PUAN NORAINI MASRI Nursing Tutor/ OPEN UNIVERSITY

TOPIC 1 : ASSESSMENT OF THE RENAL NURSING

KIDNEY FUNCTION
y Removing wastes and water from the blood y Balancing chemicals in your body y Releasing hormones y Helping control blood pressure y Helping to produce red blood cells y Producing vitamin D, which keeps the bones strong

and healthy

Structure of kidney
y y

Location-retro-peritoneal The left kidney is typically slightly larger than the right.

KIDNEY STRUCTURE

BLOOD CIRCULATION

y Each kidney is perfused at a

rate of 600 ml/min by way of the renal artery y Each renal artery branches into interlobar arteries, arcuate arteries, interlobular arteries, and then into 1.2 million afferent arterioles that each feed each nephron, the functional unit of the kidney. y After blood has been filtered through the glomerulus and transported through the nephron's vasculature it passes through the interlobular, arcuate, and interlobar that merge into the renal vein and back in to systemic circulation.

The kidney is made up of approximately one million functioning units called nephrons. Each nephron consists of the following components: y Glomerulus: mechanically filters blood
y Bowman's Capsule: mechanically filters

blood
y Proximal Convoluted Tubule: Reabsorbs

75% of the water, salts, glucose, and amino acids

y Loop of Henle: Countercurrent exchange,

which maintains the concentration gradient

y Distal Convoluted Tubule: Tubular secretion

of H ions, potassium, and certain drugs.

URINE FORMATION STEP

y Filtration y Reabsorption y Secretion

URINE FORMATION

ASSESSMENT OF RENAL FUNCTIONS

PURPOSE: General health screening to detect renal and metabolic disease 2. Diagnosis of disease or disorders of the kidneys or urine tract 3. Monitoring of patients with diabetes
1.

METHOD
1. Urinalysis 3. Radiograpy 4. Other test
PHYSICAL TEST & BIOCHEMICAL TEST

2. Blood analysis

URINALYSIS-PHYSICAL TEST
Urine output - volume minimal daily urine volume 500mls - max. can be up to 20 liters. - < 400ml per day oliguria(low urine production) - > 2 liters per day polyuria (common in D.M &D.I) Colour - Normal straw yellow to amber in colour - Abnormal bright yellow, brown, black(gray), red & green.

Transparency - Normal transperent. - Turbid (cloudy) maybe cause by either normal or abnormal process.
- Normal conditons

mucus, vaginal discharge - Abnormal condition- presence of blood cells, yeast & bacteria.

Specific gravity/urine density Normal values are between 1.020 to 1.028. Increased urine specific gravity may be due to:
y Dehydration y Diarrhea that causes dehydration y Glucosuria (glucose in urin)-rare y Heart failure (related to decreased blood flow to the kidneys) y Renal arterial stenosis y Shock

Decreased urine specific gravity may be due to:

y Aldosteronism (very rare) y Excessive fluid intake y Diabetes insipidus y Renal failure y Renal tubular necrosis y Severe kidney infection (pyelonephritis)

Odor of urin
- Urine odor varies. Urine does not usually have a strong smell. - Foul smelling urine may be due to bacteria, such as that responsible for urinary tract infections. - Sweet smelling urine may be a sign of uncontrolled diabetes or a rare disease of metabolism. - Liver disease and certain metabolic disorders may cause musty smelling urine.

Abnormal urine odor may indicate:

y Dehydration (concentrated urine can have an ammonia-like scent) y Ketonuria y Urinary tract infection

URINALYSIS - BIOCHEMICAL TEST

PH PROTEIN CAST Signal of renal disease or infection GLUCOSE glocosuria maybe the first indicator that diabetes or hyperglycaemia condition is present. Osmolarity- less then 350mOsm/kg indicative of tubule damage.

Assessment of renal function Blood analysis

CONDITION Chronic renal failure

TESTS USED IN DIAGNOSIS BUN, creatinine, estimated GFR, urinalysis

TESTS USED TO FOLLOW BUN, creatinine, estimated GFR,electrolytes, calcium, phosphate,alkaline phosphatase, parathyroid hormone,CBC

Urinary tract infections Urinalysis, urine culture Kidney stones Imaging, urinalysis

Nephrotic syndrome

Urinalysis, urine culture Urine sodium, calcium, phosphorus, citrate, oxalate, uric acid Urinalysis, serum albumin,total Urine total protein, serum protein, cholesterol, urine total cholesterol, BUN, creatinine protein, antinuclear antibody (ANA) estimated GFR test, hepatitis B test, hepatitis C test, complement levels Urinalysis,BUN,creatinine,estimated BUN, creatinine, estimated GFR, serum albumin, urine total GFR, urinalysis protein, antinuclear antibody (ANA) test, antistreptolysin O, antiglomerular basement membrane antibody, antineutrophil cytoplasmic antibodies

Nephritic syndrome

COMMON RADIOGRAPHY
y Renal Scan
- injected- detect abnormality of kidney structure

y Renal Arteriogram

y Kidney, Ureter And Bladder ( KUB )y Intravenous Pyelogram

Other Test
y Renal Biopsy

TOPIC 2

DISORDER OF THE RENAL SYSTEM

1. Pyelonephritis
Pyelonephritis is a bacterial infection of the kidney. How does it occur? y Most kidney infections result from lower urinary tract infections, usually bladder infections. y Bacteria can travel from the vagina or rectal area (anus) into the urethra and bladder. y In men the urethra extends the full length of the penis. Infections of the lower urinary tract in men can occur with prostate infections.

