Medical Surgical Nursing:Geniro Urinary Tract Disorder.

Debre Brehan University
School of Health Science

Program of Nursing
Medical-Surgical Nursing II
GENTO - URINARY SYSTEM DISORDER
Prepared by Tesfa D.(B.Sc. in Nursing)
Anatomy and physiology of
gento-urinary system
The main parts of the urinary
system are as follow.
1. Two Kidneys-These organs
extract waste from the blood
and balance body fluid, these are
also the organs of excretion that
form urine.
2. Two ureters-These tubes
conduct urine from the kidneys to
the urinary bladder.
Lecture note for regular second year
Nursing student, February 2003/2011. 2
Cont…d
3. A single urinary bladder-this
reservoir receive and stores the
urine brought to it by the two
ureters.
4. A single urethra - This tube
conducts urine from the bladder
to the out side of the body for
elimination.

Cont…d

The kidneys
LOCATION OF THE KIDNEYS
 The kidneys are a pair of brownish-red
structures located retroperitoneally
(behind and outside the peritoneal
cavity) on the posterior wall of the
abdomen from the 11th (Left) and12th
(Right) thoracic vertebra to the 3rd
lumbar vertebra in the adult.
 The two kidneys lie against the muscle of
the back in the upper abdomen.
 Each kidney is enclosed in a
membranous capsule that is made of
fibrous connective tissue.
Cont…d
Blood supply to the kidneys
 Kidney get blood supply from renal
artery and it takes 20-25% of the
total CO.
 After entering the kidney the renal
artery sub divided in to smaller and
smaller branches, which eventually
make contact with the functional
unit of the kidney called
nephyron.

Cont…d
Blood leaves the kidney by vessel
that finally merges to from the
renal vein. The renal vein carries
blood into the inferior vena-cave
for return to the heart.

Cont…d

Representation of a nephron.

Function of the kidneys
1. Regulation of:
 body fluid osmolarity and volume
 electrolyte balance
 acid-base balance
 blood pressure
2. Excretion of;
 metabolic products
 foreign substances (pesticides, chemicals etc.)
 excess substance (water, etc)
3. Secretion of;
 erythropoitin
 1,25-dihydroxy vitamin D3 (vitamin D activation)
 renin
 prostaglandin
4. Urine formation.
5. Renal clearance.

THE URETERS
The two ureters are long slander
muscular tube that originate at the
lower portion of the renal pelvis and
terminate in the trigone of the bladder
wall.
Their length naturally varies with the
size of the individual (approximately
from 25 cm - 33 cm long).
The left ureter is slightly shorter
than the right. (why?)
Function:-Transmit urine from renal
pelvis in to the bladder.

The urinary bladder
The urinary bladder is a
muscular, hollow sac located just
behind the pubic bone.
Adult bladder capacity is about
300 to 600 ml of urine.
 In infancy, the bladder is found
within the abdomen.

Cont…d
Characteristic of the bladder
 When it is empty, the urinary
bladder is located below the partial
peritoneum and behind the pubic
joint.
 When it is filled it pushes the
peritoneum up ward and may
extend well in to the abdominal
cavity.
 The urinary bladder is a temporary
reservoir for urine.

The urethra
At a neck of the bladder that the
urethra leave, there is bundles of
involuntary smooth muscle that
form a portion of the urethral
sphincter known as the internal
sphincter control by autonomic
nervous system (involuntary
control).

Cont…d
 The portion of the sphincteric
mechanism that is under voluntary
control is the external urinary
sphincter at the anterior urethra, the
segment most distal from the
bladder.
 The length of urethra varies with
sex;
Female urethra-7.5 cm (3 inches).
Male urethra-15 to 25 cm (6 to 10
inches).
Assessment of urinary system
Subjective data (The History)
This section discusses the data
related to assessment of urinary
system that a nurse should elicit
from a client to obtains a health
history.

1. Chief Compliant
Pain;
 Usually flank/loin region-
obstruction, infection.
 dull persistent-tumor.
 Pain radiate to the iliac fossa, the
testicle or the labia- ureteric stone
obstruction.
 Suprapubic region and perineum-
cystitis or urethritis.
N.B. Glomerulonephritis is usually
painless.

Cont…d
Haematuria;
 can be;
 Continuous
 Painless parenchymal renal disease
 microscopic e.g. glomerulonephritis
(occasionally macroscopic).
intermittent
painful renal tumours
macroscopic.

Cont…d
Oliguria/anuria;
 Oliguria:-passage of <500mL urine
per day.
Prerenal oliguria: decrease in
renal blood
Renal oliguria: intrinsic renal
disease
Postrenal oliguria: renal
obostruction
 Anuria:-complete absence of urine
flow.
Cont…d
Polyuria;
psychogenic polydipsia
beer drinking
diabetes mellitus
chronic renal failure
diuretic use
nephrogenic diabetes insipidus

Cont…d
Frequency;
o excessive fluid intake
o reduced functional bladder
capacity (prostatic hypertrophy
and bladder outlet obstruction).
o Cystitis
o multiple sclerosis (neurologic
disease)

Cont…d
Nocturia;
 Implies the need to empty the
bladder during the hours of sleep.
 Often associated with:
reduction of functional bladder
capacity
Diuretics use
Dysuria;
 pain immediately before, during or
after micturition.
Cont…d
Urgency;
is the loss of the normal ability to
postpone micturition beyond the
time when the desire to pass urine
is initially perceived.
Incontinence;
is the involuntary passage of
urine.
Enuresis;
is usually used to describe
noctural enuresis, or bed-wetting.
Cont…d
Slow stream, hesitancy and
terminal dribbling;
 triad of symptoms is most
frequently seen in elderly men
with prostatic hypertrophy (BPH).
Urethral discharge;
 urethritis
 sexually transmitted infection
Edema;
 facial ( periorbital ), ankle, ascites,
anasarca, etc.
Cont…d
Other constitutional symptom
 fatigue,
 headache,
 blurred vision,
 increased B/P,
 lack of appetite,
 nausea,
 itching,
 thirsts,
 chills etc...

2. History of Present Illness
 Fullelaboration of all presenting
sign and symptoms in terms of;
Duration
Location
Quality
Quantity
Aggravating factors
Relieving factors
Associated manifestation
E.t.c.
Cont…d
N.B.
 when reviewing a health history,
it is important to be sure that the
patient understand the question
being asked.
 In discussing problem involving
the genitalia, the pt may deny
symptoms b/c of anxiety. There
fore, encourage the client to talk
about it.

Cont…d
2. Past medical history
 The client should be questioned about
the existence or history of the following
disease which have known to be related
to renal problem;
 hypertension,
 diabetes mellitus,
 gout,
 connective tissue disease,
 cystitis,
 kidney infection,
 renal calculi,
 infections disease etc....
Cont…d
 The client should also be questioned
about any hospitalization related
to the above disease.
 The client should questioned if
he/she has ever been catheterized
or has had diagnostic study
involving instrumentation of the
urinary tract.
 An assessment of the client’s
current and past use of
medications is very important.
Cont…d
3. Family history
The presence of certain renal or
urological problems in a family history
accessed the likelihood of similar
problems occurring in a family member.
The specific disease related to renal
problems to ask the client is about
congenital urinary tract
abnormalities, polycystic kidney
disease, urinary tract infection,
urinary calculi, hypertension, gout,
connective tissue disorder, etc…
Cont…d
4. Social and personal history
Areas of importance to be considered
in this category include back ground
information and life style.
Background information e.g.
combination of carbon tetrachloride &
alcohol cause tubular necrosis.
Life Style e.g. high mineral content
and some foods cause renal calculi.

11 functional pattern
assessment
Fill by your self!!!

Cont…d
Objective data (The physical Exam)
A. Inspection
Skin (pallor, yellowish, changes in
turgor, bruises, crystals, etc...).
Mouth (Stomatitis and urinous breath
odor).
Face (facial edema).
Abdomen and extremities (generalized
edema).
Weight gain secondary to edema.
General state of health (fatigue,
lethargy, diminished alertness, e.t.c…).

Cont…d
B. Palpation
 The kidney are posterior organs protected
by the a abdominal organ, ribs and the
heavy back muscles.
 May be the right kidney is palpable. To
palpate the right kidney the examiner’s left
hand is placed behind and supporting the
right side b/n the rib cage and the iliac
crest.
 Some disease can be suggestive (e.g. hydro-
nephrosis, neoplasm or polycystic kidney
problem etc…).
 The bladder is palpable if it is distended
otherwise not palpable.
Right kidney palpation

Left kidney palpation

Palpation of the bladder

Cont…d
C. Percussion
 Tenderness of the flank area.
 Percussion of the bladder begins at
the midline just above the umbilicus
and proceeds downward.
 Normally a bladder is not a
percussable unit.
 If the bladder is full dullness will be
heard above the public symphysis.

Cont…d
Location of costovertabral angle

Cont…d
D/ Auscultation
◦ Auscultation is not generally used in
the assessment of the urinary system.

Diagnostic studies of
urinary system
Diagnostic studies are important in
locating and understanding
problems of the urinary system.
The accuracy at the finding at
these studies is influenced by:-
A-Adherence to the proper procedure
related to the study.
B- Cooperation of the client on
restricting fluids, collection of urine
specimen, lying quietly on the x-ray
table, e.t.c…

1.Urinanalsis
 General examination of urine to
establish baseline information or to
provide data in establishing a
tentative diagnosis & determine
further studies to be ordered.
 Findings give information about:
Colour, Smell, protein, glucose,
ketones, specific gravity,
osmolality, PH, WBC, RBC, casts,
culture for organisms, etc...
Cont…d
 Creatinine clearance - Creatinine is waste
product of protein (muscle) breakdown.
 Normal value is 85 - 135 ml/min.
 Urine Culture: Confirm suspected urinary
tract infection and identity causative
organisms.
 Normally bladder is sterile, but urethra
contains bacteria and a few WBC. If properly
collected, stored and handle, it can helps to
minimize false positivity.
 Quantitative Test: A 12 or 24 hrs urine
collection give a more accurate result of the
amount of protein in urine (N.R 0-15 oms/
hr) consisting mainly of albumin.
2. Blood Chemistry
BUN(Blood urea nitrogen ) most
commonly used to diagnose renal
problems. Concentration of urea in blood
is determined by the rate at which
kidney excrete urea ( NR:0-30 mg/dl).
RFT (Renal Function Test) is used to
evaluate the severity of kidney disease
and to follow the patient's clinical
progress.
This test also give information
concerning the kidneys effectiveness in
caring out their execratory function this
is serum creatinine (NR:0.5 - 1.5 mg/dl)
3. Radiological studies
A. KUB (kidney, ureter and bladder)
X-ray
 An x-ray study of the abdomen or
kidney, ureters, and bladder (KUB) may
be performed to delineate the size,
shape, and position of the kidneys and
to reveal any abnormalities, such as
calculi (stones) in the kidneys or
urinary tract, hydronephrosis
(distention of the pelvis of the kidney),
cysts, tumors, or kidney displacement
by abnormalities in surrounding tissues.
Cont…d
B. IVP or excretory urogram.
 It is x-ray that helps to visualize urinary
tract after I.V injection or radio opaque dye
(an organic iodine-containing contrast
medium).
 The bladder should be examined both pre-
and postmicturition for abnormalities of
contour and residual volume.
S/E of the contrast media;
bronchospasm or urticaria (1%)
cardiac arrhythmias & convulsions
(0.003%)
Allergic reaction

Cont…d
It helps to note;
Any distortion of the smooth
renal outline,
calyceal dilatation (e.g. due to
obstruction),
filling defects in renal pelves
(e.g. stones, tumour),
ureteric obstruction and
displacement (e.g.
retroperitoneal fibrosis).
Cont…d
C. Nephro-tomogram
 X-ray taken with rotating tubes,
to delineate segments of the
kidney at different levels/degree.
I.V injection of radio opaque dye is
performed before the procedure.

Cont…d
D. Retrograde Pyelogram
 In retrograde pyelography, catheters
are advanced through the ureters
into the renal pelvis by means of
cystoscopy.
 A contrast agent is then injected.
 Retrograde pyelography is usually
performed if intravenous urography
provides inadequate visualization
of the collecting systems.

Cont…d
Retrograde pyelography is mainly used;
 to investigate lesions of the ureter
 to define the lower level of ureteral
obstruction shown on excretion urography
or ultrasound plus antegrade studies.
 Itis invasive, commonly requires a
general anaesthetic, and may result in the
introduction of infection.

Cont…d
 Cystoscope and urethral catheter
are insert through it in to renal
pelvis and dye is injected through
catheter .
E. Renal arteriogram (angiogram)
 Injecting radiopaque dye in to
artery, to visualize the renal blood
vessel.

Cont…d
F. Computed tomography (CT)
CT is used;
 to characterize renal masses which are
indeterminate at ultrasonography.
 to stage renal tumours
 to detect 'lucent' calculi; low-density calculi
which are lucent on plain films (e.g. uric acid
stones).
 to evaluate the retroperitoneum for tumours,
retroperitoneal fibrosis (periaortitis) and other
causes of ureteric obstruction.
 to assess severe renal trauma.
 to visualize the renal arteries and veins.
 to stage bladder and prostate tumours.

Cont…..d
G. Magnetic resonance imaging
(MRI)
MRI is used:
 to characterize renal masses as an
alternative to CT.
 to stage renal, prostate and bladder
cancer.
 To demonstrate the renal arteries.
what is the difference b/n CT scan
and MRI?
4. Endoscopy
A. Cystoscopy
 Cystoscopy (cystourethroscopy) is a diagnostic
procedure that uses an endoscope especially designed
for urological use to examine the bladder, lower
urinary tract, and prostate gland.
 The cystoscope, which is inserted through the urethra
into the bladder, has a self-contained optical lens
system that provides a magnified, illuminated view of
the bladder.
 The cystoscope is manipulated to allow complete
visualization of the urethra and bladder as well as the
ureteral orifices and prostatic urethra.
 It can also be used to collect urine samples, perform
biopsies, and remove small stones.
 A cystoscopy typically lasts from 10 to 40 minutes.

Cont…d

Purpose
◦ Cystoscopy is performed by
urologists to examine the entire
bladder lining and take biopsies of
any questionable areas.

Cont…d
Indication:
◦ Blood in the urine (hematuria).
◦ Inability to control urination (incontinence).
◦ Urinary tract infection.
◦ Signs of congenital abnormalities in the
urinary tract.
◦ Suspected tumors in the bladder.
◦ Bladder or kidney stones.
◦ Signs or symptoms of an enlarged prostate.
◦ Pain or difficulty urinating (dysuria).
◦ Disorders of or injuries to the urinary tract.
◦ Symptoms of interstitial cystitis.

Cont…d
Preparation
 Cystoscopy can be performed in a hospital,
doctor's office, or outpatient surgical
facility.
 Spinal or general anesthesia may be used
for the procedure.
 Distension of the bladder with fluid is
particularly painful, and if it needs to be
done, as in the case of evaluating interstitial
cystitis, general anesthesia is required.
 Cystoscopy is typically performed on an
outpatient basis, but up to three days of
recovery in the hospital is sometimes
required.
Cont…d
Aftercare
Patientswho have undergone a
cystoscopy are instructed to:
◦ take warm baths to relieve pain.
◦ rest and refrain from driving for several
days, especially if general anesthesia was
needed
◦ expect any blood in the urine to clear up
in one to two days.
◦ avoid strenuous exercise during recovery.
◦ postpone sexual relations until the
urologist determines that healing is
complete.

