RENAL SYSTEM ` The renal system consists of all the organs involved in the formation and release of urine

. It includes the kidneys, ureters, bladder and urethra

URINE - is fluid produced by the kidney. Urine is stored in the bladder, and leaves the body through the urethra.

RENAL SYSTEM FUNCTION: ` Is responsible for excreting water, soluble wastes, stimulating RBC production, and maintaining the balance of pH, plasma water, and electrolytes. URINARY FUNCTION: ` Is responsible for the transportation, storage, and elimination of urine

KIDNEY ` The kidneys are bean shaped organs, which help the body produce urine to get rid of unwanted waste substances. ` When urine is formed, tubes called ureters transport it to the urinary bladder, where it is stored and excreted via the urethra ` The kidneys are also important in controlling our blood pressure and producing red blood cells.

Kidneys, Ureters, and Bladder

Kidneys:
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Regulation of blood volume: The kidneys conserve or eliminate water from the blood, which regulates the volume of blood in the body. Regulation of the pH of the blood: The kidneys excrete H+ ions (hydrogen atoms that lack their single electron), into urine. At the same time, the kidneys also conserve bicarbonate ions (HCO3-), which are an important buffer of H+.

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Regulation of blood pressure: The kidneys regulate blood pressure in 3 ways, by:Adjusting the volume of blood in the body (by regulating the quantity of water in the blood), Adjusting the flow of blood both into, and out of, the kidneys, and Via the action of the enzyme renin. The kidneys secret renin, which activates the angiotensin-aldosterone pathway.

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Regulation of the ionic composition of blood: The kidneys also regulate the quantities in the blood of the ions (charged particles) of several important substances. Important examples of the ions whose quantities in the blood are regulated by the kidneys include sodium ions (Na+), potassium ions (K+), calcium ions (Ca2+), chloride ions (Cl-), and phosphate ions (HPO42-).

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Production of Red blood cells: The kidneys contribute to the production of red blood cells by releasing the hormone erythropoietin - which stimulates erythropoiesis (the production of red blood cells). Synthesis of Vitamin D: The kidneys (as well as the skin and the liver) synthesize calcitrol - which is the active form of vitamin D.

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Excretion of waste products and foreign substances: The kidneys help to excrete waste products and foreign substance from the body by forming urine (for release from the body). Examples of waste products from metabolic reactions within the body include ammonia (from the breakdown of amino acids), bilirubin (from the breakdown of haemoglobin), and creatinine (from the breakdown of creatine phosphate in muscle fibres). Examples of foreign substances that may also be exceted in urine include pharmaceutical drugs and environmental toxins.

Glomerular Filtration also called "Ultrafiltration", ` Tubular Reabsorption also called "Selective Re-Absorption" and ` Tubular Secretion
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Renal hilus: ` This is the area of the kidney through which the ureter leaves the kidney and the other structures including blood vessels (illustrated), lymphatic vessels, and nerves enter/leave the kidney.

Renal capsule:

The renal capsule is a smooth, transparent, fibrous membrane that surrounds, encloses, and protects the kidney. ` Which helps to maintain the shape of the kidney as well as protecting it from damage. ` Also helps to protect the kidney by damage by cushioning it in cases of impact or sudden movement
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Renal cortex: ` The renal cortex is the outer part of the kidney and has a reddish colour (shown as very pale brown above). ` It has a smooth texture and is the location of the Bowman's Capsules and the glomeruli.

Renal medulla: ` The renal medulla is the inner part of the kidney. "Medulla" means "inner portion". This area is a striated (striped) red-brown colour. Renal pyramids: ` There are approx. 5 - 18 striated triangular structures called "Renal Pyramids" within the renal medulla of each kidney. The appearance of striations is due to many straight tubules and blood vessels within the renal pyramids.

Renal pelvis: ` The renal pelvis is the funnel-shaped basin (cavity) that receives the urine drained from the kidney nephrons via the collecting ducts and then the (larger) papillary ducts.. Renal artery: ` The renal vein delivers oxygenated blood to the kidney. This main artery divides into many smaller branches as it enters the kidney via the renal hilus. These smaller arteries divide into vessels such as the segmental artery, the interlobar artery, the arcuate artery and the interlobular artery. These eventually separate into afferent arterioles, one of which serves each nephron in the kidney

Renal vein: ` The renal artery receives deoxygenated blood from the peritubular veins within the kidney. These merge into the interlobular, arcuate, interlobar and segmental veins, which, in turn, deliver deoxygenated blood to the renal vein, through which it is returned to the systemic blood circulation system. Interlobular artery: ` The interlobular artery delivers oxygenated blood at high pressure to the glomerular capillaries

