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Chapter 10 Care of the Patient with a Urinary Disorder Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Presentation on theme: "Chapter 10 Care of the Patient with a Urinary Disorder Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc."— Presentation transcript:

1 Chapter 10 Care of the Patient with a Urinary Disorder Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2 Slide 2 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Overview of Anatomy and Physiology Functions of the urinary system  Excretion of waste products  Regulation of water (ADH), electrolytes, and acid- base balance (pH of blood) Kidneys (two)  Nephron: Functional unit of kidneys Urine composition and characteristics  95% water; remainder is nitrogenous wastes and salts Urine abnormalities  Albumin; glucose; erythrocytes; ketones; leukocytes

3 Slide 3 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 10-2 Coronal section through right kidney. (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6 th ed.]. St. Louis: Mosby.)

4 Slide 4 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 10-3 The nephron unit. (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6 th ed.]. St. Louis: Mosby.)

5 Slide 5 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Urine Formation 3 Phases of Urine Formation  Filtration Of water and blood products occurs in glomerulus of Bowman’s capsule  Reabsorption Water, glucose, and necessary ions back into blood (primarily done in proximal/distal convoluted tubules and Henle’s loop)  Secretion Certain ions, nitrogenous waste and drugs (primarily distal convoluted tubule); this is the reverse of reabsorption; substances move from blood to filtrate

6 Slide 6 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Hormonal Influence Increased fluid loss (hemorrhage, vomiting, diarrhea, etc.=hypotension Decreases amount of filtrate produced by kidneys Posterior pituitary releases ADH ADH causes nephrons to increase rate of water reabsorption This causes water to return to bloodstream thus raising BP and urine to be concentrated

7 Slide 7 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Overview of Anatomy and Physiology Ureters (two)  Passageway for urine from the kidneys to the urinary bladder Urinary bladder (one)  Temporary storage pouch for urine Urethra (one)  Carries urine by peristalsis from the urinary bladder out to its external opening

8 Slide 8 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 10-5 The male urinary bladder, cut to show the interior. (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6 th ed.]. St. Louis: Mosby.)

9 Slide 9 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Laboratory and Diagnostic Examinations Urinalysis (most common urologic study)  Blood urea nitrogen (BUN)  Blood creatinine  Creatinine clearance  Prostate-specific antigen (PSA)  Osmolality  Kidney-ureter-bladder radiography (KUB)  Intravenous pyelogram (IVP)  Retrograde pyelography  Voiding cystourethrography

10 Slide 10 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Laboratory and Diagnostic Examinations Endoscopic procedures  Renal angiography  Renal venogram  Computed tomography (CT)  Magnetic resonance imaging (MRI)  Renal scan  Ultrasonography  Transrectal ultrasound  Renal biopsy  Urodynamic studies

11 Slide 11 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Medication Considerations Diuretics to enhance urinary output  Thiazide diuretics  Loop (or high-ceiling) diuretics  Potassium-sparing diuretics  Osmotic diuretics  Carbonic anhydrase inhibitor diuretics Medications for urinary tract infections  Quinolone  Nitrofurantoin  Methenamine  Fluoroquinolone

12 Slide 12 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Maintaining Adequate Urinary Drainage Types of catheters  Coudé catheter  Foley catheter  Malecot, Pezzer, or mushroom catheters  Robinson catheter  Ureteral catheters  Whistle-tip catheter  Cystostomy, vesicostomy, or suprapubic catheter  External (Texas or condom) catheter

13 Slide 13 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 10-6 Different types of commonly used catheters. (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7 th ed.]. St. Louis: Mosby.)