Cont…d
Complications
Profuse bleeding
Urethral damage.
Perforated bladder.
Urinary tract infection.
Injured penis.

5. Other test
Kidney Biopsy
Biopsy of the kidney is used in diagnosing and
evaluating the extent of kidney disease.
Indications for biopsy include unexplained acute
renal failure, persistent proteinuria or
hematuria, transplant rejection, and
glomerulopathies.
A small section of renal cortex is obtained either
percutaneously (needle biopsy) or by open
biopsy through a small flank incision.
Before the biopsy is carried out, coagulation
studies are conducted to identify any risk for post
biopsy bleeding.
Contraindications to a kidney biopsy include
bleeding tendencies, uncontrolled
hypertension, and a solitary kidney.
Cont…d
Ultrasound/Ultrasonography
 It is an instrument with small
external ultrasound probe and
conductive attached to the patient.
 Computer interprets tissue density
based on sound wave & displays it
in picture form.
 What is the name of liquid
that is polished on the probe?
Cont…d
Inrenal diagnosis it is the method of
choice for:
renal measurement and for renal biopsy
or other interventional procedures.
checking for pelvicalyceal dilatation as
an indication of renal obstruction when
chronic renal obstruction is suspected.
characterizing renal masses as cystic or
solid
diagnosing polycystic kidney disease.
detecting intrarenal and/or perinephric
fluid (e.g. pus, blood).
demonstrating renal arterial perfusion or
detecting renal vein thrombosis.
Cont…d
Disadvantages;
 It does not show detailed
pelvicalyceal anatomy.
 It does not fully visualize the
normal adult ureter.
 It may miss small renal calculi
and does not detect the
majority of ureteric calculi.
 It is operator-dependent.
Disease of the kidney
1. Acute glomerulonephritis
 Acute glomerulonephritis refers to a group of kidney
disease in which there is an inflammatory reaction in
the glomeruli (glomerular capillaries).
 It is not an infection of the kidney but rather the
result of unwanted side effect of the defense
mechanism of the body.
 Acute glomerulonephritis is primarily a disease of
children older than 2 years of age, but it can occur at
nearly any age.
 As a result of antigen antibody reaction, aggregate of
molecules ( complexes ) are formed and circulates
throughout the body.
 Some of these complexes lodge in the glomeruli
filtering bed of the kidney and induce an
inflammatory response.

Cont…d
Causes
 Group A beta hemolytic streptococcal
infection. (Most common following 2-3
wks infection of throat).
 Impetigo (infection of the skin).
 Acute viral infections (upper
respiratory tract infections, mumps,
varicella zoster virus, Epstein-Barr
virus, hepatitis B, and HIV infection).
 Antigens outside the body (eg,
medications, foreign serum).
 Kidney tissue itself.

Cont…d
Pathophysiology

Cont…d

Cont…d
Clinical manifestation
Generalized edema,
Smokey urine (cola-colored),
Gross heamaturia,
Protienuria,
Headache,
Malaise,
Flank pain (mild or sever),
Hypertension,
CVA tenderness,
Some times and asymptomatic and
rarely renal failure.
Cont…d
Diagnosis
 Diagnostic History.
 Physical examination.
 Urinalysis.
 Serum IgA level.
 Antistreptolysin-O level.
 CBC.
 Renal biopsy.

Cont…d
Medical Management
 Therapeutic bed rest until the sign of
glemerular inflammation (heamaturia,
proteinuria, ) relived.
 Restricting sodium and high fluid to treat
edema.
 Loop diuretic.
 Anti-hypertensive drug.
 Low protein diet to reduce nitrogenous
waste ( E.g. elevated BUN ).
 Antibiotics (Penicillin or erythromycin).
 Corticosteroids.
 Immunosuppressant medications.

Cont…d
Nursing intervention
 Heath promotion and maintenance (E.g.
early diagnosis and treatment of sore
threat and skin lesion).
 Appropriate antimicrobial drug (usually
penicillin) is administration is essential. (If
streptococcus is found in the culture).
 Pt education concerning diet, rest, regular
follow up etc...
 Carbohydrates are given liberally to
provide energy and reduce the catabolism of
protein.
 Intake and output are carefully measured
and recorded.
Cont…d
Complications
 Hypertensive encephalopathy.
 Congestive heart failure.
 Pulmonary edema.

2. Chronic glomerulonephritis
 Chronic glomerulonephritis is a
syndrome that reflects the end stage
of glemerular inflammatory
disease.
Cause
 Repeated episodes of acute
glomerulonephritis.
 Hypertensive nephrosclerosis.
 Hyperlipidemia.
 Chronic tubulointerstitial injury.
 Hemodynamically mediated
glomerular sclerosis.
Cont…d
Pathophysiology
Antigen-antibody reaction occur repeatedly
kidneys are reduced to as little as one-fifth their

normal size (consisting largely of fibrous tissue).
The cortex shrinks to a layer 1 to 2 mm thick or
less. Bands of scar tissue distort the remaining
cortex, making the surface of the kidney rough
and irregular. Numerous glomeruli and their
tubules become scarred, and the branches of the
renal artery are thickened. The result is severe
glomerular damage that results in ESRD.

Cont…d
Diagnosis
 Hx.
 P/E.
 Urinalysis.
 Chest x-rays.
 Electrocardiogram.

Cont…d
Clinical Manifestation
 The symptom of chronic glomerulonephritis are variable
some of them with sever grades of this disease have no
symptom at all for a long time.
 Edema (periorbital and peripheral (dependent)).
 Massive protienuria.
 Hyperabuminureia.
 Elevated B/P.
 Headache.
 Dizziness.
 Anemia.
 Ascites.
 Hydrothorax (Fluid in the chest).
 Pericarditis with effusion.
Prognosis: Poor (majority fail progressively and die 1or 2 yrs. A few
patients will improve & they may enjoy fair health for many years.

Cont…d
Management
1. Medical intervention
Treatment of patient with chronic
glomerulonephritis is entirely, non-
specific and symptomatic,
depends on the situation.
The goal of treatment is to:-
Relieve edema.
Cure or control the primary disease.
Treat hypertension.
Treat the renal infection.

Cont…d
 If the patient has hypertension, the blood
pressure is reduced with;
 Sodium and water restriction,
 Antihypertensive agents, or both.
 If fluid overload;
 Diuretic medications are prescribed.
 Weight is monitored daily.
 Proteins of high biologic value (dairy products,
eggs, meats) are provided to promote good
nutritional status.
 Adequate calories are also important to spare
protein for tissue growth and repair.
 UTIs must be treated promptly to prevent further
renal damage.
 Anti-inflammatory agent (Prednisolone).

Cont…d
2. Nursing intervention
Daily weight control.
Accurate record of intake and out.
Observation of edema ( facial,
extremities, abdomen etc), cardiac and
neurologic status, fluid and electrolyte
status.
High protein diet (frequent small meal),
protect from infection.
Psychological treatment.
Complication
 Cardiovascular disorder.
 Respiratory disorder.
 Metabolic disorder.
3. Nephrotic Syndrome
 Nephritic
syndrome is primary
glomerular disease characterized
by:
◦ Marked protienuria.
◦ Hypoalbuminemia.
◦ Edema.
◦ Hypercholesterolemia/lipidemia.
 Thesyndrome is apparent in any
condition that seriously damages
the glomerular capillary
membrane and results in increased
glomerular permeability.
Cont…d
 Nephrotic syndrome can occur
with almost any intrinsic renal
disease or systemic disease that
affects the glomerulus.
 Although generally considered a
disorder of childhood, nephrotic
syndrome does occur in adults,
including the elderly.

Cont…d
Causes
◦ Chronic glomerulonephritis,
◦ Diabetes mellitus with
intercapillary glomerulosclerosis,
◦ Amyloidosis of the kidney,
◦ Systemic lupus erythematosus,
◦ Multiple myeloma, and
◦ Renal vein thrombosis.

Cont…d
Pathophysiology
The nephrotic syndrome occurs in
response to a group of diseases in
which inflammation of the
glomerulus (glomerulonephritis) is
predominant.

Cont…d

Cont…d
Clinical manifestations
◦ Localized and generalized edema(eyes
(periorbital), in dependent areas (sacrum,
ankles, and hands)).
◦ Ascites.
◦ Hydrothorax.
◦ Protienuria.
◦ Hypoproteinemia.
◦ Less urine output.
◦ Headache.
◦ Irritability.
◦ Usually pale.
◦ Fatigue/Malaise.
◦ Anorexia.
Cont…d
Diagnosis
 Hx.
 P/E.
 U/A.
 CBC.

Cont…d
Management
1. Medical
The objective of management is to preserve renal
function.
Usually it is nonspecific, depends on the cause.
It includes;
Medication;
Diuretics.
Angiotensin-converting enzyme (ACE)
inhibitors.
Antineoplastic agents (cyclophosphamide
[Cytoxan]).
Immunosuppressant medications (azathioprine
[Imuran], chlorambucil [Leukeran], or
cyclosporine).
Corticosteroids (prednisolone) if relapse occurs.
Cont…d
Diet;
Low-sodium, liberal-potassium diet.
High biologic proteins (dairy products,
eggs, meats). (Protein intake should be
about 0.8 g/kg/day).
Low saturated fat diet.
Bed rest.
Antimicrobial drugs for infection.

Cont…d
2. Nursing Intervention
 Observation of edema by controlling
weight.
 Skin care and trauma should be
avoided.
 Monitoring the effectiveness of
diuretics.
 Accurate record of intake and output.
 Protect the patient from infection.
 Psychological support (severe edema).
 Health education.
4. Pyelonephritis
 Pyelonephritis is a bacterial
infection of the renal pelvis,
tubules, and interstitial tissue of
one or both kidneys.
 Pyelonephritis is frequently
secondary to ureterovesical
reflux, in which an incompetent
ureterovesical valve allows the
urine to back up (reflux) into the
ureters.
Cont…d
 More common in female children
that male, in pregnant women
when there is failure to empty the
bladder on time.
 It can be;
1. Acute.
2. Chronic.

4.1. Acute Pyelonephritis
Causes
 Urinary tract obstruction.
 Bladder tumors.
 Strictures.
 Benign prostatic hyperplasia.
 Urinary stones.
Common bacteria responsible are
different types of bacteria as a
colon bacillus (E.coli) and rarely
staphylococci.
Cont…d
Clinical Manifestations
 Acutely ill (Sudden onset).
 Chills.
 Fever.
 Leukocytosis.
 Bacteriuria.
 Pyuria.
 Flank pain.
 CVA tenderness.
 Dysuria.
 Frequent urination.
 Headache.
 Nausea & vomiting.
 Epithelial cells, in the urine.
Cont…d
Assessment and Diagnostic Findings
 Ultrasound study.
 CT scan.
 Urine culture and sensitivity
tests.

Cont…d
Medical Management
Patients with acute uncomplicated
pyelonephritis are usually treated as
outpatients if they are not dehydrated,
not experiencing nausea or vomiting,
and not showing signs or symptoms of
sepsis.
Other patients, including all pregnant
women, may be hospitalized for at least
2 or 3 days of parenteral therapy.
Oral agents may be substituted once the
patient is afebrile and showing clinical
improvement.
Cont…d
Pharmacologic therapy
 For outpatients, a 2-week course of antibiotics is
recommended because renal parenchymal
disease is more difficult to eradicate than
mucosal bladder infections.
 Commonly prescribed agents;
 Ciprofloxacin,
 Gentamicin with or without ampicillin.
 Third-generation cephalosporin.
 After the initial antibiotic regimen, the patient may
need antibiotic therapy for up to 6 weeks if
evidence of a relapse is seen.
 A follow-up urine culture is done 2 weeks after
completion of antibiotic therapy to document
clearing of the infection.

4. 2. Chronic pyelonephritis
Repeated bouts of acute
pyelonephritis may lead to chronic
pyelonephritis.
◦ fatigue,
◦ headache,
◦ poor appetite,
◦ polyuria,
◦ excessive thirst, and
◦ weight loss.
Cont…d
Pathophysiology
There are areas of inflammation in the
kidney with interstitial infiltrations of
inflammatory cells which in time may
produce tubular destruction & abscess
formation.
Low grade interstitial inflammation may
result in atrophy and destruction of
tubules and in hyalinization of the
glomeruli.
Eventually when pyelonephritis become
chronic, the kidneys become scarred,
contracted and of little functional value.
Cont…d
 Intravenous urogram.
 Measurements of
creatinine clearance.
 BUN.

Cont…d
Medical Management
Medication (e.g. Nitrofurantoin, Oral
antimicrobial drugs (e.g. Sulfonamide,
Ampicillin, e.t.c.)).
Fluid intake 300 ml/day.
Light dite.
Bed rest – of severe complete
(hospitalization).
Follow-up urine cultures and other
discharges.
Requires surgery, e.g. Nephrotomy,
nephrectomy or pyolotomy.
Cont…d
Nursing Management
 Measure and record fluid intake and output are
carefully.
 Unless contraindicated, fluids are encouraged (3 to
4 L/day) to dilute the urine, decrease burning on
urination, and prevent dehydration.
 The nurse assesses the patient’s temperature every
4 hours and administers antipyretic and antibiotic
agents as prescribed.
 Bed rest during the acute phase of the illness.
 Protection from infection (URI).
 Patient teaching. (about medication, urine –
culture follow-up, identification of reoccurrence of
infection).

Cont…d
Complications
ESRD.
Hypertension.
Formation of kidney stone.

5. Renal Failure
 The term is used to primarily to
denote failure of the excretory
function of the kidneys, leading to
retention of nitrogenous waste
products of metabolism.
 Various other aspects of renal
function may fail at the same time,
including the regulation of fluid
and electrolyte status, endocrine
function, metabolic function, and
regulation of acid-base balance.
Cont…d
Renal failure is a systemic disease
and is a final common pathway of
many different kidney and urinary
tract diseases.
A wide range of clinical manifestations
may occur.
The most fundamental categorization of
renal failure is;
1. Acute Renal failure.
2. Chronic Renal failure.

5.1. Acute renal failure
 Acute renal failure is a sudden and almost
complete loss of kidney function(decreased
GFR), usually reversible caused by failure of the
renal circulation or by glemerular or tubular
damage over a period of hours to days/weeks.
 Oliguria (less than 400 ml/day of urine) is the
most common clinical situation seen in ARF.
Anuria (less than 50 ml/day of urine) and normal
urine output are not as common.
 Regardless of the volume of urine excreted, the
patient with ARF experiences rising serum
creatinine and BUN levels and retention of other
metabolic waste products (azotemia) normally
excreted by the kidneys.

Cont…d
Causes of Acute Renal Failure
I. Pre-renal Failure:- occurs as a result of impaired
blood flow that lead to hypo perfusion of the
kidney.
 Volume depletion resulting from:
 Hemorrhage.
 Renal losses (diuretics, osmotic diuresis).
 Gastrointestinal losses (vomiting, diarrhea, nasogastric suction).
 Impaired cardiac efficiency resulting from:
 Myocardial infarction.
 Heart failure.
 Dysrhythmias.
 Cardiogenic shock.
 Vasodilation resulting from:
 Sepsis.
 Anaphylaxis.
 Antihypertensive medications or other medications that cause
vasodilation.

