Medical-Surgical-Nursing-Care：医疗外科护理课件.ppt

1、Medical Surgical Nursing Care The Urinary System Assessment&DisordersDr Ibrahim Bashayreh,RN,PhD22/12/20101The kidneys,ureters,and bladder.(Source:Dorling Kindersley Media Library)22/12/20102 An illustration of the internal structures of the kidney.22/12/20103The structure of the nephron and the pro

2、cesses of urine formation.(Source:Pearson Education/PH College)22/12/20104Urine FormationGlomerular filtrationGlomerular filtration rateTubular reabsorptionInclude water and electrolytesTubular secretionUrine concentration22/12/20105Endocrine FunctionReninangiotensinaldosterone systemRole in blood p

3、ressure and sodium reabsorptionErythropoietinRole in RBC productionVitamin D and calcium regulationAcidbase balance22/12/20106Age-Related ChangesNephrons lost with agingReduces kidney mass and GFRLess urine concentrationRisk for dehydration22/12/20107AssessmentColor,clarity,amount of urineDifficulty

4、 initiating urination or changes in streamChanges in urinary patternDysuria,nocturia,hematuria,pyuria22/12/20108AssessmentHistory of urinary problemsUrinary or abdominal surgeriesSmoking,alcohol use,number of sexual partners and type of sexual relationshipChance of pregnancyHistory of diabetes or ot

5、her endocrine disordersHistory of kidney stones22/12/20109Physical AssessmentObtain clean-catch urine specimenColor,odor,clarityVital signs and skin assessment22/12/201010Diagnostic TestsClean-catch urine24-hour urineCulture and sensitivityBUN,creatinine and creatinine clearanceIVPCT scanRenal scan2

6、2/12/201011Diagnostic TestsUltrasoundBladder scanCystoscopyUroflowmetry22/12/201012Renal FailureAcute and ChronicRenal Obstructive Disorder Medical Surgical NursingDr ibraheem Bashayreh,RN,PhD22/12/201013Acute Renal FailureSudden interruption of kidney function resulting from obstruction,reduced cir

7、culation,or disease of the renal tissueResults in retention of toxins,fluids,and end products of metabolismUsually reversible with medical treatmentMay progress to end stage renal disease,uremic syndrome,and death without treatment22/12/201014Acute Renal FailurePersons at RisksMajor surgeryMajor tra

8、umaReceiving nephrotoxic medicationsElderly 22/12/201015 22/12/201016Acute Renal FailureCausesPrerenalHypovolemia,shock,blood loss,embolism,pooling of fluid d/t ascites or burns,cardiovascular disorders,sepsisIntrarenal Nephrotoxic agents,infections,ischemia and blockages,polycystic kidney diseasePo

9、strenal Stones,blood clots,BPH,urethral edema from invasive procedures22/12/201017Acute Renal FailureStagesOnset 1-3 days with BUN and creatinine and possible decreased UOPOliguric UOP 100 ml/min22/12/201034Chronic Renal FailureK+-The kidneys are means which K+is excreted.Normal is 3.5-5.0,mEq/L.mai

10、ntains muscle contraction and is essential for cardiac function.Both elevated and decreased can cause problems with cardiac rhythmHyperkalemia is treated with IV glucose and Na Bicarb which pushes K+back into the cellKayexalate(Sodium polystyrene sulfonate)is also used to promote the exchange of sod

11、ium and potassium in the body.22/12/201035Chronic Renal FailureCaWith disease in the kidney,the enzyme for utilization of Vit D is absentCa absorption depends upon Vit DBody moves Ca out of the bone to compensate and with that Ca comes phosphate bound to it.Normal Ca level is 4.5-5.5 mEq/LHypocalcem

12、ia=tetanyTreat with calcium with Vit D and phosphateAvoid antacids with magnesium22/12/201036Chronic Renal FailureOther abnormal findingsMetabolic acidosisFluid imbalanceInsulin resistanceAnemiaImmunoligical problems22/12/201037Chronic Renal FailureNursing diagnosisExcess fluid volumeImbalanced nutr

