples include obstruction, stones, catheters, abnormal genitourinary (GU)
tract, acute kidney injury (AKI), chronic kidney disease (CKD), kidney
transplant, diabetes, or neurologic disease.
Etiology and Pathophysiology
–
–
–
The urinary tract above the urethra is normally sterile.
Several mechanical and physiologic defense mechanisms aid in
maintaining sterility and preventing UTIs.
These defenses include
normal voiding with complete bladder emptying,
 ureterovesical junction (UVJ) competence, and
 ureteral peristaltic activity that propels urine toward the bladder.


Most UTIs result from fecal organisms that ascend from the perineum
to the urethra and the bladder and then adhere to the mucosa

Bacterial invasion of the urinary tract by:

Urethrovesical reflux, which is the reflux (backward flow) of urine from the
urethra into the bladder.

Vesicoureteral reflux refers to the backward flow of urine from the
bladder into one or both ureters.
Clinical Manifestations
–
Manifestations of UTIs range from
painful urination in uncomplicated urethritis or cystitis to
 severe systemic illness with abdominal or back pain, fever, and sepsis.

–
–
Lower urinary tract symptoms (LUTS) occur in patients who have UTIs of
the upper urinary tract, as well as those confined to the lower tract.
Symptoms are related to either
bladder storage or
 bladder emptying .

–
–
–
–
The urine may have grossly visible blood (hematuria) or sediment,
giving it a cloudy appearance.
Upper UTIs (involving the renal parenchyma, pelvis, and ureters)
typically causes fever, chills, and flank pain.
A UTI confined to the lower urinary tract does not usually have
systemic manifestations.
People with significant bacteriuria may have no symptoms or may
have nonspecific symptoms, such as fatigue or anorexia
–
Diagnostic Assessment
History and physical assessment
 Urinalysis (midstream, “cleancatch” voided specimen)
 Urine for culture and sensitivity
(if indicated)
 Imaging studies of urinary tract
(if indicated): CT scan,
ultrasound, cystoscopy

–
Management

Uncomplicated UTI
 Patient
teaching
 Adequate fluid intake (8 to 9 8oz glasses/day)
–
Drug Therapy

–
Antibiotics
 fluconazole
Recurrent UTI
Repeat urinalysis
 Urine culture and sensitivity
testing
 Adequate fluid intake (8 to 9 8oz glasses/day)
 Repeat patient teaching
 Imaging studies of urinary tract
(if indicated)

(in patients with
fungal UTI)
 fosfomycin (Monurol)
 nitrofurantoin (Macrodantin,
Macrobid)
 TMP/SMX (Bactrim, Bactrim DS)
 trimethoprim alone (in patients
with sulfa allergy)
 cephalexin
–
Drug Therapy
Antibiotic: nitrofurantoin, TMP/SMX
 Sensitivity-guided antibiotic therapy: ampicillin, amoxicillin, 1st- or
 2nd-generation cephalosporin, fluoroquinolones
 3- to 6-month trial of suppressive or prophylactic antibiotic therapy
 Postcoital antibiotic prophylaxis: cephalexin, nitrofurantoin, TMP/SMX,
fosfomycin, trimethoprim

Urethritis
–
–
Definition: Inflammation of the urethra is usually an ascending
infection and may be classified as:- Gonococcal and Non gonococci
Gonococcal urethritis is caused by N. Gonorrhea and is considered as
STDS.
•
Symptoms, in men –
 burning
sensation on urination,
 purulent discharge via urethral meatus,
•
–
in females it is asymptomatic
Non gonococcal urethritis is usually caused by C-trachomitis,
27
Clinical features of all urethritis

