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GUT

LORD IZON O. SANTOS,


M.D., R.N. Kidney Function
Excretory and Tubular
SCOPE
Anatomy and Physiology
Reabsorption
–Water
Assessment
–Electrolytes
Procedures –Wastes
Diagnostic and Laboratory Exams
Secretory
Disorders –Active Vitamin D
–Renin
RENAL CIRCULATION –Erythropoietin

DESCENDING AORTA ADH Regulation


RENAL ARTERY ADH is produced by the
INTERLOBAR ARTERY Hypothalamus
ARCUATE ARTERY ADH is stored and secreted by the
INTERLOBULAR ARTERY posterior pituitary gland
AFFERENT ARTERIOLE
With less water in the plasma ADH
GLOMERULUS
is secreted,
EFFERENT ARTERIOLE
to conserve water by reducing urine
VASA RECTA
output
THEN BACK TO THE HEART
With fluid overload in the plasma
ADH secretion stops, to excrete fluid
CIRCULATION at KIDNEY in the kidneys by increasing urine
TUBULES (URINE) output

BOWMAN’S/GLOMERULAR
ADH Disorder
CAPSULE SIADH
PROXIMALCONVOLUTED TUBULE –Abnormally high ADH
NEPHRON LOOP concentration
DESCENDING LIMB –urine output is reduced (oliguria)
ASCENDING LIMB –water retention (fluid overload)
DISTAL CONVOLUTED TUBULE –Urine SG is high (normal: 1.005
COLLECTING DUCT – 1.030)
MAJOR CALICES –Hct is low (43-48%)
MINOR CALICES DI
RENAL PELVIS –Abnormally low ADH
URETERS –urine output is increased
URINARY BLADDER (polyuria)
URETHRA –water loss (fluid deficit)
OUT OF THE BODY –Urine SG is low
–Hct is high
Aldosterone Disorders OBSTRUCTION
Weak Stream
Addison’sDisease Hesitancy
(autoimmune process, hemorrhage Terminal Dribbling
into the adrenal gland, Incomplete emptying
adrenalectomy, TB of the adrenals) Nocturia
–Abnormally low aldosterone
–Serum Na is low, serum PAIN
potassium is high Flank or lumbar
–FVD Inguinal or iliac
Initiation of
Cushing’s Disease voiding
(Adrenal hyperplasia, Adrenal End of voiding
Neoplasms, Lung and Pancreatic Painless
Tumor releasing ACTH) hematuria
–Abnormally high aldosterone
–Serum Na is high, serum Incontinence
potassium is low Stress
–FVE Urge
Overflow
NOTE: Total
Functional unit of the kidneys are Mixed
the glomerulus, vasa recta and Enuresis
kidney tubules (nephron
(nephron))
Only the renal tubules can URINE CHANGES
regenerate Pneumaturia
Acidosis—increases
Acidosis—increases hydrogen Proteinuria
secretion (kidney tubules)— Ketonuria
increases HCO3 reabsorption Glucosuria
Alkalosis—decreases
Alkalosis—decreases hydrogen Hematuria
secretion—decreases HCO3 Pyuria
reabsorption Fecaluria