Interlobular vein: ` The interlobular vein receives deoxygenated blood (at lower pressure) that it drains away from the glomerular filteration units and from the Loops of Henle. Kidney nephron: ` Kidney nephrons are the functional units of the kidneys. That this, it is the kidney nephrons that actually perform the kidney's main functions. There are approx. a million nephrons within each kidney

Collecting Duct (Kidney): ` The collecting duct labeled in the diagram above is part of the kidney nephron. The distal convoluted tubules of many nephrons empty into a single collecting duct. Many such collecting ducts unite to drain urine extracted by the kidney into papillary ducts, then into a minor calyx, then the major calyx (at the centre of the kidney), and finally into the ureter through which the urine leaves the kidney en-route to the urinary bladder

Ureter: ` The ureter is the structure through which urine is conveyed from the kidney to the urinary bladder.

Glomerular region (renal corpuscle; about 0.2 mm diameter) 1) glomerulus (capillary tuft) 2) Bowman's capsule (blind end of the nephron) Note: ` Bowman's capsule and the glomerulus together are named the Malpigian corpusle, but often referred to simply as the "glomerulus")
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Proximal convoluted and straight tubule (about 15 mm long, 0.05 mm diameter); sometimes divided into segments S1, S2, and S3 Loop of Henle - dips deeply (juxtamedullary nephron) or slightly (cortical nephron) into the medulla; each has thick (12 mm long) and thin (2-15 mm long) segments 1) descending limb 2) hairpin turn 3) ascending limb (thin and thick segments)

Distal convoluted and straight tubule (5 mm long), divided into: 1) early segment, functions as extension of Loop of Henle 2) later segment, functions as beginning of collecting tubule (connecting segment) ` Collecting tubule/duct (20 mm long)
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Kidney nephrons are the functional units of the kidneys. There are typically over 10,000 kidney nephrons in each of the two kidneys in the body

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There are two ureters, one leading from each kidney to the urinary bladder. Each of these transports urine from the renal pelvis of the kidney to which it is attached, to the bladder Both of the ureters pass beneath the urinary bladder, which results in the bladder compressing the ureters and hence preventing back-flow of urine when pressure in the bladder is high during urination

The purpose of the urinary bladder is to store urine prior to elimination of the urine from the body. ` The bladder also expels urine into the urethra by a process called micturition (also known as urination). Micturition involves the actions of both voluntary and involuntary muscles. Lack of voluntary control over this process is referred to as incontinence.
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The urethra is the passageway through which urine is discharged from the body. ` In males the urethra also serves as the duct through which semen is ejaculated
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Male Reproductive System

Patient knowledge ` Psychosocial and emotional factors; fear, anxiety ` Urologic function; include voiding habits/pattern ` Fluid intake, hygiene, allergies ` Presence of pain or discomfort
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URINALYSIS and C&S: ` is used as a screening associated with different metabolic and kidney diseases ` It is used to detect urinary tract infections (UTI) and other disorders of the urinary tract. ` It will be perform if you have symptoms like: Abdominal pain, Back pain, painful or frequent urination, blood in the urine.

Preparation: ` Advise client to save the first AM specimen. ` Clean external meatus with betadine or soap and water prior to test. Nursing Consideration: ` Overnight specimen is more concentrated. ` Obtain midstream specimen

Characteristics of urine: ` Color ± amber yellow ` Consistency ± clear, transparent ` Specific Gravity ± 1.010 ± 1.030 ` pH ± 4.5 ± 8 ` 24 production ± 1000 to 1500 cc

Culture ` Is done to find out what kind of organism (usually a bacteria) is causing an illness or infection. ` is done by collecting a sample of fluid or tissue and then rubbing the sample onto a special plate with prepared gelatin (culture) ` If there are bacteria in the sample, they will grow in the culture, usually within 2 days.

Sensitivity test ` Checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection. Culture and Sensitivity test ` May be done on many different body fluids, such as urine, mucus, blood, pus, saliva, breast milk, spinal fluid, or discharge from the vagina or penis.

Creatinine clearance ` It measures GFR in the diagnosis of renal disease. Blood chemistries ` Blood Urea Nitrogen (BUN) ± 10-20mg/dl
Reflex urea nitrogen in the blood. Urea is the product of protein metabolism Renal diseases decreases the excretion of urea, thus increasing the BUN level Formed in the liver and excreted in the kidney Used to diagnose impaired renal function. Strenuous activity, GI bleeding, fever and steroids may increase level.

Creatinine (0.5-1.2mg/dl) A by-product of protein metabolism in the blood. Results are more reliable and diagnostic of renal function than BUN ` Uric Acid
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Product of purine metabolism used to primarily detect disorders of purine metabolism such as gout. Excreted by the kidney and intestines May also be used in detecting renal disease

SODIUM (135-145 mEq/L) ` Major cation in the extracellular space ` Level remains constant until end-stage renal disease. POTASSIUM (3.5-5.5mEq/L) ` Major cation in the intracellular space ` Excreted primarily by the kidneys ` Altered level is first indication of renal disease and cardiac disease.