13、itionIneffective copingRisk for infectionRisk for injury22/12/201038Chronic Renal FailureNursing careFrequent monitoring Hydration and outputCardiovascular functionRespiratory statusE-lytesNutritionMental statusEmotional well beingEnsure proper medication regimenSkin careBleeding problemsCare of the

14、 shuntEducation to client and family22/12/201039Chronic Renal Failure Treatment 22/12/201040Chronic Renal FailureMedical treatmentIV glucose and insulinNa bicarb,Ca,Vit D,phosphate bindersFluid restriction,diureticsIron supplements,blood,erythropoietinHigh carbs,low proteinDialysis-After all other m

15、ethods have failed 22/12/201041Dialysis of patients with CRF eventually require dialysisDiffuse harmful waste out of bodyControl BPKeep safe level of chemicals in body2 types HemodialysisPeritoneal dialysis 22/12/201042Dialysis Peritoneal dialysisSemipermeable membraneCatheter inserted through abdom

16、inal wall into peritoneal cavityCost lessFewer restrictionsCan be done at homeRisk of peritonitis3 phases inflow,dwell and outflowAutomated peritoneal dialysis Done at home at nightMaybe 6-7 times/weekCAPDContinous ambulatory peritoneal dialysisDone as outpatientUsually 4 X/d22/12/201043Peritoneal D

17、ialysisAbdominal lining filters blood3 typesContinuous ambulatoryContinuous cyclicalIntermittent 22/12/201044Hemodialysis3-4 times a weekTakes 2-4 hours Machine filters blood and returns it to body22/12/201045Chronic Renal FailureHemodialysisVascular accessTemporary subclavian or femoralPermanent sh

18、unt,in armCare post insertionCan be done rapidlyTakes about 4 hoursDone 3 x a week22/12/201046Types of AccessTemporary site:subclavian or femoralPermanent:shunt,in armAV fistulaSurgeon constructs by combining an artery and a vein3 to 6 months to matureAV graftMan-made tube inserted by a surgeon to c

19、onnect artery and vein2 to 6 weeks to mature22/12/201047Temporary Catheter22/12/201048AV Fistula&Graft 22/12/201049What This Means For YouNo BP on same arm as fistulaProtect arm from injuryControl obvious hemorrhageBleeding will be arterialMaintain direct pressureNo IV on same arm as fistulaA thrill

20、 will be felt this is normal22/12/201050Access ProblemsAV graft thrombosis AV fistula or graft bleedingAV graft infectionSteal Phenomenon:also called subclavian steal syndrome(SSS),or subclavian steal steno-occlusive disease,is a constellation of signs and symptoms that arise from retrograde(reverse

21、d)flow of blood in the vertebral artery or the internal thoracic artery,due to a proximal stenosis(narrowing)and/or occlusion of the subclavian artery.Early post-opIschemic distallyApply small amount of pressure to reverse symptoms22/12/201051Nursing ConsiderationsMake sure the dressing remains inta

22、ctDo not push or pull on the catheterDo not disconnect any of the cathetersAlways transport the patient and bags/catheters as one pieceNever inject anything into catheter22/12/201052Dialysis Related ProblemsLightheaded give fluidsHypotensionDysrhythmiasDisequilibration SyndromeAt end of early sessio

23、nsConfusion,tremor,seizureDue to decrease concentration of blood versus brain leading to cerebral edema22/12/201053Chronic Renal FailureTransplantMust find donorWaiting period longGood survival rate 1 year 95-97%Must take immunosuppressants for lifeRejection Watch for fever,elevated B/P,and pain ove

24、r site of new kidney22/12/201054End-Stage Renal DiseaseSlow,insidious processFinal stage is end-stage renal diseaseIncreasing in incidenceDiabetic nephropathy and hypertension are leading causes in U.S.End-Stage Renal DiseaseNephrons destroyed by disease processRemaining nephrons hypertrophy and hav

25、e increased workloadCan compensate for a whileRenal insufficiency developsFurther insult leads to ESRDUremia developsEnd-Stage Renal Disease-ManifestationsOften not identified until uremia developsNauseaApathy WeaknessFatigueConfusion22/12/201058Chronic Renal FailurePost op careICUI/OB/PWeight chang