Cont…d
II. Intra-renal Failure:- is the result of actual
parenchymal damage.
 Prolonged renal ischemia resulting from:
 Pigment nephropathy (associated with the breakdown of
blood cells containing pigments that in turn occlude kidney
structures).
 Myoglobinuria (trauma, crush injuries, burns).
 Hemoglobinuria (transfusion reaction, hemolytic anemia).
 Nephrotoxic agents such as:
 Aminoglycoside antibiotics (gentamicin, tobramycin)
 Radiopaque contrast agents.
 Heavy metals (lead, mercury).
 Solvents and chemicals (ethylene glycol, carbon
tetrachloride, arsenic).
 Nonsteroidal anti-inflammatory drugs (NSAIDs)
 Angiotensin-converting enzyme inhibitors (ACE inhibitors).
 Infectious processes such as:
 Acute pyelonephritis.
 Acute glomerulonephritis.

Cont…d
III. Post-renal Failure:-are usually
the result of an obstruction some
where distal to the kidney,
ureter, urethra.
 Urinary tract obstruction,
including:
 Calculi (stones).
 Tumors.
 Benign prostatic hyperplasia.
 Strictures.
 Blood clots.
Cont…d
PHASES OF ACUTE RENAL FAILURE
There are four clinical phases of
ARF:
1. Initiation.
2. Oliguria.
3. Diuresis.
4. Recovery.

Cont…d
1. Initiation:-The initiation period begins with
the initial insult and ends when oliguria
develops.
2. Oliguria:-The oliguria period is accompanied
by a rise in the serum concentration of
substances usually excreted by the kidneys
(urea, creatinine, uric acid, organic acids,
and the intracellular cations [potassium and
magnesium]). In this phase uremic
symptoms first appear and life-
threatening conditions such as
hyperkalemia develop. This phase lasts
approximately 10 days.

Cont…d
3. Diuresis:-In the diuresis period, the
patient experiences gradually
increasing urine output, which
signals that glomerular filtration has
started to recover.
4. Recovery:-The recovery period signals
the improvement of renal function and
may take 3 to 12 months. Laboratory
values return to the patient’s normal level.
Although a permanent 1% to 3% reduction
in the GFR is common, it is not clinically
significant.
Cont…d
◦ The patient may appear critically ill
and lethargic.
◦ Persistent nausea, vomiting, and
diarrhea.
◦ The skin and mucous membranes are
dry from dehydration.
◦ The breath may have the odor of
urine(uremic fetor).
◦ Central nervous system signs and
symptoms include drowsiness,
headache, muscle twitching, and
seizures.
Cont…d
Assessment and Diagnostic
Findings
 Hx.
 P/E.
 U/A.
 Ultrasonography
 E.t.c.

Cont…d
Medical Management
The objectives of treatment of ARF
are to restore normal chemical
balance and prevent complications
until repair of renal tissue and
restoration of renal function can
take place.
◦ Any possible cause of damage is
identified, treated, and eliminated.
◦ maintaining fluid balance,
◦ avoiding fluid excesses,
◦ performing dialysis.
Cont…d
 Cation-exchange resins (sodium
polystyrene sulfonate [Kayexalate]) orally
or by retention enema.
 Sorbitol is often administered in
combination with Kayexalate to induce a
diarrhea-type effect (it induces water loss
in the GI tract).
 Low-dose dopamine (1 to 3 g/kg) is often
used to dilate the renal arteries through
stimulation of dopaminergic receptors.
 Diuretic agents.

Cont…d
Monitoring fluid and electrolyte
balance.
Reduce metabolic rate.
Promoting pulmonary function.
Prevention of infection.
Providing skin care.
Providing support.

5.2. CHRONIC RENAL FAILURE
(END-STAGE RENAL DISEASE)
Chronic renal failure, or ESRD, is
a progressive, irreversible
deterioration in renal function in
which the body’s ability to
maintain metabolic and fluid
and electrolyte balance fails,
resulting in uremia or azotemia
(retention of urea and other
nitrogenous wastes in the blood).
Cont…d
Causes
 Systemic diseases, such as diabetes mellitus
(leading cause).
 Hypertension.
 Chronic glomerulonephritis.
 Pyelonephritis.
 Obstruction of the urinary tract.
 Hereditary lesions, as in polycystic kidney
disease.
 Vascular disorders.
 Infections.
 Medications.
 Environmental and occupational toxic agents
(lead, cadmium, mercury, and chromium).
Cont…d
Stages of Chronic Renal Disease
Stage 1:-Reduced renal reserve
Characterized by a 40% to 75% loss
of nephron function. The patient
usually does not have symptoms
because the remaining nephrons are
able to carry out the normal
functions of the kidney.
It is mild.

Cont…d
Stage 2:-Renal insufficiency
Occurs when 75% to 90% of
nephron function is lost.
At this point, the serum creatinine
and blood urea nitrogen rise, the
kidney loses its ability to concentrate
urine and anemia develops.
The patient may report polyuria and
nocturia.
It is moderate.
Cont…d
Stage 3:-End-stage renal disease
(ESRD)
The final stage of chronic renal failure,
occurs when there is less than 10%
nephron function remaining.
All of the normal regulatory, excretory,
and hormonal functions of the kidney
are severely impaired.
ESRD is evidenced by elevated
creatinine and blood urea nitrogen
levels as well as electrolyte
imbalances.
Cont…d
 Neurologic:- Weakness and fatigue,
confusion, inability to
concentrate, disorientation,
tremors, seizures, asterixis,
restlessness of legs, burning of
soles of feet, behavior changes.
 Integumentary:- Gray-bronze skin
color, dry and flaky skin, pruritus,
ecchymosis, purpura, thin, brittle
nails, coarse and thinning of hair.
Cont…d
 Cardiovascular:- Hypertension; pitting
edema (feet, hands, sacrum);
periorbital edema; pericardial friction
rub; engorged neck veins; pericarditis;
pericardial effusion; pericardial
tamponade; hyperkalemia; cardiac
arrhythymia, hyperlipidemia.
 Pulmonary:- Crackles; thick, tenacious
sputum; depressed cough reflex;
pleuritic pain; shortness of breath;
tachypnea; Kussmaul-type
respirations; uremic pneumonitis;
“uremic lung”.

Cont…d
 Gastrointestinal:- Ammonia
odor to breath (“uremic fetor”);
metallic taste; mouth
ulcerations and bleeding;
anorexia, nausea, and vomiting;
hiccups; constipation or
diarrhea; bleeding from
gastrointestinal tract.
 Hematologic:- Anemia;
thrombocytopenia.
Cont…d
 Reproductive:- Amenorrhea;
testicular atrophy; infertility;
decreased libido.
 Musculoskeletal:- Muscle
cramps; loss of muscle strength;
renal osteodystrophy; bone
pain; bone fractures; foot drop.

Cont…d
 Hx.
 P/E.
 U/A.
 CV examination.
 Respiratory examination.
 E.t.c.

Cont…d
Complications
◦ Hyperkalemia.
◦ Pericarditis, pericardial effusion,
and pericardial tamponade.
◦ Hypertension.
◦ Anemia.
◦ Bone disease and metastatic
calcifications.

Cont…d
Medical Management
 Both Ca and P binding antacids
(aluminum-based antacids) with food to
be effective or calcium carbonate.
 Antihypertensive and Cardiovascular
Agents.
 Antiseizure Agents.
 Erythropoietin (recombinant human
erythropoietin (Epogen)).
 Nutritional therapy.
 Dialysis.

6. Renal hypertension
 Defn-Renal hypertension is
increment of blood pressure in the
renal system.
Cause:-rennin juxtaglamerular cell
tumors, nephroblastomas.

Cont…d
Pathophysiology
 Any condition which reduce the blood flow through
the kidneys or destroy renal function tissue cause
hypertension. Such condition are sclerotic changes or
stenosis of a renal artery (nephritis and polycystic
kidney disease).
 The ischemic kidney reacts by secreting a proteolytic
enzyme called rennin.
 In the blood stream, rennin acts up on a plasma
protein to reduce angiotensin I which is converted
to angiotensin II cause wide spread vasoconstriction
of the arterioles & increased peripheral resistance
leading to an elevation of arterial blood pressure.
 Angiotensin II is also alleged to increase the secretion
of aldosterone by the adrenal glands which as
previously ceiled increase the blood pressure through
its influence on sodium and water retention.

Cont…d
◦ Decrease overall activity of the
kidney.
◦ Acute and chronic
glomerulonephritis.
◦ Polycystic kidney disease.
◦ Chronic pyelonephritis.
◦ Renal artery stenosis.

Cont…d
Mx
◦ Depends up on the cause.
◦ E.g. Ant hypertensive medication
for HTN and dialysis treatment for
renal failure e.t.c….

7. Neoplasm of the kidney
 Renal tumor may arise from renal
capsule parenchyma (renal cell
carcinoma), connective tissue
(sarcomas) or fatty tissue or they
may be neurologic or vascular.
 Almost 90% of tumors are renal
adenocarcinomas, these tumors
occur more frequently in males &
may metastasize early to the lungs,
bone, liver, brain and contra
lateral kidneys.
Cont…d
Risk Factors for Renal Cancer
Gender: Affects men more than
women.
Tobacco use.
Occupational exposure to
industrial chemicals, such as
petroleum products, heavy metals,
and asbestos.
Obesity.
Unopposed estrogen therapy.
Polycystic kidney disease.
Cont…d
 Gross painless Heamaturia.
 Wt loss.
 Weakness (generalized).
 Anemia.
 Flank pain (Colicky pains occur if a clot
or mass of tumor cells passes down the
ureter).
 Some times palpable mass.
 Anorexia.

Cont…d
Method of diagnosis
 Radiological;
 IV or retrograde pyelogram (catheters are advanced
through the ureters into the renal pelvis by means of
cystoscopy. A contrast agent is then injected) to
determine location of neoplasm’s changes in the
renal outline (invasion of the renal pelvis
calcification) etc...
 Cystocopy.
 Renal angiogram (The femoral (or axillary)
artery is pierced with a needle, and a catheter
is threaded up through the femoral and iliac
arteries into the aorta or renal artery. A
contrast agent is injected to opacify the renal
arterial supply) may be done to asses the
expect of blood vessels involvement.
 Ultrasound.

Cont…d
Management
 If disease is localized to one kidney a
radical nephrectomy is performed,
followed by radiation and
chemotherapy.
 If renal pelvis is involved the ureters is
removed along with the kidney,
nephrouerelectomy will be done.
 If the tumor is inoperetable, radiation
therapy is used as a palliative therapy.
 Diet:- a normal diet may be given to
these patients as soon as peristaltic
activity is present.
Cont…d
Pre operative nursing care.
Post operative nursing care.

8. Nephrolithiasis/Urolithiasis
 Nephrolithiasis/Urolithiasis is
the presence of stones in the
kidney and in the urinary tract
respectively.
 The term calculi is refers to the
stone and lithiasis to stone
formation.
 There are many factors involved in
the incidence and type of stone
formation.
Cont…d
 Factors in the development of urinary
tract calculi;
Dietary;
Large intake of dietary proteins
increasing uric acid excretion.
Excessive amount of tea or fruit
juices elevating the urinary oxalate
level.
Large intake of calcium and oxalate.
Excessive intake of vitamin D.
Excessive intake of milk and alkali.
Cont…d
Genetic;
Family hx of stone formation, cystinuria, gout
or renal tubular acidosis.
Life style;
Sedentary occupation, client on bed rest
(affects 320,000 hospitalized patient).
Climate;
High atmospheric temperature resulting in
increased fluid loss, low urine volume, and
increased solute concentration in the urine.
Medications (antacids, acetazolamide
(Diamox), vitamin D, laxatives, and high
doses of aspirin.
Medical disorder (hyperparathyroidism).
Cont…d
Infection (the presence of urease
splitting bacteria such as Proteus,
Pseudomonas, Klebsiella,
Staphylococcus, or Mycoplasma
species).
Inflammatory bowel disease (it
increase the absorption of
oxalate).

Cont…d
Different types of stones are
formed in the urinary tract by
the deposit of different
crystalline substances. Such as
calcium phosphate/oxalate
(75% of all cases), uric acid (5%
to 10% of all stones), cystine
stone (1% to 2% of all stones) &
struvite (15% of urinary calculi)
which are excreted in the urine.
Cont…d

Cont…d
 The manifestation of renal calculus
depend upon the size of the stone
of the stone, obstruction,
infection, and edema, and whether
it remains stationary.
 It may remain latent over a long
period, producing no symptoms.
 Small gravel-like stones may be
passed without any disturbance.

Cont…d
◦ Increase in hydrostatic pressure.
◦ Infection (pyelonephritis and cystitis
with chills, fever, and dysuria).
◦ An intense, deep ache in the
costovertebral region (Stones in the
renal pelvis) that radiates anteriorly
and downward toward the bladder in
the female and toward the testis in
the male).
◦ Hematuria.
◦ Pyuria.
Cont…d
Ureteral colic symptom (Stones
lodged in the ureter (ureteral
obstruction) cause acute,
excruciating, colicky, wavelike
pain, radiating down the thigh
and to the genitalia. Often, the
patient has a desire to void, but
little urine is passed, and it
usually contains blood because of
the abrasive action of the stone.
Cont…d
Findings
Hx.
P/E.
X-ray films of the kidneys, ureter, and
bladder (KUB)
Ultrasonography.
Intravenous urography.
 Retrograde pyelography.
Blood chemistries.
A 24-hour urine test.
Cont…d
Medical Management
 The basic goals of management are;
to eradicate the stone.
to determine the stone type.
to prevent nephron destruction.
to control infection,
to relieve any obstruction.
to relieve the pain.

Cont…d
It includes;
 Opoid analgesics.
 NSAIDs.
 Hot baths or moist heat to the flank
areas.
 Encourage fluids intake.
 Nutritional therapy.

Cont…d
Dietary Recommendations for Prevention of
Kidney Stones;
 Restricting protein to 60 g/day is
recommended to decrease urinary excretion of
calcium and uric acid.
 A sodium restriction of 3–4 g/day is
recommended. Table salt and high-sodium
foods should be reduced because sodium
competes with calcium for reabsorption in the
kidneys.
 Low-calcium diets are not generally
recommended, except for true absorptive
hypercalciuria.
 Restricting oxalate-containing foods (spinach,
strawberries, tea, peanuts, wheat bran).

9. Nephrosclerosis
 It is hardening, or sclerosis, of the arteries of
the kidney due to prolonged hypertension.
Pathophysiology
 There are two forms of nephrosclerosis:
Malignant (accelerated);
 Often associated with malignant hypertension
(diastolic blood pressure higher than 130 mm Hg).
 It usually occurs in young adults, and men are
affected twice as often as women.
 The disease process progresses rapidly. Without
dialysis, more than half of patients die from uremia
in a few years.
Benign;
 It is usually found in older adults and is often
associated with atherosclerosis and
hypertension.