14 Slide 14 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Urinary System Urinary retention  Etiology/pathophysiology The inability to void despite an urge to void  Clinical manifestations/assessment Distended bladder Discomfort in pelvic region Voiding frequent, small amounts

15 Slide 15 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Urinary System Urinary retention (continued)  Medical management/nursing interventions Warm shower or sitz bath Natural voiding position if possible Urinary catheter Surgical removal of obstruction Analgesics

16 Slide 16 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Urinary System Urinary incontinence  Etiology/pathophysiology Involuntary loss of urine from the bladder  Total incontinence; dribbling; stress incontinence Secondary  Infection; loss of sphincter control; sudden change in pressure in the abdomen Permanent or temporary

17 Slide 17 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Urinary System Urinary incontinence (continued)  Clinical manifestations/assessment Involuntary loss of urine  Leaking with coughing, sneezing, or lifting  Medical management/nursing interventions Treat underlying cause Surgical repair of bladder Temporary or permanent catheter Bladder training Kegel exercises

18 Slide 18 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Urinary System Neurogenic bladder  Etiology/pathophysiology Loss of voluntary voiding control Results in urinary retention or incontinence Lesion of the nervous system that interferes with normal nerve conduction to the urinary bladder Two types  Spastic  Flaccid

19 Slide 19 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Urinary System Neurogenic bladder (continued)  Clinical manifestations/assessment Infrequent voiding Incontinence Diaphoresis, flushing, nausea prior to reflex incontinence  Medical management/nursing interventions Antibiotics; urecholine Intermittent catheterization Bladder training

20 Slide 20 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Urinary System Urinary tract infections  Etiology/pathophysiology Type depends on location Pathogens enter the urinary tract  Nosocomial infection  Bladder obstruction  Insufficient bladder emptying  Decreased bactericidal secretions of the prostate  Perineal soiling in females  Sexual intercourse

21 Slide 21 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Disorders of the Urinary System Urinary tract infections (continued)  Clinical manifestations/assessment Urgency; frequency; burning on urination Nocturia Abdominal discomfort; perineal or back pain Cloudy or blood-tinged urine  Medical management/nursing interventions Pharmacological management  Antibiotics; urinary antiseptics/analgesics Encourage fluids Perineal care

22 Slide 22 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Obstructive Disorders of the Urinary System Urinary obstruction  Etiology/pathophysiology Strictures; kinks Cysts; tumors Calculi Prostatic hypertrophy  Clinical manifestations/assessment Continuous need to void Voiding small amounts frequently Pain Nausea

23 Slide 23 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Urinary obstruction (continued)  Medical management/nursing interventions Establish urinary drainage  Indwelling catheter  Suprapubic cystostomy  Ureterostomy  Nephrostomy Pharmacological management  Pain relief o Narcotics o Anticholinergics Obstructive Disorders of the Urinary System

24 Slide 24 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Hydronephrosis  Etiology/pathophysiology Dilation of the renal pelvis and calyces Unilateral or bilateral Obstruction of the urinary tract  Clinical manifestations/assessment Dull flank pain (slow onset) Severe stabbing pain (sudden onset) Nausea and vomiting Frequency, dribbling, burning, and difficulty starting urination Obstructive Disorders of the Urinary System

25 Slide 25 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Hydronephrosis (continued)  Medical management/nursing interventions Pharmacological management  Antibiotics  Narcotic analgesics Surgery to relieve obstruction Nephrectomy  Severely damaged kidney Obstructive Disorders of the Urinary System

26 Slide 26 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Urolithiasis  Etiology/pathophysiology Formation of urinary calculi (stones) Develops from minerals Identified according to location  Nephrolithiasis; ureterolithiasis; cystolithiasis  Clinical manifestations/assessment Flank or pelvic pain Nausea and vomiting Hematuria Obstructive Disorders of the Urinary System

27 Slide 27 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Urolithiasis (continued)  Medical management/nursing interventions Antibiotics Encourage fluids Ambulate STRAIN ALL URINE Surgical procedures  Cystoscopy; ureterolithotomy; pyelolithotomy; nephrolithotomy Lithotripsy Obstructive Disorders of the Urinary System

28 Slide 28 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 10-7 Location and methods of removing renal calculi from upper urinary tract. (From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3 rd ed.]. St. Louis: Mosby.)

