MEDICAL NURSING III

DISEASES OF THE GENITOURINARY SYSYTEM

Objectives

• By the end of the lesson, students will be able to:
• state 5 general signs and symptoms of diseases of the urinary system
• mention 4 general diagnostic measures of diseases of the urinary system
• Describe the pathophysiology of Acute Glomerulonephritis
• Outline 4 diagnostic measures of glomerulonephritis
• State 8 clinical manifestations of GN
• Describe 4 nursing management practices of GN

GENERAL SIGNS AND SYMPTOMS OF RENAL DISORDERS.

• Frequency-frequent voiding
• Urgency-strong desire to void
• Dysuria-painful or difficult voiding
• Hesitancy- Delay, difficulty in initiating voiding
• Nocturia- Excessive urination at night
• Incontinence- involuntary loss of urine
• Enuresis –involuntary voiding during sleep
• Stress incontinence- Involuntary urination with increased pressure (sneezing or coughing)��

��GENERAL SIGNS AND SYMPTOMS OF RENAL DISORDERS�

• Polyuria- a volume of urine in excess of the normal (over 2000mls in 24hrs)
• Oliguria- Urine output less than 400mls in 24hrs
• Anuria-Urine output less than 100ml in 24hrs
• Haematuria- Red blood cells in the urine
• Proteinuria- abnormal amounts of protein in the urine
• Retention of urine- Inability to urinate even though bladder contains excessive amount of urine��

GENERAL DIAGNOSTIC INVESTIGATIONS OF RENAL DISORDERS

• URINALYSIS ; urine color, urine clarity and odour, urine PH and specific gravity, tests to detect protein, glucose, and ketone bodies in the urine (proteinuria, glycosuria and ketonuria respectively)

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• Microscopic examination / Culture of urine sediments after centrifuging to detect RBCs (haematuria), white blood cells, casts (cylindruria), crystals (crystalluria), pus (pyuria), and bacteria (bacteriuria)

GENERAL DIAGNOSTIC INVESTIGATIONS OF RENAL DISORDERS

• X-ray films, cystography, urologic endoscopic procedure, Voiding Cystourethrography, Renal Angiography, Computed Tomography (CT scan) and Magnetic Resonance Imaging of kidneys and bladder

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• Ultrasonography, Nuclear Scans, Intravenous Urography, Retrograde Pyelography, Kidney Biopsy, and renal function tests.

Definition and Description

• Glomerulonephritis (G) is an inflammation of the glomerular capillaries.
• Acute glomerulonephritis (AG) aka acute nephritic syndrome is primarily a disease of children over 2 years, but it can occur at any age.
• There are immunological processes resulting in antibody-antigen complexes
• It is typically preceded by an ascending infection or occurs secondary to another systemic disorder.
• Depending on the cause, the acute episode may completely resolve.

Causes of AG

1. Infectious causes:

• Group A beta-haemolytic streptococcus, measles, mumps, cytomegalovirus, varicella, coxsackie virus, pneumonia due to mycoplasma, pneumococcal infection

2. Systemic disorders:

• systemic lupus erythematosus, viral hepatitis B or C, thrombocytopenia purpura, or multiple myeloma (i.e. cancer of plasma cells)

Pathophysiology

• Antigens outside the body (e.g., medications, foreign serum) or autoimmune (kidney tissue) initiate the process, resulting in antigen-antibody complexes deposited in the glomeruli setting up the inflammation process.
• Leukocytes infiltrate the glomerulus
• Thickening, scarring and loss of glomerular filtration membrane
• Decreased glomerular filtration rate (GFR)

Pathophysiology

Antigen (group A beta-hemolytic streptococcus)

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Antigen–antibody product

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Deposition of antigen–antibody complex in glomerulus

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Increased production of epithelial cells lining the glomerulus

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Leukocyte infiltration of the glomerulus

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Thickening of the glomerular filtration membrane

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Scarring and loss of glomerular filtration membrane

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Decreased glomerular filtration rate (GFR)

Signs and symptoms

• Haematuria (cardinal)
• Proteinuria
• Peripheral oedema
• Elevated blood pressure
• Oliguria—decrease in urine output
• Nausea, vomiting, loss of appetite as renal function declines
• Headache
• Malaise
• Flank pain
• Fever

Diagnostic Investigations

• Renal biopsy to determine cause
• History-anuria for 1 or more days or voids about 50-200 mls daily which is cola-coloured with an elevated specific gravity
• Urinalysis shows red blood cells and red blood cell casts.
• Glomerular filtration rate will be decreased.
• 24-hour urine collection for protein will show elevated protein level.
• BUN level will be increased.
• Serum albumin will be decreased.