Cont…d
◦ Hx.
◦ P/E.
◦ U/A.
◦ E.t.c.
Medical Management
◦ Aggressive antihypertensive therapy.
◦ ACE inhibitor, alone or in
combination with other
antihypertensive medications.
10. Hydronephrosis
It is dilation of the renal pelvis and calyces
of one or both kidneys due to an obstruction.
Cause
Obstruction to the normal flow of urine due
to;
Renal stone.
Tumor.
Kinking.
Odd angle of the ureter (altered
anatomical position of kidney).
Pregnancy.
BPH.
Cont…d
Pathophysiology
 Obstruction to the normal flow of urine causes
the urine to back up, resulting in increased
pressure in the kidney.
 If the obstruction is in the urethra or the
bladder, the back pressure affects both kidneys,
but if the obstruction is in one of the ureters only
one kidney is damaged.
 Whatever the cause, as the urine accumulates in
the renal pelvis, it distends the pelvis and its
calyces. In time, atrophy of the kidney results.
 As one kidney undergoes gradual destruction, the
other kidney gradually enlarges (compensatory
hypertrophy).
 Ultimately, renal function is impaired.

Cont…d
 Aching in the flank and back
(acute obstruction).
 Dysuria, chills, fever,
tenderness, and pyuria (If
infection is present).
 Hematuria and pyuria.
 Signs and symptoms of chronic
renal failure (If both kidneys are
affected).
Cont…d
Medical Management
The goals of management are;
◦ to identify and correct the cause of the
obstruction.
◦ to treat infection.
◦ to restore and conserve renal function.
It includes;
◦ Nephrostomy or another type of
diversion.
◦ Antibiotic agents.
◦ Surgical removal of obstructive lesions.
◦ Nephrectomy.

11. Renal TB
 It is the involvement of renal system by
tuberculosis infection.
Pathophysiology
 Tuberculosis of the urinary tract is caused
by the organism Mycobacterium
tuberculosis.
 The organism usually travels from the lungs
by means of the bloodstream
(hematogneous spread) to the kidneys.
 On arrival in the kidney, the microorganism
may lie dormant for years. After the
organism reaches the kidney, a low-grade
inflammation and the characteristic
tubercles are seen.
Cont…d
Ifthe organism continues to
multiply, the tubercles enlarge
to form cavities, with eventual
destruction of parenchymal
tissue.
The organism spreads down the
urinary tract into the bladder
and may also infect the
prostate, epididymis, and
testicles in men.
Cont…d
◦ Slight afternoon fever.
◦ Weight loss.
◦ Night sweats.
◦ Loss of appetite.
◦ general malaise.
◦ Hematuria (microscopic or gross) and
◦ Pyuria.
◦ Pain, dysuria, and urinary frequency
(due to bladder involvement).
Cont…d
Urine culture.
ESR.
PCR (polymerase chain
reaction) (PCR).
Intravenous urography.
Biopsy.

Cont…d
Medical Management
 The goal of treatment is to eradicate the offending
organism.
 Combinations of ethambutol, isoniazid, and rifampin
are used to delay the emergence of resistant organisms.
 Shorter-course chemotherapy (4 months) has been
effective in eradicating the organism and in
penetrating renal tissue.
 Surgical intervention may be necessary to treat
obstruction and to remove an extensively diseased
kidney.
 Proper nutrition, adequate rest, and good hygiene
practices.
 A scrotal support may be used by male patients with
genital swelling.

Cont…d
Nursing Management
Patient education to promote effective
self-care at home.
Instructions are provided about taking
prescribed medications properly,
recognizing adverse effects, and
understanding the importance of
completing the course of therapy.
Instructions are also given regarding
the nature of tuberculosis; its cause,
spread, and treatment; and necessary
follow-up care.
Cont…d
Men are instructed to use condoms
during sexual intercourse to
prevent spread of the organisms;
those with penile or urethral
tuberculosis are instructed to
abstain from intercourse during
treatment.
The patient is encouraged to
maintain a healthy lifestyle with a
well-balanced diet, adequate
intake of fluids, and exercise.
Cont…d
The patient is counseled about the
need for follow-up examinations
(urine cultures, intravenous
urograms), usually for 1 year.
Treatment is reinstituted if a
relapse occurs and the tubercle
bacilli again invade the
genitourinary tract.
Monitored for these complications.
12. Renal cysts
Renal cysts are abnormal, fluid-filled
sacs that arise from the kidney tissue.
They may be genetic in origin, acquired,
or associated with a host of unrelated
conditions.
Cysts of the kidney may be single or
multiple (polycystic), involving one or
both kidneys.
Polycystic disease of the adult is
inherited as an autosomal dominant
trait and affects men and women
equally.
Autosomal dominant polycystic
kidney disease
Autosomal dominant polycystic kidney
disease is a common inherited
condition, occurring in between 1 in
200 and 1 in 1,000 of the population.
Renal stone disease is also common,
occurring in 20% of patients.
Polycystic renal disease is also
associated with cystic diseases of
other organs (liver, pancreas, spleen)
and aneurysms of the cerebral
arteries.

Cont…d
Ithas long been recognized that
patients on long term dialysis
(both hemodialysis and
peritoneal dialysis) develop
multiple cysts on their
nonfunctioning kidneys.
Many of these cysts contain
cancer cells.

Acquired cystic kidney disease
An acquired form of polycystic
disease occurring as a result of
ESRD associated with dialysis is
called acquired cystic kidney
disease.
Acquired cystic kidney disease has
been associated with cyst infection,
cyst hemorrhage, retroperitoneal
hemorrhage, and spontaneous
rupture of the kidney.
Cont…d
Abdominal or lumbar pain.
Hematuria.
Hypertension.
Palpable renal masses.
Recurrent UTIs.
Renal insufficiency and failure.

Cont…d
Diagnostic method
◦ Intravenous urography.
◦ CT scan.
◦ Transabdominal ultrasound.
◦ Urine cytology.

Cont…d
Management
 Patient care focuses on relief of pain, symptoms,
and complications.
 Hypertension and UTIs are treated aggressively.
 Dialysis is initiated when signs and symptoms of
renal insufficiency and failure occur.
 Genetic counseling is part of management with
polycystic kidney disease that is genetic in origin.
 The patient is advised to avoid sports and
occupations that present a risk for trauma to
the kidney.
 Cyst drainage percutaneously for simple cyst.
 Rest and antibiotic treatment.

Diseases of ureters, bladder
and urethra
1. Uretric disorder
 Primary disorder of the ureters occurs
less frequently than disease of the
other part of the urinary system.
 A congenital anomaly or rarely a
neoplasm may occur in ureters.
 The most common anomaly is a defect
at the opening of the ureters in to the
bladder normally urine can only flow the
ureters in to the bladder.

Cont…d
 The ureters vesicle defect
permits a urinary reflux a
background flow of urine in to
the ureter from the bladder this
predispose pyelonephritis.
 Surgery is carried out to correct
the defect primary neoplasm of the
ureters is quite rare.

A. Ureteritis
 Ureteritis is an inflammation of
ureter.
Cause
Infection (e.g. pyelonephritis).
Renal stone.
Neoplasm.
 e.t.c
Mgx
 Treatment of pyelonephritis.
 Surgery.
B. Ureteral constriction
 It is narrowing of the ureters.
Cause
Infection.
Foreign body.
Congenital anomaly.
Tumors.

Cont…d
◦ Patient shows all the sign and
symptom of infection.
◦ E.g. Pain and other urinary
compliants.
Mgx
◦ Surgical intervention;
 Uretroplasty.
 Anastomosis.
◦ Analgesics.
◦ Antispasmodics.
2. Disorder of the bladder
A. Cystitis
 Cystitis is an acute or chronic
inflammation of the urinary
bladder characterized by
frequency, urgency and dysuria
and abnormal urinary
constituents.
 Incidence is common in female
because of shorter urethra.

Cont…d
Cause
◦ Ascending bacteria infection from
the urethra.
◦ Urethrovesicular reflux (flowing back
of urine from the urethra in the
bladder).
◦ Organisms from rectal and vaginal
discharge can enter easily.
◦ Mechanical (use of catheters and
other examination objects &
administration of some drugs).
Cont…d
◦ Predisposing factors (e.g. in infective
cystitis are trauma of the tissue,
stagnation of urine and distortion or
compression of the bladder by outer
large neighbor organs).
◦ Congenital malformation (e.g.
hypospadiasis).
◦ In male prostatic hyperplasia or
infection may cause cystitis.

Cont…d
 Altered urinary pattern (urgency,
frequency and dysuria).
 Suprapubic pain.
 Dysuria & Foul Smelling urine.
 In Some Individuals Haematuria.
 The Presence of Fever, Nausea,
vomiting & flank tenderness
usually indicate pyelonephritis.

Cont…d
Method of diagnosis
◦ Hx.
◦ P/E.
◦ Urinalysis.
◦ Urine for culture and
sensitivity.
◦ Radiological examination.
◦ Cystoscopy.
Cont…d
Mgx
Analgesic (Antispasmodics).
Sodium bicarbonate relives bladder
irritation.
Increase fluid intake.
Antimicrobial drugs for 10 -14
days. E.g. Sulfonamides and
antibiotics.
Health education e.g. about use of
fluid intake, regular emptying of
bladder etc.
B. Bladder Stone (Calculi)
Itis the formation of stone in the
bladder.
Cause
◦ Urinary stasis (in prostate
hypertrophy).
◦ Neurological disease or injury that
hat resulted in the loss of voluntary
bladder control or interruption of the
sacral reflex arc.
◦ Bladder diverticula’s.

Cont…d
◦ Urethral stricture or prolonged
immobility.
◦ Dehydration ( increased urine
concentration).
◦ Indwelling catheter for a prolonged
period of time.
◦ Infection.

Cont…d
◦ Sudden cessation of urinary flow.
◦ Haematuria.
◦ Sever pain during micturation.
Methods of diagnosis
 Cystoscopy
 Radiological Examination;
 IVP.
 U/S.
Cont…d
Mgx
 Mechanical crushing of the
stone by ultrasonic lithotripsy.
 Surgery (cystolithotomy).
 Large amount of fluid to help
wash of the bladder.
 Cause should be treated (e.g.
prostatic hypertrophy).

C. Trauma of the bladder
 It is a kick or blow in the lower
abdomen when the bladder is full.
 In accidental injury if urinary
bladder causing perforation and
ensuring extravasations of the
urine (escape of urine from the
bladder) is common.
 It may occur when the pelvis is
fractured.
 If the bladder is full and distended
at the time of accident it is more
vulnerable.
Cont…d
Cause
◦ Trauma.
◦ Accidental direct kick or blow.
◦ E.t.c...
Intra peritonial rupture:-
peritonitis due to escape of urine in
to the peritoneal cavity (necrosis).
Sever pain of abdomen.
Tenderness of abdomen.
Distended abdomen.

Cont…d
Shock.
Extraperitonial rupture:- urine
escapes in to the surrounding
tissue cause cellulites, infection
and necrosis of tissue.
Abdominal and peritoneal
fistula develops.

Cont…d
Method of Diagnosis
◦ Urinalysis.
◦ Cystoscopy.
Mgx
Shock and hemorrhage should be
treated with blood transfusion and
IV infusion.
An indwelling catheter is inserted
in to the bladder and prepare patient
for abdominal surgery.
Cont…d
Surgical intervention
The site of injury is repaired and
temporary cystostomy (incision of
the bladder and introduction of
suprapubic catheter) done to
establish urinary drainage &
prevent the possibility of pressure
on the repair suture line .
If the rupture was in intraperitonial
the extravsated fluid should be
aspirated before closure.
Cont…d
StrictObservation for sign of
shock (Infection).
An accurate fluid intake and out
put should be done.
Antimicrobial drugs may be
administered.

D. Tumor (neoplasm) of the
bladder
Neoplasm in the bladder may
develop at any age but have more
frequently after the age of 50
years and have a high incidence
in male than in female (3:1).

Cont…d
cause
◦ Cigarette smoking.
◦ Carcinogens in the work environment
such as dyes, rubber, leather ink or
paint.
◦ Chronic parasitic infestations that
irritates the bladder (E.g. schistosmasis).
◦ Cancer arising from another place
(prostate, colon and rectum in and from
the lower gynecologic tract in female)
may metastasize to the bladder.

Cont…d
◦ Gross painless heamaturia.
◦ Cystitis – frequency, urgency &
dysuria.
◦ Pelvic and for back pain may be due
to metastasis.
◦ Renal failure due to obstruction of
ureter cause hydronephrosis.
◦ Anemia may be develop as a result
the patient manifests weakness &
loss of body weight.
Cont…d
Method of Diagnosis
Urinalysis.
Cystoscopy.
Cystogram
Biopsy.
CT scans.
Ultrasound examination.

Cont…d
Mgx
 Treatment of bladder cancer depends on the
grade and growth of the tumor, the patients
age, physical, mental & emotional status are
considered in determining treatment modalities.
 Surgical interventions = Cystostomy or partial
cystectomy.
 Radiation.
 Chemotherapy.
 Combination of surgery, radiation &
Chemotherapy.
 Encourage fluid intake.
 Seitz bath.
 Psychological and emotional support.

E. Diverticulum's of the
bladder
A pouch or sac protruding from
the wall of the bladder.
It results from long period of
voiding against resistance
obstruction at the bladder neck
or in the urethra and inherent
weakness of the musculature of
the bladder.

Cont…d
Common in male due to the
hypertrophy of prostate.
The condition is frequently
complicated by sepsis, stone
formation and the occurrence of
new tissue growth.
Mgx
 Treating the cause.
 Excision of the diverticulum.
3. Disorder of the urethara
A. Urethritis
 It is an inflammation of the urethral
mucosa usually an ascending.
 There is gonorrheal and non
gonorrheal urethritis.
Cause
◦ Bacterial (gonococci streptococcal,
e.t.c..)
◦ Viral.
◦ Protozoan (trichomonal).
◦ Fungal.
◦ Trauma.

Cont…d
Dysuria, frequency.
Burning sensation during
micturatin.
Discharge (yellowish green
could be scanty or profuse, thin
or mucoids thick and purulent).

Cont…d
Method of Diagnosis
Urinalysis.
Urine culture (smear of discharge
(gram stain and wet smear).
Mgx
Antimicrobial drugs depending on to
causative microorganisms.
Analgesics if necessary.
Perennial care after bowel movement.
Urinary antiseptics.
Encourage to drink copious amount of
fluid.
B. Urethral Stricture
Itis a narrowing of the lumen of the
urethra due to scar tissue and
contraction.
Causes
Injury - insertion of surgical instruments
during transurethral surgery, indwelling
catheter or cystoscopic procedure.
Straddle injuries.
Automobile Accident.
Untreated Gonorrhea.
Congenital Abnormality.

Cont…d
◦ The force & size of urinary stream is
diminished and symptoms of
urinary infection and retention
occur.
◦ Stricture cause urine to back up
resulting in cystitis, prostatitis and
pyelonephritis.

Cont…d
Mgx
 Dilatation of the narrowed area.
 Operation under direct vision- internal
urethrotomy (surgical removal of the
stricture).
 Hot sitz bath and non - narcotic
analgesics are given to control pain.
 Antimicrobial drugs are given for several
days after dilatation to minimize infection.
 Surgical excision or urethroplasty may be
necessary for sever cases.
 Rarely a temporary cystostomy is
necessary, b/c of sever retention.

