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E CCRINE DYSFUNCTION IN ANHIDROSIS

Eccrine glands, located over most of the

skin, help regulate body temperature by Normal skin
secreting sweat. A change or dysfunction

cle
us
Ar foll land
in these glands can result in anhidrosis of

Pa bu nd

im
H ine s

nd
gla

g
l
oc sse

pil
varying severity.These illustrations show a

re icle
H ous

gla
Se haft
pil lb
Ap d ve

or

ine
ce
normal eccrine gland and some common

ct
r

H la
s
ba
oo

air

air

air

cr
Ec
abnormalities.

Bl
Epidermis

Dermis

Subcutaneous tissue

perature. Frequently assess the skin and
sweating pattern. Assess the patient’s LOC.
Because even a careful evaluation can be
inconclusive, you may need to administer
specific tests to evaluate anhidrosis. These
include wrapping the patient in an electric
blanket or placing him in a heated box to ob-
serve the skin for sweat patterns, applying a
topical agent to detect sweat on the skin, and
administering a systemic cholinergic drug to
stimulate sweating.
PATIENT TEACHING
Review the signs and symptoms of overheat-
ing and heatstroke. Inform the patient about
measures to prevent dehydration and heat-
stroke, such as spending time in a cool envi-
ronment, moving slowly during warm
weather, and avoiding strenuous exercise
and hot, spicy foods. Tell him to drink about
a quart of noncaffeinated, nonalcoholic flu-
ids an hour when in extremely hot environ-
ments.
Educate the patient about the anhidrotic
effects of certain medications.
Anuria
◆
Anuria is defined as urine output of less than
100 ml in a 24-hour period. Causes include
urinary tract obstruction and acute renal fail-

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Obstructed Atrophy Destruction Congenital

eccrine gland (occurs with aging) (occurs with burns) absence
(occurs in miliaria) (occurs in anhidrotic
ectodermal dysplasia)

Sweat duct Atrophic eccrine Destroyed eccrine Eccrine gland

obstruction gland gland absent

Retained
sweat

ure due to various mechanisms. (See Major
causes of acute renal failure, page 24.) Anuria is
rare; even with renal failure, the kidneys usu-
ally produce at least 75 ml of urine daily.
Because urine output is easily measured
when the patient is in a controlled setting,
anuria rarely goes undetected. However,
without immediate treatment, it can rapidly
cause uremia and other complications of
urine retention.
Act now When anuria is detected, it’s es-
sential to determine whether urine formation
is present. An indwelling urinary catheter may be
inserted to determine the presence of residual urine,
mechanical obstruction, or cloudy, foul-smelling
urine. Urine output greater than 75 ml/day may in-
dicate a lower urinary tract obstruction. Urine out-
put less than 75 ml/day may indicate renal dys-
function or an obstruction higher in the urinary tract.
ASSESSMENT
History
Obtain a complete history, including changes
in voiding pattern or urine characteristics.
Ask the patient how much fluid he normally
ingests each day, how much he ingested in
the past 24 to 48 hours, and the time and
amount of his last urination. Note a history
of kidney disease, urinary tract obstruction
or infection, prostate enlargement, renal cal-
culi, neurogenic bladder, or congenital ab-
normalities. Ask about abdominal, renal, or
urinary tract surgery and about drug use.

ANURIA 23
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M AJOR CAUSES OF
ACUTE RENAL
FAILURE
PRERENAL CAUSES
◆ Decreased cardiac output
◆ Hypovolemia
◆ Peripheral vasodilation
◆ Renovascular obstruction
◆ Severe vasoconstriction
INTRARENAL CAUSES
◆ Acute tubular necrosis
◆ Cortical necrosis
◆ Glomerulonephritis
◆ Papillary necrosis
◆ Renal vascular occlusion
◆ Vasculitis
Pediatric pointers
In neonates, anuria is defined as the absence
of urine output for 24 hours. It can be classi-
fied as primary or secondary. Primary anuria
results from bilateral renal agenesis, aplasia,
or multicystic dysplasia. Secondary anuria,
associated with edema or dehydration, re-
sults from renal ischemia, renal vein throm-
bosis, or congenital anomalies of the geni-
tourinary tract. Anuria in children commonly
results from loss of renal function.
Geriatric pointers
In elderly patients, anuria is a gradually oc-
curring sign of underlying pathology. Hospi-
talized or bedridden elderly patients may be
unable to generate the necessary pressure to
void if they remain in a supine position. El-
derly patients with disease processes; such as
Alzheimer’s disease or dementia; may be dif-
ficult or impossible to evaluate due to uri-
nary incontinence or an inability to record
their own urinary output.