ETIOLOGY
a)Ascending tract infection is infection spread from bladder to the ureter and finally spread to the kidney b) Ureterovesicle reflux- allow urine backflow to the ureter when urinating due to incomplete ureterovesicle valve. c) Obstruction renal calculi, tumour or stricture will obstruct the flow of urine and cause bacterial growth.

Clinical Manifistation
y High fever y Chills and rigor y Nausea y Flank(rusuk) pain/loin pain-this is due to the

distension of renal capsule y Headache y Muscle pain y Dysuria- Painful or difficult urination y Urgency and frequency in urination y Cloudy, bloody or foul smelling urine

Diagnostic Assesment
1. 2. 3. 4. 5. 6. 7. 8.

Urine FEME-presence of RBC, WBC,casts, bacteria Urine culture and sensitivity to determine the pathogen and selection of appropriate antibiotic Blood profile- blood urea serum electrolite Random blood glocose Blood C&S FBC X-ray IVP, KUB Ultrasound of kidney

MANAGEMENT
y Surgical

underlying causes such as renal calculli

y Medical antibiotic therapy. y General counceling

drink more water 2-3 liter per

day.

NURSING CARE PLAN (nursing diagnosis, objectives, intervention & evaluation) #1 Fever related to inflammation process #2 Pain related to distention of renal capsule #3 Risk of disease recurrence related to lack of knowledge on after discharge care

2. Glomerulonephritis

It s an inflammation of the glomeruli caused by the antigen-antibody reaction in the glomerular capillaries. This disease is in the inflammatory disease category. Glomerulonephritis usually occurs in both kidneys and causes trouble with filtering wastes from the blood Signs & symptoms: Haematuria (dark cola urine), proteinuria, generalised edema,oliguria, ascites, pulmanary edema, dyspnea,pleural effusion, Signs & symtoms of CCF

Pathophysiology
Is a non-infectious inflammation that occurs in the glomeruli This inflammation is due to antigen antibody reaction in the body defenses mechanism. As a result of this reaction, antigen antibody complexes (AgAb complexes)are formed. When Ag-Ab complexs are filtered in glomerulus, its being trapped and causes the inflammation process. It may be present with isolated hematuria and/or proteinurea, or as a nephrotic syndrome, nephritic syndrome(kidney inflammation), ARF, or CRF.

Pathophysiology (cont.)
y They are categoried into several difference pathological patterns, which are broadly groups into 2 type:

a)Non proliferative - characterised by low number of cells(lack of hypercellularity) in the glomeruli. They usually cause nephrotic syndrome. These include minimal change glomerulonephritis, Focal Segmental Glomerulosclerosis(FSGS), membrane glomeruloneprtis. b. Proliferative is characterised by an increase number of cells in the glomerulus(hypercellular. )Proliferative glomerulonephritis is usually present as a nephritic syndrome and slowly progress to ESRF.

Investigations
Lab tests can confirm anemia which is a sign of loss of kidney function. A biopsy of the kidney may be able to visibly see signs such as swelling, polyneuropathy, fluid retention, and hear distorted heart or lung sounds. Imaging tests - Abdominal CT scan, Abdominal ultrasound, and chest x ray. urinalysis - looking for is total protein, uric acid, urine creatine, urine protein, urine RBC, and urine specific gravity. An abnormal find with any of these would cause him to suspect glomerulonephritis

Treatment
Rx depends on the underlying cause Medication Corticosteroids may relieve symptom in some case. - Medication (azathioprine)cyclophosphamide)that suppress the immune system may precribed on the cause. Plasmapheresis- a procedure that removes the fluid part of the blood containing antibodies and replaces it with fluids or donated plasma without antibodies, can be done patient for disease caused from immune-related issues. The may be asked to be on a low sodium, low protein diet. If the person develops kidney failure, dialysis or a transplant would be needed.

Possible complication
y CCF y Pulmonary edema y Hyperkalemia y ARF y CRF y ESRF

Nursing mx
a)Edema - Restrict fluid intake - Daily wt - Infusion diuretic - Reduce salt intake - Continously monitor the progress of edema to detect any sign of pulmonary edema and heart failure b) Risk of infection - Medication - Apply aseptic technique for all sterile prosedure - Practise hand washing when handling patient. - Observe the sign of infection. c) Patient teaching - Advice pt to take precaution to prevent infection.(avoid crowded area/wash hand/avoid taking raw meat and vegetable/change clothes )

3. Nephrotic syndrome

Non specific disorder which the basement membrane of capsule Bowmen is damage , causing them to leak large amount of protein from blood into the urine.

