GENITO- URINARY

TRACT
RENAL FAILURE
TYPES

ACUTE

Sudden loss of renal function;

reversible

CHRONIC

Gradual, progressive loss of renal

function; irreversible
CAUSES:

-PRE RENAL
-decreased renal tissue perfusion

-INTRA RENAL
-toxic substances affecting the kidneys

-POST RENAL
-mechanical obstruction to urine flow
below the level of the kidneys
STAGES OF ACUTE RENAL FAILURE

OLIGURIC PHASE

Urine output= 400 mls./< per day

Increased BUN, s. creatinine
Edema, HPN
Hyperkalemia
Hyponatremia
Hypermagnesemia
Hyperphosphatemia
Metabolic acidosis
Lasts 1 to 3 weeks
DIURETIC PHASE

Urine output =3-5L/day

Initially
BUN, s. creatinine elevated
BP elevated
Metabolic acidosis
Later
Normalize
Hypokalemia
Last 1 week
RECOVERY PHASE

Takes 3-12 months

Avoid nephrotoxic drugs
STAGES of CHRONIC RENAL FAILURE

-RENAL IMPAIRMENT: GFR 40-50 %

-RENAL INSUFICIENCY: GFR 20-40%
-RENAL FAILURE: GFR 10-20 %
-ESRD/ “uremia”: GFR below 10 %
 ASSESSMENT:

INABILITY OF THE KIDNEYS TO EXCRETE METABOLIC

WASTE PRODUCTS OF PROTEIN THROUGH URINE FORMATION

Oliguria
Increased BUN , s. Creatinine (AZOTEMIA)
Uriniferous odor of breath
Stomatitis and GI Bleeding- urea is converted back into
ammonia which irritates mucous membrane
Destruction of RBC, WBC, PLATELETS

Renal encephalopathy

Uremic frost
Causes pruritus and dryness of skin

Decreased libido, impotence, infertility

Caused by hormonal imbalances
INABILITY OF THE KIDNEYS TO MAINTAIN FLUID-
ELECTROLYTE, ACID- BASE BALANCE

Edema
Hyperkalemia
Hypo/ hypernatremia
Hyper Mg
Metabolic acidosis
The kidneys are unable to buffer H ions; unable to
regenerate bicarbonate and unable to excrete waste
products which are mostly acidic
INABILITY OF THE KIDNEYS TO
SECRETE ERYTHROPOIETIN

Anemia
INABILITY OF THE KIDNEYS TO METABOLIZE VIT. D

Hypocal
Hyperphosphatemia
Renal osteodystrophy

ALTERED BIOCHEMICAL ENVIRONMENT

Glucose intolerance
 MEDICAL MANAGEMENT

CONSERVATIVE MNGT

Fluid control
Electrolyte control
-Hyperkalemia
-Metabolic acidosis
-Hypocalcemia/ hyperphosphatemia
-Dietary control
Treatment of intercurrent
disorders

-Anemia
-Gastrointestinal disturbances
-Other conditions: hypertension,
CHF, pulmonary edema,
hypocalcemia,
hyperphosphatemia, etc.
GUIDELINES FOR THE CARE FOR
THE PERSON WITH CHRONIC
RENAL FAILURE
MAINTAIN FLUID AND ELECTROLYTE BALANCE

Monitor for fluid and electrolyte balance

Assess I and O every 8 hours

Weigh patient everyday
Assess presence and extent of edema
Auscultate breath sounds
Monitor cardiac rhythm and BP every 8 hours
Encourage patient to remain within prescribed fluid
restrictions

Provide small quantities of fluid spaced over the day to

stay within fluid restrictions

Encourage a diet high in CHO and within prescribed

sodium, potassium, phosphorous ad CHON limits

Administer phosphate- binding agents with meals as

prescribed (amphogel/ AL-OH)
 PREVENT INFECTION AND INJURY

Promote meticulous skin care

Encourage activity within prescribed limits but avoid
fatigue
protect confused person from injury
protect person from exposure to infectious agents
maintain good medical/ surgical asepsis during
treatments and procedures
avoid aspirin products
encourage use of soft toothbrush
 PROMOTE COMFORT

medicate pt. as needed for pain

medicate with prescribed antipryritics, use emollient baths,
keep skin moist and control environmental temperature to
relieve pruritus
encourage use of damp cloth to keep lips moist; give good
oral hygiene
encourage to rest for fatigue; however, encourage self –care
as tolerated
provide calm, supportive atmosphere
ASSIST WITH COPING IN LIFE- STYLE
AND SELF- CONCEPT

Promote hope

Provide opportunity for pt. to express

feelings about self

Identify available community resources

 GUIDELINES FOR TEACHING THE PERSONS
WITH CHRONIC RENAL FAILURE

Relationship bet. Symptoms and their causes.