CALCIUM (9-10.5mg/dl ` Major mineral in bone ` Responsible for the contraction of muscle, neurotransmission and clotting factors. ` Evaluates parathyroid function and calcium metabolism ` Used in monitoring in renal failure ` Absorption is decrease in renal disease

PHOSPHOROUS (3-4.5 mg/dl) ` Inverse relationship between phosphorous and calcium balance ` Primarily excreted by the kidneys ` Levels increase with renal failure BICARBONATE (20-30 mg/dl) ` Kidneys reabsorbed filtered bicarbonate ` Kidneys produce more bicarbonate when needed ` Metabolic acidosis and low bicarbonate levels result from renal failure

Ultrasound scan of the abdomen and pelvis ` Images of renal structures obtained bu sound waves Preparations: ` Non-invasive procedure ` No preparation Nursing Considerations: ` No preparations or post-test care required
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Is a radiological procedure used to visualise disturbances of the urinary system, including the kidneys, ureters, and bladder. ` It provides X-Ray visualization of kidneys, Ureters and Bladder. ` It is done as a series of X-rays before and after a contrast agent is injected into a vein
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Preparations: (IVP) ` Bowel preparations ` NPO after midnight ` Burning may occur during injection of radiopaque dye into vein. ` X-Rays are taken at interval after dye. Nursing considerations: ` Post-procedure x-ray usually done ` Client should be alert to signs of dye reaction (edema, itching, wheezing, dyspnea)

Is a test that allows your doctor to look at the inside of the bladder and the urethra using a thin, lighted instrument called a cystoscope ` It is a direct visualization into the bladder ` Tiny surgical instruments can be inserted through the cystoscope that allow your doctor to remove samples of tissue (biopsy) or samples of urine.
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Small bladder stones and some small growths can be removed during cystoscopy. It can be done: ` If you have hematuria ` painful urination (dysuria), urinary incontinence ` urinary frequency or hesitancy, an inability to pass urine (retention) ` a sudden and overwhelming need to urinate (urgency).
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Find the cause of problems of the urinary tract, such as frequent, repeated urinary tract infections or urinary tract infections that do not respond to treatment. Look for problems in the urinary tract, such as blockage in the urethra caused by an enlarged prostate, kidney stones, or tumors. Evaluate problems that cannot be seen on X-ray or to further investigate problems detected by ultrasound or during intravenous pyelography, such as kidney stones or tumors.

Remove tissue samples for biopsy. ` Remove foreign objects. ` Place ureteral catheters (stents) to help urine flow from the kidneys to the bladder ` Treat urinary tract problems. For example, cystoscopy can be done to remove urinary tract stones or growths, treat bleeding in the bladder, relieve blockages in the urethra, or treat or remove tumors
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Place a catheter in the ureter for an X-ray test called retrograde pyelography. A dye that shows up on an X-ray picture is injected through the catheter to fill and outline the ureter and the inside of the kidney.

Bowel preparations ` Forced fluids ` Teach patient to deep-breathe to decrease discomfort Nursing interventions: ` Monitor character and volume of urine ` Check for abdominal distention, frequency, fever ` Check for bleeding ` Provide antimicrobial prophylaxis
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Kidney tissue obtained by needle aspiration for pathological evaluation ` A renal biopsy is the removal of a small piece of kidney tissue for laboratory examination ` Ultrasound will be used to find the proper biopsy site. ` a tiny cut in the skin and inserts a biopsy needle into the area and to the surface of the kidney.
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If you have an unexplained drop in kidney function. ` If you have persistent blood in the urine, or protein in the urine ` The test is sometimes used to evaluate a transplanted kidney.
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X-Ray taken prior to the procedure ` Skin is marked to indicate lower pole of the kidney (fewer blood vessels) ` Position (Prone or bent at diaphragm ` Client is instructed to hold breath during needle insertion
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Nursing interventions: (Post-test) ` Pressure is applied to site for 20 minutes ` Pressure dressing is applied ` Client kept flat in bed ` Bed rest for 24 hours ` Observe for hematuria and site bleeding

Knowledge deficiency ` Pain ` Fear
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Patient teaching: provide a description of the tests and procedures in language the patient can understand Use appropriate, correct terminology. Encourage fluid intake unless contraindicated. Instruct patient in methods to reduce discomfort: sitz baths, relaxation techniques. Administer analgesics and antispasmodics as prescribed. Assess voiding and provide instruction related to voiding practices and hygiene. Provide privacy and respect.