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Medical Management

• Management consists primarily of treating, causes, symptoms, attempting to preserve kidney function, and treating complications promptly.
• Antibiotics: penicillin
• Corticosteroids and immunosuppressant medications
• Loop diuretics: furosemide
• Antihypertensive agents: nefidipine
• Restrict diet protein and sodium: renal insufficiency and nitrogen retention i.e. BUN up

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Nursing Management

• Monitor vital signs, intake and output, weigh daily.
• Assess respiratory system for lung sounds, difficulty breathing, crackles in lungs suggesting fluid overload.
• Assess cardiovascular status, heart rate, heart sounds, presence of S3 suggesting fluid overload.
• Assess extremities for oedema.
• Teach patient about medications, disease process effective self-care at home
• Diet: high caloric to reduce protein catabolism

Complications

• Chronic glomerulonephritis
• Hypertensive encephalopathy
• Heart failure
• Pulmonary oedema
• Renal failure

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CHRONIC GLOMERULONEPHRITIS

• It is a slowly progressive disease, characterized by inflammation of the glomerulus which result in scaring, sclerosis and eventual renal failure.

CAUSES

• Repeated episodes of acute Glomerulonephritis
• Hypertension
• Hyperlipidemia
• Chronic tubulo interstitial injury
• Glomerular sclerosis
• Nephrotic syndrome
• Pylonephritis (ascending urinary tract infection that has reached the pelvis of the kidney).
• Systemic Lupus erythematous (SLE)

PATHOPHYSIOLOGY

• The kidneys are reduced to as little as one fifth(1/5) their normal size (consisting largely of fibrous tissue).
• The cortex shrinks to a layer 1-2mm in thickness or less.
• Bands of scar tissues distort the remaining cortex, making the surface of the kidney rough and irregular.

PATHOPHYSIOLOGY CONTD.

• Numerous glomeruli and their tubules become scarred and the branches of the renal artery are thickened.
• The outcome is severe glomerular damage that results in ESRD (end state renal disease)

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SIGNS AND SYMPTOMS

• Patients may remain asymptomatic for many years.
• Elevated blood pressure (Hypertension)
• Oedema (periorbital and peripheral)
• Most patient report that their feet are slightly swollen at night.

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SIGNS AND SYMPTOMS CONTD

• Severe nose bleed (Epistaxis)
• Nocturia
• Anaemia (mucous membrane are pale)
• Headaches
• Dizziness
• Increasing irritability
• Loss of weight and strength

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SIGNS AND SYMPTOMS CONT’D

• Crackles can be heard in the lungs
• Digestive disturbance
• Proteinuria and cast.
• Dyspnoea
• Pruritus
• fatigue

DIAGNOSIS

• History of the illness
• Urinalysis Reveals fixed specific gravity (about 1.010), variable proteinuria, cast (protein plugs)
• Blood studies –increase potassium levels, BUN and creatinine levels, decrease serum calcium level and increase serum phosphorus.
• X-Ray exhibit symmetrically contracted kidneys with normal calyces.
• Chest x-ray may show cardiac enlargement and pulmonary oedema

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DIAGNOSIS contd.

