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Renal System Disorders

Nio C. Noveno,
Noveno, RN
RN,, MAN
The Human Kidney

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The Nephron

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Functions of the Renal System
 Excretion of waste

 Regulation of acid-base balance

 Formation of erythropoietin

 Regulation of fluid and electrolyte balance
(RAAS)

 Regulation of phosphate and calcium

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Classification of Renal Disorders

Obstructive disorders

Acute renal failure

Chronic renal failure

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Obstructive disorders
 Can occur anywhere in the urinary
tract

 Signs and symptoms depend on the
site of location and size of
obstruction

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Causes
of urinary tract obstruction
Lower urinary tract Ureteral obstruction
 Bladder neoplasms  Calculi
 Urethral strictures  Trauma

 Calculi  Enlarged lymph nodes
 Congenital anomalies
 Tumors
 Benign prostatic
hypertrophy Kidney
 Calculi
 Polycystic kidney disease

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Renal stones
 Crystallization of minerals around an
organic matrix (blood, pus,
devitalization tissue)

 Usually idiopathic:
– Infection

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SITES OF STONE FORMATION

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Composition of renal stones
Calcium (oxalate and phosphate) Uric acid
Hypercalcemia  High purine diet
 Hyperthyroidism  Gout
 Vitamin D intoxication  Chemotherapy

 Immobilization
Cystine
 Tumors
 Genetic disorder
 Renal tubular acidosis
 Intake of steroids Struvite
 Infection related

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Renal Stones
Diagnostics
 Urinalysis
 KUB-UTZ
 KUB-IVP
 CT scan
 Cystoscopy
 BUN, Creatinine

Clinical manifestations
 Pain
 Hematuria

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Diagnostic Procedures

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Medical management
Medications
 Pain medications
 Medications to  Ca & PO4 content
– Ascorbic acid
 Medications to  uric acid formation
– Sodium bicarbonate
– Allopurinol
 Surgery
 Extracorporeal shockwave lithotripsy
 Percutaneous lithotripsy

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EXTRACORPOREAL
SHOCKWAVE LITHOTRIPSY

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Nursing management
 Administer medications as
ordered

 Strain urine to detect passage
of stones

 Monitor I & O

 Encourage to increase OFI
>3 L/day

 Instruct client on infection
prevention
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Bladder carcinoma
 Most common among 60-70 years old
 Males>females

Predisposing factors:
– Cigarette smoking
– Exposure to rubber dyes
– Abuse of phenacetin-containing
analgesics
– Recurrent UTI
– Recurrent nephrolithiasis
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Bladder carcinoma
Clinical manifestations
– Gross painless hematuria
– Dysuria
– Frequent urination

Diagnostics
– Urinalysis
– IVP
– Cystoscopy with biopsy
– CT scan
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Bladder carcinoma
Medical Management Nursing management

 Surgical treatment  Encourage to:
 Radiation – Increase OFI
 Chemotherapy – Quit smoking

 Assess for presence
of UTI

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Bladder carcinoma
Care of the STOMA  Teach patient on stoma
Immediate post-OP: care
 Color of drainage is bright Opening should be
red/pink no more than 2-3
mm larger than the
Report: gray or black stoma
discoloration Change every 3-5
 Position pouch at the side of days
bed for drainage
 Monitor urine output daily
Report signs of UTI
 Monitor for signs of peritonitis
– Cloudy urine
Abdominal pain, – Hematuria
distention, fever – Strong odor
– Fever
– Flank pain
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Benign Prostatic Hyperplasia (BPH)

 Most common
problem of adult male
reproductive organ

 Cause is not
completely
understood

 Not a predisposing
factor for prostatic
carcinoma
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Benign Prostatic Hyperplasia (BPH)

Clinical manifestations Diagnostics
 Dribbling  Digital rectal exam
 Hesitancy  Urinalysis
 Diminution in caliber  BUN/Creatinine
and force of urinary  Cystourethroscopy
stream  PSA
 Feeling of incomplete
emptying
 Irritative symptoms

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Benign Prostatic Hyperplasia (BPH)

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Benign Prostatic Hyperplasia (BPH)

Medical Management Non-surgical
procedures
 Pharmacologic
 Thermotherapy
treatment
 Prostatic balloon
 Anti-androgens device
– Finasteride  Stents/coils
– Alpha-adrenergic  TULIP (transurethral
blockers ultrasound-guided
laser prostatectomy)
– Terazosin
 Surgical procedures

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Benign Prostatic Hyperplasia (BPH)
Nursing management:
1. Provide medications as ordered
2. Maintain patency of 3-way Foley
• Observe aseptic technique
• Irrigate with NSS (as ordered)
3. Control & treat bladder spasms
• Short, frequent walks
• Decrease frequency of bladder irrigation
• Administer anti-cholinergics and anti-
spasmodics
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Benign Prostatic Hyperplasia (BPH)
4. Prevent hemorrhage
• Prevent straining (heavy lifting, constipation),
prolonged periods of travel, sexual activity
until doctor approves so.
• Avoid rectal procedures.
5. Provide for bladder training after Foley
catheter removal
• Perineal exercise
• Limit fluid intake in the evening
• Restrict intake of caffeine-containing
compounds
• Withhold anti-cholinergics and anti-
spasmodics if permitted
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Benign Prostatic Hyperplasia (BPH)