Urethral Catheter (Indwelling) ` May be used to drain the bladder ` Complications of catheter use may include: urinary tract or kidney infections, blood infections (septicemia), urethral injury, skin breakdown, bladder stones, and blood in the urine (hematuria) ` After many years of catheter use, bladder cancer may also develop.

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Double lumen with inflatable balloon towards the tip

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Is basically an indwelling catheter that is placed directly into the bladder through the abdomen. The catheter is inserted above the pubic bone. This catheter must be placed by a urologist during an outpatient surgery. A suprapubic catheter may be recommended in people who require long term catheterization, after some gynecological surgeries, and in people with urethral injury or obstruction.

A nephrostomy is a surgical procedure by which a tube, stent, or catheter is inserted through the skin and into the kidney. ` It is anchored in renal pelvis through flank incision ` It is placed as temporary basis when the ureter is blocked and urine back up to kidney. Can cause serious complication
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Nephrostomy is performed in several different circumstances: ` The ureter is blocked by a kidney stone. ` The ureter is blocked by a tumor. ` There is a hole in the ureter or bladder and urine is leaking into the body. ` As a diagnostic procedure to assess kidney anatomy. ` As a diagnostic procedure to assess kidney function.

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Is the temporary placement of a catheter (tube) to remove urine from the body. Straight Catherization It is used for bladder outlet obstruction in male Post-op after surgical problems in reproductive organs This is usually done by placing the catheter through the urethra (the tube that leads from the bladder to the outside opening) to empty the bladder.

Short-term (intermittent) catheterization may be necessary for: ` Anyone who is unable to properly empty the bladder ` People with nervous system (neurological) disorders ` Women who have had certain gynecological surgeries

Goal (Intermittent) ` Completely empty the bladder ` Prevent further bladder or kidney damage ` Prevent urinary tract infections

Reasons: ` bladder cancer or other pelvic malignancies, birth defects, trauma, strictures, neurogenic bladder, chronic infection or intractable cystitis; used as a last resort for incontinence

Cutaneous urinary diversion:
x ileal conduit,
x Cutaneous ureterostomy, x Vesicostomy and nephrostomy

Continent urinary diversion:
x Indiana pouch x Kock pouch x ureterosigmoidostomy

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Anxiety Imbalanced nutrition Deficient knowledge

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Risk for impaired skin integrity Acute pain Disturbed body image Potential for sexual dysfunction Deficient knowledge

AZOTEMIA ± Toxic condition where there is an excess of nitrogenous waste in the blood. ` DIFFUSION ± The movement of solutes across the semipermeable membrane from an area of higher concentration to an area of lower concentration until an equal distribution is established between the 2 areas.
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GFR ± the amount of fluid that is passed through all of the nephron in minute. ` HOMEOSTASIS ± A balance or consistency in the internal functioning of the body. ` OSMOSIS ± The movement of pure solvent such as water across the semipermeable membrane, from an area with a lower solute content to a higher solute content.
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UREMIA ± Presence of excess urea and other waste in the blood. ` DYSURIA ± Painful urination ` EFFLUX ± Movement of urine from the kidneys, through the ureter to the bladder. ` FREQUENCY ± The feeling of a need to void often. ` INCONTINENCE ± Uncontrolled leakage of urine from the bladder.
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MICTURATION ± Urination, voiding; the process of emptying the bladder. ` REFLUX ± Movement of urine in a backward motion from the bladder into the ureters and possibly to the kidneys. ` RETENTION ± Inability to empty the bladder completely. ` URGENCY ± The feeling of a need to void immediately.
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COMMON HEALTH PROBLEMS
(GENITO-URINARY SYSTEM)

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An inflammation of the glomerular capillaries Acute glomerulonephritis Chronic glomerulonephritis Nephrotic syndrome

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Also called as Acute Glomerulonephritis ` Is a relatively common bilateral inflammation of the glomeruli, the kidney¶s blood vessels. ` It follows a streptococcal infection of the respiratory tract or less often, a skin infection such as impetigo.
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CAUSES: ` Trapped antigen-antibody complexes in the glomerular capillary membranes, inducing inflammatory damage and impending glomerular function. ` Untreated pharyngitis (inflammation of the pharynx)

ASSESSMENT FINDINGS: ` Azotemia, Edema, fatigue ` Hematuria, oliguria, Proteinuria DIAGNOSTIC TEST: ` Increase serum creatinine level ` 24 hour urine sample decrease creatinine clearance and impaired glomerular filtration. ` Renal biopsy ± may confirm the diagnosis (APSGN)

Renal UTZ ± may show a normal or slightly enlarged kidney. ` Throat culture ± may show GABHS ` Urinalysis ± reveals proteinuria, hematuria. ` KUB X-Ray ± shows bilateral kidney enlargement.
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TREATMENT: ` Bed rest ` Fluid restriction ` High calorie, low sodium, low potassium, low protein diet. ` Dialysis (occasionally necessary)

INTERVENTION: ` Check V/S, electrolyte values ` Monitor fluid I and O, and daily weight ` Assess renal function daily through serum creatinine and BUN levels and urine creatinine clearance ` Watch for signs of acute renal failure (azotemia, Oliguria, acidosis) ` Consult the dietitian ± to provide a diet for the patient.