• Computed tomography (CT) and magnetic resonance imaging(MRI) scans show a decrease in the size of the renal cortex

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MEDICAL MANAGEMENT

• Same as AGN

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Nursing Management

• Nursing diagnoses
• Oedema related to proteinuria
• Breathless related to fluid accumulation in the lungs

Planning

Goal:

1. to reduce oedema
2. To ease brethlessness

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Implementation

• BED REST
• Ensure bed rest to reduce stress on the kidney, promote Diuresis and reduce Haematuria.
• Put patient in Semi-Fowler’s position to ease breathing

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�NUTRITION�

• Restrict fluid intake to help control oedema
• Provide patient with Low sodium diet
• Protein of high Biologic value is recommended for tissue growth and repair (Dairy product, eggs, meat)

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• Low potassium diet is encouraged (Hyperkalaemia)

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NUTRITION�

• Low fat intake is also encouraged (prevent fat deposition in Renal vessels which may lead to renal failure)
• Increase carbohydrates intake to provide energy and prevent protein catabolism.
• Increase Dietary vitamins especially C&B

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OBSERVATIONS

• Assess vital signs 4 hourly or depending on severity
• Monitor intake and output of fluids (This is to assess fluid excess or deficit)
• Daily weighing to assess wether oedema is subsiding or aggravating
• Assess breath sounds
• Colour of urine ,amount,consistency and odour must all be observed for and documented.

MEDICATIONS

• Serve prescribed antihypertensive, diuretic or steroid, considering all the 10 rights.
• Observe therapeutic and side effects of medication.

PATIENT EDUCATION

• Explain the disease process to the patient
• Educate patient on the need to treatment of upper respiratory tract infections promptly
• Teach how to take the medication
• Encourage patient to have enough rest
• Patient should be encouraged to avoid over the counter drugs.

COMPLICATIONS

• Hypertension
• Cardiac failure
• Renal failure

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NOTE:

• More than 95% of patients with Acute Post Streptococcal Glomerulonephritis (APSGN) recover completely or improve rapidly with conservative management. Accurate recognition and assessment are critical, since chronic glomerulonephritis develops in 5% to 15% of the affcted persons, and�irreversible renal failure occurs in 1% of patients.��

ACUTE PYELONEPHRITIS (ACUTE TUBULO INTERSTITIAL NEPHRITIS)

• It is a sudden inflammation caused by bacteria that primarily affect the interstitial area and the renal pelvis or less often the renal tubules

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CAUSATIVE ORGANISMS

• Escherichia coli
• Pseudomonas
• Staphylococus aureus
• Streptococcus faecalis

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CAUSES

• Vesico ureter reflux
• Instrumentation (catheterization, cystoscopy or urologic surgery)
• Hematogenic infections (septicaemia or endocarditis)
• May result from inability to empty the bladder (Neurogenic Bladder)
• Urinary tract obstructions due to tumors, strictures BPH.
• Systemic infections (such as TB)

INCIDENCE

• Sexually active women – intercourse increases the risk for Bacteria contamination
• Pregnant women
• Diabetics (Neurogenic Bladder)
• Persons with other Renal diseases

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SIGNS AND SYMPTOMS

• Chills
• Haematuria
• Fever
• Urine may appear cloudy and have fishy odour
• Flank pains
• Urinary urgency
• Nausea and vomiting
• headache

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SIGNS AND SYMPTOMS CONT’D.

• Anorexia
• Urinary frequency
• General fatigue
• Dysuria
• Bacteriuria {10⁵ colonies of bacteria per milliliter of urine for women and 10⁴ colonies of bacteria per milliliter of urine for men }
• Nocturia
• Pyuria {presence of pus in urine}

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DIAGNOSTIC INVESTIGATIONS

• Urinalysis- pus, Blood, Bacteria, RBCs, WBCs
• Urine culture and sensitivity test
• CT scan to locate any obstruction in the urinary tract.
• WBC count- Elevated

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CHRONIC PYLONEPHRITIS

• Repeated bouts of Acute pyelonephritis may lead to chronic pyelonephritis

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SIGNS AND SYMPTOMS

• Fatigue
• Headache
• Poor appetite
• Polyuria
• Polydipsia
• Weight loss
• Low urine specific gravity

SIGNS AND SYMPTOMS CONTD.

• Leucocytes in urine
• Proteinuria
• Flank pain
• Anaemia
• Hypertension in late stages
• Patient usually have a history of unexplained childhood fevers or Bed-wetting

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DIAGNOSIS

• SAME as acute pyelonephritis

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MEDICAL MGT

• Antimicrobial Agents-trimethoprim-sulfamethoxazole, ciprofloxacin, Gentamycin with or without Ampicillin.

