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Pathophysiology- Renal System

by: Shelby Stephens

Pathophysiology- Renal System NUR 305

Shelby Stephens
GPA 3.5

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This 8 page Study Guide was uploaded by Shelby Stephens on Wednesday December 9, 2015. The Study Guide belongs to NUR 305 at University of Alabama - Tuscaloosa taught by Owings in Fall 2015. Since its upload, it has received 25 views. For similar materials see Pathophysiology in Nursing and Health Sciences at University of Alabama - Tuscaloosa.

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Date Created: 12/09/15
Week 4: The Renal System. Chapters 24­27 Chapter 24. Review the following: Urine formation, Glomerular Filtration, & Tubular  Reabsorption and Secretion.  Understanding –How the Kidney Concentrates Urine. Review Regulation of Renal blood flow­important for understanding kidney  failure. Side note: Diagnosis for all disorders­do history & physical exam. The kidneys are super­efficient filters that also have important metabolic  functions  Fluid volume: responds to ADH & Aldosterone, kidneys are very efficient at  reabsorbing water and concentrating waste products for excretion (ammonia,  urea, uric acid, K+, anything that we have too much). Blood pressure:   ADH causes the kidneys to reabsorb (keep) water and put it back into the  vascular space (bloodstream).  Aldosterone causes the kidneys to reabsorb water & sodium and put it back  into the vascular space.  Renin is produced and released by the kidneys, causes the conversion of  Angiotension I to Angiotension II (this conversion actually happens in the lungs).  Angiotension II is a potent vasoconstrictor­causes the blood vessels to  constrict.  Metabolic waste and drug excretion: ammonia, urea, uric acid, K+, anything  that we have too much. The kidneys & electrolytes:   Usually excrete K+ and keep Na+. If we do not have aldosterone we will not  keep Na+ and as much H O.2  Parathyroid hormone (released by the parathyroid glands) causes bones to  release calcium and kidneys to reabsorb calcium and put it back into the  bloodstream. In exchange, the kidneys will excrete phosphate.  Atrial natriuretic peptide: Released by cells in the cardiac atria when the atria  are distended due to plasma volume increases. Decreases sodium and water  reabsorption. The kidneys excrete sodium and water (diuretic effect). Also  inhibits renin secretion.  *ANP helps the body get rid of sodium & water. And helps compensate when a  patient  goes into HF. In summary:  Kidneys reabsorb:  Na+, H O, C2++, HCO – (kidne3  also make HCO ­),  3 glucose,  Kidneys get rid of (excrete): ammonia, urea, uric acid, electrolytes  that are in  excess in the extracellular fluid (remember that it’s all about balance)  Vitamin D is converted into an active form that helps the bones absorb calcium  as well as vitamin D.  Acid­base balance: secretes bicarbonate, can excrete or retain hydrogen ions  Hormone synthesis: renin, erythropoietin, atrial natriuretic peptide How do we determine kidney function? Kidney function tests.  Draw blood, send it to the lab and determine if the kidney is effectively removing  wastes from our blood.  *Best indicator of renal function is glomerular filtration rate.  Creatinine is more specific to renal function than BUN.  Creatinine: men 0.6­1.2 mg/dL; women 0.5­1.1mg/dL. Specific to kidney disease.  Waste product off creatine phosphate from skeletal muscle.  Elevated (above 1.2mg/dL) in kidney disease.  BUN to creatinine ratio is often used to look at kidney function (creatinine 1: to BUN 10). BUN (Blood Urea Nitrogen)­normal range 10­20 mg/dL  Waste product of protein metabolism. Levels go up (above 20mg/dL) in kidney  disease, poor blood perfusion to the kidneys, heart failure, shock, dehydration, GI bleeding, high protein diet. Decreased in over­hydration, liver failure.  Creatinine Clearance (24 hour urine creatinine clearance): the nurse collects  the patient/client’s urine for 24 hours in a brown container and keeps it on ice.   The following are measured: glomerular filtration rate, can also be used to  measure byproducts of hormones to evaluate certain endocrine disorders. Urinalysis: see lab value sheet in the supplemental folder.  Notice how most  things should be “negative” meaning they should not be present. For example­ glucose. Urine Sediment: cellular fragments, crystals, byproducts of metabolism. Often see lots  of sediment in renal failure.  