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Acute dysuria, frequency, and pyuria,
gross hematuria, Suprapubic or pelvic pain with abrupt onset of illness.
Nocturia
Incontinence
Back pain
Urine discoloration, dribbling,
Burning sensation
Pusy or foamy discharge
In patients with complicated UTIs manifestations can range to sepsis with
shock
28
Diagnostic tests
–
Urine analysis
–
CBC
–
Urine culture and sensitivity
–
Wet smear
–
Digital finger examination
–
Gram stain
29
Medical management
1. Based on the cause
 For gonococal case of STD
 Rx :- Ceftriaxone 250 mg IM stat OR spectinomycin 2gm IM stat
plus Azythromycin 1gm po stat
 For fungal case : Clotrimazole 200 mg vaginal tab at bed time for 3
days
 For herpus simplex type 2, Acyclovir 800mg bid
 For trichomonas vaginalis, metronidazole 2 gm po stat
30
31
2. Based on severity

For simple or uncomplicated UTI:
1.
2.
3.
4.
Ciprofloxacin 500 mg bid for
05 days or
Norfloxacin 400mg bid for 710 days or
Doxycycline 100 mg bid for 710 days or
Amoxicillin 500mg tid for 5-7
days

For complicated and recurrent
UTI:1. Ceftriaxone 1gm IV/IM bid
for 03 days or
2. Gentamycin 80 IM/IV TID
for 5-7 days
3. Cefix 200mg po daily for
05 days
Nursing management
–
–
–
–
–
–
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A high (2 L daily) fluid intake should be encouraged during treatment
and for some subsequent weeks.
Safe sexual intercourse
Appropriate taking of prescribed drugs
Frequent voiding
Frequent personal hygiene
Use appropriate sanitary pad
Circumcision for male patients
32
Cystitis
33
–
–
Definition: Is inflammation of
the urinary bladder
Cause:
ascending infection from the
urethra,
 urethrovesical reflux,
 fecal contamination,
 Use of catheter or cyst scope


Risk factors
Inability or failure to empty the
bladder completely
 Obstructed urinary flow
 Immuno-suppression
 Instrumentation
 Contributing conditions including
DM, pregnancy, gout neurologic
disorders
 Anal sex

Clinical manifestations
–
Frequency and urgency of urination
–
Burning and pain on urination,
–
Suprapubic pain or spasm and urine retention ,hesitancy,
–
Nocturia, dysuria and Foul smelling urine,
–
In some clients hematuria and pyuria (WBC or pus in urine),
–
There may be fever, nausea, vomiting malaise, dizziness and flank
tenderness
34
Diagnostic tests
–
Urine analysis
–
Urine culture
–
Ultrasound
–
Gram stain
–
Antibody – coated bacterial test
–
Complete blood cell count
35
Medical management
–
Ciprofloxacin 500mg bid for 05 days or
–
Cotrimoxazole 960 mg bid for 7-10 days or
–
Cefix 200mg daily for 5-7 days or
–
Cephalexin 500mg bid for 5-7 days or
–
Ceftriaxone 1 gm IV/IM bid for 3-5 days or
–
Gentamycin 80 mg IV/IM tid 5-7 days
36
Nursing management
–
–
–
–
–
–
–
–
–
Encourage high fluid intake
Voiding after sexual intercourse
Circumcision for male
Keep personal hygiene
Encourage shower bath rather tub bath
Keep the dryness of perineal area
Follow strict sterility during instrumentation
Avoid taking of very irritant drinks and foods to bladder
Encourage frequent urine voiding
37
Upper Urinary Tract Infection


An infection of ureter (ureteritis) and kidney (pyelonephritis)
Pyelonephritis


is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of
one or both kidneys, by bacteria that come from bladder and rarely from
blood
Pyelonephritis can be acute or chronic
 Chronic
pyelonephritis usually has no symptoms of infection unless an acute
exacerbation occurs
38
Pyelonephritis
–