4. Disorder of Male reproductive system
A. Prostatitis
 Prostatitis
is inflammation of
prostate gland caused by infections
agent.
Cause
◦ Infections agents – bacterial (E.coli,
klebsiella), fungi & mycoplasma.
◦ Urethral stricture.
◦ Hyperplasia of prostate (BPH).
Microorganisms usually are carried
to the prostate from the urethra.
Cont…d
◦ Perineal pain and discomfort.
◦ Urethrtitis-Urgency, frequency and
dysuria.
◦ Prastatodynia (pain in the prostate)
on voiding.
◦ Acute bacterial prostatitis may
produce a sudden on set of fever &
chills.
◦ Perineal, rectal, low back pain and
dysuria.
Cont…d
Methods to Diagnosis
◦ Careful history.
◦ Culture of prostate fluid or tissue.
◦ Urine culture.
◦ Digital examination.
Mgx
The goal of treatment is to avoid the
complication of abscess formation and
septicemia.
A broad spectrum antimicrobial drugs
for 10 - 14 days, I.V administration of
the drug may be necessary to achieve
high serum and tissue level.
Cont…d
Bed rest, antispasmodics, laxatives to
soften stool and sitz bath.
Patient education
◦ Foods and liquids that have diuretic
action or that increase prostatic
secretions, such as alcohol, coffee, tea,
chocolate, cola, and spices, should be
avoided.
◦ Avoidance of sexual intercourse during
acute inflammation.
◦ Prolonged sitting also be avoided.
◦ Medical follow up for at least 6 months
to 1 year.

5. Benign prostatic hyperplasia
(hypertrophy)-BPH
 Itis the most common problem of
the adult male reproductive
system.
 This problem occurs in about 50
percent of men over 50 years of
age and 75% of men over 70 years.
 The prostate gland enlarges
extending up ward in to the bladder
and obstructing the outflow of urine
by encroaching on the vesicle orifice.

Cont…d
Cause
 Uncertain but evident suggests a
hormonal (effect of androgen
hormone) cause as initiating
hyperplasia of the supporting
stromal tissue and a glandular
element in the prostate.
 Other factors that cause over
production of this responsible
hormone, such as infection.
Cont…d
 Increasing potency of urination.
 Nocturia, hesitancy.
 In starting urination increasing of force of
urinary stream but a decrease and interruption
of urinary stream will occur.
 Sensation of incomplete emptying of the
bladder.
 Urine dribbles out after urination.
 An acute urinary retention (infection).
 Fatigue secondary to anorexia, nausea and
vomiting due to impaired renal function.
 Epigastric discomfort due to distended bladder.
 Heamaturia, uremia at the later stage.

Cont…d
Diagnostic Evaluation
 Rectal examination.
 Complete hematological
investigation (CBC).
 X-ray.
 Cystoscopy examination.
 RFT.

Cont…d
Mgx
The plan of treatment depends on the
cause, the severity of obstruction, the
condition of the patient, age.
Catheterization to treat an acute
urinary retention.
Some times a suprapubic cystostomy
to give adequate drainage.
Water and electrolyte replacement in
necessary.
Antimicrobial drugs may be necessary
to treat UTI.

Cont…d
 Alpha-adrenergic receptor blockers (e.g,
terazosin [Hytrin]) relax the smooth
muscle of the bladder neck and prostate.
 5-alpha-reductase inhibitors such as
finasteride have been effective in
preventing the conversion of
testosterone to dihydrotestosterone
(DHT).
 Prostatectomy:-surgery to remove the
hyper plastic prostate tissue to provide
permanent relief of the obstruction.
Cont…d
1. Transurethral Resection.
Not require abdominal incision; it is a
removal of prostatic tissue by instrument
introduced through urethra.
2. Suprapubic Prostatectomy.
Require open surgery, an opening made in
the bladder.
3. Perineal prostatectomy.
Require open surgery-an incision made in
the perineum.
4. Retro pubic Prostatectomy.
 Requires open surgery-a low abdominal
incision is made.

Cont…d
Per-operative nursing care
◦ Assessment of the pts general
health status.
◦ Adequate nutrition.
◦ Adequate rest to have best physical
condition before surgery.
◦ Appropriate antimicrobial drug to
come back infection.
◦ Foley catheter maybe inserted.
◦ Reduce Anxiety.

Cont…d
Post-operative nursing care
◦ Frequent observation for symptoms of
shock & hemorrhage.
◦ Frequent observation for infection &
thrombosis.
◦ Urologist should change dressing on the
first post operative day.
◦ Careful aseptic technique is practiced.
◦ Rectal temperature, rectal tubes and
enemas are to be avoided.
◦ Pts undergoing prostatectomy (with the
exception of transurethral resection)
have a high incidence of develop vein
thrombosis.
Cont…d
◦ Dressing should be changed frequently
for drainage and bleeding.
◦ Encourage fluid in take.
◦ In take and out put should be recorded.
◦ If the pt is too old additional attention
must be given (skin care, frequent change
of position keeping the pt safe e.t.c…).
◦ Following transurethral prostatic
resection the catheter must drain well.
◦ Furosemide is given to initiate post
operative diuresis to keep the catheter
potent.

Cont…d
◦ Check V/S.
◦ Analgesics.
◦ Patient Education.
 Encourage to walk not to sit for long
times.
 Keep bowel movement soft.
 Should be advised not to urinate as
soon as the desire to do so felt.
 Avoid heavy exercise and lift.
 Spice food, alcohol, coffee etc should
be avoided may cause discomfort .
 Encourage to take fluid.
C. Cancer of the prostate
gland
Cancer of the prostate is the
second most common cause of
cancer.
The most prevalent cancer
overall in black men with
increasing number of men in
the old age group.
Due to this greater attention will
be focused on this condition .
Cont…d
Risk factor
 Age
 A familial predisposition
 A diet high in red meat and fat.
Cause
 Unknown/Idiopathic.

Cont…d
Clinical manifestation
 Early Ca of the prostate does not
usually produce symptoms if the
neoplasm is large enough to
encroach on the bladder neck and
cause obstruction of urine.
There are signs and symptoms of
obstruction namely;
◦ Difficulty & frequent urination.
◦ Urinary retention.
◦ Decreased size and force of urinary
stream.
Cont…d
Method of Diagnosis
 Finger rectal examination; palpable of it is
advanced, stony hard.
 Histological examination by surgically
transurethral resection, open prostatectomy
or needle biopsy perennial or trans rectal.
 Serum acid phosphate level is frequently
increased.
 Skeletal x-ray to revel osteoblastic
metastasis.
 Urogram to demonstrate changes from
urethral obstruction.
 RFT.

Cont…d
Mgx
 Radical Prostatectomy.
 Radiation as a palliative therapy.
 Hormonal therapy maybe selected to
suppress all androgenic stimulation to the
prostate due to orchiectomy or
administration of estrogen.
 Blood transfusion.
 Analgesics.
 Strict observation.
 V/S check up.
 Sign of anemia, shock, fluid balance etc...
Should be checked.
D. Hydrocele
A hydrocele is a collection of fluid
generally in the tunica vaginalis of
testis.
The tunica vaginalis become widely
distended with fluid.
Cause
◦ Occurs in association with acute
infectious disease of the epididymitis,
such as mumps .
◦ The cause of chronic hydrocele is
unknown.
Cont…d
Mgx
Usually therapy is not required.
Treatment is necessary only of the
hydrocele become tense and
comprise testicular circulation or
if the scrotal mass becomes large,
uncomfortable or embarrassing.
Withdrawing the fluid through a
large needle or removing the sac
of the fluid.

Cont…d
Surgical incision through the
wall of the scrotal down to the
distended tunica vaginalis.
Some time sclerotic substance is
injected in to the sac after
aspirating fluid to cause the wall
of hydrocele to become inflamed
and disappear.
Eventually post operative scrotal
support is done.
D. Varicocele
A varicocele is an abnormal
dilation of the veins of the
pampiniform venous plexus in
the scrotum (the network of veins
from the testis and the
epididymis that constitute part of
the spermatic cord).
Varicoceles usually occur in the
veins on the upper portion of the
left testicle in adults.
Cont…
In some men, a varicocele has
been associated with
infertility.
Few, if any, subjective
symptoms may be produced
by the enlarged spermatic
vein.

Cont…d
C/M
Pain.
Tenderness.
Discomfort in the
inguinal region.

Cont…d
Mgx
No treatment is required unless
fertility is a concern.
It is corrected surgically by
ligating the external spermatic
vein at the inguinal area.
An ice pack may be applied to the
scrotum for the first few hours
after surgery to relieve edema.
The patient then wears a scrotal
supporter.
E. Epididymitis
 Epididymitis is an infection of
the epididymis that usually
descends from an infected
prostate or urinary tract.
Cause
 Complication of gonorrhea.
 Chlamydia trachomatis (In men
younger than age 35).

Cont…d
C/M
Unilateral pain and soreness in the
inguinal canal along the course of the
vas deferens.
Pain and swelling in the scrotum and
the groin.
The epididymis becomes swollen and
extremely painful.
Temperature is elevated.
Pyuria and bacteriuria.
Chills and fever.
Cont…d
Medical management
 If the patient is seen within the first 24 hours after
onset of pain, the spermatic cord may be infiltrated
with a local anesthetic agent to relieve pain.
 If the epididymitis is from a chlamydial infection,
the patient and his sexual partner must be
treated with antibiotics.
 The patient is observed for abscess formation as
well.
 If no improvement occurs within 2 weeks, an
underlying testicular tumor should be considered.
 An epididymectomy (excision of the epididymis
from the testis) may be performed for patients with
recurrent, incapacitating episodes of
epididymitis or for those with chronic, painful
conditions.

Cont…d
Nursing Management
 Bed rest.
 Scrotum is elevated with a scrotal bridge
or folded towel to prevent traction on the
spermatic cord and to promote venous
drainage and relieve pain.
 Antimicrobial agents are administered as
prescribed until the acute inflammation
subsides.
 Intermittent cold compresses to the
scrotum may help ease the pain. Later,
local heat or sitz baths may help resolve the
inflammation.

Cont…d
Analgesic medications are administered
for pain relief as prescribed.
Health education;
◦ to avoid straining, lifting, and
sexual stimulation until the
infection is under control.
◦ continue taking analgesic agents
and antibiotics as prescribed and
◦ using ice packs if necessary to
relieve discomfort.

F. Orchitis
 Orchitis is an inflammation of the
testes (testicular congestion).
Cause
 Pyogenic (bacterial).
 Viral.
 Spirochetal.
 Parasitic.
 Traumatic.
 Chemical.
 Unknown factors.

Cont…d
Medical Management
Directed at the specific infecting
organism.
Rest.
Elevation of the scrotum.
Ice packs to reduce scrotal edema.
Antibiotics.
Analgesic agents.
Anti-inflammatory medications.
G. Hypospadias and Epispadias
Hypospadias and epispadias are
congenital anomalies of the
urethral opening.
 In hypospadias, the urethral
opening is a groove on the underside
of the penis.
In epispadias, the urethral opening
is on the dorsum.
These anatomic abnormalities may
be repaired by various types of
plastic surgery, usually when the
boy is very young.
H. Phimosis and Paraphimosis
1. Phimosis, a condition in which
the foreskin is constricted so that
it cannot be retracted over the
glans.
Cause
Congenitally.
Inflammation.
Edema.

Cont…d
With the trend away from routine
circumcision of newborns, early
instruction should be given
about cleansing the prepuce.
In elderly men, penile carcinoma
may develop.
Mgx
Phimosis is corrected by
circumcision.
Cont…d
2. Paraphimosis is a condition in
which the foreskin is retracted
behind the glans and, because of
narrowness and subsequent
edema, cannot be returned to its
usual position (covering the glans).

Cont…d
Mgx
◦ Manual reduction:-by firmly
compressing the glans to reduce
its size and then pushing the
glans back while simultaneously
moving the prepuce forward.
◦ Circumcision is usually
indicated after the inflammation
and edema subside.
I. Cancer of the penis
Penile cancer occurs in men
older than age 60.
Since most penile cancers occur
in uncircumcised men, it has
been suggested that the etiology of
this cancer may be the irritative
effect of smegma and poor
hygiene.

Cont…d
Cancer of the penis appears on
the skin of the penis as a
painless, wartlike growth or
ulcer.
Cancer of the penis can involve
the glans, the coronal sulcus
under the prepuce, the corporal
bodies, the urethra, and regional
or distant lymph nodes.
Cont…d
Medical Management
 Excision (for smaller lesions involving only
the skin).
 Topical chemotherapy with 5-fluorouracil
cream.
 Radiation therapy is used to treat small
squamous cell carcinomas of the penis or
for palliation in advanced tumors or lymph
node metastasis.
 Partial penectomy (removal of the some
part of penis).
 Total penectomy is indicated when the
tumor is not amenable to conservative
treatment.
Congenital malformation of
the urinary tract
1. Horseshoe kidney
 Horseshoe kidney is abnormal
fusion of the lower portion of the
kidneys during fetal development.
 It is often associated with other
anomalies.
 The two kidneys are normally
separated.
 The condition is asymptomatic but
it can increase the risk of
kidney disease and complications.

Cont…d
Cause
Congenital disorder.
Wilm's tumour.
Transitional cell carcinoma.
Turner syndrome.
Vesicourethral reflux.

Cont…d
C/M
 Asymptomatic.
 Fusion of kidney.
Dx
Hx.
P/E.
Mgx
It depends on the renal problem that
occur following this problem.

2. Duplication of the ureter
Duplicated ureter is a congenital
condition in which the ureteric bud
(the embryological origin of the
ureter), splits (or arises twice),
resulting in two ureters draining a
single kidney.
It is the most common renal
abnormality, occurring in
approximately 1% of the population.
The additional ureter may result in a
ureterocele, or an ectopic ureter.
Cont…d
Classification
Ureteral duplication is either:
◦ Partial
 The two ureters drain into the bladder
via a single common ureter.
 Partial, or incomplete, ureteral duplication
is rarely clinically significant.

Cont…d
◦ Complete
 The two ureters drain separately.
 Complete ureteral duplication
may result in one ureter opening
normally into the bladder, and the
other being ectopic, ending in the
vagina, the urethra or the vulval
vestibule.
 These cases occur when the
ureteric bud arises twice (rather
than splitting).

Cont…d
C/M
Urinary tract infection - most
commonly due to vesicoureteral
reflux.
Urinary incontinence in females
occurs in cases of ectopic ureter
entering the vagina, urethra or
vestibule.

Cont…d

Cont…d
Mgx
 It depends on the renal problem
associated to this congenital
problem.

Dialysis
 Dialysis also defined as movement
of fluid and particles across a semi
permeable membrane from one
compartment to another.
 Dialysis is the process of separating
crystalloids and colloids in solution
by the difference in their rates of
diffusion through a semi permeable
membrane: crystalloids pass
through readily, colloids very
slowly or not at all.
Cont…d
Used to remove fluid and uremic
waste products from the body
when the kidneys cannot do so.
The two methods used as an
artificial membrane (cellophane
or cuprophane) as the dialyzing
surface which is in contact with
the client’s blood.

Cont…d
Dialysis in general, used to correct
fluid & electrolyte imbalances,
remove wastes products and
drugs, and replace renal
function in acute and chronic
renal failure.

Cont…d
Methods of therapy include
hemodialysis, continuous renal
replacement therapy (CRRT) and
various forms of peritoneal
dialysis.
The need for dialysis may be
acute or chronic.