29 Slide 29 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Renal Tumors Etiology/pathophysiology  Adenocarcinomas that develop unilaterally  Renal cell carcinomas arise from cells of the proximal convoluted tubules Clinical manifestations/assessment  Early: Intermittent painless hematuria  Late Weight loss Dull flank pain Palpable mass in flank area Gross hematuria

30 Slide 30 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Renal Tumors Medical management/nursing interventions  Radical nephrectomy  Radiation  Chemotherapy

31 Slide 31 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Renal Cysts Etiology/pathophysiology  Cysts form in the kidneys  Polycystic kidney disease Cysts cause pressure on the kidney structures and compromise function Clinical manifestations/assessment  Abdominal and flank pain  Voiding disturbances  Recurrent UTIs  Hematuria  Hypertension

32 Slide 32 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Renal Cysts Medical management/nursing interventions  No specific treatment  Pharmacological management Analgesics Antibiotics Antihypertensives  Relieve pain  Heat (unless bleeding)  Dialysis  Renal transplant

33 Slide 33 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Tumors of the Urinary Bladder Etiology/pathophysiology  Most common site of cancer in the urinary tract  Range from benign papillomas to invasive carcinoma Clinical manifestations/assessment  Painless intermittent hematuria  Changes in voiding patterns Medical management/nursing interventions  Localized—remove tissue by burning  Invasive lesions—partial or total cystectomy

34 Slide 34 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Conditions Affecting the Prostate Gland Benign prostatic hypertrophy  Etiology/pathophysiology Enlargement of the prostate gland Common in men 50 years old and older Cause is unknown

35 Slide 35 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Conditions Affecting the Prostate Gland Benign prostatic hypertrophy (continued)  Clinical manifestations/assessment Frequent urination Difficulty starting urination Dysuria Frequent UTIs Hematuria Oliguria Nocturia

36 Slide 36 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Benign prostatic hypertrophy (continued)  Medical management/nursing interventions Relieve obstruction—Foley catheter Prostatectomy Postoperative  TURP o Bladder irrigations o Urine will be pink to cherry red  Suprapubic or abdominal o Assess dressings Conditions Affecting the Prostate Gland

37 Slide 37 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Cancer of the prostate  Etiology/pathophysiology Malignant tumor of the prostate gland  Clinical manifestations/assessment Initially  No symptoms Advanced stages  Urinary obstruction Conditions Affecting the Prostate Gland

38 Slide 38 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Cancer of the prostate (continued)  Medical management/nursing interventions Localized: radiation and/or surgery Men over 70 years old: Radiation and hormone therapy Advanced  Estrogen therapy  Orchiectomy  Radiation therapy  Chemotherapy Conditions Affecting the Prostate Gland

39 Slide 39 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Urethral Strictures Etiology/pathophysiology  Narrowing of the lumen of the urethra that interferes with urine flow; congenital or acquired Clinical manifestations/assessment  Dysuria; nocturia  Weak urinary stream  Pain with bladder distention Medical management/nursing interventions  Correction of stricture  Analgesics

40 Slide 40 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Urinary Tract Trauma Urinary tract trauma  Etiology and pathophysiology Injury to the urinary tract may result from accidents, surgical intervention, and fractures  Clinical manifestations Hematuria Abdominal pain and tenderness  Medical management/nursing interventions

41 Slide 41 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Immunological Disorders of the Kidney Nephrotic syndrome  Etiology/pathophysiology Physiologic changes of the glomeruli interfere with selective permeability  Clinical manifestations/assessment Proteinuria; hypoalbuminemia Generalized edema Anorexia Fatigue Oliguria

42 Slide 42 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Immunological Disorders of the Kidney Nephrotic syndrome (continued)  Medical management/nursing interventions Pharmacological management  Corticosteroids  Diuretics Diet  Low sodium  High protein