Inflammation of the renal pelvis, and kidney tissues
 Acute----Bacterial ”ascending infection”.
 Chronic----Non bacterial and inflammatory processes.
Acute pyelonephritis: Active infection manifested by Fever, Chills, CVA tenderness, N/V, Tachycardia, symptoms of lower
UTI such as dysuria and frequency;
 Upper UTI is associated with antibody coating of the bacteria in the urine.
Chronic Pyelonephritis: May be due to repeated bouts of acute pyelonephritis
 Pts have usually no symptoms of infection unless acute exacerbation occurs.
 Noticeable signs include Fatigue, Head Ache, Poor Appetite, Polyuria, Excessive thirst, and Weight
loss.
 Its complication include end - stage renal disease
39
Acute pyelonephritis
–
Acute Pyelonephritis is a bacterial infection of the renal pelvis, tubules,
and interstitial tissue of one or both kidneys, by bacteria
–
Pt with acute pyelonephritis usually has enlarged kidneys with interstial
infestation of inflammatory cells.
–
Abscess may be noted, eventually atrophy and destruction of tubules
and the glomeruli will be occur
40
Risk factors






It is usually seen in association with pregnancy, chronic health
problems, such as diabetes mellitus or hypertensive kidney disease
Sexually active women ages 20 to 50 but may also occur in those who
are not sexually active or in young girls.
Perineal colonization by Escherichia coli [E.cloli]
Sexual intercourse
Insertion of instruments into the urinary tract
Obstruction of the bladder or urethral with resultant stagnant of urine.
41
Pathophysiology

Pyelonephritis is frequently secondary to ureterovesical reflux into
the ureters
Urinary tract obstruction
 Bladder tumors, strictures, benign prostatic hyperplasia, and urinary stones
 Interstitial infiltrations of inflammatory cells
 Abscesses
 Atrophy and destruction of tubules and the glomeruli
 When pyelonephritis becomes chronic, the kidneys become scarred,
contracted, and nonfunctioning

42
Clinical Manifestations







Enlarged kidneys
Appears acutely ill
Chills and fever
Leukocytosis, bacteriuria and pyuria,
Flank pain
CVA tenderness
Symptoms of lower urinary tract involvement such as dysuria and
frequency.
43
Assessment and Diagnostic Findings

Ultrasound

CT scan

Urine culture and sensitivity

Complete blood cell count

Digital finger examination

Cystoscopy

Antibody coated bacterial test
44
Management

Patients with acute uncomplicated pyelonephritis are usually treated as
outpatients if they are not dehydrated, not experiencing nausea or
vomiting, and not showing signs or symptoms of sepsis.

Drug therapy is almost similar with lower UTI cotrimoxazole,
ciprofloxacin, gentamicin with or without amoxaccilin, ampicillin, or a
third-generation cephalosporin.)
45
Nursing Management
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–
–
–
–
–
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Unless contraindicated fluid intake is encouraged
Urine output are carefully measured and recorded,,
Teach emptying the bladder regularly and performing recommended
perineal hygiene.
Frequent voiding
Avoidance of sugars and sugary foods
Avoid caffeinated drinks
Drinking unsweetened cranberry juice as well as taking vitamin C with
that last meal of a day
46
Prevention:–
–
–
–
–
–
Cleaning the urethral meatus after intercourse
Urination within 15 min of sexual intercourse to allow flow of urine to
expel the bacteria before specialized extensions anchor the bacteria
to the walls of the urethra
Having adequate fluid intake, especially water
Not resting the urge to urinate
Bathing in warm water without soap, bath foams etc
Practicing good hygiene including wiping from the front to back to
avoid contamination of the urinary tact by fecal pathogens
47
Chronic pyelonephritis
–
–
–
Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis.
The infection commonly starts in the adrenal medulla and then spread
adjacent cortex. The infected portion of the kidney heals, resulting in
fibrosis and scarring and the kidney may become contracted and become
non functional.
Clinical Manifestation; Have no symptoms, unless pt has acute exacerbation
Noticeable s/s may include; Fatigue, Poor appetite, Headache, Excessive
thirst, Wt loss & Persistent and recurrent infection may produce progressive
scarring of the kidneys with renal failure the end result
48
Diagnosis is the same to acute type
Medical management
–
For mild case like that of acute pyelonephritis
 For sever and complicated form needs hospitalization and treated with: Gentamycin 80 mg IV Tid for 7-10 days or
 Ceftriaxone 1gm Iv Bid for 5-7 days or
 Ciprofloxacin 200mg IV bid for 5-7 days or
 Ceftazidim 2 gm IV tid for 5-7 days plus
 Vancomycin 1 gm Iv bid for 5-7 days