26、esElectrolytesMay have fluid volume deficitHigh risk for infection22/12/201059Transplant MedsPatients have decreased resistance to infectionCorticosteroids anti-inflammaroryDeltosoneMedrolSolu-MedrolCytotoxic inhibit T and B lymphocytesImuranCytoxanCellceptT-cell depressors-Cyclosporin22/12/201060Ob

27、structive Renal Disorders22/12/201061Hydronephrosis,Hydroureter,and Urethral StrictureOutflow obstructionUrethral strictureCauses bladder distention and progresses to the ureters and the kidneysHydronephrosis Kidney enlarges as urine collects in the pelvis and kidney tissue due to obstruction in the

28、 outflow tractOver a few hours this enlargement can damage the blood vessels and the tubulesHydroureter Effects are similar,but occurs lower in the ureter22/12/201062Causes of ObstructionTumorStonesCongenital structural defectsFibrosisTreatment with radiation in pelvis22/12/201063Complication of Obs

29、tructionIf untreated,permanent damage can occur within 48 hoursRenal failureRetention of Nitrogenous wastes(urea,creatinine,uric acid)Electrolytes(K,Na,Cl,and Phosphorus)Acid base balance impaired22/12/201064Renal CalculiCalled nephrolithiasis or urolithiasisMost commonly develop in the renal pelvis

30、 but can be anywhere in the urinary tractVary in size from very large to tinyCan be 1 stone or many stonesMay stay in kidney or travel into the ureterCan damage the urinary tractMay cause hydronephrosisMore common in white males 30-50 years of age22/12/201065Renal CalculiPredisposing factorsDehydrat

31、ionProlonged immobilizationInfection ObstructionAnything which causes the urine to be alkalineMetabolic factorsExcessive intake of calcium,calcium based antacids or Vit DHyperthyroidismElevated uric acid22/12/201066Renal CalculiSubjective symptomsSever pain in the flank area,suprapubic area,pelvis o

32、r external genitaliaIf in ureter,may have spasms called“renal colic”Urgency,frequency of urinationN/VChills 22/12/201067Renal CalculiObjective symptomsIncreased temperaturePallorHematuria Abdominal distentionPyuriaAnuriaMay have UTI on urinalysis22/12/201068Renal Calculi-ManifestationsKidney/PelvisM

33、ay be asymptomaticDull,aching flank painUreterAcute severe flank pain,may radiateNausea/vomitingPallorHematuriaRenal Calculi-ManifestationsBladderMay be asymptomaticDull suprapubic painHematuriaRenal CalculiDiagnostic proceduresUrinalysis with C and S24 hour urineKUBIVPRenal CTKidney ultrasoundCysto

34、scopy with retrograde pyleogram22/12/201071Renal CalculiTreatmentMost are passed without interventionMay need cysto with basket retrieval Lithotripsy:Extracorporeal shock wave lithotripsy(ESWL)is the non-invasive treatment of kidney stones(urinary calculosis)and biliary calculi(stones in the gallbla

35、dder or in the liver)using an acoustic pulse.Lasertripsy:Lithotomy:is a surgical method for removal of calculi,stones formed inside certain hollow organs,such as the bladder and kidneys(urinary calculus)and gallbladder(gallstones),that cannot exit naturally through the urethra,ureter or biliary duct

36、 22/12/201072Renal CalculiAssessmentHistory and physical examLocation,severity,and nature of painI/OVital signs,looking for feverPalpation of flank area,and abdomen?N/V22/12/201073Renal CalculiNursing interventionsPrimary is to treat pain usually with opioidsAmbulateForce fluids,may have IVWatch for

37、 fluid overloadStrain urine send stone to lab if passedAccurate I/OMedicate N/V22/12/201074Renal CalculiSurgical removalRoutine pre and post op careMay return with catheter,drains,nephrostomy tube and ureteral stent must maintain patency and may need to irrigate as orderedMeasure drainage from all t

38、ubes need at least 30 cc/hrWatch site for bleedingMay need frequent dressing changes due to fluid leakage,or may have collection bag 22/12/201075Renal CalculiDischarge and preventionContinue to force fluids post dischargeMay need special dietStones are analyzed for calcium or other mineralsMay need to watch products with calcium22/12/201076