Chapter 10 Care of the Patient with a Urinary Disorder

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.

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 As the body takes in nutrients to meet the body’s requirements to sustain life, the breakdown of these elements results in waste products. The management of these waste products is handled by the urinary system. How is the body impacted by the different substances ingested by the body?

Coronal section through right kidney.
Figure 10-2 The kidneys are dark red, bean-shaped organs. They are located, one on each side, toward the back of the body, just below the diaphragm. Describe the parts of the kidney. (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.) Coronal section through right kidney.

Figure 10-3 The nephron unit.
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.) The nephron unit.

Urine Formation 3 Phases of Urine Formation Filtration Reabsorption
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

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

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 The urinary system is comprised of two ureters, the bladder, and one urethra. What is the function of each of the parts listed?

The male urinary bladder, cut to show the interior.
Figure 10-5 (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.) The male urinary bladder, cut to show the interior.

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 When attempting to diagnose a disorder of the urinary system, the first line of testing involves the urine. The urine provides clues into many disorders. Collection of the specimen will vary by test. What is each of the listed tests used to evaluate? What education should the nurse provide to the patient regarding each of the listed tests?

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 In addition to analyzing the urine, detecting disorders of the urinary system can also include scanning or biopsy procedures. Review each of the tests listed and discuss the nursing implications for each.

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 Diuretics’ method of action is accomplished by increasing the kidney’s filtration of elements. In what disorders are the use of diuretics prescribed? There are different types of diuretics. What are examples of each type of diuretic? How do the types differ? In the event of an infection of the urinary system, antimicrobial medications can be prescribed. What nursing implications are indicated with each of the medications listed?

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 Catheters are indicated when a patient’s condition does not allow successful elimination of urine. In what cases is each of the catheter types indicated?

Different types of commonly used catheters.
Figure 10-6 Pictured are the types of catheters. Discuss the types and the times when their use is indicated. What are the nursing responsibilities associated with the care of a patient having an indwelling urinary catheter? (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.) Different types of commonly used catheters.

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 When urinary retention results, what potential hazards exist? What nursing assessments are indicated to determine the presence of urinary retention?

Urinary retention (continued) Medical management/nursing interventions Warm shower or sitz bath Natural voiding position if possible Urinary catheter Surgical removal of obstruction Analgesics Numerous interventions can be attempted to manage urinary retention. What are the goals of management? Ask students what interventions they have used or have observed being used in the clinical environment to manage urinary retention.

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 Urinary incontinence is a common problem experienced by women. What subjective data should be assessed? What questions might assist the nurse in obtaining the needed information? What are potential causes of incontinence? Postmenopausal women have a greater risk for the development of urinary incontinence. What is the relationship between this stage in the lifespan of a woman and incontinence?

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 The goals of management are the treatment of the underlying causes of incontinence. Urinary incontinence is an embarrassing problem. What role does the nurse have in assisting the patient at this difficult time?

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 A neurogenic bladder can be caused by a variety of factors. What are examples of potential causes?

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 When performing an assessment of a neurogenic bladder, the primary focus is locating the underlying cause and preventing complications. In addition to the observation of clinical manifestations, what diagnostic tests might be indicated? Medication therapies can be instituted in the management of a neurogenic bladder. What is the rationale for the use of these medications?

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 Urinary tract infections result when pathogens enter the urinary tract. There are populations at risk for their development. Why are these people/groups at an increased risk? Compare and contrast urethritis, cystitis, interstitial cystitis, prostatitis, and pyelonephritis.

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 Urinary tract infections can lead to increasingly complicated medical problems. Prevention of urinary tract infections is possible in many cases. What interventions can be instituted to reduce their incidence? Complementary and alternative therapies can be used to manage/prevent urinary tract infections.

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 An obstruction at any location within the urinary tract can adversely affect functioning. The onset of the obstruction can be sudden or result over a long period of time. What are potential causes for each of the categories listed above?