49
Nursing management
–
–
–
–
–
–
–
Monitor vital sign Q2-4 hrs, monitor urine by catheter and malodor
Administer antipyretic and antibiotic
Encourage adequate hydration
Avoid fluid that may irritate the bladder (Eg Coffee, tea, alcohols,
cola)
Encourage voiding frequently
Encourage perineal hygiene
Educate to avoid sexual intercourse until urethritis is cured, and instruct
the sexual partner to be evaluated for urethritis
50
Nephrotic syndrome
–
–
–
Type of renal failure characterized by increased glomerular
permeability and massive proteinuria
Seriously damaged glomerular capillary membrane
Clinical findings:

–
proteinuria, hypoalbuminemia, diffuse edema, high serum cholesterol,
hyperlipidemia
Although the liver is capable of increasing the production of albumin, it
cannot keep up with the daily loss of albumin through the kidneys.
Pathophysiology
–
–
Nephrotic syndrome occurs with
many intrinsic renal diseases
and systemic diseases that
cause glomerular damage.
It is not a specific glomerular
disease but a constellation of
clinical findings that result from
the glomerular damage.
Clinical Manifestations
–
Edema
soft and pitting
 Periorbital
 dependent areas (sacrum, ankles, and hands),
 in the abdomen (ascites).

–
–
–
Irritability
Headache
Malaise
Assessment and Diagnostic Findings
–
–
–
–
–
History
Physical examination
Proteinuria (albumin) exceeding 3.5 g/day is the hallmark of the
diagnosis of nephrotic syndrome
Increased WBCs, granular and epithelial casts in urine
Needle biopsy of the kidney for histologic examination.
–
Medical Management

Treatment is focused on:
treating the underlying
disease
slowing progression of CKD,
relieving symptoms.

Typical treatment includes:
 Diuretics
for edema,
 ACE inhibitors to reduce
proteinuria,
 Lipid lowering agents for
hyperlipidemia
 Antibiotics for infections
–
Nursing Management
Similar to care for patient with acute glomerulonephritis and ESRD.
 adequate medication and dietary instructions
 Patients must be made aware about communicating any health related
change to their health care providers as soon as possible

–
Complications
Infection (due to a deficient
immune response),
 Thromboembolism (renal vein,
pulmonary emboli)
 ARF (due to hypovolemia)
 Atherosclerosis (due to
hyperlipidemia)

Renal Failure
–
Sever impairment or total lack
of kidney function, resulting in
an inability to:
remove metabolic end products
from the blood
 regulate the fluid, electrolyte,
and pH balance
 respond to functional
disturbances of all body system

–
can be acute or chronic
Acute Renal failure /ARF/
–
ARF is a sudden and almost
complete loss of kidney function
(ed GFR), over a period of
hours or days, with progressive
azotemia.
–
I. Prerenal Failure (hypo-perfusion
of kidney)
 50-70% of causes
 factors out side the kidneys
impair renal blood flow
lead to decreased glomerular
perfusion and filtration
–
I.
II.
Pre-renal causes may include:
Hypovolemia due to:
hemorrhage
dehydration
burns
GI losses
Vasodilatation b/c of:
sepsis
anaphylaxis
Vasodilator
drugs
ed CO caused by:
III.
myocardial infraction
 HF
 dysrhythmias
 cardiac shock