Cont…d
Acute dialysis;
◦ It is indicated when there is a
high and rising level of serum
potassium, fluid overload, or
impending pulmonary edema,
increasing acidosis,
pericarditis, and severe
confusion.

Cont…d
Itmay also be used to remove
certain medications or other
toxins (poisoning or medication
overdose) from the blood.

Cont…d
Chronic or maintenance dialysis;
 It is indicated in chronic renal failure,
known as end-stage renal disease (ESRD),
in the following instances: the presence of
uremic signs and symptoms affecting all
body systems (nausea and vomiting,
severe anorexia, increasing lethargy,
mental confusion), hyperkalemia, fluid
overload not responsive to diuretics and
fluid restriction, and a general lack of well-
being.
 An urgent indication for dialysis in
patients with chronic renal failure is
pericardial friction rub.

Hemodialysis
The most commonly used method of
dialysis which is used for patients who
are acutely ill and require short-term
dialysis (days to weeks) and for
patients with ESRD who require long-
term or permanent therapy.
A dialyzer (once referred to as an
artificial kidney) serves as a synthetic
semipermeable membrane, replacing
the renal glomeruli and tubules as the
filter for the impaired kidneys.

Cont…d
For patients with chronic renal
failure, hemodialysis prevents
death, although it does not cure
renal disease and does not
compensate for the loss of
endocrine or metabolic activities
of the kidneys.
Patients receiving hemodialysis
must undergo treatment for the
rest of their lives or until they
undergo a successful kidney
transplantation.
Cont…d
Hemodialysis system:
◦ Blood from an artery is pumped into a
dialyzer where it flows through the
cellophane tubes, which act as the
semipermeable membrane (inset).
◦ The dialysate, which has the same
chemical composition as the blood
except for urea and waste products,
flows in around the tubules.
◦ The waste products in the blood diffuse
through the semipermeable membrane
into the dialysate.
Cont…d
Complications of Hemodialysis
 Hypotension.
 Painful muscle cramping.
 Dysrhythmias.
 Air embolism.
 Chest pain because of anemia or
on pt with arteriosclerotic heart
disease.

Peritoneal dialysis
Peritoneal dialysis may be the
treatment of choice for patients
with renal failure who are unable or
unwilling to undergo hemodialysis
or renal transplantation.
In peritoneal dialysis, the
peritoneum, a serous membrane
that covers the abdominal organs
and lines the abdominal wall, serves
as the semipermeable membrane.
Cont…d
Sterile dialysate fluid is introduced into
the peritoneal cavity through an
abdominal catheter at intervals.
Urea and creatinine, metabolic end
products normally excreted by the
kidneys, are cleared from the blood by
diffusion and ossmosis as waste
products move from an area of higher
concentration (the peritoneal blood
supply) to an area of lower
concentration (the peritoneal cavity)
across a semipermeable membrane
(the peritoneal membrane).

Cont…d
Complications of Peritoneal
Dialysis;
 Peritonitis.
 Leakage of diayalysate.
 Bleeding.
 Long-term complications
includes hernias (inscisional),
cardiodiovascular.

Nursing responsibilities for
a patient with Cystostomy
 A cystotomy is a surgical opening created
in the wall of the urinary bladder.
 This procedure allows the surgeon to look
inside the bladder.
Indications
 removal of bladder stones, bladder
tumors, and blood clots
 to obtain a biopsy sample of the urinary
bladder
 to repair a rupture or severe trauma to
the urinary bladder
 abnormal insertion of the ureters into
the bladder

Cont…d
Preoperative care
 Lab test
 Radiographs (x-rays)
 abdominal ultrasound
 complete blood count
 serum biochemical test
 urinalysis
 EKG
 General anesthesia
Cont…d
Postoperative care
 safe and effective pain medicines.
 urinary catheter will have been placed at
surgery.
 home care requires reduced activity until
the stitches are removed in 10 to 14 days.
 inspect the suture line daily for signs of
redness, discharge, swelling, or pain and
monitor your pet's urinary habits.
 Some blood-tinged urine is expected for the
first few days, but obvious pain, straining or
a lack of urination is not normal and should
prompt a call to your
veterinarian/physician.
Cont…d
Complications
general anesthesia
bleeding (hemorrhage)
postoperative infection
urine leakage
wound breakdown (dehiscence)

Nursing responsibilities for
a patient with Nephrectomy
 Nephrectomy is the surgical removal of
a kidney.
Indications
Renal cell carcinoma.
A non-functioning kidney.
A congenitally small kidney.
Nephrectomy is also performed for the
purpose of living donor kidney
transplantation.
Partial Nephrectomy has also been
performed to repair injury e.g. rupture,
caused by trauma such as falls and motor
vehicle accidents.

Cont…d
Care after the procedure
◦ Pain medication is often given to the
patient after the surgery because of
pain at the site of the incision.
◦ An IV with fluids is administered.
◦ Electrolyte balance and fluids are
carefully monitored.
◦ A patient has to stay in the hospital
between 2 and 7 days depending on
the procedure and complications.

Fluid and
electrolytic
balance

Fundamental Concepts
Amount and composition of body
fluids;
 Water is essential for life. It is the
major solvent in our body system. It
surrounds and present in every cell.
 Approximately 60% of a typical adult’s
weight consists of fluid (water and
electrolytes).
 Factors that influence the amount of
body fluid are;
Cont…d
Age:-younger people have a higher
percentage of body fluid than older
people,
Gender:-men have proportionately
more body fluid than women.
Body fat:-Obese people have less
fluid than thin people because fat
cells contain little water.

Cont…d
 Body fluid is located in two fluid compartments:
 intracellular space (fluid in the cells)-two thirds
of body fluid primarily in skeletal muscle mass.
 extracellular space (fluid outside the cells).
 Intravascular:-the fluid within the blood
vessels (6L). E.g. pasma and blood cells.
 Interstitial:-fluid that surrounds the cell (11
to 12 L). E.g. Lymph.
 Transcellular:- the smallest division (1L). E.g.
cerebrospinal, pericardial, synovial,
intraocular, and pleural fluids; sweat; and
digestive secretions.

Cont…d
Loss of ECF into a space that does
not contribute to equilibrium
between the ICF and the ECF is
referred to as a third-space fluid
shift, or “third spacing”.
Third-space shifts occur in
ascites, burns, peritonitis, bowel
obstruction, and massive
bleeding into a joint or body
cavity.
Cont…d
Electrolytes
Electrolytes in body fluids are active
chemicals (cations, which carry
positive charges, and anions, which
carry negative charges).
Electrolyte concentration in the body
is expressed in terms of
milliequivalents (mEq) per liter, a
measure of chemical activity.
a milliequivalent is defined as being
equivalent to the electrochemical
activity of 1 mg of hydrogen.
Major electrolyte content
in body fluid

Regulation of body
fluid compartments
 Capillary membrane separates
intravascular and interstitial space.
 Water and molecules move in both
direction across the semipermable
membrane.
 Body fluid compartments are regulated
by two mechanisms;
 Passive transport
 Osmosis
 Diffusion
 Filtration
 Active transport

Cont…d
 Osmosis is the movement of fluid through
semipermable membrane from low solute
concentration to high solute concentration
until equilibrium reached.

Cont…d
 Diffusion is the movement of ions and
molecules across semipermable membrane
from high concentration to low
concentration until equilibrium reached.

Cont…d
 Filtration is the movement of
water and solute occurs by force of
pressure (from high hydrostatic
pressure to low hydrostatic
pressure).
 Active transport is the movement
of ions by using energy (ATP). E.g.
Na+ -K+ pump.

Routes of fluid gains and
losses
A healthy person gains fluids by;
◦ Drinking
◦ Eating
In patients with some disorders,
fluids may be provided by;
◦ Parenteral route (intravenously
or subcutaneously)
◦ Enteral feeding tube in the
stomach or intestine.
Average Daily Intake and
Output of fluid in Adult

Cont…d
 Kidneys
◦ The usual daily urine volume in the
adult is 1 to 2 L with 1 mL/kg/h
formula in all age groups.
 Skin
◦ Sensible
 Sweating:- 0 to 1,000 mL . The chief solutes
in sweat are sodium, chloride, and potassium.
Environmental temperature (hot) increases
the value.
◦ Insensible ( 600 mL/day). Fever and
burn increases its value.
Cont…d
Lungs
◦ 400 mL every day. The loss is much
greater with increased respiratory
rate or depth (hyperpnoea and
tahypenea), or in a dry climate.
GI Tract
◦ 100 to 200 mL daily. Diarrhea and
fistulas cause large losses.
N.B. In healthy people, the daily
average intake and output of water
are approximately equal.
Laboratory tests for
evaluating fluid status
Osmolality;
It is a measure of a solution’s ability
to create osmotic pressure and affect
the movement of water.
Most often used in clinical pratice.
Osmolality is reported as milliosmoles
per kilogram of water (mOsm/kg).
 It also measures the solute
concentration per kilogram in blood
and urine.
Cont…d
◦ Serum osmolality
 Primarily reflects the concentration of
sodium.
 Normal value is 280 to 300 mOsm/kg.
 Formula used to calculaate it;

Cont…d
◦ Urine osmolality
 Determined by urea, creatinine,
and uric acid.
 Normal value 250 to 900
mOsm/kg.
N.B. When measured with serum
osmolality, urine osmolality is the
most reliable indicator of urine
concentration.

Cont…d

Cont…d
Types of solution
Isotonic:- the same osmolality with
ECF. E.g. N/S.
Hypertonic:- concentrated/greater
osmolality than ECF.
Hypotonic:- dilute/lower osmolality
than ECF.
Tonicity is ability of all solute to
cause osmotic driving force in a
solution.
Cont…d
Urine specific gravity;
It measures the kidneys’ ability to
excrete or conserve water.
Measured by a refractometer or
dipstick with a reagent for this purpose.
Normal value is 1.010 to 1.025.
BUN;
It is made up of urea, an end product of
metabolism of protein (from both muscle
and dietary intake) by the liver.
The normal BUN is 10 to 20 mg/dL
(3.5–7 mmol/L).

Cont…d
 Factors that increase BUN;
◦ decreased renal function
◦ GI bleeding
◦ dehydration
◦ increased protein intake
◦ fever
◦ sepsis
 Factors that decrease BUN;
◦ end-stage liver disease,
◦ a low-protein diet
◦ starvation
◦ any condition that results in expanded fluid
volume (e.g, pregnancy).

Cont…d
Creatinine;
 It is the end product of muscle
metabolism.
 It is a better indicator of renal function
than BUN because it does not vary with
protein intake and metabolic state.
 The normal serum creatinine is
approximately 0.7 to 1.5 mg/dL.
 Its concentration depends on lean body
mass and varies from person to person.
 Serum creatinine levels increase when
renal function decreases.

Cont…d
Hematocrit;
It measures the volume percentage
of red blood cells (erythrocytes) in
whole blood.
normally ranges from 44% to 52%
for males and 39% to 47% for
females.
Conditions that;
◦ Increase-dehydration and polycythemia.
◦ Decrease-overhydration and anemia.

Cont…d
Urine sodium;
◦ Normal urine sodium levels range
from 50 to 220 mEq/24 h (50–220
mmol/24 h).

Homeostatic mechanisms
Organs involved in homeostasis
include;
◦ kidneys
◦ lungs
◦ heart
◦ adrenal glands
◦ parathyroid glands
◦ pituitary gland
Cont…d
Kidney;
Regulation of ECF volume and
osmolality by selective retention
and excretion of body fluids.
Regulation of electrolyte levels in the
ECF by selective retention of
needed substances and excretion
of unneeded substances.
Regulation of pH of the ECF by
retention of hydrogen ions.
Excretion of metabolic wastes and
toxic substances.
Cont…d
Heart and Blood Vessel;
◦ The pumping action of the heart
circulates blood through the kidneys
under sufficient pressure to allow for
urine formation.
Lung
◦ The lungs also have a major role in
maintaining acid–base balance.
◦ The lungs remove approximately 300
mL of water daily in the normal
adult.
Cont…d
Pituitary
 The hypothalamus manufactures ADH, which is stored in
the posterior pituitary gland and released as needed.
 Functions of ADH include maintaining the osmotic pressure
of the cells by controlling the retention or excretion of water
by the kidneys and by regulating blood volume
Adrenal
 Aldosterone, a mineralocorticoid secreted by the zona
glomerulosa (outer zone) of the adrenal cortex, has a
profound effect on fluid balance
Parathyroid
 Regulate calcium and phosphate balance by means of
parathyroid hormone (PTH).
 PTH influences bone resorption, calcium absorption from the
intestines, and calcium reabsorption from the renal tubules.

Other Mechanisms
Baroreceptors;
 The baroreceptors are small nerve
receptors that detect changes in pressure
within blood vessels and transmit this
information to the central nervous system.
◦ low-pressure receptors:-in cardiac
atria, particularly the left atrium.
◦ high-pressure receptors:-in the aortic
arch, cardiac sinus, and afferent
arteriole of the juxtaglomerular
apparatus of the nephron.
Cont…d
Renin–angiotensin–aldosterone system;
ADH and thirst;
Osmoreceptors;
◦ Located on the surface of the hypothalamus,
osmoreceptors sense changes in sodium
concentration. As osmotic pressure increases, the
neurons become dehydrated and quickly release
impulses to the posterior pituitary, which increases
the release of ADH.
Atrial natriuretic peptide;
 released by cardiac cells in the atria of the heart in
response to increased atrial pressure.
 The ANP measured in plasma is normally 20 to 77
pg/mL (20—77 ng/L).

Fluid volume imbalance
 Various types of FVI could occur.
 The variation is the result of which
component the fluid is excess or deficient.
 Types of FVI;
1. Hyper osmolar imbalance:- water in ECF is
less than the solute proportion normally
expected.
2. Hypo osmolar imbalance:- water in ECF is
excess.
3. Isotonic volume deficit:- whole deficit in
ECF (electrolyte and water).
4. Isotonic volume excess:- whole excess.

Fluid volume deficit
(hypovolemia)
Occurs when loss of extracellular
fluid (water and electrolytes)
volume in the same proportion
exceeds the intake of fluid.
The ratio of serum electrolytes to
water remains the same.
It is called IVD.
Dehydration-to loss of water
alone with serum electrolyte
level is the same.
Cont…d
Causes
 inadequate intake
◦ Nausea and inability to gain access to fluids

 abnormal fluid losses;
◦ vomiting, diarrhea, GI suctioning, sweating,

 third-space fluid shifts
Risk factors
 diabetes insipidus
 adrenal insufficiency
 osmotic diuresis
 hemorrhage
 coma

Cont…d
can be mild, moderate, or severe
◦ Skin-cool, clammy, decreased skin
turgor.
◦ CVS-postural hypotension; a weak,
rapid heart rate; flattened neck
veins; increased temperature;
decreased central venous pressure.
◦ GUS-oliguria; concentrated urine.
◦ Mouth-dry mucus membrane.
◦ Others-acute weight loss; thirst;
anorexia; nausea; lassitude; muscle
weakness; and cramps.
Cont…d
Assessment and diagnostic findings
BUN elevated out of proportion to the
serum creatinine level (a ratio greater
than 20:1).
hematocrit level is increased.
Urine specific gravity is increased.
Urine osmolality is greater than 450
mOsm/Kg.
Hyperkalemia.
Decreased central venous pressure
with normal cardiovascular function.
Cont…d
Medical Management
Mild to moderate;
 Oral fluid intake-small frequent sip.
 Frequent mouth care.
 Giving non irritating fluid.
Acute and severe;
 IV route is required.
 Isotonic electrolyte solutions (e.g, lactated Ringer’s or
0.9% sodium chloride).
 As soon as the patient becomes normotensive, a
hypotonic electrolyte solution (eg, 0.45% sodium
chloride).
 Accurate and frequent assessments of intake and output,
weight, vital signs, central venous pressure, level of
consciousness, breath sounds, and skin color should be
performed not to avoid overload the patient.