Urinary obstruction (continued) Medical management/nursing interventions Establish urinary drainage Indwelling catheter Suprapubic cystostomy Ureterostomy Nephrostomy Pharmacological management Pain relief Narcotics Anticholinergics When an obstruction is suspected, diagnostic tests will be performed to detect the location and cause. What tests can be anticipated for this purpose? What factors will determine the prognosis for a patient experiencing a urinary obstruction?

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 When urine cannot adequately pass through the renal pelvis, potential damage can result. This is the pathophysiology of hydronephrosis. Not all patients experiencing hydronephrosis experience visible symptoms. The onset of hydronephrosis can be rapid or result after a long-term assault on the urinary system. Differentiate between the signs and symptoms that present both rapidly and slowly. What objective data will be collected from the patient demonstrating the clinical manifestations associated with hydronephrosis?

Hydronephrosis (continued) Medical management/nursing interventions Pharmacological management Antibiotics Narcotic analgesics Surgery to relieve obstruction Nephrectomy Severely damaged kidney In addition to the clinical picture presented, a series of diagnostic tests will be ordered to confirm the diagnosis and determine the degree of damage. What tests can be anticipated? Management options will vary, depending on the severity of the disease and the patient’s response to treatment. What are the responsibilities of the nurse when providing care to this patient? What complications can occur as a result of hydronephrosis?

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 Kidney stones are a painful event. Although there is no exact cause for their occurrence, there are predisposed populations and risk factors associated with their development. What populations experience kidney stones most frequently? What lifestyle changes can be implemented to reduce the risk in identified populations?

Urolithiasis (continued) Medical management/nursing interventions Antibiotics Encourage fluids Ambulate STRAIN ALL URINE Surgical procedures Cystoscopy; ureterolithotomy; pyelolithotomy; nephrolithotomy Lithotripsy When a patient presents with clinical manifestations associated with developing kidney stones, diagnostic tests will be performed to support the diagnosis. What tests can be anticipated? What findings will support the presence of kidney stones?

Figure 10-7 (From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.) Location and methods of removing renal calculi from upper urinary tract.

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 Men are affected more commonly by renal tumors than women. Unfortunately, finding a renal tumor occurs late, when the tumor is quite large. What risk factors support the development of renal tumors? Which of these risk factors are modifiable?

Renal Tumors Medical management/nursing interventions
Radical nephrectomy Radiation Chemotherapy Discuss the role of the nurse in the care of the patient diagnosed with renal tumors. What is the anticipated prognosis of the patient who has renal tumors?

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 Single cysts might never be detected because they might not hinder kidney functioning. Polycystic kidney disease is a genetic condition in which numerous cysts form in the kidney. What impact does the presence of cysts have on the kidney’s ability to function?

Renal Cysts Medical management/nursing interventions
No specific treatment Pharmacological management Analgesics Antibiotics Antihypertensives Relieve pain Heat (unless bleeding) Dialysis Renal transplant When preparing to confirm a diagnosis of polycystic kidney disease, laboratory tests can be ordered. In addition, the physician could order screening tests to view the kidney. How will the kidney appear if the condition is present?

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 Tumors of the urinary system are more common in men than women. Other than gender, what are some other risk factors for the development of these tumors? Often, the diagnosis of tumors of the bladder does not take place until the disease is advanced and the tumors are quite large. To what can this delay in diagnosis be attributed? What diagnostic tests might be ordered when evaluating tumors of the urinary system?

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 The man’s urethra is surrounded by the prostate gland. What is the function of the prostate gland? As men age, the gland might increase in size, causing problems. Although the cause is not known for certain, what theories could explain this occurrence?

Benign prostatic hypertrophy (continued) Clinical manifestations/assessment Frequent urination Difficulty starting urination Dysuria Frequent UTIs Hematuria Oliguria Nocturia

Benign prostatic hypertrophy (continued) Medical management/nursing interventions Relieve obstruction—Foley catheter Prostatectomy Postoperative TURP Bladder irrigations Urine will be pink to cherry red Suprapubic or abdominal Assess dressings When a patient presents with complaints involving the prostate gland, what diagnostic tests can be anticipated? Review the technique needed to examine the prostate gland. What findings will support a prostate disorder? When an enlarged prostate is diagnosed, what will determine the course of treatment?