II. Intra-renal Failure (actual damage to kidney tissue)
20-30% of causes
 Include conditions that lead to actual damage to the renal tissues-Acute
Tubular Necrosis/ATN
 Nephrotoxic injury (30%) caused by drugs like:

 aminoglycosides,
 heavy
metals (lead, mercury)
 radiocontrast agents
 NSAIDs
 ACE inhibitors
–
Intra-renal Failure cause…
Ischemia due to renal hypo-perfusion (>50%)
 Medical conditions: CKD, diabetes, heart failure, hypertension, and cirrhosis
can lead to ATN
 Myoglobinuria: trauma, crush injuries, burns
 Hemoglobinuria: transfusion reaction, hemolytic anemia
 Primary renal disorders (APN, AGN)
 Toxemia of pregnancy /eclampsia
 Systemic lupus erythematosus

III. Post renal Failure (obstruction to urine flow)



1-10% of causes
Involve mechanical obstruction of urinary out flow some where distal to the kidney
The most common causes are: Prostate
cancer
 Benign prostatic hyperplasia\BPH
 Calculi
 Stricture
 Tumors
 Blood clots
ARF: Clinical Courses
–
Clinically ARF may progress
through 4 phases of:
A.
B.
C.
D.
Initiation
Oliguria
Diuresis, and
Recovery
I. Initiation period
Begins with the initial insult
 Ends when oliguria develops

II. Oliguric phase
The most common initial manifestation
 Caused by a reduction in the GFR
 Usually occurs with in 1 to 7 days of causative event
 Accompanied by a rise in urea, creatinine, uric acid, organic acid &
intracellular cations like K+, Mg2+
 The average duration is about 10-14 days

 but,
rarely exceeds 4 weeks
 the longer the oliguric phase lasts the poorer for the prognosis of renal function
–
Common changes that occur during oliguric phase
decreased urine output
 fluid volume excess
 metabolic acidosis
 potassium excess
 waste product accumulation
 neurologic disorders

III. Diuresis phase (high output phase)
Begins with a gradual increase in the daily urine output of 1-3 liter/day, but
may reach >3-5L/day
 Caused by osmotic diuresis due to:

 the
high urea concentration in the glomerular filtrate
 the inadequate concentrating ability of the tubules
Signals that glomerulus has started to recover
 Lab values stop to increase and eventually decrease

–
Because of the large losses of fluid and electrolytes, the patient must
be monitored for:
hyponatremia,
 hypokalemia
 dehydration

–
The phase may last for 1 to 3 weeks.
IV. Recovery phase (convalescent phase)
begins when the GFR increases so that BUN and serum creatinine levels start
to stabilize and then decrease.
 major improvements occur in the first 1 to 2 weeks of this phase

 but,
renal function can continue to improve for up to 12 months after ARF
Some patients may experience slight reduction in kidney function for the rest
of their life, so they will still be at risk for fluid and electrolyte imbalances.
 some patients may progress to CRF

Comparing Clinical Characteristics of ARF
Clinical Manifestations
–
–
Almost every system of the body is affected
Clinical manifestations are related to azotemia, as well as the
underlying cause
acute renal failure does not produce a classic set of symptoms.
 decreased urine output (70% of patients).
initially, weight gain
peripheral edema

–
Later, as nitrogenous products accumulate, symptoms of uremia may develop,
including:




–
–
Dry skin and mucous membrane
If uremic pericarditis is present

–
–
persistent nausea, vomiting and diarrhea
drowsiness, headache, muscle twitching, and seizures
the breath may have the odor of urine
patients may appear critically ill and lethargic
chest pain, a pericardial friction rub, and findings of pericardial tamponade may occur
Fluid accumulation in the lungs may cause dyspnea and crackles on auscultation.
Other findings depend on the underlying cause
Diagnosis
–
–
–
–
–
–
–
History
Physical examination
RFT
Serum electrolytes
U/A
X-ray
Renal ultra sound/MRI/CT Scan
ARF: Medical Management
–
Goal:
Restore normal chemical
balance
 Prevent complications until
repair of renal tissue
 Restoration of renal function