43 Slide 43 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nephritis (acute glomerulonephritis)  Etiology/pathophysiology Previous infection with β-hemolytic streptococcus (2-3 weeks prior) Preexisting multisystem diseases Immunological Disorders of the Kidney

44 Slide 44 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nephritis (acute glomerulonephritis) (continued)  Clinical manifestations/assessment Edema of the face Pallor Malaise Anorexia Dyspnea with exertion Hematuria Changes in voiding patterns Oliguria; dysuria Immunological Disorders of the Kidney

45 Slide 45 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nephritis (acute glomerulonephritis) (continued)  Medical management/nursing interventions Pharmacological management  Antibiotics  Diuretics  Antihypertensives Supportive management Diet  Protein and sodium restrictions  Increase calories Immunological Disorders of the Kidney

46 Slide 46 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nephritis (chronic glomerulonephritis)  Etiology/pathophysiology Slow, progressive destruction of glomeruli Commonly caused by other chronic illnesses  Diabetes mellitus  Systemic lupus erythematosus Immunological Disorders of the Kidney

47 Slide 47 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nephritis (chronic glomerulonephritis) (continued)  Clinical manifestations/assessment Malaise; morning headaches Dyspnea with exertion Visual and digestive disturbances Generalized edema Weight loss Fatigue Hypertension Anemia Proteinuria Immunological Disorders of the Kidney

48 Slide 48 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nephritis (chronic glomerulonephritis) (continued)  Medical management/nursing interventions Same as acute glomerulonephritis Renal dialysis Kidney transplant Immunological Disorders of the Kidney

49 Slide 49 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Renal Failure Acute renal failure  Etiology/pathophysiology Kidney function altered  Interference with ability to filter blood  Decrease in blood flow to the kidney Three phases  Oliguric phase  Diuretic phase  Recovery phase

50 Slide 50 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Renal Failure Acute renal failure (continued)  Clinical manifestations/assessment Anorexia Nausea Vomiting Edema Dry mucous membranes Poor skin turgor Urine output less than 400 mL/24 hours (oliguric phase)

51 Slide 51 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Renal Failure Acute renal failure (continued)  Medical management/nursing interventions Pharmacological management  Diuretics  Antibiotics  Kayexalate Administer fluids Assess for and treat electrolyte imbalances Dialysis Diet: High in carbohydrates; low in protein, potassium, and sodium

52 Slide 52 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Renal Failure Chronic renal failure  Etiology/pathophysiology End-stage renal failure Kidneys are unable to regain normal function Develops slowly over an extended period of time Result of kidney disease or other disease process that compromises renal blood flow

53 Slide 53 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Renal Failure Chronic renal failure (continued)  Clinical manifestations/assessment Headache Lethargy; decreased strength Anorexia Pruritus Anuria Muscle cramps or twitching Dusky yellow-tan or gray skin color Disorientation and mental lapses Anemia

54 Slide 54 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Renal Failure Chronic renal failure (continued)  Medical management/nursing interventions Dialysis Renal transplant Medications to treat symptoms Diet: High in calories; restricted protein, potassium, and sodium Restricted fluids  300 to 600 mL above urine output

55 Slide 55 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Care of the Patient Requiring Dialysis A medical procedure for the removal of certain elements from the blood through a semi-permeable membrane (external or peritoneum) Mimics kidney function Two types  Hemodialysis  Peritoneal dialysis

56 Slide 56 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Surgical Procedures for Urinary Disorders Nephrectomy Nephrostomy Kidney transplantation Urinary diversion  Ileal conduit  Continent ileal urinary reservoir or Kock pouch

57 Slide 57 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Renal transplantation. (From Belcher, A.E. [1992]. Cancer nursing. St. Louis: Mosby.)