Provide good nutrition, use good hygienic technique, and prevent contact with infected people. ` Bed rest is necessary during an acute phase. ` Encourage the patient to gradually resume normal activities as symptoms subside ± to prevent fatigue ` Provide emotional support for the patient and family if the patient is on dialysis, explain the procedure fully.
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Patient assessment Maintain fluid balance Fluid and dietary restrictions Patient education Follow-up care

Any condition that seriously damages the glomerular membrane and results in increased permeability to plasma proteins ` Results in hypoalbuminemia and edema ` Causes: Chronic glomerulonephritis, diabetes mellitus with intercapillary glomerulosclerosis Lupus erythematosus, multiple myeloma Renal vein thrombosis
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Results when the kidneys cannot remove wastes or perform regulatory functions. A systemic disorder that results from many different causes or the kidneys cease to function.

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ACUTE RENAL FAILURE ` Rapid onset generally occurring over hours to day that has the potential to be reversible with supportive care. CAUSES: (other) ` Nephrotoxic agent ` Glomerulonephritis ` Pyelonephritis, BPH ` Prostate cancer, tumors

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Hypovolemia Hypotension over an extended period of time. Reduced cardiac output and heart failure Obstruction of the kidney or lower urinary tract Obstruction of renal arteries or veins

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Clinical Manifestation of (ARF) ` Initially decreased urinary output that may be less than 400ml in a 24 hour period. ` Proteinuria ` Fluid retention ` Decreases serum bicarbonate ` Increased serum potassium, sodium, creatinine and BUN

Multisystem disease with gradual onset over months to years resulting in an irreversible destruction of as much as 95% of the nephrons found in the ESRD. CAUSES: ` Unsuccessful treatment of Acute renal failure. ` Cystic kidney disease
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Diabetes mellitus ` Hypertension ` Chronic glomerulonephritis ` Pyelonephritis or other infections ` Obstruction of urinary tract ` Hereditary lesions ` Vascular disorders ` Medications or toxic agents
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COMPLICATIONS: ` Acute Renal failure
Depends on the client¶s overall state of health, pre-renal failure with hyperkalemia being the most severe.
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Chronic Renal failure
Progressive azotemia and uremia leading to ESRD. (increased nitrogenous wastes in the blood).

NEUROLOGICAL ` Lethargy, Decreased concentration ` Muscular irritability ` Seizures, Confusions, Coma CARDIOVASCULAR ` Hypertension, Cardiomayopathy ` CHF, Pericarditis ` Pleural effusion, Arrhythmias

RESPIRATORY ` Uremic fector or halitosis (urine smelling breath odor) ` Tachypnea, hyperpnea ` Suppressed cough reflex ` Pulmonary edema ` Uremic lung or pneumonitis HEMATOLOGIC ` Anemia ` Bleeding

METABOLIC

Increase BUN, serum creatinine ` Hyperglycemia, hyperinsulinemia ` Hyperkalemia, hypernatremia ` Metabolic acidosis
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INTEGUMENTARY

Yellow discoloration of the skin ` Dry skin, Pruritus, Ecchymosis, Purpura ` Uremic frost (urea crystal occurring on the face, axilla, and groin from evaporated perspiration.
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MUSCULOSKELETAL ` Renal osteodystrophy ± skeletal changes including: Osteomalacia (lack of bone mineralization Osteitis fibrosa (bone resorption), and calcification of the soft tissue of the body.

GASTROINTESTINAL ` Stomatitis, N/V ` Metallic taste in the mouth ` Diarrhea or constipation ` Uremic gastritis URINARY ` Polyuria and nocturia early ` Oliguria leading to anuria late ` Proteinuria, hematuria ` Dilute pale yellow urine

REPRODUCTIVE ` Decreased libido ` Infertility ` Amenorrhea DIAGNOSTIC TEST: ` Serum electrolytes ` Serum creatinine and BUN ` Urinalysis ` 24 hour urine for creatinine clearance ` Renal UTZ, CT-Scan

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Hemodialysis Peritoneal dialysis Continuous renal replacement therapies (CCRT)

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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 I&O and IV administration pump records

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Assess for signs and symptoms of uremia and electrolyte imbalance; regularly check laboratory 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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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 Provide CAPD catheter care