–
Management includes:
Eliminating the underlying cause
 Maintaining fluid balance:
avoiding fluid excesses
 Providing renal replacement
therapy (as indicated)
 Controlling symptoms
 Correcting hypovolemia
(prerenal)

–
–
–
–
–
–
Maintaining cardiac out put to
ensure adequate perfusion of the
kidneys
Loop diuretics like furosimide /lasix/
Osmotic diuretic (manitol) to prevent
volume over load
Monitoring fluid intake during the
oliguric phase
Treat hyperkalemia
Phosphate binding agents (e.g.
aluminum hydroxide) to treat
elevated phosphorus.
–
Nutritional management
–
phosphate restriction
 sodium restriction
 protein limited to about
1g/kg/day during oliguric phase
to minimize protein breakdown.
Dialysis (if indicated)

Preventing Acute Renal Failure
–
Provide adequate hydration to patients at risk for dehydration
including:
before, during, and after surgery
 patients undergoing intensive diagnostic studies requiring fluid restriction
and contrast agents
 patients with neoplastic disorders or disorders of metabolism (eg, gout) and
those receiving chemotherapy
 Prevent and treat shock promptly with blood and fluid replacement
 Monitor central venous and arterial pressures

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Hourly monitor urine output of critically ill patients
Treat hypotension promptly
Continually assess renal function
Take precautions to ensure that the appropriate blood is administered to the
correct patient
Prevent and treat infections promptly
Pay special attention to wounds, burns, and other precursors of sepsis.
Give meticulous care to patients with indwelling catheters.
Remove catheters as soon as possible.
Closely monitor dosage, duration, and blood levels of all medications
metabolized or excreted by the kidneys
Chronic Renal Failure (End-Stage Renal Disease)
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Kidney damage that require
renal replacement therapy on a
permanent basis,
Final (5th) stage of CKD,
referred to as chronic renal
failure (CRF) or ESRD
Pathophysiology
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As renal function declines, the end products of protein metabolism
accumulate in the blood.
Uremia develops and adversely affects every system.
The greater the buildup of waste products, the more pronounced the
symptoms are.
The rate of decline in renal function and progression of ESRD is
related:
underlying disorder,
 the urinary excretion of protein,
 the presence of hypertension.

Clinical Manifestations
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Patients exhibit a number of signs and symptoms
The severity of these signs and symptoms depends:
the degree of renal impairment,
 other underlying conditions,
 the patient’ s age

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CVD is the predominant cause of death in ESRD
Assessment and Diagnostic Findings
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History
Physical examination
Glomerular Filtration Rate
Sodium and Water Retention
Blood tests:
Acidosis
 BUN, Creatinine
 Anemia/Hgb
 Calcium and Phosphorus Imbalance

Medical Management
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Goal: to maintain kidney function and homeostasis for as long as possible.
All factors that contribute to ESRD that are reversible are identified and
treated.
Management is accomplished primarily with:




Dietary therapy
Medications (Calcium and Phosphorus Binders like alciumcarbonate or calcium
acetate), Antihypertensive and Cardiovascular Agents (diuretic, inotropic agents),
sodium bicarbonate supplements, Antiseizure (diazepam or phenytoin),
erythropoietin)
Dialysis
KIDNEY TRANSPLANTATION
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Nutritional Therapy
Careful regulation of protein intake, fluid intake to balance fluid losses,
sodium intake to balance sodium losses, and some restriction of potassium.
 Adequate caloric intake and vitamin supplementation
 The allowed protein must be of high biologic value (dairy products, eggs,
meats).
 Calories are supplied by carbohydrates and fat to prevent wasting
 Vitamin supplementation (for protein restriction and dialysis patients)