58 Slide 58 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Ileal conduit or ileal loop.

59 Slide 59 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Kock pouch. (From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. (13 th ed.). St. Louis: Mosby.) Figure 10-14

60 Slide 60 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing diagnoses  Urinary elimination, impaired  Tissue perfusion: renal, ineffective  Pain, acute and chronic  Infection, risk for  Fluid volume excess  Sexuality patterns, ineffective  Knowledge, deficient Nursing Process

61 Chapter 15 Cardiovascular and Renal Medications Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 61

62 Chapter 15 Lesson Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

63 Learning Objectives  Identify the approved way to give different forms of antianginal therapy  Discuss the uses and general actions of cardiac drugs used to treat dysrhythmias  Describe the common treatment for various types of lipoprotein disorders 63 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

64 Urinary System 64 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

65 Chapter 15 Lesson Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

66 Learning Objectives  List the general uses and actions of cardiotonic drugs  Explain the actions of different categories of drugs used to treat hypertension  Identify indications for electrolyte replacement 66 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

67 Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract Diuretics  Indirectly reduce blood pressure by producing sodium and water loss and lowering the tone or rigidity of the arteries  Types  Thiazide and sulfonamide diuretics  Loop diuretics  Potassium-sparing diuretics 67 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

68 Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract (cont.) Adrenergic Inhibitors  Beta-adrenergic blockers  Nonselective; block beta 1 and beta 2 sites  Selective; block beta 1 sites  Central adrenergic inhibitors  Cause vascular relaxation and lower blood pressure  Peripheral adrenergic antagonists  Limit norepinephrine release, prevent vasoconstriction 68 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

69 Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract (cont.)  Alpha 1 -adrenergic inhibitors  Lower peripheral resistance and blood pressure  Combined alpha- and beta-adrenergic blockers Angiotensin-Related Agents  Angiotensin-converting enzyme inhibitors  Angiotensin II receptor antagonists Vasodilators Calcium Channel Blocking Agents 69 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

70 High Blood Pressure  Stage I: Lifestyle Changes  Stage II: Drug Therapy  Adverse Reactions  Drug specific  Drug Interactions 70 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

71 Drugs Useful in Treating Urinary Problems  Urinary incontinence  Treatment: anticholinergics/antispasmodics, alpha- adrenergic agonists, estrogens, cholinergic agonists, and alpha-adrenergic antagonists  Benign prostatic hyperplasia  Treatment: alpha1-adrenergic receptor blockers  Analgesia  Treatment: phenazopyridine 71 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

72 Williams' Basic Nutrition & Diet Therapy Chapter 21 Kidney Disease Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved th Edition

73 Lesson 21.1: Kidney Anatomy, Physiology, and Disease  Kidney disease interferes with the normal capacity of nephrons to filter waste products of metabolism.  Short-term kidney disease requires basic nutrition support for healing rather than dietary restriction. 73 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

74 Introduction (p. 425)  100,000 Americans diagnosed with end-stage renal disease each year  84,000 die per year  Reduced kidney function often undiagnosed  Requires extensive medical nutrition therapy  Dialysis extends lives but carries high costs 74 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

75 Basic Structure and Function of the Kidneys (p. 425)  Kidneys filter about 1.2 L of fluid per minute  Structures  Nephron Glomurulus: cluster of capillaries filters the blood Tubules: carries filtered fluid to kidney medulla 75 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

76 Basic Structure and Function of the Kidneys (cont’d) (p. 427) 76 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

77 Tubules (p. 426)  Proximal tubule: reabsorbs needed nutrients and returns them to blood  Loop of Henle: exchanges sodium, chloride, water  Distal tubule: secretes hydrogen ions as needed  Collecting tubule: produces concentrated urine 77 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

78 Function (p. 427)  Excretory and regulatory functions  Filtration: removes most particles from blood except proteins and RBCs  Reabsorption: substances body needs are reabsorbed and returned to blood  Secretion: additional hydrogen ions secreted as needed to maintain acid-base balance  Excretion: waste materials excreted in concentrated urine 78 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

79 Endocrine Functions (p. 428)  Renin secretion: maintains hormonal control of body water balance  Erythropoietin secretion: stimulate RBC production within bone marrow  Vitamin D activation: converts inactive form to final active vitamin D 79 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