5. Provide health teaching on:
• Increasing OFI
• Signs of UTI and report once noted
• Avoidance of heavy lifting, straining and
prolonged travel.
• Possible impotence

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Prostate cancer
 Highest incidence in African-American over
age 60
 Adenocarcinoma; growth related to presence
of androgens

Clinical manifestations:
– Same as BPH
– Hard, nodular, fixed mass upon rectal exam

Laboratory diagnostics:
– Elevated PSA, acid & alkaline phosphatase
– Bone scan
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Prostate cancer

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Prostate cancer
Medical management: Nursing interventions:
1. Administer prescribed
Drug therapy:
medications
Estrogens, 2. If with radiotherapy:
chemotherapeutic • Double flush the toilet
agents after use.
Radiation therapy • Advise to avoid placing
children on their lap.
Surgery: Perineal
• Avoid sexual intercourse
prostatectomy for the whole duration of
therapy.
3. Provide care post-
prostatectomy

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Acute renal failure (ARF)
Sudden cessation of kidney function; reversible

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Acute renal failure (ARF)
Sudden cessation of kidney function; reversible
Causes:
1. Ischemic (pre-renal)
• Dehydration 3. Obstruction (post-renal)
• Blood loss (surgery, trauma) • Stones
• Cardiac failure • Tumors
• Shock • Strictures/stenosis

2. Toxic substance (renal)
• Solvents (carbon 4. Other causes:
tetrachloride, methanol, • Acute
ethylene glycol) glomerulonephritis
• Heavy metals (lead, arsenic,
mercury) • Malignant
hypertension
• Antibiotics
(aminoglycosides, • Hemolysis
amphotericin B)
• Pesticides
• Mushrooms

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Physiologic effect Findings Symptoms
Drowsiness, Confusion, Coma
Oliguric ↑ BUN, Crea
GI bleeding
Inability to excrete wastes Asterixis
Pericarditis

Cardiac dysrhythmias
↑ K+, ↓ Na+, acidosis
Inability to regulate electrolytes Kusmaull’s breathing
Coma

CHF
Fluid overload
Inability to excrete fluid loads Pulmonary edema
Hypertension
Urine output of 4-5 L/day
Hypotension
Hypovolemia Tachycardia
Improving mental alertness
Diuretic ↓ Na+ Weight loss
↓ K+ Dry mucous membranes
Muscle weakness
Constipation

Recovery Return to normal
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Nursing management:
Medical management:
 Supportive
 Dialysis

Nursing management:
1. Maintain F & E balance
• Accurate I & O
• Weigh daily
• Maintain fluid restrictions
• Assess for signs of fluid overload
2. Maintain nutrition
• Moderate CHON, low K+, high CHO, high fat
• Measures to relieve nausea

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Nursing management:
3. Maintain rest-activity balance
• Provide assistance in ADL
• Maintain strict bed rest in acute phase

4. Prevent injury
• Keep side rails elevated (pad if necessary)
• Protect from bleeding

5. Prevent infection
• Maintain asepsis
• Reverse isolate
• Turn frequently
• Meticulous skin care
• Relieve pruritus

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Chronic renal failure (CRF)
Causes:

Chronic systemic disease
DM, HTN
Polycystic kidney disease
Long standing obstruction
Chronic glomerulonephritis
Recurrent infections

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Stages of CRF
1. Decreased renal reserve (renal
impairment) 4. End-stage renal disease
• GFR: 40-50% • GFR: <10%
• BUN & crea are normal • BUN & crea severely
• Asymptomaitc increased
• Signs of CHF
2. Renal insufficiency
• GFR: 20-40% • Hypocalcemia,
hyperphosphatemia,
• BUN & crea begins to rise hyperkalemia,
• Mild anemia, mild azotemia hyponatremia
• Polyuria, nocturia • Fractures, joint pains
3. Renal failure • Infertility, amenorrhea
• GFR: 10-20% • Uremia
• BUN & crea increase
• Anemia, azotemia,
metabolic acidosis

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Stages of CRF

Decreased renal
reserve
Renal insufficiency

Renal failure

End-stage renal
disease
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Chronic renal failure (CRF)
Diagnostics:  Anemia
Blood chemistry – Epoieitin alfa
Urinalysis
– Iron
KUB-TUZ
– Folate and Vitamin B12
Medical management: – Blood transfusion
Conservative TX
 Fluid and electrolyte control  Hypertension
– Hyperkalemia
 Diet
 Dialysis Dialysis
 Exchange resins
– Hypocalcemia/
hyperphosphatemia Renal transplant
 Phosphate binders
 Diet
 Vitamin D

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Peritoneal Dialysis

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Peritoneal Dialysis
Intermittent:
8-12 H x 3-5x/week