Relationships among diet, fluid restriction, medication and blood

chemistries.

Preventive health care measures: good oral hygiene, prevention of

infection, avoidance of bleeding
Dietary regimen, including fluid restrictions

Prescribed Na, K, phosphorous and CHON restrictions

Means of identifying contents of foods

Use of small, frequent feedings to maintain nutrient intake when

anorexic or nauseated

Fluid prescription and sources of fluid in the diet

Avoidance of salt substitutes containing potassium

Monitoring for fluid excess

Accurate measurement and recording of I and O

Monitoring for weight gain and edema

MEDICATIONS

-Actions, doses, purposes and side effects of prescribed

medications

-avoidance of OTC drugs, especially aspirin, cold

medications and NSAIDs

-planning for gradual increase in physical

-measures to control pruritus

 MEDICAL MANAGEMENT

DIALYSIS

PHYSIOLOGIC PRINCIPLES OF DIALYSIS

Diffusion
Osmosis
Ultrafiltration
HEMODIALYSIS

Vascular access:

Arteriovenous fistula
Arteriovenous graft
External arteriovenous shunt
Femoral vein catheterization
Subclavian vein catheterization
PRACTICE ARM PRECAUTION AS NEEDED

ASSESS FOR PATENCY: AUSCULTATE FOR

BRUIT, PALPATE FOR THRILL

TOURNIQUET BE ALWAYS AVAILABLE IF A-V

SHUNT IS PRESENT

A-V SHUNT MAY BE USED IMMEDIATELY

A-V FISTULA MAY BE USED AFTER 4- 6 WEEKS

TO WAIT FOR HEALING. IT CAN BE USED FOR 3-4
YEARS
NURSING INTERVENTION IN HEMODIALYSIS

FACILITATING FLUID AND ELECTROLYTE BALANCE

-Administer blood transfusion as ordered

-Omit dose of hypertensive drugs

PREVENTING DISEQUILIBRIUM PHENOMENON

-Initial hemodialysis be done for 30 minutes

only
-Disequilibrium syndrome is caused by more
rapid removal of waste products from
the blood than from the brain. This is due to
the presence of BBB, cerebral edema causes
signs and symptoms of increased ICP
-Preventing blood loss
PROMOTING COMFORT
-Provide hygienic measures

MAINTAINING ACTIVITY AND NUTRITION

FACILITATE LEARNING
 EVALUATION

Lack of excessive fluid weight gain between dialysis

treatments
States that no pain is present and that discomfort
experienced during dialysis decreased
Participates in a program to maintain prescribed activity
level
Eats according to preference during therapy
Correctly explains dialysis, care of venous access, common
side effects and recommended work/ activity schedule.
 PERITONEAL DIALYSIS

The major advantages of peritoneal dialysis:

It provides a steady state of blood chemistries

Patient can dialyze alone in any location without need for
machinery
Patient can readily be taught the process
Patient has few dietary restrictions; because of loss of CHON
in dialysate, the patient is usually placed on a high CHON diet
Patient has much control for patients that are
hemodynamically unstable
CARE DURING PERITONEAL DIALYSIS

Regulating fluid volume and drainage

Promoting comfort
Preventing complicstions
-Monitor urine/ blood gluose levels
 Facilitate learning

The teaching plan should include the following:

The process of dialysis and how the dialysis relates to the pateients own
body needs
Signs and symptoms of infection of the peritoneal cavity or catheter site
and when to obtain care if these occur
Appropriate care of the permanent peritoneal catheter
Common side effects of treatment, means of controlling mild symptoms
and means of obtaining medical attention for severe or persistent
complications
Changes In medication schedule required before and after dialysis
A work and activity schedule as physical capabilities permit, with
minimal interference from scheduled dialysis time
 URINARY CALCULI

-MALES 30-50 YEARS ARE MORE COMMONLY AFFECTED

UTI URINARY STASIS

BACTERIA
PUS PRECIPITATION OF ORGANIC
MATTER
BLOOD
ALKALINE URINE
DEVITALIZED
TISSUES AMMONIA

PRECIPITATION OF Ca, PO4, Mg, NH3

CRYSTALIZATION OF MINERALS

NIDUS
PREVENTION:

Increase fluid intake

Ambulation

Diet
 ASSESSMENT:

KUB, IVP,RPG, UTZ, CYSTOSCOPY, URINALYSIS

PAIN (COLICKY)

G.I. MANIFESTATIONS: NAUSEA, VOMITING, DIARRHEA OR

CONSTIPATION

HEMATURIA

FEVER, CHILLS

FREQUENCY

DYSURIA
TYPES OF STONES

ALKALINE

- Ca oxalate
-Ca phosphate
-STRUVITE/ STAGHORN (Mg NH3PO4)

ACIDIC

-Uric acid
-Cystine
 NURSING INTERVENTIONS:

Fluids (3000 mls/ day)

Strain all urine
Adjust urine pH
>Ca stones
*Limit dairy products
*Acid ash diet ( cranberry/ prune
juice, meat, eggs, fish, poultry,
grapes, whole grain citrus fruits)
*Vitamin C
>Oxalate stones
*Avoid excess tea, chocolate, spinach

>Acidic stones
*Alkalinize urine
Na Bicarbonate tablets
Alkaline- ash diet (milk, vegs., fruits, salmon)
*Uric acid stones
Avoid purine foods
(Organ meat,Shellfish,Meat
soups,Gravy,Legumes Salted
anchioves,Mushroom,Sardines)
Encourage ambulation

Pain control (demerol)

Allupurinol ( to decrease uric acid)

Surgery (nephrolithomy, pyelolithotomy, ureterolithotomy, lithopaxy)

ESWL (EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY) Crushing of

stone with the use of ultrasonic waves while the body is half- immersed in
water.
BENIGN PROSTATIC HYPERPLASIA

CAUSE: UNKOWN

PREDISPOSING FACTOR:

Aging process
Hormonal imbalance
Estrogen > androgen
HyperplasiA
Urinary obstruction
Renal insuffieciency
ASSESSMENT

RECTAL EXAM
CYSTOSCOPY
UTZ

NOCTURIA
FREQUENCY
HESITANCY
CALIBER OF URINARY STREAM AND FORCE
RESIDUAL URINE
HEMATURIA
UTI
 MANAGEMENT:

TURP ( TRANSURETHRAL RESECTION OF THE PROSTATE)

No incision
Continous bladder irrigation (CBI) or cystoclysis is done postop
This is to irrigate the bladder and remove blood clots
No incontinence, no impotence postop
SUPRAPUBIC PROSTATECTOMY

Incision over lower abdomen and bladder

With cystostomy atube and2 –way foley catheter postop

No incontinence, no impotence postop

RETROPUBIC PROSTETECTOMY

Incision over the abdomen

No incontinence, no impotence postop

PERINEAL PROSTATECTOMY

Incision over the perineal area

With incontinence and impotence postop

 POSTOP CARE

CARE THE PT. WITH CBI ( post TURP)

-Maintain patency of catheter
-If drainage is:
Reddish- flow rate of CBI

Clear- flow rate of CBI/ muscles and help regain of voiding

-Practice asepsis
-Use sterile NSS to prevent water
intoxication
-Prevent thrombophlebitis
-Monitor for hemorrhage
RED TO LIGHT PINK URINE- 1ST 24 HOURS; AMBER – 3 DAYS
POSTOP

May feel urge to void/ sensation of bladder fullness is due to pressure

on the internal sphincter by the balloon of catheter
ADVISE NOT TO VOID AROUND THE CATHETER  BLADDER
SPASM

Increase fluid intake

Relieve pain- analgesic- spasm decrease after 24-48 hours

 CLIENT TEACHING

After removal of catheter : observe for urinary retention/ dribbling muscles and help
regain control of voiding

Avoid the ff to prevent bleeding and thrombophlebitis

-Vigorous exercise
-Heavy lifting
-Sexual intercourse-3 weeks after discharge
-Driving
-2 weeks after discharge
-Straining with defacation
-Prolonged sitting/ standing
-Crossing legs
-Long trips
TOXIC SHOCK SYNDROME

CAUSES: STAPHYLOCOCCUS AUREUS

ASSESSMENT:

HIGH FEVER
Diarrhea
HPN
Acidosis
Vomiting
red macular rash
shock lung
 NURSING INTERVENTION

monitor I and O and VS

observe
-hematomas
-cyanosis
-petechiae
-bleeding at IV sites
monitor for compromised circulation
patient teaching
-use sanitary napkins at night; X tampons
-change tampons regularly and insert carefully to avoid abrasions
-good handwashing technique
-if with history of TSS: X use tampons until TSS bacteria is no longer
present in vaginal flora
NEPHROTIC SYNDROME