Cont…d
Nursing Management
 Monitors and measures fluid
intake and output at least every 8
hours, and sometimes hourly.
 Monitoring daily body weights.
Wt loss of 0.5 kg 500 mL
fluid loss.
Monitoring vital signs closely.
Skin and tongue turgor is
monitored on a regular basis.
Cont…d
Prevention
Identify patients at risk.
Takes measures to minimize fluid
losses.
For example, if the patient has
diarrhea, diarrhea use
antidiarrheal medications and
small volumes of oral fluids at
frequent intervals.
Fluid volume excess
(hypervolemia)
an isotonic expansion of the ECF caused
by the abnormal retention of water and
sodium in approximately the same
proportions in which they normally exist
in the ECF.
is always secondary to an increase in the
total body sodium content, which, in
turn, leads to an increase in total body
water.
related to simple fluid overload or
diminished function of the homeostatic
mechanisms responsible for regulating
fluid balance.
Cont…d
Cause
Contributing factors;
◦ heart failure,
◦ renal failure,
◦ cirrhosis of the liver.
◦ consumption of excessive amounts
of table or other sodium salts.
◦ Excessive administration of
sodium.

Cont…d
edema
distended neck veins
crackles (abnormal lung sounds)
tachycardia; increased
blood pressure, pulse pressure,
and central venous pressure
increased weight
increased urine output
shortness of breath
wheezing.
Cont…d
Findings
BUN and hematocrit levels
decreased.
Serum osmolality decreased.
Chest x-rays may reveal
pulmonary congestion.

Cont…d
Medical Management
Directed at the causes.
Pharmacologic;
◦ Diuretics are prescribed when dietary
restriction of sodium alone is
insufficient to reduce edema.
◦ The choice of diuretic is based on
 severity of the hypervolemic state.
 the degree of impairment of renal
function.
 potency of the diuretic.
Cont…d
◦ Thiazide diuretics;
 5% to 10% of filtered sodium excreted.
 Act on distal tubule.
 Ordered for mild to moderate
hypervolemia.
◦ Loop diuretics;
 Act on loop of henle.
 20% to 30% of filtered sodium is
excreted.
 Ordered for severe hypervolemia.

Cont…d
Hemodialysis/peritoneal dialysis;
◦ A choice when renal function is
severely impaired that diuretics
cannot act efficiently.
◦ Used to remove;
 nitrogenous wastes
 control potassium
 acid–base balance
 to remove sodium and fluid.
Cont…d
Nutritional;
◦ An average daily diet not restricted in
sodium contains 6 to 15 g of salt.
◦ The restriction vary from mild to 250
mg of sodium per day.
◦ It is the sodium salt, sodium chloride,
rather than sodium itself that
contributes to edema.

Cont…d
Nursing Management
◦ measures intake and output.
◦ assess breath sounds.
◦ monitors the degree of edema in the
most dependent parts of the body,
such as the feet and ankles in
ambulatory patients and the sacral
region in bedridden patients.
◦ Maintaining semi fowlers position.
◦ Frequent positioning.
◦ Teaching patient about edema.

Electrolyte Imbalances
Sodium Imbalance
 sodium is the primary determinant of ECF
osmolality.
 Most abundant electrolyte in ECF.
 Controls water distribution throughout the
body.
 The primary regulator of ECF volume as
its movement coupled with water.
 Necessary for muscle contraction and the
transmission of nerve impulses.
 Its normal concentration ranges from 135
to 145 mEq/L (135—145 mmol/L).

Cont…d
Sodium proportion change in plasma may be due
to;
 Low sodium amount with low water where the
magnitude of sodium loss is greater in
proportion.
 Normal sodium amount with greater amount of
total body water.
 Sodium is greater with an even greater body
water gain.
 Sodium is greater with normal body water or
decreased total body water.
Sodium deficit and excess are the two most

common sodium imbalances.

Sodium deficit
(hyponatremia)
Serum sodium level that is below normal
(less than 135 mEq/L [135 mmol/L]).
Can be superimposed on an existing
FVD or FVE.
Occurs when;
◦ low quantity of total body sodium with a
lesser reduction in total body water,
◦ normal total body sodium content with
excess total body water,
◦ an excess of total body sodium with an
even greater excess of total body water.

Cont…d
Causes
Sodium loss due to vomiting,
diarrhea, fistulas, or sweating.
Diuretics use.
a low-salt diet.
Adrenal insufficiency

Cont…d
Water intoxication (dilutional hyponatremia);
 No loss of sodium but excess amount of water in
ECF (hyper osmolar state is created).
 Predisposing factors are;
◦ SIADH.
◦ Hyperglycemia.
◦ electrolyte-poor parenteral fluids.
◦ use of tap-water enemas, or the irrigation of
nasogastric tubes with water instead of
normal saline solution.
◦ excessive parenteral administration of
dextrose and water solutions.
◦ compulsive water drinking (psychogenic
polydipsia).

Cont…d
 depend on the cause, magnitude, and speed
with which the deficit occurs.
◦ Poor skin turgor
◦ dry mucosa
◦ decreased saliva production,
◦ orthostatic fall in blood pressure,
◦ nausea
◦ abdominal cramping
◦ altered mental status
◦ anorexia, muscle cramps, and a feeling of
exhaustion if it is associated with sodium
loss and water gain
Cont…d
When the serum sodium level
drops below 115 mEq/L (115
mmol/L);
◦ lethargy
◦ Confusion signs of
◦ muscle twitching increasing
◦ focal weakness intracranial
◦ Hemiparesis pressure
◦ papilledema
◦ Seizures
Cont…d
 Serum sodium level is less than 135
mEq/L (regardless of th cause).
 Serum sodium level 100 mEq/L (100
mmol/L) or less (SIADH).
 Serum osmolality is also decreased.
 Urinary sodium content is less than 20
mEq/L (20 mmol/L) (Sodium loss).
 Urinary sodium content is greater than 20
mEq/L (SIADH).
 Urine specific gravity is 1.002 to 1.004
(Sodium loss).
 Urine specific gravity over 1.012 (SIADH).

Cont…d
Medical Management
 Sodium replacement:-sodium loss
◦ For patients who can eat and drink, sodium is
easily replaced by mouth.
◦ For those who cannot consume sodium,
lactated Ringer’s solution or isotonic saline
(0.9% sodium chloride) solution may be
prescribed parenteraly.
◦ The maximum serum sodium replacement is 12
mEq/L in 24 hours, to avoid neurologic damage
due to osmotic demyelination.
◦ Rapidly replacement above 140 mEq/L
produce lesions in the pons that cause
paraparesis, dysarthria, dysphagia, and
coma.

Cont…d
SIADH
◦ Administration of hypertonic saline
solution alone cannot change the
plasma sodium concentration.
◦ Diuretic furosemide (Lasix).
Water restriction
In a patient with normal or excess
fluid volume.
restricting fluid to a total of 800
mL in 24 hours.

Cont…d
Nursing Management
 Identification of patients at risk and
early detection and treatment of to
avoid complication.
 Monitor fluid intake and output as well
as daily body weights.
 Note abnormal losses of sodium or
gains of water and GI manifestations,
such as anorexia, nausea, vomiting,
and abdominal cramping.
 Alert for central nervous system
changes, such as lethargy, confusion,
muscle twitching, and seizures.

Sodium excess
(hypernatremia)
 Serum sodium level exceeding
145 mEq/L [145 mmol/L].
 Occurs when;
 a gain of sodium in excess of
water
 a loss of water in excess of
sodium.
 It can occur in patients with
normal fluid volume or in those
with FVD or FVE.
Cont…d
Causes (common)
 Fluid deprivation in unconscious patients.
 Administration of hypertonic enteral feedings.
 IV administration of hypertonic saline or excessive
use of sodium bicarbonate
 Watery diarrhea and greatly increased insensible
water loss (e.g, hyperventilation, denuding effects
of burns).
 Diabetes insipidus.
Less common causes are;
 heat stroke
 near-drowning in sea water (which contains a
sodium concentration of approximately 500
mEq/L),
 malfunction of either hemodialysis or peritoneal
dialysis proportioning systems.
Cont…d
 Primarily neurologic and are presumably the
consequence of cellular dehydration.
◦ Moderate:-restlessness and weakness
◦ Severe:- disorientation, delusions, and
hallucinations
 Other signs;
◦ Dry swollen tongue
◦ Sticky mucous membranes.
◦ Flushed skin
◦ Peripheral and pulmonary edema
◦ Postural hypotension
◦ Increased muscle tone and deep tendon reflexes
◦ Mild rise in body temperature
Cont…d
Findings
Serum sodium level exceeds
145 mEq/L (145 mmol/L).
Serum osmolality exceeds 295
mOsm/kg (295 mmol/L).
The urine specific gravity and
urine osmolality are increased.
What do you expect if the cause
is DI?
Cont…d
Medical Management
 Infusion of a hypotonic electrolyte
solution (e.g, 0.3% sodium chloride) or
an isotonic nonsaline solution(eg,
dextrose 5% in water [D5W]).
 D5W is indicated when water needs to be
replaced without sodium.
 Hypotonic sodium solution to be safer
than D5W because it allows a gradual
reduction in the serum sodium level
and decreases the risk of cerebral
edema.
Cont…d
 Hypotonic sodium solution is the solution of
choice in severe hyperglycemia with
hypernatremia.
 Diuretics also may be prescribed to treat the
sodium gain.
 Desmopressin acetate (DDAVP) may be
prescribed to treat diabetes insipidus if it is the
cause of hypernatremia.
How it can act ?
N.B. The serum sodium level is reduced at
a rate no faster than 0.5 to 1 mEq/L to
allow sufficient time for readjustment
through diffusionm across fluid
compartments.

Cont…d
Nursing Management
 fluidlosses and gains are carefully
monitored
 Assess for abnormal losses of water or low
water intake and for large gains of sodium.
 Obtain a medication history because some
prescription medications have a high
sodium content.
 Note the patient’s thirst or elevated body
temperature and evaluates it in relation to
other clinical signs.
 The nurse monitors for changes in behavior,
such as restlessness, disorientation, and
lethargy.

Cont…d
Prevention
Supply fluids for debilitated
patients at regular intervals.
If fluid intake remains
inadequate, the nurse consults
with the physician to plan an
alternate route for intake, either
by enteral feedings or by the
parenteral route.
For patients with diabetes
insipidus, adequate water intake
must be ensured.
Potassium imbalance
98% of the body’s potassium is inside
the cells (major intracellular electrolyte).
Normal serum potassium concentration
ranges from 3.5 to 5.5 mEq/L (3.5–5.5
mmol/L).
Important in neuromuscular function
(that is 2% is in the ECF).
Under the influence of the sodium-
potassium pump and based on the
body’s needs, potassium is constantly
moving in and out of cells.

Potassium deficit
(hypokalemia)
Serum potassium concentration
level is less than 3.5mEq/L (3.5
mmol/L).
Hypokalemia may occur in patients with
normal potassium stores; however, when
alkalosis is present, a temporary shift of
serum potassium into the cells occurs.
Hypokalemia is a common imbalance .

Cont…d
Causes
 GI loss of potassium (most common).
◦ Vomiting
◦ Diarrhea
◦ Prolonged gastric suction
◦ Laxative
 Recent ileostomy
 Villous adenoma
 Alkalosis
 Hyperaldosteronism
 High-carbohydrate parenteral fluids.
 Magnesium depletion

Cont…d
Medication
◦ Potassium-losing diuretics, such as
thiazides (eg, chlorothiazide)
◦ Corticosteroids
◦ Penicillins (e.g. sodium penicillin,
Carbenicillin)
◦ Amphotericin B
Poor potassium diet intake;
◦ Debilitated elderly people
◦ Alcoholics
◦ Anorexia nervosa
Bulimia.

Cont…d
 Severe-death through cardiac or respiratory
arrest.
◦ Dysrhythmias Anorexia
◦ Nausea Vomiting
◦ Muscle weakness Leg cramps
◦ Decreased bowel motility Fatigue
◦ Glucose intolerance Paresthesias
◦ Increased sensitivity to digitalis
 If prolonged
◦ Polyuria
◦ Nocturia
◦ Excessive thirst

Cont…d
Assessment and diagnostic findings
Electrocardiographic (ECG) changes
◦ Flat T waves and/or inverted T waves
◦ Depressed ST segments
◦ An elevated U wave
Increased sensitivity to digitalis
Urinary potassium excretion
exceeding 20 mEq/24 h with
hypokalemia suggests that renal
potassium loss is the cause.
Cont…d
Medical Management
 Administration of 40 to 80 mEq/day of potassium
in adult , if no abnormal loss of potassium .
 Dietary intake of potassium in the average adult is
50 to 100 mEq/day, if risky for potassium loss.
 Foods high in potassium;
◦ Fruits (especially raisins, bananas, apricots,
and oranges)
◦ Vegetables, legumes, whole grains, milk, and
meat.
 Oral potassium supplements (salt substitutes
contain 50 to 60 mEq of potassium per
teaspoon).
 When oral administration of potassium is not
feasible, the IV route is indicated.

Cont…d
 The IV route is mandatory for patients with
severe hypokalemia (e.g., a serum level of 2
mEq/L). E.g. potassium chloride, potassium
acetate or potassium phosphate.
 For routine maintenance needs, potassium is
suitably diluted and administered at a rate no
faster than 10 mEq/h.
 Even in extreme hypokalemia, however,
potassium should be administered no faster than
20 to 40 mEq/h (suitably diluted).
 In critical situations, more concentrated
solutions (such as 40 mEq/L) may be
administered through a central line.
Cont…d
Nursing Management
 Monitor for its early presence in patients at risk.
 Monitoring of fluid intake and output is necessary
because 40 mEq of potassium is lost for every
liter of urine output.
 When available, the ECG may provide useful
information.
 Patients receiving digitalis who are at risk for
potassium deficiency should be monitored
closely for signs of digitalis toxicity.
 Physicians usually prefer to keep the serum
potassium level above 3.5 mEq/L (3.5 mmol/L)
in patients receiving digitalis medications such as
digoxin.

Cont…d
Preventing hypokalemia
Encouraging the patient at risk to
eat foods rich in potassium, such
as fruit and fruit juices (bananas,
melon, citrus fruit), fresh and
frozen vegetables, fresh meats,
and processed foods. (when the
diet allows).

Potassium excess
(hyperkalemia)
 Serumpotassium concentration greater than 5.5
mEq/L (5.5 mmol/L).
 Pseudohyperkalemia
◦ Falsely high level of potassium
◦ Causes;
 Use of a tight tourniquet around an
exercising extremity
 Hemolysis of the sample before analysis.
 Marked leukocytosis (white blood cell
count exceeding 200,000) or
thrombocytosis (platelet count exceeding 1
million),
 Drawing blood above a site where
potassium is infusing.