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Fluid status Nutritional status Patient knowledge Activity tolerance Self-esteem Potential complications

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Excess fluid volume Imbalanced nutrition Deficient knowledge Risk for situational low self-esteem

Hyperkalemia ` Pericarditis ` Pericardial effusion ` Pericardial tamponade ` Hypertension ` Anemia ` Bone disease and metastatic calcifications
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Assess for signs and symptoms of fluid volume excess; keep accurate I&O and daily weight records ` Limit fluid to prescribed amounts ` Identify sources of fluid ` Explain to patient and family the rationale for the restriction. ` Assist patient in coping with the fluid restriction. ` Provide or encourage frequent oral hygiene
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Assess nutritional status, weight changes, and lab data Assess patient nutritional patterns and history; note food preferences Provide food preferences within restrictions Encourage high-quality nutritional foods while maintaining nutritional restrictions Assess and modify intake related to factors that contribute to altered nutritional intake, ie, stomatitis or anorexia Adjust medication times related to meals

Assess patient and family responses to illness and treatment ` Assess relationships and coping patterns ` Encourage open discussion about changes and concerns ` Explore alternate ways of sexual expression ` Discuss role of giving and receiving love, warmth, and affection
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It is the infection of the urinary bladder. ` It is common in women, children and older man. CAUSES: ` DM, Incorrect aseptic technique during catherization ` Incorrect perineal care, Kidney infection ` Obstruction of the urethra, pregnancy ` Sexual intercourse, stagnation of urine in the bladder
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ASSESMENT FINDINGS: ` Burning or pain on urination ` Dribbling, dysuria, foul-smelling urine ` Flank tenderness or suprapubic tenderness ` Lower abdominal discomfort ` Low grade fever, nocturia ` Urge to bear down on urination ` Urinary frequency ` Urinary urgency

DIAGNOSTICS ` Cystoscopy ± shows obstruction or deformity ` Urine Chemistry - shows hematuria, pyuria, and increased protein, leukocytes and urine specific gravity ` Urine C&S ± positively identified microorganism (E. coli, Streptococcus fecalis, proteus vulgaris)

Nursing Diagnosis ` Impaired urinary elimination ` Urge urinary incontinence ` Acute pain TREATMENT: ` Diet modification ` Increased intake of fluid ` Intake of Vitamin C

DRUG THERAPY ` Antibiotics (Bactrim, Levofloxacin, ciprofloxacin) ` Antipyretic (Tylenol) ` Urinary antiseptic (pyridium)

Nursing interventions: ` Assess renal status ± to determine baseline and detect changes. ` Monitor and record V/S, I&O, Laboratory studies ± to assess patient status and detect early complications. ` Maintain the patient¶s diet ± to promote nutrition.

Force fluids (cranberry or orange juice 3L/day) ± because dilute urine lessens the irritation to the bladder mucosa and lowering urine pH with orange juice and cranberry juice consumption helps diminish bacterial growth ` Administer medications as prescribed ± to maintain or improve patient¶s condition. ` Perform sitz bath and perineal care ± to relieve perineal or suprapubic discomfort.
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Encourage voiding every 2 to 3 hours ± frequent bladder emptying decreases bladder irritation and prevents stasis of urine. Teaching topics: ` Avoiding coffee, tea, alcohol and carbonated beverages ` Increase intake to 3L/day using orange juice and cranberry juice ` Voiding every 2 to 3 hours and after intercourse
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Performing perineal care correctly ` Avoiding bubble baths, vaginal deodorants and tub baths ` Recognizing that urine maybe orange while taking phenazopyridine
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Also called as painful bladder syndrome. ` Is a chronic condition characterized by a combination of uncomfortable bladder pressure, bladder pain and sometimes pain in your pelvis, which can range from mild burning or discomfort to severe pain. ` Most affected are women
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SIGNS AND SYMPTOMS: ` The signs and symptoms of interstitial cystitis vary from person to person. If you have interstitial cystitis, your symptoms may also vary over time, periodically flaring in response to common triggers such as menstruation, seasonal allergies, stress and sexual activity.

Interstitial cystitis symptoms include: ` A persistent, urgent need to urinate. ` Frequent urination, often of small amounts, throughout the day and night. People with severe interstitial cystitis may urinate as often as 60 times a day. ` Pain in your pelvis (suprapubic) or between the vagina and anus in women or the scrotum and anus in men (perineal).