Cancer of the prostate Etiology/pathophysiology Malignant tumor of the prostate gland Clinical manifestations/assessment Initially No symptoms Advanced stages Urinary obstruction Unfortunately, when cancer of the prostate gland is present, metastasis can result. What body structures are most prone to becoming sites of metastasis? Why is this type of cancer at a high risk for spreading?

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 What prognosis is associated with cancer of the prostate?

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 Urethral stricture can be a painful condition. Identify potential causes of acquired urethral strictures. Discuss the assessment of a patient presenting with suspected urethral strictures. What questions should be asked during the data collection phase and the physical examination?

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 Urinary tract trauma may result from lacerations and contusions to urinary tract structures. What diagnostic tests may be ordered to assess for the presence of urinary tract trauma?

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 Nephrotic syndrome is a grouping of interrelated clinical manifestations in which the permeability of the glomerulus is altered, resulting in changes in the composition of both blood and urine. Provide a detailed discussion of the resulting changes in the blood and urine. How might the urine of the patient experiencing nephrotic syndrome appear?

Nephrotic syndrome (continued) Medical management/nursing interventions Pharmacological management Corticosteroids Diuretics Diet Low sodium High protein The goal of treatment is geared at locating and treating the underlying causes. What are potential causes of nephrotic syndrome? What is the prognosis for the patient diagnosed with nephrotic syndrome? What impact does this condition have on the body’s immune response?

Nephritis (acute glomerulonephritis) Etiology/pathophysiology Previous infection with β-hemolytic streptococcus (2-3 weeks prior) Preexisting multisystem diseases Nephritis results from an inflammation of the kidney. Multiple disorders belong to this classification. Acute glomerulonephritis results after an immune response is triggered by an illness in the body. Explain the pathophysiological mechanism of the condition.

Nephritis (acute glomerulonephritis) (continued) Clinical manifestations/assessment Edema of the face Pallor Malaise Anorexia Dyspnea with exertion Hematuria Changes in voiding patterns Oliguria; dysuria Discuss the objective and subjective data that should be collected for the patient suspected of having acute glomerulonephritis.

Nephritis (acute glomerulonephritis) (continued) Medical management/nursing interventions Pharmacological management Antibiotics Diuretics Antihypertensives Supportive management Diet Protein and sodium restrictions Increase calories The physician will order a series of tests to confirm a diagnosis. These tests will include BUN, serum creatinine, potassium levels, erythrocyte sedimentation rate, antistreptolysin-O titer, and urinalysis. What test findings will support the diagnosis? The treatment is aimed at caring for the presenting symptoms. What are the nursing responsibilities relating to patient education?

Nephritis (chronic glomerulonephritis) Etiology/pathophysiology Slow, progressive destruction of glomeruli Commonly caused by other chronic illnesses Diabetes mellitus Systemic lupus erythematosus Glomerulonephritis may be acute or chronic. How do the two types differ? Does the patient diagnosed with acute glomerulonephritis have the risk of developing chronic glomerulonephritis? If so, how?

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 Patients suffering from chronic glomerulonephritis could exhibit alterations in mental functioning/abilities. What is the underlying cause of these changes on cognition? What questions/assessment tools can be used in the assessment process?

Nephritis (chronic glomerulonephritis) (continued) Medical management/nursing interventions Same as acute glomerulonephritis Renal dialysis Kidney transplant Management of chronic glomerulonephritis involves treating the side effects of the disorder. Dialysis could be indicated. What will dialysis accomplish? What is the role of the nurse in providing care of this patient? Identify the prognosis for the patient with chronic glomerulonephritis.

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 Renal failure is a serious medical problem. The onset could be the result of chronic urinary dysfunction or an unexpected rapidly progressing disease process. There are predisposing factors associated with the onset of renal failure. Identify some of the more common factors. What role can be played by nurses in preventing the onset of renal failure?