Cont…d
Causes
Decreased renal excretion of potassium.
Infection.
Excessive intake of potassium in food or
medications.
Hypoaldosteronism.
Addison’s disease.
Acidosis.
Medications (in more than 60% )
◦ Potassium chloride, heparin, ACE
inhibitors, captopril, NSAIDs, and
potassium-sparing diuretics.
Cont…d
 Not significant below a concentration of 7 mEq/L (7 mmol/L),
but they are almost always present when the level is 8
mEq/L (8 mmol/L) or greater.
◦ Disturbances in cardiac conduction occur.
 Peaked, narrow T waves
 ST-segment depression;
 Shortened QT interval
 PR interval becomes prolonged
 disappearance of the P waves.
 decomposition and prolongation of the QRS complex
 Ventricular dysrhythmias and cardiac arrest
 Skeletal muscle weakness and even paralysis
 GI manifestations,
 Nausea
 intermittent intestinal colic
 diarrhea

Cont…d
Findings
Serum potassium levels.
ECG changes.
Arterial blood gas analysis
(metabolic acidosis).

Cont…d
Medical Management
 An immediate ECG should be obtained to
detect changes.
 Obtain a repeat serum potassium level from a
vein.
 In non-acute situations;
◦ Restriction of dietary potassium and
potassium-containing medications may
suffice.
 Administration of either orally or by retention
enema, of cation exchange resins (eg,
Kayexalate) may be necessary in patients with
renal impairment. (Cation in paralytic ileus,
hypomagnesemia, hypocalcemia, sodium
retention and fluid overload).
Cont…d
Emergency pharmacologic therapy
IV calcium gluconate.
Monitoring the blood pressure.
The ECG should be
continuously monitored during
administration.
Extra caution is required if the
patient has been “digitalized”.

Cont…d
IV administration of sodium.
IV administration of regular
insulin and a hypertonic dextrose
solution.
Beta-2 agonists such as
salbutamol, salmeterol,
terbutaline, and eformoterol shifts
ptassium into the cells.

Cont…d
Nursing Management
Patients at risk for potassium excess
monitored closely for signs of
hyperkalemia.
Observes for signs of muscle
weakness and dysrhythmias.
The presence of paresthesias, GI
symptoms such as nausea and
intestinal colic should be noted.
For patients at risk, serum
potassium levels are measured
periodically.
Cont…d
 Avoid prolonged use of tourniquet and
exercise.
 Blood sample should be delivered to the
laboratory as soon as possible.
Preventing hyperkalemia
 Encouraging the patient to adhere to the
prescribed potassium restriction.
 Potassium-rich foods to be avoided include coffee,
cocoa, tea, dried fruits, dried beans, and
wholegrain breads.
 Conversely, foods with minimal potassium
content include butter, margarine, cranberry
juice or sauce, ginger ale, gumdrops or jellybeans,
hard candy, root beer, sugar, and honey.

Cont…d
Correcting hyperkalemia
 When potassium is added to parenteral
solutions, the potassium is mixed with
the fluid by inverting the bottle several
times.
 Potassium chloride should never be added
to a hanging bottle because the potassium
might be administered as a bolus
(potassium chloride is heavy and settles
to the bottom of the container).
 Most salt substitutes contain approximately
50–60 mEq of potassium per teaspoon.

Calcium imbalance
significance of calcium
 More than 99% of the body’s calcium is
located in the skeletal system; it is a
major component of bones and teeth.
 About 1% of skeletal calcium is rapidly
exchangeable with blood calcium; the
rest is more stable and only slowly
exchanged.
 The small amount of calcium located
outside the bone circulates in the serum,
partly bound to protein and partly
ionized.
 The normal total serum calcium level is 8.5
to 10.5 mg/dL (2.1–2.6 mmol/L).
Cont…d
Function;
◦ Transmitting nerve impulses
◦ Regulate muscle contraction and
relaxation, including cardiac
muscle.
◦ Activating enzymes that stimulate
many essential chemical reactions
in the body.
◦ Blood coagulation.

Cont…d
It exists in plasma in three forms:
◦ Ionized:-About 50% (4.5 to 5.1
mg/dL (1.1–1.3 mmol/L)) and
physiologically active and clinically
significant.
◦ Bound:-Less than half of the plasma
calcium is bound to serum proteins,
primarily albumin. The remainder is
combined with non-protein anions:
phosphate, citrate, and carbonate.
◦ Complexed.
Cont…d
Calcium is absorbed from foods in
the presence of normal gastric
acidity and vitamin D.
Calcium is excreted primarily in
the feces, the remainder in
urine.
The serum calcium level is
controlled by PTH and
calcitonin.
Calcium deficit (hypocalcemia)
Lower-than-normal serum
concentration of calcium.
A patient may have a total body
calcium deficit (as in
osteoporosis) but a normal serum
calcium level.

Cont…d
Causes
Primary hypoparathyroidism
Surgical hypoparathyroidism
(more common).
Massive dministration of
citrated blood (transient
hypocalcemia).
Pancreatitis

Cont…d
 Renal failure
 Inadequate vitamin D consumption,
 Magnesium deficiency,
 Medullary thyroid carcinoma,
 Low serum albumin levels,
 Alkalosis
 Alcohol abuse.
 Medications (e.g. Aluminum-containing
antacids, Aminoglycosides, Caffeine,
Cisplatin, Corticosteroids, mithramycin,
phosphates, isoniazid, and loop
diuretics).

Cont…d
Tetany (most)
Sensations of tingling the tips of
the fingers, around the mouth,
and less commonly in the feet.
Spasms of the muscles of the
extremities and face may occur.
Pain
Trousseau’s sign (positive)

Cont…d
Trousseau’s sign

Cont…d
Chvostek’s sign (positive)
Seizures
Mental changes (such as
depression, impaired memory,
confusion, delirium, and even
hallucinations.
A prolonged QT interval
Prolonged ST segment

Cont…d
 Determination of serum calcium level, by
this formula as follows;
 Arterial blood gas analaysis.

 Determination of serum albumin level. For
every decrease in serum albumin of 1 g/dL
below 4 g/dL, the total serum calcium level
is underestimated by approximately 0.8
mg/dL.
Cont…d
Medical Management
Acute symptomatic
hypocalcemia is life-
threatening and requires prompt
treatment with IV administration
of calcium.
Parenteral calcium salts include
calcium gluconate, calcium
chloride, and calcium
gluceptate.
Cont…d
Vitamin D therapy
Aluminum hydroxide, calcium
acetate, or calcium carbonate
antacids.
For the patient with chronic renal
failure. Increasing the dietary
intake of calcium to at least
1,000 to 1,500 mg/day in the
adult is recommended (eg, milk
products; green, leafy vegetables;
canned salmon; sardines; fresh
oysters).
Cont…d
Nursing Management
 Observe for hypocalcemia in patients at risk.
 Seizure precautions.
 Health education about;
◦ Adequate dietary calcium intake, calcium
supplements (for peoples risk for
osteoporosis)
◦ Regular weight-bearing exercise
◦ Effect of medications (alcohol, caffeine,
cigarette smoking, alendronate (Fosamax),
risedronate (Actonel), raloxifene (Evista), and
calcitonin).
◦ Teaching also addresses strategies to reduce
risk for falls.

Calcium excess (hypercalcemia)
Excess of calcium in the plasma.
It is a dangerous imbalance when severe.
Hypercalcemic crisis has a mortality rate
as high as 50% if not treated promptly.
The more severe symptoms tend to
appear when the serum calcium level is
approximately 16 mg/dL (4 mmol/L) or
above. However, some patients become
profoundly disturbed with serum
calcium levels of only 12 mg/dL (3
mmol/L).

Cont…d
Causes
Malignancies and
hyperparathyroidism (most
common).
Immobility.
Thiazide diuretics.
Milk-alkali syndrome.
Vitamin A and D intoxication,
Lithium use

Cont…d
◦ Muscle weakness,
◦ Incoordination
◦ Anorexia
◦ Constipation
◦ Cardiac standstill (18 mg/dL (4.5
mmol/L))
◦ Digitalis toxicity
◦ Nausea
◦ Vomiting
◦ Dehydration
◦ Abdominal and bone pain
Cont…d
 Excessive urination
 Abdominal distention
 Paralytic ileus
 Severe thirst
 Peptic ulcer disease like symptoms.
 Confusion,
 Impaired memory
 slurred speech,
 lethargy
 Acute psychotic behavior,
 Coma

Cont…d
Hypercalcemic crisis refers to an acute
rise in the serum calcium level to 17
mg/dL (4.3 mmol/L) or higher.
It has the same clinical presentation with
varying degree.

Cont…d
The serum calcium level is greater
than 10.5 mg/dL (2.6 mmol/L).
ECG changes;
◦ shortening of the QT interval and ST
segment.
◦ PR interval is sometimes prolonged.
The double-antibody PTH test.
X-rays
The Sulkowitch urine test
Cont…d
Medical Management
General measures
◦ Administering fluids to dilute serum
calcium and promote its excretion by
the kidneys.
◦ Mobilizing the patient.
◦ Restricting dietary calcium intake.
◦ IV administration of 0.9% sodium
chloride solution.
◦ Administering IV phosphate.
◦ Furosemide (Lasix)
Cont…d
◦ Mithramycin
◦ Bisphosphonates (Pamidronate
(Aredia))
◦ Inorganic phosphate salts
◦ IV phosphate
◦ Calcitonin (salmon)
◦ Corticosteroids
For patients with cancer;
◦ surgery,
◦ chemotherapy, or
◦ radiation therapy.
Cont…d
Nursing Management
 Monitor the patients at risk.
 Encourage hospitalized patient to move.
 Fluids containing sodium should be administered
unless contraindicated.
 Patients are encouraged to drink 3 to 4 quarts of
fluid daily.
 Adequate fiber should be provided in the diet.
 Safety precautions are taken, as necessary, when
mental symptoms of hypercalcemia are present.
 The patient and family are informed that these
mental changes are reversible with treatment.
 Assess for signs and symptoms of digitalis toxicity.
 Cardiac rate and rhythm are monitored for any
abnormalities.

Acid-Base Balance
 Acid;
A solution with a higher concentration
of hydrogen ions than hydroxide ions.
An acid separates into one or more
hydrogen ions and one or more negative
ions.
 Base;
A solution with a higher concentration
of hydroxide ions than hydrogen ions.
A base separates into one or more
hydroxide ions and one or more positive
ions.

Cont…d
pH;
◦ The unit of measurement used to
describe the alkalinity or acidity of
a substance.
◦ It stands for the potential of
hydrogen.
◦ Measured on a scale 0-14.
◦ Scale represents the hydrogen ion
concentration.
◦ Normal Blood pH is 7.35 – 7.45.
Cont…d
14
Increasingly Basic 13
(Alkaline) 12
11
10
9
8
Neutral 7
6
5
4
3
2
Increasingly Acidic 1
0

Cont…d
As the value or pH decreases, the
hydrogen ion concentration
increases and therefore the
acidity increases.
As the value or pH increases, the
hydrogen ion concentration
decreases and therefore the
acidity decreases.

Regulation of Acid - Base
Balance
◦Buffer systems –
carbonic acid-
bicarbonate system.
◦Respiratory System.
◦Renal System.

Cont…d
Carbonic Acid-Bicarbonate Buffer
System
Primary extracellular fluid buffer
system.
Maintains a ratio of 20 parts
bicarbonate to 1 part carbonic
acid.
Uses the process of hydration of CO2
to break it down so it can be
neutralized.
Cont…d
Respiratory Regulation
◦ Respiratory System regulates by
adjusting rate and depth of
respirations.
◦ By increasing rate and depth
more CO2 will be blown off.
◦ By decreasing rate and depth
CO2 will be conserved.

Cont…d
Renal Regulation
◦ Works slower than respiratory
compensation.
◦ Effects are more long lasting.
◦ Primarily regulates amount of
bicarbonate absorbed or
excreted.
◦ Also regulates ammonia and
electrolytes which can effect
acid-base.
Acid-base Imbalance
 Alkalosis
◦ Respiratory
◦ Metabolic
Acidosis
◦ Respiratory
◦ Metabolic

Respiratory Alkalosis
 Deficiency of carbon dioxide.
 Too much carbon dioxide is
released.
Causes:
◦ Hyperventilation
◦ Hypoxemia
◦ High altitudes
◦ Salicylate overdose
Cont…d
 Numbness/tingling in extremities
 Lightheadedness
 Confusion/ agitation
 Heart palpitations
 Muscle cramping
 Deep rapid respirations
 pH high (>7.45)
 pCO2 low (< 35)

Cont…d
Management
◦ Treat cause
◦ Oxygen
◦ Re-breathing CO2
◦ Compensation – kidneys will
attempt to compensate by
excreting more bicarbonate

Cont…d
Nursing Care
◦ Relieve anxiety
◦ Sedation
◦ Reassurance
◦ Paper bag
◦ Rest

Respiratory Acidosis
 Excess acid (CO2)
Causes:
◦ Hypoventilation
◦ Anesthesia
◦ Sedatives
◦ COPD
◦ Respiratory infections
◦ Inadequate ventilatory
management
◦ Excessive CO2 production

Cont…d
◦ Decreased rate and depth of
respirations
◦ Hypoxia
◦ Hypotension
◦ Hypercapnic encephalopathy
◦ pH low (< 7.35)
◦ PCO2 high (>45)

Cont…d
Management
◦ Treat cause
◦ Ventilatory support
◦ Pulmonary hygiene
◦ Emotional support

Metabolic Alkalosis
Excess of base
Causes:
◦ Gain of base
◦ Excretion of too much acid

Cont…d
◦ Shallow breathing
◦ Nausea/vomiting/diarrhea
◦ Confusion
◦ Numbness / tingling
◦ Hypocalcemia
◦ Hypokalemia
◦ pH high (> 7.45)
◦ HCO3 high (>26)
Cont…d
Management
◦ Replace fluids and electrolytes.
◦ Diamox (Acetazolamide) enhances
excretion of bicarbonate.
◦ Proper functioning kidneys will
excrete excess bicarbonate with
adequate fluid volume and
appropriate potassium.

Cont…d
Nursing Care
◦ Monitor vital signs closely.
◦ Monitor fluid status.
◦ Safety measures ( change in level of
consciousness).
◦ If nasogastric suction, irrigate with
NS, not water.

Metabolic Acidosis
 Acid
excess or base deficit
Causes:
Renal failure
Diabetic ketoacidosis
Lactic acidosis
Large amount drainage from
ileostomy tube
Malnutrition

Cont…d
◦ Headache
◦ Drowsiness
◦ Nausea/ vomiting/ diarrhea
◦ Kussmaul’s respirations
◦ Fruity-smelling breathe
◦ Hyperkalemia
◦ Hypotension
◦ Bradycardia
◦ GI distention
◦ pH low (< 7.35)
◦ HCO3 low (< 22)
Cont…d
Management
◦ Treat cause
◦ Administer bicarbonate in extreme
cases
◦ Replace fluids and electrolytes
◦ Safety

The End!


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Debre Brehan University

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Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

kidneys are reduced to as little as one-fifth their

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year

Lecture note for regular second year