ASSESSMENT PROCEDURES & Dx


IRRITATION Urine specimen collection
Dysuria Urinalysis
Frequency Catheterization
Urgency Urinary diversion
Nocturia Serum BUN and CREA
Strangury Serum electrolytes
CBC
Renal biopsy
MRI (with injection of contrast
media)
Renal Angiography
Intravenous Pyelography IVP or
Excretory Urography Lab and Diagnostic
Retrograde Urography There is no single test for renal
Collection of Urine function
Specimen
Best results are obtained by
Random urine sample combining a number of clinical tests
Clean catch urine, Mid stream Renal function is variable from
catch urine time to time
Urine straining Renal function may be within
24-hour normal limits until >50% of renal
Double catch function is lost
Diversionary Method
–Catheter Insertion Blood Studies
Blood Urea Nitrogen or serum
URINALYSIS BUN
Appearance - clear Specific for kidney disease
Odor - faint aromatic odor normal value = 20-30 mg/dl
Color - clear yellow or amber
Normal pH is around 6 (acid) or 4.6- Serum Creatinine
7.5 is more specific for renal function
SG Normal range is from 1.010- test
1.025 is not affected by dietary intake or
Normal range is from 300-1090 hydration status
mOsm/L can not be reabsorbed by the
kidney tubules
Types of Catheterization normal value 0.5-1.5 mg/dl
Foley, Indwelling
Straight, Intermittent SerumElectrolytes Evaluation
All electrolytes are elevated in
Diversion: CRF except calcium and HCO3
Cystostomy Tube Diuretics may alter serum
Ureterostomy Tube electrolytes
Nephrostomy Tube CBC
Erythropoietin activity
Surgical Urinary Diversion RBC – significantly low in CRF
Cutaneous Ureterostomy WBC
Cutaneous Platelets
Vesicostomy
Ileal Conduit Radiology and Imaging
Colon Conduit Radiology and Imaging UTZ
Intravenous Pyelography IVP or Blocks Aldosterone receptors in
Excretory Urography the kidneys
Retrograde Urography H20 and Na loss, K retention
MRI (with injection of contrast (hyperkalemia)
media) Use: Hyperaldosteronism, HPN,
Renal Angiography edema
Renal Biopsy Taken with food, 2-3 days to take
Supine position effect
Hold breath when the kidney is Avoid high K diet
about to puncture Spironolactone (Aldactone)
Bleeding time must be checked
before the test Carbonic Anhydrase Inhibitors
Prone position after the test Decreases the rate of Carbonic
Avoid palpation and manipulation Acid and H ion production in the
on the area kidneys
Avoid strenuous activity 2-3 weeks Increases the excretion of solute
after the test and H20
Monitor complications: Used in treating Open-angle
Colicky pain = clot in the ureter/s Glaucoma
Flank pain = bleeding in the muscle Acetazolamide (Diamox)
Evaluate hematuria = collect serial
urine specimen
Osmotic Diuretics
Acts by increasing the osmotic
DIURETICS pressure of GFR, reducing the rate
Thiazide of tubular reabsorption while
blocks Na reabsorption in the increasing the rate of urine output
distal CT Used in increased ICP tx, drug
Na and K are excreted (HPN, overdose
edema, CHF) IV filter must be used for infusing
Hyponatremia and Hypokalemia the solution (above 15% solution)
taken early AM Mannitol (Osmitrol)
report sore throat
Chlorthiazide (Diuril) Disorders
Chlorthalidone (Hygroton) UTI
Ureteritis = inflammation of ureter
Loop Diuretics (maybe caused by stone in the
Inhibits Na, Cl and K reabsorption ureter)
at the proximal portion of ascending Cystitis = inflammation of bladder
Loop of Henle (caused by ascending bacterial
Hypokalemia infection usually E. coli)
Use: HPN, PE, CHF, Cirrhosis Urethritis = inflammation of
Furosemide (Lasix) urethra (may lead to prostatitis and
epididymitis)
Potassium Sparer
FACTORS THAT CONTRIBUTE TO Nephrolithiasis = kidney stone
UTI Ureterolithiasis = ureter stone
FEMALE (PROXIMITY TO THE Cystolithiasis = bladder stone
ANUS, SHORTER URETHRA) Urethrolithiasis = stone at the
POOR HYGIENE urethra
UNSAFE SEXUAL PRACTICES The stone is usually calcium
BACK TO FRONT STROKE phosphate/oxalate and uric acid
HIGH pH –Struvite = acid ash diet is
URINARY STASIS recommended
KIDNEY STONES –Staghorn = large stone
OBSTRUCTION OF URINE FACTORS THAT CONTRIBUTE TO
OUTFLOW STONE FORMATION
HYPERURICEMIA (GA)
S/Sx: HYPERCALCEMIA
(PARATHYROIDISM)
PAIN assessment
DEHYDRATION
Pain during and after urination =
cystitis PROLONGED IMMOBILITY
Pain after urination = urethritis HEREDITARY
Inguinal pain = ureteritis
Flank pain = pyelonephritis s/sx
Inflammatory manifestations Pain assessment will be
fever and chills dependent on the site of stone
Flank pain = kidney or ureter
Cx: Groin pain = ureter
Ascending infection Watchout for obstruction (bladder
distention)
Obstruction (stones/calculi)
Descending stone may scratch the
membrane irritating the membrane
Management leading to inflammation, bleeding
E. coli (most common C.A.) may occur also
Increase fluids Adhesions may follow after healing
Warm sitz bath
EMPTY the bladder CALCULI(Stones)
Good hygiene MANAGEMENT
Observe safe sexual practice Increase fluid intake 3-4L/day
Front to back stroke Determine the CAUSE and type of
Acidify urine (cranberry juice, stone (calcium or uric acid)
prune, plums) Encourage ambulation
C/S test before giving antibiotics If its calcium give cranberry (acid
For urosepsis give ash diet) or ascorbic acid
aminoglycosides If its uric acid give dairy products
Observe complications (alkali ash diet) or Allopurinol
Antibiotics prophylactically
LITHIASIS
I & O, strain urine (stone must be urine and watchout for
submitted to lab to identify the type obstruction and bleeding
of stone)
Drugs:
–Sodium cellulose phosphate (GI Benign Prostatic Hyperplasia
abs. is decreased) Male Reproductive Organ
–Thiazide (inc. tub. Reabs., Testes are formed in the abdominal
decreasing calculi formation in cavity near the kidney
the kidney tubules) During last month of fetal life they
–Cholestyramine (binds oxalates descend into the groin (spermatic
in the feces) cord)
–Allopurinol (decreased uric acid Internal inguinal canal to the
formation) scrotum
–Antibiotics (chronic UTI is a Testes descend into the scrotum
precursor to calculi formation) Testes are encased by the scrotum
–Narcotics and NSAID for pain (slightly lower temperature than the
management rest of the body to facilitate
–Antispasmodic (Probanthine) spermatogenesis)
–Rowatinex to dissolve stone