Pelvic pain during sexual intercourse. Men may also experience painful ejaculation. ` Chronic pelvic pain. ` Some people affected by interstitial cystitis experience only pain, and some experience only frequent, urgent urination
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CAUSES: ` Autoimmune reaction ` Heredity ` Infection or allergy. ` Defect in the protective lining (epithelium) of their bladder

RISK FACTORS: ` Sex. Women receive a diagnosis of interstitial cystitis far more often than do men or children. Men can have nearly identical symptoms to those of interstitial cystitis, but they're more often associated with an inflammation of the prostate gland (prostatitis)

Age. Most people with interstitial cystitis are diagnosed in their 30s or 40s. ` Other chronic disorders. Interstitial cystitis may be associated with other chronic pain syndromes, such as irritable bowel syndrome and fibromyalgia. Any common connection between these syndromes is unknown.
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COMPLICATIONS: ` Reduced bladder capacity. Interstitial cystitis can lead to a stiffening of the wall of your bladder and reduced bladder capacity, meaning your bladder holds less urine. ` Lower quality of life. Frequent urination and pain may interfere with social activities, work and other activities of daily life.

Relationship troubles. Frequent urination and pain may strain your personal relationships, and sexual intimacy is commonly affected. ` Emotional troubles. The chronic pain and interrupted sleep associated with interstitial cystitis may cause emotional stress and can lead to depression. Likewise, having depression or anxiety can worsen symptoms of interstitial cystitis.
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Diagnostic Test: ` Complete pelvic exam. During this exam, your doctor examines your external genitals, vagina and cervix and feels (palpates) your internal pelvic organs. Your doctor may also examine your anus and rectum. ` Urine test. A sample of your urine will be analyzed for evidence of a urinary tract infection.

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Potassium sensitivity test.In this test, your doctor places two solutions ² water and potassium chloride ² into your bladder one at a time. You're asked to rate on a scale of 0 to 5 the pain and urgency you feel after each solution is instilled. If you feel noticeably more pain or urgency with the potassium solution than with the water, your doctor may diagnose interstitial cystitis. People with normal bladders can't tell the difference between the two solutions.

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Cystoscopy. Doctors sometimes use this test to rule out other causes of bladder pain. Cystoscopy involves an examination of your bladder through a thin tube with a tiny camera (cystoscope) inserted through the urethra. Cystoscopy allows your doctor to see the lining of your bladder. In conjunction with cystocopy, your doctor may instill a liquid into your bladder to help measure your bladder capacity.

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Biopsy. During cystoscopy under anesthesia, your doctor may remove a sample of tissue (biopsy) from the bladder and the urethra for examination under a microscope. This is to check for bladder cancer and other rare causes of bladder pain.

TREATMENT: (DRUGS) ` Ibuprofen (Advil, Motrin, others) and other nonsteroidal anti-inflammatory drugs, to relieve pain ` Tricyclic antidepressants, such as amitriptyline or imipramine (Tofranil), to help relax your bladder and block pain. ` Antihistamines, such as diphenhydramine (Benadryl, others) and loratadine (Claritin, others), which may reduce urinary urgency and frequency and relieve other symptoms

OTHER TREATMENT:
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Nerve stimulation Transcutaneous electrical nerve stimulation (TENS) - uses mild electrical pulses to relieve pelvic pain and, in some cases, reduce urinary frequency. Electrical wires are placed on your lower back or just above your pubic area, and pulses are administered for minutes or hours, two or more times a day, depending on the length and frequency of therapy that works best for you. In some cases a TENS device may be inserted into a woman's vagina or a man's rectum.

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Bladder distention Some people notice a temporary improvement in symptoms after undergoing cystoscopy with bladder distention. Bladder distention is the stretching of the bladder with water or gas. The procedure may be repeated as a treatment if the response is long lasting

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Medications instilled into the bladder In bladder instillation, the prescription medication dimethyl sulfoxide, or DMSO, (Rimso-50) is placed into your bladder through a thin, flexible tube (catheter) inserted through the urethra. The solution sometimes is mixed with other medications, such as a local anesthetic. After remaining in your bladder for 15 minutes, the solution is expelled through urination. Delivering DMSO directly to your bladder may reduce inflammation and possibly prevent muscle contractions that cause frequency, urgency and pain.

SURGERY: ` Bladder augmentation. In this procedure, surgeons remove the damaged portion of the bladder and replace it with a piece of the colon, but the pain still remains and some women need to empty their bladders with a catheter multiple times a day.

Fulguration. This minimally invasive method involves insertion of instruments through the urethra to burn off ulcers that may be present with interstitial cystitis. ` Resection. This is another minimally invasive method that involves insertion of instruments through the urethra to cut around any ulcers
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INTERVENTIONS:
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Dietary changes - The most irritating foods can be summarized as the "four Cs." The four Cs include carbonated beverages, caffeine in all forms (including chocolate), citrus products and food containing high concentrations of vitamin C. Bladder training - may involve learning to control the urge to urinate by using relaxation techniques, such as breathing slowly and deeply, or distracting yourself with another activity.