Nursing Diagnosis
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Excess fluid volume related to decreased urine output, dietary excesses, and
retention of sodium and water
Imbalanced nutrition: less than body requirements related to anorexia, nausea,
vomiting, dietary restrictions, and altered oral mucous membranes
Deficient knowledge regarding the condition and treatment
Activity intolerance related to fatigue, anemia, retention of waste products, and
dialysis procedure
Risk for situational low self-esteem related to dependency, role changes,
change in body image, and change in sexual function
Hyperkalemia; pericarditis, pericardial effusion, and pericardial tamponade;
hypertension; anemia; bone disease and metastatic calcifications (collaborative
nursing diagnosis)
Nursing intervention
–
Nursing care is directed toward:

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assessing fluid status and identifying potential sources of imbalance,
implementing a dietary program to ensure proper nutritional intake within the limits
of the treatment regimen,
promoting positive feelings by encouraging increased selfcare and greater
independence.
emotional support for the patient and family
Provide explanations and information concerning:



ESRD,
treatment options
potential complications
–
Assess fluid status:
 Daily weight
 Intake and output balance
 Skin turgor and edema
 Distention of neck veins
 Bp, pulse rate, and rhythm
 Respiratory rate and effort
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Limit fluid intake
Identify potential sources of fluid:

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Medications and fluids: oral and
intravenous
Foods
Explain to patient and family
rationale for fluid/food restriction.
Assist patient to cope with the
discomforts resulting from fluid
restriction.
Provide or encourage frequent oral
hygiene
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Encourage high-calorie, low-protein, low-sodium, and low potassium
snacks between meals.
Provide written lists of foods allowed.
Provide pleasant surroundings at meal-times.
Assess for evidence of inadequate protein intake:
Edema formation
 Delayed wound healing
 Decreased serum albumin levels

Complications
–
Potential complications of chronic renal failure:
Hyperkalemia
 Pericarditis, pericardial effusion, pericardial tamponade
 Hypertension
 Anemia
 Bone disease

Nursing intervention
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Pericarditis, Pericardial Effusion, and Pericardial Tamponade


Assess patient for fever, chest pain, pericardial friction rub (if present), notify
physician.
If patient has pericarditis, assess for the following every 4 hrs:
 Paradoxical
pulse 10 mm Hg
 Extreme hypotension
 Weak or absent peripheral pulses
 Altered level of consciousness
 Bulging neck veins


Prepare patient for cardiac ultrasound.
Prepare patient for emergency pericardiocentesis
Nursing intervention …cont’ed
–
Hypertension
Monitor and record blood pressure as indicated.
 Administer antihypertensive medications as prescribed.
 Encourage compliance with dietary and fluid restriction therapy.
 Teach patient to report signs of fluid overload, vision changes, headaches,
edema, or seizures.
 Hyperkalemia
 Monitor serum potassium levels; Notify physician if greater than 5.5 mEq/L,
and prepare to treat hyperkalemia.
 Assess patient for muscle weakness, diarrhea, ECG changes

Nursing intervention …cont’ed
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Anemia
Monitor RBC count, Hgb, and hematocrit levels.
 Administer medications as prescribed, including:

 Iron
 Folic
acid supplements,
 Epogen,
 Multivitamins
Avoid drawing unnecessary blood specimens.
 Teach patient to prevent bleeding
 Administer blood component therapy as indicated.

Nursing intervention …cont’ed
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Bone Disease and Metastatic Calcifications
Administer: phosphate binders, calcium supplements, vitamin D supplements
as prescribed.
 Monitor serum lab values as indicated (calcium, phosphorus, aluminum levels)
and report abnormal findings to physician.
 Assist patient with an exercise program

References
1.
2.
3.
Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 14th
edition
Focus on Adult Health_ Medical-Surgical Nursing-2nd edition
Lewiss Medical-Surgical Nursing Assessment and Management of
Clinical Problems-11th EDITION