CAUSES

Allergy
Infections (herpes zoster)
Systemic diseases (DM, sickle cell disease)
Circulation problems (CHF, pericarditis)
Pregnancy
NURSING INTERVENTIONS

Bed rest (if with severe edema)

Increase caloric
Increase CHON
Decrease Na diet
Diuretics
Corticosteroids ( prednisone)
ACUTE GLUMERULONEPHRITIS

2-3 WEEKS AFTER STREPTOCOCCAL INFECTION

Pre school/ school age

Recovery: 2 years
STREPTOCOCCAL INFECTION

ANTIGEN- ANTIBODY REACTION

DESTRUCTION OF GBN

INCREASE
MEMBRANE POROSITY

DERANGEMENT OF CELLS IN
GBM

PROTEINURIA – HEMATURIA
URINE SPECIFIC GRAVITY OLIGURIA
INCREASES BUN; S.CREATININE
MILD GENERALIZED INCREASES
EDEMA H/A; SOB, WEAKNESS,
ASO TITER INCREASES ANOREXIA
BP INCREASES
PREVENTION

Prompt treatment of URTI/ sore throat

C and S; antibiotics as indicated

IMPLEMENTATION

REST
Penicillin
Low Na diet
Diuretics
Anti- HPN drugs
CHO diet; decrease CHON (if BUN and s. Creatinine increases)
CHRONIC GLUMEROLUNEPHRITIS

NO history of infection

Slow, progressive destruction ( sclerosis) of glumeruli
Gradual loss of renal function
Size of kidney decrease
Tubular atrophy
Chronic interstitial inflammation, arteriosclerosis
ASSESSMENT:

URINALYSIS: ALBUMIN, CASTS, BLOOD

HEADACHE
DYSPNEA
BLURRING OF VISION
LASSITUDE
WEAKNESS, FATIGUE, WEIGHT LOSS
EDEMA
NOCTURIA
 BODY SYSTEM MANIFESTATIONS IN THE CHRONIC RENAL FAILURE

SIGNS/ SYMPTOMS ASSESSMENT

CAUSES PARAMETER
HEMATOPOETIC SYSTEM Anemia hematocrit
Suppression of RBC Leukocytosis hemoglobin
production Defects in platelet platelet count
Decreased survival time of function observe for bruising,
RBCs thrombocytopenia hematemesis, melena
Loss of blood through
bleeding
Loss of blood during dialysis
Mild thrombocytopenia
Decreased activity of
platelets
 SIGNS/ SYMPTOMS ASSESSMENT
CAUSES PARAMETER
CARDIOVASCULAR SYSTEM hypovolemia vital signs
fluid overload HPN body weight
renin- angiotensin Tachycardia electrocardiography
mechanism Dysrhytmias heart sounds
fluid overload, anemia CHF monitor electrolytes
chronic HPN pericarditis assess for pain
calcification of soft tissues
uremic toxins in
pericardial fluid
fibrin formation in
epicardium
 SIGNS/ SYMPTOMS ASSESSMENT
CAUSES PARAMETER
GASTROINTESTINAL anorexia Monitor I and O
SYSTEM N/V Hct
change in platelet GI bleeding Hgb
activity Abdominal distension GUIAC TEST for all
serum uremic toxins Diarrhea stools
electrolyte imbalances Constipation Assess quality of stools
urea converted to Uremic fetor ( halitosis) Assess for abdominal
ammonia by saliva pain
 SIGNS/ SYMPTOMS ASSESSMENT
CAUSES PARAMETER

NEUROLOGIC SYSTEM Lethargy, confusion Level of orientation

Uremic toxins Convulsions Level of consciousness
Electrolyte imbalance Stupor, coma Reflexes
Cerebral swelling Sleep disturbances Electroencephalogram
resulting from fluid Unusual behavior Electrolyte levels
shifting Asterixis
Retarded growth
 SIGNS/ SYMPTOMS ASSESSMENT
CAUSES PARAMETER

SKELETAL SYSTEM Osteodytrophy Serum phosphorous

Decreased calcium Renal rickets Serum calcium
absorption Joint pain Assess for joint pain
Decreased phosphate Retarded growth
excretion
REPRODUCTIVE SYSTEM Infertility Monitor I and O
Hormonal abnormalities Decreased libido Monitor VS
Anemia, HPN Impotence Hct
Malnutrition Amenorrhea Hgb
Medications Delayed puberty
LABORATORY AND DIAGNOSTIC TESTS
1.ROUTINE URINALYSIS

COLOR Amber/ straw

PH 4.5 – 8.0 (average: 6)