Ambulatory:
3-5 passes/day

Continuous cycling:
3-7x during sleep

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Peritoneal dialysis
 Must consider:
 (+) pink-tinged effluent
– Explaining or presence of small
procedure strings is normal

– Monitor VS (+  Blood is normal for
weight) several days

– Note for signs of  With ascites from other
source, substitute a
infection lower concentration of
dialysate
– Assess skin
integrity
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Hemodialysis
AV Fistulas
– Internal AVF
– Internal Graft AVF
– Internal AV Graft
with external
access device
Complications
– Thrombosis
– Local infections
– Aneurysms
– Steal syndrome
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Hemodialysis

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HEMODIALYSIS PERITONEAL DIALYSIS

AVF
ACCESS Subclavian vein Peritoneum
Arteriovenous graft

DURATION 2-4 H 36 H

Disequilibrium syndrome Exit site infection
Hypotension Peritonitis
COMPLICATIONS Bleeding Hernias
Sepsis Pulmonary complications
Hepatitis Protein loss

Monitor for VS and changes in
Weigh before and after HD behavior
VS q 15 mins Check patency of catheter
Monitor I & O, signs of DE May procaine HCl in the
NURSING INTERVENTIONS WOF signs of bleeding dialysate to minimize
Do NOT use the AVF other than for discomfort
dialysis Observe for signs of peritonitis
Provide diversional activities Maintain aseptic technique
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Chronic renal failure (CRF)
Nursing management:
 Maintain F & E balance
– I & O q 80
– Weigh daily
– Assess edema
 Auscultate breath sounds
 V/S q 80
 Assess LOC q 80
 High CHO diet, within prescribed Na+, K+, and
CHON limits
 Administer medications as ordered
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Renal Transplant

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Renal Transplant

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Chronic renal failure (CRF)
Nursing management cont…:
 Prevent infection and injury
– Promote meticulous skin care
– Protect from infectious agent
– Protect confused person
– Maintain asepsis
– Avoid aspirin products
– Encourage use of soft bristle toothbrush

 Promote comfort
– Give anti-pruritics
– Use emolient baths, keep skin moist
– Provide good oral hygiene

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ACID-BASE DISORDERS
Disorder Clinical manifestation Compensation

↑Paco2, ↑ or normal Kidneys eliminate H+
Respiratory acidosis
HCO3-, ↓ pH and retain HCO3-

↓ Paco2, ↓ or normal Kidneys conserve H+
Respiratory alkalosis
HCO3-, ↑ pH and eliminate HCO3-

↓ or normal Paco2, Lungs eliminate CO2
Metabolic acidosis
↓HCO3-, ↓ pH and conserve HCO3-

Lungs hypoventilate to
↑ or normal Paco2, ↑ Paco2, kidneys
Metabolic alkalosis
↑HCO3-, ↑ pH conserve H+ excrete
HCO3-
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Causes of Acid-Base Disorders
Nursing management:
Metabolic acidosis
 Administer sodium
Causes:
bicarbonate
 DKA, uremia,
starvation, diarrhea,  Monitor for signs of
severe infections hyperkalemia
 Provide alkaline
Manifestations: mouthwash
 Headache, nausea  Lubricate lips to prevent
and vomiting dryness
 Signs of hyperkalemia  I & O
 Seizures, coma,  Institute seizure precaution
hyperventilation
 Monitor ABG & electrolyte
losses
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Causes of Acid-Base Disorders
Metabolic alkalosis
Causes: Nursing management:
 Severe vomiting, NGT  Decreased
suctioning, diuretic respirations
therapy, excessive  Replace fluids nad
ingestion of NaHCO3, electrolytes losses
biliary drainage  I&O
 Assess for signs of
Manifestations: hypokalemia
 Nausea and vomiting  Monitor ABG &
 Signs and symptoms electrolytes
of hypokalemia
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Causes of Acid-Base Disorders
Respiratory acidosis
Causes:
 Hypoventilation: COPD, Nursing management:
barbiturate or sedative  Semi-Fowler’s
overdose, acute airway
obstruction,  Patent airway
neuromuscular disorders  Turn, cough, deep-
breath
Manifestations:  Administer fluids
 Headache, weakness,  O2 therapy
visual disturbances, rapid
respirations, confusion,  Monitor ABG
drowsiness, tachycardia,
coma
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Causes of Acid-Base Disorders
Respiratory alkalosis
Causes: Nursing management:
 Hyperventilation,
mechanical  Offer reassurance
overventilation,  Encourage breathing
encephalitis into a paper bag
Manifestations:
 Provide sedation as
 Numbness and tingling of
mouth and extremities ordered
 Inability to concentrate  Monitor mechanical
 Rapid respirations, dry ventilation and ABG
mouth, coma

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Interpretation

UC PC FC

pH ↓ or ↑ ↓ or ↑ normal

↓ or ↑
HCO3- ↓ or ↑ ↓ or ↑
normal
↓ or ↑
Paco2 ↓ or ↑ ↓ or ↑
normal
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Renal System Disorders
Nio C. Noveno, USRN, MAN