80 Disease Process and Dietary Considerations (p. 428)  General causes of kidney disease  Infection and obstruction: bladder infections, kidney stones  Damage from other diseases: diabetes mellitus, hypertension  Toxins: environmental agents, animal venom, certain plants, heavy metals, drugs  Genetic or congenital defects: cystic diseases, congenital abnormalities 80 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

81 General Causes of Kidney Disease (p. 428)  Risk factors  Diabetes, hypertension, CVD  Older than 60, smoke, obese  Family history of kidney disease 81 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

82 Case Study  Mrs. Hendricks is a 65-year-old female who has poor glycemic control with her Type 2 diabetes of 32 years, hypertension, and smokes 1 pack of cigarettes per day. Her most recent glomerular filtration rate is 22 mL/min. 82 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

83 Case Study (cont’d)  What are Mrs. Hendrick’s risk factors for chronic kidney disease (CKD)? 83 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

84 Case Study (cont’d)  What clinical assessment parameters would be useful to find out from Mrs. Hendricks? 84 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

85 Medical Nutrition Therapy in Kidney Disease (p. 429)  Based on the nature of the disease process and individual responses  Length of disease: acute or chronic Long term: more specific nutrient modifications  Degree of impaired renal function Extensive: extensive nutrition therapy required  Individual clinical symptoms 85 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

86 Nephron Diseases (p. 429)  Acute glomerulonephritis or nephritic syndrome  Disease process: affects glomeruli  Clinical symptoms: hematuria, proteinuria, possible edema, mild hypertension  Medical nutrition therapy: diet modifications usually not crucial 86 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

87 Nephrotic Syndrome (Nephrosis) (p. 430)  Disease process: nephron tissue damage allows protein to pass into tubule  Clinical symptoms: hypoalbuminemia, edema, ascites, distended abdomen, reduced plasma protein level 87 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

88 Nephrotic Syndrome (Nephrosis) (cont’d) (p. 430)  Medical nutrition therapy:  Protein: moderate  Energy: adequate to support nutrition status  Sodium, potassium: restricted and monitored  Calcium, phosphorus: 1 to 1.5 g/day calcium, maximum 12 mg/day phosphorus  Fluid: restricted according to output and losses 88 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

89 Lesson 21.2: Treatment of Kidney Disease  The progressive degeneration of chronic kidney disease requires dialysis treatment and nutrient modification according to individual disease status.  Current therapy for kidney stones depends more on basic nutrition and health support for medical treatment than on major food and nutrient restrictions. 89 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

90 Kidney Failure (p. 431)  Acute kidney injury  Disease process Prerenal: inadequate blood flow to kidneys and subsequent reduced GFR Intrinsic: damage to a part of the kidney Postrenal obstruction: obstruction of urine flow 90 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

91 Acute Kidney Injury (p. 431)  Clinical symptoms: RIFLE classification system assesses severity of:  Risk  Injury  Failure  Loss  End-stage kidney disease 91 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

92 Acute Kidney Injury (cont’d) (p. 431)  Medical nutrition therapy  Basic objective: improve or maintain nutrition status  Principle: prevent protein catabolism, electrolyte and hydration disturbance, acidosis, uremic toxicity 92 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

93 Chronic Kidney Disease (CKD) (p. 432)  Disease process:  Progressive breakdown of kidney tissue  Most often results from Primary glomerular disease Metabolic diseases with kidney involvement Inherited diseases Other causes: immune diseases, obstruction, infection, hypertension 93 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

94 Clinical Symptoms (p. 433)  Water balance: large amounts of dilute urine  Electrolyte balance: metabolic acidosis  Nitrogen retention  Anemia  Hypertension  Azotemia 94 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

95 General Signs and Symptoms (p. 433)  Progressive weakness  Shortness of breath  General lethargy  Fatigue  Possible thirst, anorexia, weight loss, diarrhea, vomiting 95 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