Male Reproductive Organ


MANAGEMENT Seminiferous tubules (sperm)
Medical and Surgical Intervention Leydig’s cells (testosterone)
Nephrolithotomy Prostate gland (alkaline fluid)
Ureterolithotomy Bulbourethral glands, Cowper’s
Cystolithotomy Glands (alkaline fluid)
PUL percutaneous ultrasonic Seminal vesicle (nutrients:
lithotripsy fructose)
Nephroscope is inserted to kidney,
an ultrasonic waves disintegrates
Lobules of the testes
stones followed by suction and
seminiferous tubules (sperm)
irrigation
stored at the epididymis
Laser lithotripsy = non invasive vas deferens
procedure sperm plus secretions from seminal
–Post nsg care = increase fluids, vesicle
encourage ambulation, strain will drain into the
urine and watchout for ejaculatory duct
obstruction and bleeding plus drainage of fluids coming from
ESWL extra corporeal shock wave P.G. and B.G. together with the
lithotripsy sperm
Client is immersed to water, slow will now move towards the
waves disintegrate stones (non direction of urethra
invasive) (seminal fluid)
–Post nsg care = increase fluids, 3-5ml/ejaculation (50-130
encourage ambulation, strain million/ml
300-500 million/ejaculation
Surgical incision at the perineum
BPH area (may lead to impotence)
Benign Prostatic Hyperplasia
Slow enlargement of the prostate Post-resection of the Prostate
Men over 40 year (prostate gland Following this procedure
enlargement begins) CBI (continuous bladder irrigation)
On the latent phase it will constrict must be instituted for the sole
the urethra which interferes in purpose of preventing clot formation
urination that may obstruct urine outflow.

