Urinary Tract Trauma - Middlesex County Vocational and ...

Urinary Tract Trauma - Middlesex County Vocational and ...

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. Slide 1 Overview of Anatomy and Physiology Functions of the urinary system Excretion of waste products Regulation of water (ADH), electrolytes, and acidbase 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2 Figure 10-2 (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)

Coronal section through right kidney. Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3 Figure 10-3 (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.) The nephron unit. Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4 Urine Formation 3 Phases of Urine Formation Filtration Of water and blood products occurs in glomerulus of

Bowmans capsule Reabsorption Water, glucose, and necessary ions back into blood (primarily done in proximal/distal convoluted tubules and Henles loop) Secretion Certain ions, nitrogenous waste and drugs (primarily distal convoluted tubule); this is the reverse of reabsorption; substances move from blood to filtrate Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5

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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 7 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. Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9 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

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11 Maintaining Adequate Urinary Drainage Types of catheters

Coud 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12 Figure 10-6

(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. Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 17 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 18 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19 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

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 21 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 22 Obstructive Disorders of the Urinary System Urinary obstruction (continued) Medical management/nursing interventions Establish urinary drainage Indwelling catheter

Suprapubic cystostomy Ureterostomy Nephrostomy Pharmacological management Pain relief o Narcotics o Anticholinergics Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23 Obstructive Disorders of the Urinary System 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 24 Obstructive Disorders of the Urinary System Hydronephrosis (continued) Medical management/nursing interventions Pharmacological management Antibiotics Narcotic analgesics Surgery to relieve obstruction Nephrectomy

Severely damaged kidney Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25 Obstructive Disorders of the Urinary System 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 26 Obstructive Disorders of the Urinary System Urolithiasis (continued) Medical management/nursing interventions

Antibiotics Encourage fluids Ambulate STRAIN ALL URINE Surgical procedures Cystoscopy; ureterolithotomy; pyelolithotomy; nephrolithotomy Lithotripsy Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 27 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. Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 28 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 29 Renal Tumors Medical management/nursing interventions

Radical nephrectomy Radiation Chemotherapy Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 30 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 31 Renal Cysts Medical management/nursing interventions

No specific treatment Pharmacological management Analgesics Antibiotics Antihypertensives Relieve pain Heat (unless bleeding) Dialysis Renal transplant Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 32 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

Localizedremove tissue by burning Invasive lesionspartial or total cystectomy Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 33 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 34 Conditions Affecting the Prostate Gland Benign prostatic hypertrophy (continued) Clinical manifestations/assessment Frequent urination Difficulty starting urination Dysuria

Frequent UTIs Hematuria Oliguria Nocturia Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 35 Conditions Affecting the Prostate Gland Benign prostatic hypertrophy (continued) Medical management/nursing interventions Relieve obstructionFoley catheter Prostatectomy Postoperative

TURP o Bladder irrigations o Urine will be pink to cherry red Suprapubic or abdominal o Assess dressings Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 36 Conditions Affecting the Prostate Gland Cancer of the prostate Etiology/pathophysiology Malignant tumor of the prostate gland

Clinical manifestations/assessment Initially No symptoms Advanced stages Urinary obstruction Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37 Conditions Affecting the Prostate Gland 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 38

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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 39 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 40 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 41 Immunological Disorders of the Kidney Nephrotic syndrome (continued)

Medical management/nursing interventions Pharmacological management Corticosteroids Diuretics Diet Low sodium High protein Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42

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

Clinical manifestations/assessment Edema of the face Pallor Malaise Anorexia Dyspnea with exertion Hematuria Changes in voiding patterns Oliguria; dysuria Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 44 Immunological Disorders of the Kidney Nephritis (acute glomerulonephritis) (continued) Medical management/nursing interventions Pharmacological management Antibiotics Diuretics Antihypertensives Supportive management Diet

Protein and sodium restrictions Increase calories Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 45 Immunological Disorders of the Kidney Nephritis (chronic glomerulonephritis) Etiology/pathophysiology Slow, progressive destruction of glomeruli Commonly caused by other chronic illnesses

Diabetes mellitus Systemic lupus erythematosus Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 46 Immunological Disorders of the Kidney 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 47 Immunological Disorders of the Kidney

Nephritis (chronic glomerulonephritis) (continued) Medical management/nursing interventions Same as acute glomerulonephritis Renal dialysis Kidney transplant Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 48 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 49 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) Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 50 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 51 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 52 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 53

Renal Failure Chronic renal failure (continued) Medical management/nursing interventions Dialysis Renal transplant Medications to treat symptoms Diet: High in calories; restricted protein, and sodium Restricted fluids potassium,

300 to 600 mL above urine output Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 54 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 55 Surgical Procedures for Urinary Disorders Nephrectomy Nephrostomy Kidney transplantation Urinary diversion Ileal conduit Continent ileal urinary reservoir or Kock pouch

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 56 Figure 10-12 (From Belcher, A.E. [1992]. Cancer nursing. St. Louis: Mosby.) Renal transplantation. Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 57 Figure 10-13 Ileal conduit or ileal loop. Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 58 Figure 10-14 (From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. (13th ed.). St. Louis: Mosby.) Kock pouch. Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 59 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 Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 60 Chapter 15 Cardiovascular and Renal Medications Copyright 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 61

Chapter 15 Lesson 15.1 Copyright 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 62 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. 63 Urinary System Copyright 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 64 Chapter 15 Lesson 15.2 Copyright 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 65 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. 66 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 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 (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 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.) 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 Copyright 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 69 High Blood Pressure Stage I: Lifestyle Changes Stage II: Drug Therapy Adverse Reactions

Drug specific Drug Interactions Copyright 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 70 Drugs Useful in Treating Urinary Problems Urinary incontinence

Benign prostatic hyperplasia Treatment: anticholinergics/antispasmodics, alphaadrenergic agonists, estrogens, cholinergic agonists, and alpha-adrenergic antagonists Treatment: alpha1-adrenergic receptor blockers Analgesia Treatment: phenazopyridine Copyright 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 71 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

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 Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 75

Basic Structure and Function of the Kidneys (contd) (p. 427) 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

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 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

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 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

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. Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 82 Case Study (contd)

What are Mrs. Hendricks risk factors for chronic kidney disease (CKD)? Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 83 Case Study (contd) What clinical assessment parameters would be useful to find out from Mrs. Hendricks? 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 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 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 Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 87 Nephrotic Syndrome (Nephrosis) (contd) (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 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 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 Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 91 Acute Kidney Injury (contd) (p. 431) Medical nutrition therapy Basic objective: improve or maintain nutrition status

Principle: prevent protein catabolism, electrolyte and hydration disturbance, acidosis, uremic toxicity 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 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 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 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 Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 96 Case Study (contd) Mrs. Hendricks is in what stage of chronic kidney disease?

Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 97 Case Study (contd) Outline appropriate medical nutrition therapy plan of care for Mrs. Hendricks. 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 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 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

Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 101 Peritoneal Dialysis (contd) (p. 437) Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 102 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 Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 103 Transplantation (contd) (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

Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 104 Transplantation (contd) (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 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 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 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

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

Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 109 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 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 Copyright 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 111

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