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) The progression of renal failure is typically described in phases. During each phase, there are a series of characteristic events. What occurs during each phase? Discuss the role of the nurse regarding the assessment and education in each phase.

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 The clinical findings associated with renal failure will be combined with laboratory testing to confirm a diagnosis. What tests can be anticipated? What results will confirm the onset of renal failure? What are the goals of medical management for acute renal failure? Recovery from acute renal failure can occur. What factors will affect the body’s ability to regain renal function?

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 In some cases, it might be impossible for the body’s kidneys to resume functioning. This total loss of function results in end-stage renal failure. What populations are at highest risk for this to happen?

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 The presenting symptoms of chronic renal failure are very individualized. The patient’s overall health status will have a large impact on the clinical presentation.

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 The goals of medical management are to safeguard renal function as long as possible. Dialysis, dietary modification, and drug therapy could be instituted. The patient in renal failure will face numerous challenges concerning the prescribed diet. What elements are restricted in the diet? What is the underlying rationale for the dietary restrictions? Review the actual foods limited in the care of a patient in chronic renal failure.

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 When the kidneys fail to adequately remove toxins from the body, dialysis is instituted. The physician could order either peritoneal dialysis or hemodialysis. How do these procedures differ? Which patients are most suited for each type? What emotional stressors are associated with dialysis?

Surgical Procedures for Urinary Disorders
Nephrectomy Nephrostomy Kidney transplantation Urinary diversion Ileal conduit Continent ileal urinary reservoir or Kock pouch Surgical intervention might be needed if less invasive measures of treatment are not successful in managing urinary disorders. Review the procedure of each of the listed surgeries. When is each of them performed? What is the role of the nurse in the preoperative and postoperative phases of care for the patient undergoing surgical management of a urinary disorder?

Figure 10-12 Renal transplantation.
(From Belcher, A.E. [1992]. Cancer nursing. St. Louis: Mosby.) Renal transplantation.

Ileal conduit or ileal loop.
Figure 10-13 Ileal conduit or ileal loop.

Figure 10-14 (From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. (13th ed.). St. Louis: Mosby.) Kock pouch.

Nursing Process Nursing diagnoses Urinary elimination, impaired
Tissue perfusion: renal, ineffective Pain, acute and chronic Infection, risk for Fluid volume excess Sexuality patterns, ineffective Knowledge, deficient

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

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

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

Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract
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 Hypertension is a disorder in which the patient’s blood pressure is elevated above normal limits for age. Blood pressures above 150/90 mm Hg are associated with accelerated vascular damage of the heart, brain, and kidneys, which leads to increased risk of death. Primary hypertension affects 80% to 90% of people with high blood pressure; the cause is unknown. The other 10% to 20% have secondary hypertension, in which elevated blood pressure is the result of another disease process or problem. Loop diuretics block the active transport of chloride, sodium, and potassium in the thick ascending loop of Henle. These drugs work well in patients with impaired renal function. Potassium-sparing diuretics increase the excretion of water and sodium by saving potassium. These drugs are used in patients with kidney disease or who are at risk for potassium imbalance. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract (cont.)
Adrenergic Inhibitors Beta-adrenergic blockers Nonselective; block beta1 and beta2 sites Selective; block beta1 sites Central adrenergic inhibitors Cause vascular relaxation and lower blood pressure Peripheral adrenergic antagonists Limit norepinephrine release, prevent vasoconstriction The elderly population are more susceptible to developing adverse reactions (hypotension, impaired mental activity, hypokalemia, increased serum glucose levels) when using diuretics. Lower doses are advised in this population, and the drug is gradually discontinued to avoid a rebound effect. The various adrenergic inhibitors block the transmission of epinephrine and norepinephrine at the alpha and/or beta sites. Nonselective beta blockers reduce the heart rate and force of contraction, prevent renin release, and slow the outflow of sympathetic nervous system messages from the brainstem to the vasomotor center, which tells the body to constrict the blood vessels and increase heart rate. Central adrenergic inhibitors stimulate peripheral alpha-adrenergic receptors, causing brief vasoconstriction, and then stimulate alpha2-adrenergic receptors in the brainstem that coordinate cardiac function. Peripheral adrenergic antagonists decrease total peripheral resistance to blood flow by relaxing smooth muscle. Most of these medications are no longer available in the United States. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antihypertensives, Diuretics, and Other Drugs Affecting the Urinary Tract (cont.)
Alpha1-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 The renin-angiotensin mechanism directly increases blood pressure. ACE inhibitors (angiotensin-converting enzyme inhibitors) inhibit the conversion of angiotensin I to angiotensin II in the liver and lungs. Angiotensin II receptor antagonists interfere with angiotensin II acting on the adrenal cortex to increase aldosterone secretion. Vasodilators reduce systolic and diastolic blood pressure by direct relaxation of smooth muscle, which lowers vascular resistance. Calcium channel blocking agents limit the passage of extracellular calcium ions through specific ion channels of the cell membrane in cardiac, vascular, and smooth-muscle cells. This lowers peripheral resistance and decreases blood pressure. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