Specific gravity 1.010 – 1.025
PROTEIN ABSENT

RBC 0-5/hpf
WBC 0-5/ hpf
Pus Absent
Glucose Absent
Ketones Absent
Casts 0-4
 2.CREATININE CLEARANCE ( 24 HOUR URINE SPECIMEN)
3. BLOOD STUDIES

BUN 10-20 mg/dl

SERUM CREATININE 0.4 - 1.2 mg/dl

SERUM URIC ACID 2.5 -8.9 mg/dl
ALBUMIN 1.– 5.5 mg/dl
RBC 4.5 -5 M/ cu.mm
Hct 38-54 vol %
SERUM ELECTRLYTES 3.5 – 5 mEq/ L
K 135- 145 mEq/L
Na 4.5- 5.5 mE q/L
Ca 1.5- 2.5 mEq /L
magnesium 3.5- 5.5 mEq/L
Phosphorous 98-108 mEq/L
chloride
BLOOD Ph ( metabolic acidosis in renal failure)
DIAGNOSTIC STUDIES

CYSTOSCOPY

Direct visualization of urethra, bladder wall, trigone, uretral opening

Preparation for cystoscopy
-Secure written consent
-Force fluids
-Inform that the desire to void is felt
-Done under local/ general anesthesia
Place in lithotomy position
After systoscopy:

Bed rest until VS are stable

Pink- tinged urine is normal (24 – 48 hours)
Dysuria, frequency, hematuria
-Due to tissue irritation
Observe:
-Urine retention
-Signs of infection
-Prolonged / excessive hematuria
Monitor output and VS
Hot sitz bath to relieve pelvic discomfort
Warm, moist, soak to relieve leg cramps
Force fluid
KUB (ABDOMINAL X-RAY FILM)

X-ray visualixation of the kidneys, ureters,

bladder
Assure that it is PAINLESS
Bowel preparation to prevent gas/ feces
interference with visualization
EXCRETORY UROGRAM / INTRAVENOUS PYELOGRAPHY (IVP)

X-ray visualixation of kidneys, ureters and bladder

Contrast medium /IV
E.g. HYPAQUE
Preparation
-Written consent
-NPO 6-8 hours
-Bowel preparation
-Assess allergy to seafoods / iodine
-Warm/ flushing sensation on IV injection of the dye is normal
-Prepare epinephrine ( anaphylactic shock may occur)
Care after IVP:

Monitor VS
Increase fluid intake to excrete dye
Burning sensation on voiding may be
experienced
Observe for signs and symptoms of delayed
allergic reaction
E.g. rashes, pruritus, Dyspnea
RETROGRADE PYELOGRAM

Outlines renal pelvis and ureters

Contrast medium through cystoscope
Preparation
-Written consent
-Check for allergy to the dye (iodine)
-Inform on discomfort of the procedure
-Prepare epinephrine for anaphylactic shock is the most life
threatening complication
Care after RPG
-Monitor VS

Observe:

Urinary retention
Infection
Prolonged/ excessive hematuria
VOIDING CYSTOURETHROGRAM FILM

BEFORE VOIDING

Outlines bladder wall

DURING VOIDING

Outlines urethra and reflux of urine into ureters

AFTER VOIDING

Demonstrates if bladder is emptied completely

Contrast medium is instilled into the bladder through cystoscope
Nursing interventions same as RPG
CYSTOMETROGRAM

Records pressure exerted at varying phases of filling of the

bladde
Helps evaluate neuro- sensory status , tonicity
Assess time to initiate stream, degree of hesitance,
intermittence of voiding, presence of terminal dribbling
Retention catheter is attached to manometer, sterile NSS is
introduced into the bladder at prescribed rate
Amounts of bladder volume and pressures are recorded at
intervals including first desire to void and feeling of maximum
fullness
ULTRASOUND

Detects tumors, cysts obstructions, abscess

Cleanse the bowel
Distend the bladder (1 liter of p.o
WithholAd voiding
RENAL BIOPSY

NPO for 6-8 hours

Check PTT, PT(bleeding is a common complication)
Mild sedation
Prone position during the procedure
Local anesthesia
Hold breath, remain still during needle insertion
X-ray of kidney should be readily available
UTZ to locate kidney
Care after renal biopsy:

Bed rest 24 hour

Monitor VS
Check for pain, nausea, vomiting
Fluids to 3000 mls
Hct and Hgb in 8 hours to detect bleeding
Avoid strenuous activities for 2 weeks

Risks:

BLEEDING
HEMATOMA
INFECTION