Self care approach: ` Wear loose clothing. Avoid belts or clothes that put pressure on your abdomen. ` Reduce stress. Try methods such as visualization and biofeedback, and lowimpact exercise. ` Try pelvic floor physiotherapy. Gently stretching and strengthening the pelvic floor muscles, possibly with help from a pelvic floor physiotherapist, may reduce muscle spasms.

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If you smoke, stop. Smoking may worsen any painful condition, and smoking is harmful to the bladder

Is a scar in or around the urethra, which can block the flow of urine, and is a result of inflammation, injury or infection. ` Are more common in men because their urethras are longer than those in women. Thus men's urethras are more susceptible to disease or injury.
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CAUSES: ` May occur anywhere from the bladder to the tip of the penis. ` Unknown ` Trauma to the urethra and gonorrheal infection ` Stricture of the posterior urethra is often caused by a urethral injury associated with a pelvic bone fracture (e.g., motor vehicle or industrial accident)

Patients who sustain posterior urethral injuries from pelvic fracture generally suffer a disruption of the urethra, where the urethra is cut and separated. ` Catheter is inserted until the repair can be perform. ` Trauma such as straddle injuries, direct trauma to the penis and catheterization can result in strictures of the anterior urethra.
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Signs and symptoms: ` painful urination ` slow urine stream ` decreased urine output ` spraying of the urine stream ` blood in the urine ` abdominal pain ` urethral discharge

DIAGNOSTICS: ` Physical Examination ` Urethral Imaging (X-Ray or UTZ) ± with contrast dye ` Urethroscopy ` Retrograde Urethrogram ± to determine strictures ` Antegrade urethrogram ± to determine the length of the strictures

PREVENTION: ` Avoid injury to the urethra and pelvis. ` Avoid STD, Chlamydia, Gonnorhea ` Use of condom during sexual intercourse and avoid contact with infected individuals

Treatment options: ` Dilation - enlarging the stricture by gradual stretching ` Urethrotomy - A knife blade or laser operating from the end of the cystoscope is then used to cut the stricture, creating a gap in the narrowing

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Urethral Stent This procedure involves placement of a metallic stent that has the appearance of a circular chain link fence. The lining of the urethra eventually covers the stent, which remains in place permanently.

UROLITHIASIS ` Refers to the formation of urinary stones; urinary calculuses are formed in the ureters. NEPHROLITHIASIS ` Refers to the formation of kidney stones; kidney stones are formed in the renal parenchyma

DESCRIPTION: ` Calculuses or stones can form anywhere in the urinary tract; however, the most frequent site is the kidney. ` The problems that can occur as a result of calculuses are pain, obstruction, and tissue trauma with secondary hemorrhage and infection. ` KUB film, IVP, CT-Scan and Renal UTZ will determine the stone location

A stone analysis will be done after passage to determine the type of stone and assist in determining treatment. ` When a calculus occludes the ureter and blocks the flow of urine, the ureter dilates, producing a condition known as hydroureter. ` If the obstruction is not removed, urinary stasis results in infection, impairment of renal function on the side of the blockage, and resultant hydronephrosis and irreversible kidney damage.
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CAUSES: ` Family history of stone formation ` Diet high in calcium, Vit.D, Milk, Proteins, oxalate, purines or alkali ` A high intake of purine-rich foods ` Obstruction and urinary stasis ` Dehydration ` UTI, and prolonged catherization ` Immobilization ` Hypercalcemia and hyperparathyroidism ` Elevated uric acid, such as gout

Assessment findings: ` Renal colic, which originates in the lumbar region and radiates around the side and down towards the testicles in men and to the bladder in women. ` Ureteral colic, which radiates towards the genitalia and thigh ` Sharp severe pain of sudden onset ` Dull, aching pain in the kidney ` N/V, pallor and diaphoretic during acute pain

Urinary frequency with alternating retentions ` Signs of a UTI, Low grade fever ` High number of RBC, WBC, and bacteria in the urine ` Hematuria
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Nursing Interventions: ` Monitor V/S, I&O ` Assess for fever chills and infection ` Monitor for N/V and diarrhea ` Encourage fluid intake up to 3000ml/day unless contraindicated, to facilitate passage of the stone and prevent infection. ` Strain all urine for the presence of stones ` Send stones to the laboratory for analysis

Provide warm baths and heat to the flank area. ` Administer analgesics at regularly scheduled intervals as prescribed to relieved pain ` Assess the client¶s response to pain medication ` Administer fluids intravenously as prescribed to increase the flow of urine and facilitate the passage of the stone
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Assist the client in performing relaxation techniques in relieving pain ` Instruct the client in the diet specific to the stone formation ` Maintain urinary pH depending on the type of stone ` Turn and reposition immobilized patients ` Prepare the client for surgical procedures if prescribed
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