Urine will be dark, very concentrated looking. Glomerular Filtration Rate: best indicator of renal function. Changes with Aging: remember­renal function decreases some in older adults. So an  80 year old may have a BUN of 25 and a creatinine of 1.7mg/dL and this will be  “normal” for them, as long as there are no other symptoms. Chapter 26. Renal Failure: Acute versus Chronic Chronic Kidney disease. Very good summary of chronic renal failure. Acute is temporary and they can recover given the appropriate therapy. Chronic is irreversible and they will gradually lose renal function until they reach  ESRD (end stage renal disease) stage. Once they reach ESRD they require dialysis to  live. A patient in ESRD may live a couple of weeks without dialysis but eventually the  fluid, waste products and potassium build up to the point where they develop pulmonary edema rapidly leading to pulmonary failure and their potassium gets so high that their  heart will develop brady­dysrhythmias and asystole (heart stops). ARF­prerenal, intrarenal, postrenal. Prerenal conditions (basically this is a severe lack of blood flow to the kidney)  Extremely low blood pressure or blood volume  Heart dysfunction Intrarenal conditions   Reduced blood supply within the kidneys  Hemolytic uremic syndrome  Renal inflammation  Toxic injury Postrenal conditions (something prevent urine from leaving the body, it has to go  somewhere so it backs up)  Ureter obstruction  Bladder obstruction and dysfunction  Know the 4 phases of ARF­asymptomatic, oliguric, diurectic, recovery 1. Asymptomatic phase 2. Oliguric phase ­ daily urine output decreases to approximately 400 mL or less,  and waste products accumulate.  3. Diuretic phase ­ daily urine output increases to as much as 5 L.  4. Recovery phase ­ glomerular function gradually returns to normal. Know the manifestations of ARF   Oliguric phase:                                   decreasing urine output   electrolyte disturbances   fluid volume excess   azotemia   metabolic acidosis Diuretic phase:   increased urine output   electrolyte disturbances  dehydration   hypotension Recovery phase:   symptoms begin resolving Treatment of ARF­   Correct fluid & electrolyte problem,  Treat hypertension  Diet high calories but low in protein, sodium, potassium, and phosphates.  Give them erythropoietin injections to prevent anemia (kidneys not able to  produce it)  Dialysis used if absolutely necessary. CRF­gradual loss of renal function The biggest risk factors are diabetes and hypertension. Next is renal obstructions. Definitions  Renal impairment­60% of nephrons lost  Renal insufficiency­75% of nephrons lost, GFR reduced by 20%, erythropoietin  not produced=anemia.  End stage renal disease (ESRD)­90% of nephrons lost, GFR is only 10ml/hr.  Requires dialysis to live. Chapter 27. Urinary Incontinence­types include stress, urge, reflex, overflow,  mixed, functional, gross total.  Be familiar with the basic definition of urinary incontinence: loss of urinary control for a variety of reasons.  Stress incontinence­loss of control with coughing, straining, exercise,  laughing, etc…  Urge incontinence­this one is associated with overactive bladder.  Reflex incontinence­ due to nervous system damage.  Risk factors for incontinence= female gender, elderly, overweight, smoker, etc…  Treatment: bladder training, scheduled toileting, fluid intake management,  improve pelvic muscle strength & control (pelvic exercises).  Neurogenic bladder­interruption in nervous system innervation to the bladder.  Most common cause is spinal disorders. th  Congenital disorders­kidneys form in the fetus during the 5  week of gestation­ may be exposed to something that damages kidney formation.  Polycystic Kidney Disease: inherited, multiple fluid filled cysts form in and on the  kidneys replacing normal, functioning kidney tissue. Eventually they go into the ESRD  and require dialysis.  Wilm’s Tumor: rare cancer of the kidney that affects kids usually is just one tumor­but  it gets big. Urinary Tract Infections (UTI): most common­lower urinary tract infection, caused by E. Coli.  