High Blood Pressure Stage I: Lifestyle Changes Stage II: Drug Therapy
Adverse Reactions Drug specific Drug Interactions What lifestyle changes may help a patient reduce hypertension risk factors? (Losing weight, increased physical activity, reduction of fat, salt, and calories in the diet, smoking cessation, and reducing alcohol intake) The initial drug of choice is an oral thiazide or adrenergic beta blocker. The drug is started in low dosage and increased as needed until maximum dosage is reached. Loop diuretics are used when hypertension is severe, and blood pressure must be brought down quickly. Antiadrenergic agents may be added if the maximum diuretic or beta-blocker dose is not effective. Vasodilators are most effective when used with a beta-adrenergic blocking agent. Adrenergic-inhibiting agents are powerful and are used only when necessary because of their high risk of side effects. Refer to Table for adverse reactions of these drugs. What are some of the nursing implications and patient-teaching issues for these medications? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

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 There are a variety of drugs to treat urinary symptoms related to incontinence, benign prostatic hyperplasia (BPH), and urinary tract pain secondary to infections. Anticholinergic agents used for urinary incontinence stop bladder contraction and decrease the response of some bladder muscles. Antispasmodic drugs directly cause smooth-muscle relaxation. Estrogens may help restore urethral mucosa and increase vascularity, tone, and the ability of the urethral muscle to respond. Benign prostatic hyperplasia (BPH) is a noncancerous growth of the prostate gland that can cause voiding problems. Tamsulosin (Flomax) and finasteride are two drugs specifically used for this problem. What are some of the nursing implications and patient teaching issues for these medications? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Williams' Basic Nutrition & Diet Therapy
14th Edition Chapter 21 Kidney Disease Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 72

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. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 73

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 In one survey, fewer than 6% of individuals with reduced kidney function were aware of their condition. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 74

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 Specific substances are reabsorbed and secreted by the four parts of the tubules. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 75

Basic Structure and Function of the Kidneys (cont’d) (p. 427)
What is the glomerular filtration rate? (The rate at which blood is filtered through the glomerulus) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 76

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 The concentrated urine usually amounts to 1% or less of the filtered fluid. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 77

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 At birth, each person has far more nephrons than are actually needed. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 78

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 Renin initiates the renin-angiotensin-aldosterone system. Parathyroid hormone activates vitamin D. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 79

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 Agents that are toxic to the kidneys are said to be nephrotoxic. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 80

General Causes of Kidney Disease (p. 428)
Risk factors Diabetes, hypertension, CVD Older than 60, smoke, obese Family history of kidney disease Can a person born with only one kidney lead a healthy life without treatment? (Yes. Because of the abundance of nephrons at birth, people born with one kidney often are unaware of their condition and lead full lives.) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 81

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. 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. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 82

Case Study (cont’d) What are Mrs. Hendrick’s risk factors for chronic kidney disease (CKD)? Risk factors for CKD: Older age Race Poor glycemic control/diabetes Hypertension Smoker Decreased glomerular filtration rate Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 83