CAUSE OF NEPHROTIC SYNDROME

From primary (idiopathic) glomerulonephritis:
y Lipid nephrosis (nil lesions): usually occurs in children y Membranous glomerulonephritis y Focal glomerulosclerosis y Membranoproliferative glomerulonephritis

Other causes
y Metabolic diseases: diabetes mellitus y Collagen-vascular disorders: systemic lupus

erythematosus y Circulatory diseases: heart failure, sickle cell anemia, and renal vein thrombosis y Nephrotoxins: mercury, gold, and bismuth. y Infections: tuberculosis, enteritis; allergic reactions; pregnancy; hereditary nephritis y Neoplastic: multiple myeloma

SIGN AND SIMPTOM

1.Proteinuria(>3.5g/day), hypoalbuminemia, hyperlipidemia 2. Edema which is generalized & also known as anasarca or dropsy. 3. Lipiduria (lipids in urine) 4. Hyponatremia also occurs with a low fractional sodium excretion 5. Anemia (iron resistant microcytic hypochromic type) maybe present due to transferrin loss. 6. May have features of the underlying cause, such as the rash associated with systemic lupus erythematosus or the neuropathy associated with diabetes

A few other characteristics seen in nephrotic syndrome are: y excess fluid in the body due to the serum hypoalbuminemia. Lower serum oncotic pressure causes fluid to accumulate in the interstitial tissues. Sodium and water retention aggravate the edema. This may take several forms: y Puffiness around the eyes, characteristically in the morning. y Pitting edema over the legs y Fluid in the pleural cavity causing pleural effusion. More commonly associated with excess fluid is pulmonary edema. y Fluid in the peritoneal cavity causing ascites

Investigation
a) 24 hours urine sample shows proteinuria b) Comprehensive metabolic panel(CMP) shows c) d) e) f)

hypoalbuminuremia High level of cholesterol (hypercholesterolemia),specifically elevated LDL Urea and creatinine : to evaluate renal function Biopsy of kidney Auto-immune markers(ANA,ASOT, C3, cryoglobulin, serum electrophoresis.

Treatment
General measure 1. Monitoring urine output,BP regularly 2. Fluid restrict to 1L 3. Diuretics 4. Monitoring kidney function 5. Prevent and treat any complication (eg. Venous thrombosis, infection,pulmonary edema) Specific treatment underlysing cause - Immunosuppression drug prednisolone, cyclosporin,cyclophosphamide. - BP control - ACE inhibitor drug - Blood glucose controle if diabetes

Complications
Venous thrombosis 2. Infection 3. ARF
1.

Nursing Diagnosis
1.

Disturbed body image

2. Excess fluid volume 3. Imbalanced nutrition: Less than body requirements 4. Ineffective tissue perfusion: Renal 5. Risk for infection 6. Risk for injury

Nursing Outcome
1.

Express positive feelings about him.

2. Maintain fluid balance. 3. Show no signs of malnutrition. 4. Maintain adequate urine output. 5. Free from signs or symptoms of infection. 6. Avoid or minimize complications.

Nursing Intervention
1. 2.

3. 4.

5.

Assessment and Document the location and character of the patient's edema Measure blood pressure with the patient lying down and standing. Immediately report a decrease in systolic or diastolic pressure exceeding 20 mm Hg. If the patients receive a renal biopsy, watch for bleeding and signs of shock. Monitor intake and output and weigh the patient each morning after he voids and before he eats. Make sure he's wearing the same amount of clothing each time you weigh him. Ask the dietitian to plan a low-sodium diet with moderate amounts ofprotein.

Nursing Intervention
6. Frequently check urine for protein. 7. Monitor plasma albumin and transferrin concentrations to evaluate overall nutritional status. 8. Provide meticulous skin care to combat the edema that usually occurs with nephrotic syndrome. 9.Use a reduced-pressure mattress or padding to help prevent pressureulcers. 10.To prevent the occurrence of thrombophlebitis, encourage activity andexercise, and provide antiembolism stockings as ordered. 11.Give the patient and family reassurance and support, especially during the acute phase, when edema is severe and the patient's body image changes

Patient Teaching & Home Care Guide

If the patients receive immunosuppressants, teach him and family members to report even mild signs of infection. 2. If the patients receive long-term corticosteroid therapy, teach him and family members to report muscle weakness and mental changes. 3. To prevent GI complications, suggest to the patient that he take steroids with an antacid or with cimetidine or ranitidine. Explain that the adverse effects of steroids subside when therapy stops, but warn the patient not to discontinue the drug abruptly or without a physician's consent. 4. Stress the importance of adhering to the special diet. 5. If the physician prescribes antiembolism stockings for home use, show the patient how to safely apply and remove them.
1.

TERIMA KASIH