POSTRENAL CAUSES
◆ Bladder obstruction
◆ Ureteral obstruction
◆ Urethral obstruction
Physical examination
Inspect and palpate the abdomen for asym-
metry, distention, or bulging. Inspect the
flank area for edema or erythema, and per-
cuss and palpate the bladder. Palpate the kid-
neys anteriorly and posteriorly, and percuss
them at the costovertebral angle. Auscultate
over the renal arteries, listening for bruits.
MEDICAL CAUSES
● Acute tubular necrosis (ATN). Oliguria
(occasionally anuria) is a common initial
finding with ATN. Associated symptoms
may reflect the underlying cause, such as hy-
perkalemia (muscle weakness, cardiac ar-
rhythmias), uremia (anorexia, nausea, vomit-
ing, confusion, lethargy, twitching, convul-
sions, pruritus, uremic frost, and Kussmaul’s
respirations), and heart failure (edema, jugu-
lar vein distention, crackles, and dyspnea).
● Cortical necrosis (bilateral). Bilateral corti-
cal necrosis is characterized by a sudden
change from oliguria to anuria, along with
gross hematuria, flank pain, and fever.
● Glomerulonephritis (acute). Acute
glomerulonephritis produces anuria or olig-
uria. Related effects include mild fever,
malaise, flank pain, gross hematuria, facial
and generalized edema, elevated blood pres-
sure, headache, nausea, vomiting, abdominal
pain, and signs and symptoms of pulmonary
congestion (crackles, dyspnea).
● Hemolytic-uremic syndrome. Anuria com-
monly occurs in the initial stages of hemolyt-
ic-uremic syndrome and may last from 1 to
10 days. The patient may experience vomit-
ing, diarrhea, abdominal pain, hematemesis,
melena, purpura, fever, elevated blood pres-
sure, hepatomegaly, ecchymosis, edema,
hematuria, and pallor. He may also show
signs of an upper respiratory tract infection.

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● Papillary necrosis (acute). Bilateral papil-
lary necrosis produces anuria or oliguria. It
also produces flank pain, costovertebral an-
gle tenderness, renal colic, abdominal pain
and rigidity, fever, vomiting, decreased bow-
el sounds, hematuria, and pyuria.
● Renal artery occlusion (bilateral). Bilateral
renal artery occlusion produces anuria or se-
vere oliguria, commonly accompanied by se-
vere, continuous upper abdominal and flank
pain; nausea and vomiting; decreased bowel
sounds; fever up to 102 F (38.9 C); and di-
astolic hypertension.
● Renal vein occlusion (bilateral). Bilateral
renal vein occlusion occasionally causes
anuria; more typical signs and symptoms in-
clude acute low back pain, fever, flank ten-
derness, and hematuria. Development of
pulmonary emboli — a common complica-
tion — produces sudden dyspnea, pleuritic
pain, tachypnea, tachycardia, crackles, pleu-
ral friction rub, and possibly hemoptysis.
● Urinary tract obstruction. Severe obstruc-
tion can produce acute, and sometimes, total
anuria, alternating with or preceded by burn-
ing and pain on urination, overflow inconti-
nence or dribbling, increased urinary fre-
quency and nocturia, voiding of small
amounts, or altered urine stream. Associated
findings include bladder distention, pain and
a sensation of fullness in the lower abdomen
and groin, upper abdominal and flank pain,
nausea and vomiting, and signs of secondary
infection, such as fever, chills, malaise, and
cloudy, foul-smelling urine.
● Vasculitis. Vasculitis occasionally pro-
duces anuria. More typical findings include
malaise, myalgia, polyarthralgia, fever, ele-
vated blood pressure, hematuria, proteinuria,
arrhythmias, pallor, and possibly skin le-
sions, urticaria, and purpura.
OTHER CAUSES
● Diagnostic tests. Contrast media used in
radiographic studies can cause nephrotoxici-
ty, producing oliguria and, rarely, anuria.
● Drugs. Many classes of drugs can cause
anuria or, more commonly, oliguria through
their nephrotoxic effects. Antibiotics, espe-
cially aminoglycosides, are the most typical-
ly seen nephrotoxins. Anesthetics, heavy
metals, ethyl alcohol, and organic solvents
can also be nephrotoxic. Adrenergics and an-
ticholinergics can cause anuria by affecting
the nerves and muscles of micturition to pro-
duce urine retention.
APHASIA
NURSING CONSIDERATIONS
If catheterization fails to initiate urine flow,
prepare the patient for diagnostic studies —
such as ultrasonography, cystoscopy, retro-
grade pyelography, and renal scan — to de-
tect an obstruction higher in the urinary
tract. If these tests fail to reveal an obstruc-
tion, prepare the patient for further kidney
function studies. If these tests reveal an ob-
struction, immediate surgery may be indicat-
ed to remove the obstruction, and a nephros-
tomy or ureterostomy tube may be inserted
to drain urine.
Carefully monitor the patient’s vital signs
and intake and output, initially saving any
urine for inspection. Restrict daily fluid al-
lowance to 600 ml more than the previous
day’s total urine output. Restrict foods and
juices high in potassium and sodium, and
make sure that the patient maintains a bal-
anced diet with controlled protein levels.
Provide low-sodium hard candy to help de-
crease thirst. Record fluid intake and output,
and weigh the patient daily.
PATIENT TEACHING
Explain all tests and procedures to the pa-
tient. Depending on the cause of anuria, re-
view the disorder’s early warning signs and
symptoms. If the patient requires surgery,
withhold food and fluids. Review medica-
tions that may worsen renal function.
Aphasia
◆
Aphasia is an impairment in expressing or
comprehending written or spoken language.
It generally reflects disease or injury to the
brain’s language centers. (See Where language
originates, page 26.) Depending on its severity,
aphasia may slightly impede communication
or may make it impossible. It can be classi-
fied as Broca’s, Wernicke’s, anomic, or global
aphasia. Anomic aphasia eventually resolves
in more than 50% of patients, but global
aphasia is usually irreversible. (See Identifying
types of aphasia, page 27.)
Act now Quickly look for signs and
symptoms of increased intracranial pressure
(ICP), such as pupillary changes, decreased level of
consciousness (LOC), vomiting, seizures, bradycar-
dia, widening pulse pressure, and irregular respira-
tions. If you detect signs of increased ICP, insert a
25