SIGNS/SYMPTOMS Pediatric Renal Disorders


SUBJECTIVE Acute Glomerulonephritis
Frequency Chronic Glomerulonephritis
Urgency Nephrotic Syndrome
Difficulty initiating stream
Incomplete emptying of the AGN acute glomerulonephritis
bladder after urination Infection of kidney due to immune
response
OBJECTIVE Previous infection from group A beta
Nocturia hemolytic streptococcus
Hematuria S/Sx – proteinuria, hematuria,
Weak stream oliguria, edema and HPN
Urinary retention
Biopsy reveals hyperplasia CGNchronic glomerulonephritis
Rectal Examination slowly developing disease
S/Sx – same with AGN
Management
NephroticSyndrome
Urinary obstruction (divert urine by
Severely damaged glomerular
catheter, cystostomy)
activity that leads to increased
Finasteride (can stop glandular
capillary permeability
hyperplasia)
S/Sx – proteinuria,
Medical and Surgical Intervention hypoalbuminemia, edema and
hyperlipidemia
Prostate Resection Caused by CGN, DM and SLE
TURP transurethral resection of
the prostate AGN
Resectoscope or laser is inserted Bilateral infection of the glomeruli
to urethra to resect prostate Caused by:
Supra pubic prostatectomy –Post infection (GABS)
Surgical incision at the pubis COMMON
Perineal prostatectomy
–Systemic diseases (SLE, –Plasmapheresis to reduce
goodpasture’s syndrome or circulating antibodies
glomerular deposits) –Dialysis or kidney
–Idiopathic transplantation
Common in boys ages 3-7
Pathophysiology CGN
Acute poststreptococcal infection The unfortunate outcome of AGN
ANTIGEN stimulates formation of Most common cause of ESRD
ANTIBODIES s/sx: same with AGN
ANTIGEN-ANTIBODY-COMPLEXES –HPN and OLIGURIA are the
are lodged in the glomerular dominant clinical features
capillaries Microscopic hematuria is usually
Increasing capillary permeability present than GROSS hematuria
Prognosis is POOR
AGN Management: same with AGN
S/sx: DIALYSIS and KIDNEY transplant
–proteinuria, periorbital edema,
hematuria, oliguria, azotemia and NEPHROTIC SYNDROME
HPN Clinical complex
–smoky or coffee-colored urine, Acute onset
bibasilar crackles, nausea and Caused by: SLE, AGN, CGN and
malaise DM
Dx: same with AGN
Dx Tests: S/sx: same with
–Elevation of BUN and crea AGN (↑
(↑ capillary permeability)
–Serum protein levels are –Hypoalbuminemia
reduced –Edema (anasarca)
–Hb count is also reduced –Hyperlipidemia (due to
–ASO titers are elevated catabolism and ↓COP)
–KUB (bilateral enlargement) Management: same with AGN
–UA (postive RBC, WBC, and –Increase CALORIE to stop
protein) catabolism
–Give plasma expanders to
Management: control edema
–Treat the underlying cause
–Antibiotics 7-10 days MASSIVE PROTEINURIA
–Diuretics to reduce fluid RENAL FAILURE
overload
–DIET restrictions: sodium and Pre renal
electrolytes, CHON is restricted decreased renal tissue perfusion
in severe AZOTEMIA from:
–Fluids restriction –DM (most common)
–Strict I and O
–Vasodilators to control HPN
–Hypovolemia
–Steroids to reduce inflammation –Shock
–Hemorrhage
–Burns Reversible
–Impaired cardiac output
–Diuretic therapy Clinical Course:

Post-renal Oliguric-anuricPhase
due to obstruction or disruption to may last 7-14 days
urine flow anywhere along the Non-oliguric or high output RF
urinary tract: yet nitrogenous waste
–Cystitis products are still high in the
–Urethritis blood.
–Pyelonephritis DiuresisPhase
–Urolithiasis return to normal urine output
RecoveryPeriod
–Injuries to the bladder and
may take 6 months to 1 year
urethra
from the initial onset
–Cancer of the bladder
–Prostatitis Chronic Renal Failure
–BPH Progressive deterioration of renal
function which end fatally in uremia
Intra-renal Dialysis or kidney transplant is
AGN acute glomerulonephritis necessary
Infection of kidney due to immune Irreversible
response Clinical Course:
Previous infection from group A beta Decreased Renal Reserve 40-
hemolytic streptococcus 70 GFR
S/Sx – proteinuria, hematuria, Renal Insufficiency 20-
oliguria, edema and HPN 40 GFR
CGN chronic glomerulonephritis Renal Failure 10-
slowly developing disease 20 GFR
S/Sx – same with AGN End-Stage Renal Disease ↓
Nephrotic Syndrome 10 GFR
Severely damaged glomerular
Both kidneys are severely affected
activity that leads to increased
and renal function is absent
capillary permeability
S/Sx – proteinuria,
hypoalbuminemia, edema and SIMILARITIES in
hyperlipidemia ARF and CRF
Caused by CGN, DM and SLE ↓ waste product excretion
 chaotic acid and base regulation
Acute Renal Failure  elevation of electrolytes
Sudden decline in renal function,  water retention
usually associated with increased in ↓ production of erythropoietin
BUN, creatinine & elec. ↓ active vitamin D secretions
Causes: ↑ renin activation
intra, pre and post RENAL
s/sx Impaired skin integrity related to
Na and water retention – inc BV- uremic frost
edema – HPN – CHF - ascites Constipation related to fluid
↓ RP – renin activation – restriction and phosphate binding
angiotensin and aldosterone agent administration
production – inc BV – inc BP High risk for injury (fracture)
↓ H ion excretion – metabolic related to osteoclast activity
acidosis Non compliance to therapeutic
↓ nitrogenous excretion – regimen related to restrictions
azotemia – toxic to CNS – imposed by CRF and its treatment
CHANGES IN LOC
↓ formation of active vit D – ARF Management
hypocalcemia I&O
↓ secretion of erythropoietin – Weighing
anemia Infection monitoring
↓ electrolyte excretion – elevation Examine gross and occult blood
of electrolytes in the blood Diet (CHON moderate, increase
CHO)
Let’s Diagnose! Electrolyte management (Pls refer
Serum crea – elevated (normal to Fluids and Electrolytes Study
0.5-1.5 mg/dl) Guide by Sonny M. Moreno)
Serum BUN – elevated (normal Neurologic assessment
20-30 mg/dl)
Serum electrolytes – all CRF Management
electrolytes are elevated except for Restrict water and sodium intake
HCO3 and Calcium ABG monitoring and NaHCO3
CBC – anemia (due to reduced administration
erythropoietin production) Neurologic assessment
Renal Ultrasonography – to Dialysis
estimate renal size and obstruction
Diet (CHON restriction, inc CHO)
Other tests that may help in
Give vit D and calcium supplement
detecting the cause
Give synthetic erythropoietin
(Epogen)
Nursing Diagnosis Manage electrolyte imbalance
FVE related to decreased GFR
and sodium retention
Dialysis
Risk for infection related to
Hemodialysis
reduced host defenses
PeritonealDialysis
Altered Nutrition related to
catabolic state, anorexia
CVVH (removes water from blood)
Risk for internal bleeding related to
EMERGENCY DIALYSIS
stress ulcer
ARTERIOVENOUS FISTULA
Altered thought processes related
to effects of uremic toxins to CNS
Fluids and electrolytes imbalance Kidney Transplant
Rejection and Infection Drugs (Immunosuppresive and
Donor and Recipient Preparation Antibiotics, prophylactically
HLA test, ABO, Rh test Isolation (Reverse)
KIDNEY SURGERY
Donor Living = anemia, prone to
THE TRANSPLANTED KIDNEY
infection,bleeding,Cadaveric KIDNEY TRANSPLANT
Recipient Stages of Rejection URETERAL STENTING
(HA, AA, A, C)

Short Quiz
1. Priority during dwelling time?
A. respiratory B. pain
C. bowel movement D. all
2. palpate for?
A. bruit B. thrill
3. auscultate for?
A. bruit B. thrill

4. and 5. Two types of donor in kidney transplant?