96 Medical Nutrition Therapy (p. 433)  Basic objectives: monitor at regular intervals  Principles  Protein: generally limited to.0 to 0.8 g/kg body weight  Energy: 35 kcal/day for those under 60 with GFR less than 25 ml/min  Sodium/potassium: may be restricted  Phosphorus/calcium: phosphorus may be restricted, calcium 1.0 to 1.5 g/day  Vitamins/minerals: help patients meet needs for B-complex vitamins and vitamin C  Fluid: intake balanced with output 96 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

97 Case Study (cont’d)  Mrs. Hendricks is in what stage of chronic kidney disease? 97 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

98 Case Study (cont’d)  Outline appropriate medical nutrition therapy plan of care for Mrs. Hendricks. 98 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

99 End-Stage Renal Disease (p. 434)  Disease process  Patient, family, physician face life-support decisions  Irreversible damage to majority of nephrons  Options are long-term dialysis for kidney transplant 99 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

100 Hemodialysis (p. 434)  Artificial kidney machine removes toxins and restores metabolites and nutrients  Three to six treatments per week  Medical nutrition therapy  Protein: major concern of patients on dialysis  Energy: 35 kcal/day for patients <60 years  Sodium/potassium: may be restricted  Phosphorus/calcium: monitored and limited  Vitamins/minerals: achieve the DRI 100 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

101 Peritoneal Dialysis (p. 437)  About 6% of patients  Exchange of fluids occurs within the body, allows mobility  Medical nutrition therapy  Protein: increased slightly  Energy: maintain lean body weight  Sodium/potassium: intake slightly more liberal  Phosphorus/calcium, vitamins/minerals: same as for hemodialysis 101 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

102 Peritoneal Dialysis (cont’d) (p. 437) 102 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

103 Transplantation (p. 438)  Improves quality of life and survival  More cost effective than maintenance dialysis  Waiting lists can be long  Donor matches difficult to find 103 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

104 Transplantation (cont’d) (p. 439)  Transplantation  Complications: bone disorders, malnutrition, anemia, hormonal and blood pressure imbalances, depression, reduced quality of life  Nutrition support: enteral or parenteral feedings customized to dialysis 104 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

105 Transplantation (cont’d) (p. 439)  Osteodystrophy  Bone disease and disorders common with CKD  Decreased activation of vitamin D has cascade effect  Neuropathy  Central and peripheral disturbances common at initiation of dialysis  Patients should be periodically assessed 105 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

106 Kidney Stone Disease (p. 442)  Basic cause is unknown  Factors relating to urine or urinary tract environment contribute to formation  Present in 5% of U.S. women and 12% of U.S. men  Major stones are formed from one of three substances:  Calcium  Struvite  Uric acid 106 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

107 Calcium Stones (p. 442)  Most common type: 80% of cases  High levels of urinary oxalate  Long-term megadosing of vitamin C  Dietary calcium intake inversely related to stones 107 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

108 Struvite Stones (p. 442)  10% of all stones  Caused primarily by urinary tract infection  No diet therapy  Usually surgically removed 108 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

109 Uric Acid Stones (p. 443)  Caused by impairment of purine metabolism with some diseases  Account for 9% of stones  Other stones  Due to inherited disorders or complications of medications 109 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

110 Clinical Symptoms and Medical Nutrition Therapy (p. 443)  Clinical symptoms  Severe pain  Urinary symptoms  Weakness, fever  Medical nutrition therapy  Protein: no more than DRI  Calcium: normal calcium intake  Sodium: no more than 2300 to 3450 mg/day  Oxalates: avoid  Vitamins/minerals: limit to DRI  Fluid: high intake 110 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

111 Objectives Specific to Type of Stone (p. 444)  Calcium stones: reduce dietary intake of stone constituents, consider fiber intake  Uric acid stones: raise urinary pH, maintain healthy weight, limit animal protein  Cystine stones: reduce intake of cystine and dilute urine 111 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.


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