Urgency­feel like you need to urinate all the time  dysuria­pain & burning during urination  frequency­urinating often but very small amounts each time   hematuria­blood in the urine  Bacturia­bacteria in the urine  cloudy and foul­smelling urine­ cloudiness from white blood cells, mucus,  pus.   fever Cystitis­bladder infection, bladder is inflamed, same symptoms as UTI plus lower  abdominal and pelvic pain & pressure. Treatment: increase intake of fluids (no caffeine), acidify the urine by drinking cranberry juice and eating citrus fruits, antibiotics are often required. Teach females to wipe from  front to back after urinating, urinate after intercourse. Avoid putting off urination (holding  it for long periods). Avoid perfumed bubble bath. *Pyelonephritis: serious, infection has made up to the kidneys, usual cause is E. Coli.  Kidneys get edematous & fill with exudate, this leads to renal artery compression.  Very painful­have flank pain, chills, fever, nausea, vomiting, hematuria, burning & pain during urination, and other symptoms. Needs prompt treatment­risk of  permanent kidney damage if not promptly treated.  Requires antibiotics­4­6weeks, increase fluids, treat pain, nausea, other  symptoms. Glomerulonephritis: serious, inflammation of the glomeruli, usually from streptococcal infection.   Leaky glomeruli­Hematuria “coca cola” urine, proteinuria  Oliguria (ineffective excretion of fluid): edema, malaise, headache, N,V, elevated  B/P and fluid volume overload, dark urine with blood (cola colored), dyspnea,  cardiomegaly, pulmonary edema  Anemia­not producing erythropoietin  What is the difference in glomerular permeability in Nephritic syndrome versus  Nephrotic syndrome? Nephrotic Syndrome:   Manifestations: Nephrotic Syndrome: autoimmune, antigen­antibody complexes lodge in glomerular  membrane, complement system is activated and immune system “coats” the glomerular membrane and the immune system attacks it.  Manifestations: fluid retention (edema), ascites, large amounts of protein spilled in the urine, anorexia, weight gain. Urolithiasis (kidney stones): stones are composed of calcium, oxalate, phosphate,  struvite, cysteine, or a mix. Symptoms are somewhat similar to pyelonephritis. Kidney  tend to manifest suddenly, Sometimes need to do an xray or ultrasound to rule out  pyelonephritis. There is hydronephrosis if it is a kidney stone and we can see the stone  on the ultrasound/xray.  flank area pain  Groin or leg pain   bloody, cloudy, or foul­smelling urine  Dysuria  Frequency  Nausea, vomiting  fever; and chills  *A cause of post­renal acute renal failure. Hydronephrosis­ the renal pelvis (area within the kidney) is distended. Urinary Tract obstruction: see kidney stones/urolithiasis above except physician will  usually go in with a cytoscope and remove the stone if it blocks the urinary tract. Can  cause renal failure if the stone completely block the urinary tract. Bladder Cancer­preventable causes include smoking, exposure to toxic chemicals  (occupational), analgesics, and sources of chronic irritation (long term catheter,  recurrent UTIs, etc…). *Painless hematuria.  Other: abnormal urine color, dysuria, frequency, back pain, abdominal pain, frequent  UTIs. Kidney cancer­ preventable causes include smoking, exposure to toxic chemicals.  More common in males. Benign Prostatic Hyperplasia­enlarged prostate, compresses the urethra. Patients  with BPH cannot fully empty the bladder, experience dribbling during urination. Hormones Influencing Renal function • Antidiuretic  • Released from  Water  Makes Distal Collecting  hormone (ADH) posterior pituitary reabsorbed Tubule and Collecting  Duct permeable to water  to maximize reabsorption  and produce a  concentrated urine. • Aldosterone • Released from  Water &  • Promotes sodium  adrenal cortex Sodium  reabsorption and  reabsobed potassium secretion in  Distal Collecting Tubule  and Collecting Duct; water  and chloride follow sodium movement. • Erythropoietin Renal parenchyma Stimulates bone marrow to make red blood cells. Activated  Renal parenchyma Promotes absorption of  vitamin D calcium in the  gastrointestinal tract. Renin Juxtaglomerular  Raises blood pressure as  cells of the afferent  result of angiotensin  and efferent arterioles (vasoconstriction) and aldosterone (volume  expansion) secretion. Atrial natriuretic  Released by cells in  Decreases sodium and  peptide the cardiac atria  water reabsorption. The  when the atria are  kidneys excrete sodium  distended due to  and water (diuretic effect). plasma volume  Also inhibits renin  increases. secretion.  *ANP helps the body get  rid of sodium & water. And helps compensate when a  patient goes into HF.


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