Case Study (cont’d) What clinical assessment parameters would be useful to find out from Mrs. Hendricks? Some clinical symptoms might include: Polyuria/oliguria/anuria, electrolyte imbalances, nitrogen retention, anemia, hypertension, azotemia, weakness, shortness of breath, fatigue, thirst, appetite loss, bleeding, muscular twitching Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 84

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 When a patient is being treated with dialysis, working closely with an RD for customized nutrition therapy is especially important. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 85

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 Glomerulonephritis is one of the three most common causes of end-stage renal disease. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 86

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 With nephrosis, both filtration and reabsorption functions of the nephron are disrupted. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 87

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 The primary goals of nutrition therapy are to control major symptoms and replace nutrients lost in the urine. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 88

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. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 89

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 Acute renal failure presents a life-threatening situation. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 90

Acute Kidney Injury (p. 431)
Clinical symptoms: RIFLE classification system assesses severity of: Risk Injury Failure Loss End-stage kidney disease The major sign of acute kidney injury is an increase in serum creatinine and oliguria. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 91

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 Enteral or parenteral nutrition may become necessary. Medical nutrition therapy may vary greatly, depending on the patient. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 92

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 Some risk factors are modifiable, including control of blood pressure and smoking. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 93

Clinical Symptoms (p. 433) Water balance: large amounts of dilute urine Electrolyte balance: metabolic acidosis Nitrogen retention Anemia Hypertension Azotemia Anemia results because the kidneys cannot perform their normal function of stimulating RBC production through erythropoietin. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 94

General Signs and Symptoms (p. 433)
Progressive weakness Shortness of breath General lethargy Fatigue Possible thirst, anorexia, weight loss, diarrhea, vomiting Nervous system involvement may cause muscular twitching, burning sensations in the extremities, or convulsions. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 95

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 Some recommendations vary depending on whether the patient is receiving dialysis. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 96

Case Study (cont’d) Mrs. Hendricks is in what stage of chronic kidney disease? Mrs. Hendricks is in stage 4: Severely decreased GFR 15 to 29 mL/min. Mrs. Hendrick’s is at 22 mL/min. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 97

Case Study (cont’d) Outline appropriate medical nutrition therapy plan of care for Mrs. Hendricks. Goals Reduce protein breakdown Avoid dehydration or excess hydration Correct acidosis Correct electrolyte imbalances Control fluid and electrolyte losses Maintain optimal nutritional status Maintain appetite and morale Control complications of hypertension, bone pain, nervous system involvement Slow rate of renal failure Principles Provide enough protein therapy to maintain tissue integrity while avoiding excess Provide amino acid supplements for protein supplementation as necessary Reserve protein for tissue synthesis by ensuring adequate carbohydrates and fats Maintain adequate urine volume with water (Possibly) restrict sodium, phosphate, calcium as necessary Supplement diet with multivitamin as necessary Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 98

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 Dialysis is the chief treatment for end-stage renal disease. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 99

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 Medical nutrition therapy involves registered dietitians specializing in renal care. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 100

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 The diet is slightly more liberal for the patient receiving peritoneal dialysis. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 101

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 Medical nutrition therapy for patients awaiting kidney transplantation is highly individualized. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 103

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

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 Patients with any level of kidney dysfunction should be evaluated for bone disease. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 105

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 Review Box 21-2 for the risk factors for kidney stone development. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 106

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 It is a common error to limit calcium intake in persons who form calcium oxalate stones. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 107

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

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 Uric acid stones may occur with the rapid tissue breakdown during wasting disease or with diarrheal illness, diabetes, obesity and metabolic syndrome. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 109

Clinical Symptoms and Medical Nutrition Therapy (p. 443)
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 A large fluid intake helps to dilute urine and prevent the accumulation of materials that form stones. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 110

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 All of these approaches include the goal of reducing the intake of the stone constituent. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 111

Chapter 10 Care of the Patient with a Urinary Disorder

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