6. Dialysis work in what process or mechanism?


7.
8.

9. Common problem encountered by first timer in hemodialysis?


10. Action of an immunosuppressive drug?

WHAT IS THE COMMON AGENT OF UTI?


PRESENCE OF STONE IN THE ENTIRE GU TRACT?
COMMON TYPE OF STONE IN urolithiasis?
IMPORTANT FINDINGS THAT MUST BE REPORTED FOLLOWING EXTRA
CORPOREAL SHOCK WAVE LITHOTRIPSY?
BPH ONSET? (AGE)
DRUG THAT IS ABLE TO STOP GLANDULAR (PROSTATE)
ENLARGEMENT?
COMMON AGENT IN AGN DEVELOPMENT?
DIFFERENCE BETWEEN AGN AND NEPHROTIC SYNDROME (S/SX)
MAIN PURPOSE OF CYSTOCLYSIS?
EXAMPLE OF AN ACID ASH DIET AND ALKALI ASH DIET?

Common type of kidney stone?


Drug that is able to reduce the size of renal stone?
Early diagnostic exam to determine BPH?
Common agent that leads to UTI?
Type of catheter inserted following prostate resection?
Nursing instruction following laser lithotripsy?
Nursing instruction to decreased pH of urine?
Nursing instruction to prevent UTI development?
Example of an alkali ash diet?
Interruption of sleep due to increase in frequency?

What is the primary reason of edema formation in Glomerulonephritis?


Edema is more severe in
A. AGN B. CGN C. NS
Azotemia is more pronounce in
A. AGN B. CGN C. NS
What is the common cause of AGN development?
What is the early sign of renal failure?
ARF is irreversible? TRUE or FALSE
CRF is bilateral involvement of the kidneys? TRUE or FALSE
What is the common cause of death in RF?
What is the common prerenal condition that leads to ARF?
NURSING Dx in FVE?
Nursing Dx in hyperkalemia?
Drug of choice to reduce potassium?
Drug of choice to reduce PO4?
Problem and nsg action in ↓RBC?
Early sign of
Type of isolation in RF management?
Best DIURETIC for RF?
ELEVATION of NH3 in the blood would lead to?
High in CHON and low in CHO is the DIET of choice to spare protein in RF?
TRUE or FALSE?
Uremic frost is an accumulation of?
A. NWP in the skin B. NWP in the blood
C. waste in the joints D. drug metabolites

Board Questions
A client is undergoing peritoneal dialysis. The dialysate dwell time is completed,
and the clamp is opened to allow the dialysate to drain. The nurse notes that
drainage has stopped and only 500 ml has drained, the amount of dialysate
instilled was 1,500 ml. Which of the following interventions would be done
first?

a. check the client’s position


b. call the physician
c. check the catheter for kinks or obstruction
d. clamp the catheter and instill more dialysate at the next exchange time
The most significant complication in clients undergoing peritoneal dialysis, is

a. pulmonary embolism c. dyspnea


b. hypotension d. peritonitis

A client returns to the room with CBI continuous bladder irrigation following
TURP, the client reports bladder pain, what should the nurse do first?
A. notify the physician
B. give Meperidine 50 mg IM as prescribed
C. assess patency of the drainage system
D. increase the flow rate

The nurse is caring for a client in acute renal failure, the nurse should expect
hypertonic glucose insulin infusion to treat:

A. hypernatremia
B. cerebral edema
C. hyperkalemia
D. hyperglycemia

A client requires hemodialysis. Which of the following drug drugs should be


withheld before this procedure?

A. cardiac glycosides
B. insulin
C. antibiotics
D. phosphate binders

A client with GUT problem is being examined in the ER, the nurse should keep in
mind the anatomical fact that:

A. left kidney is lower than the right


B. adrenal glands are situated on top of the kidneys
C. kidneys lie between 12th thoracic and 3rd lumbar vertebrae
D. the average kidney measures 2.5 cm thick, 5 cm wide and 11 cm long

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