NURSING MANAGEMENT

• Reassure and offer patient psychological support to allay his or her anxiety
• Ensure bed-Rest to relieve stress on kidney and promote diuresis

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NURSING MANAGEMENT CONT’D

• NUTRITION
• Provide patient with High calorie/carbohydrates to provide energy
• Restrict the intake of sodium
• Moderate intake of proteins should also be encouraged
• Unless contra-indicated encourage fluids intake to dilute urine, decrease burning on urination and prevent dehydration(3-4L/day)
• Vitamins intake
• Acid –ash diet to prevent renal stone formation

NURSING MANAGEMENT CONT’D

Acid-ash diet

• The acid-ash diet is based on the principle that one can alter the composition of his diet to change the pH of his urine -- in this case, making it more acidic, which may help eliminate some types of kidney stones.
• Animal proteins and grain-based items are central to the acid-ash diet, with very limited amounts of fruits and vegetables

NURSING MANAGEMENT CONT’D

• Observations
• Monitor vital signs 4 hourly
• Monitor intake and output daily
• Monitor Therapeutic effects and side effects of Drugs.

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NURSING MANAGEMENT CONT’D

• Patient Education
• Conditions (causes, s/s, mgt, complications)
• How to prevent the infection
• Adequate fluid intake
• Emptying bladder regularly
• Recommended perineal hygiene (e.g. cleaning anus backward after defaecation in women)
• Advice patient on routine check ups for urinary tract infections.

COMPLICATIONS

• Renal failure(ESRD)
• Hypertension
• Congestive heart failure
• Renal abscess
• Septicaemia

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NEPHROTIC SYNDROME

• A primary Glomerular disease that results from increased glomerular permeability characterised by
• Proteinuria,
• Hypoalbuminaemia,
• Hyperlipidaemia and
• oedema

TYPES OF NEPHROTIC SYNDROME

• Primary /idiopathic .

e.g. minimal –change nephropathy, focal glomerulosclerosis, membranous nephropathy, Hereditary nephropathy.

• Secondary from other diseases.

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CAUSES

• Chronic Glomerulonephritis
• Diabetes mellitus
• SLE
• Nephrotoxins –mercury, lead, gold
• Sickle cell Anaemia
• Renal vein thrombosis

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CAUSES contd.

• Multiple myeloma(malignant tumor arising from cells of the bone marrow specifically plasma cells)
• Neoplastic Diseases.
• Collagen vascular Disorders(SLE,RA.)
• Infections such as TB, Hep B
• Idiopathic (children)
• Amyloidosis of the kidneys (Disorder in which fibrous protein amyloid is deposited in organ of the body)

PATHOPHYSIOLOGY

• In Nephrotic syndrome, there is increase glomerular protein permeability, leading to increase urinary excretion of protein especially albumin, and subsequent Hypoalbuminaemia.
• The oncotic pressure of the plasma decreases and fluid shift from intravascular space to interstitial spaces leading to oedema.

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PATHOPHYSIOLOGY CONTD.

• There is also salt and water retention due to activation of renin-angiotensin system which also contributes to Oedema (Face, periorbital, ankles and sacrum).
• The decrease oncotic pressure also stimulates Lipoprotein synthesis in the liver, resulting in Hyperlipidaemia

S/S

• Oedema
• Swelling of the external genitalia
• Ascites
• Orthostatic hypotension
• Proteinuria
• Hypoalbuminaemia

s/s contd.

• Anorexia
• Lethargy
• Depression
• Pallor
• Signs of pleural effusion
• Irritability, malaise, headache

DIAGNOSTIC MEASURES

• Clinical history
• Urinary urinalysis-proteinuria>3-3.5g/day, WBCs, Cast, Oval fat bodies
• Needle Biopsy of kidney for histological examination to confirm diagnosis.
• Serum analysis-increased cholesterol, phospholipids, triglycerides, and decrease Albumin levels.

MEDICAL MANAGEMENT

• Correct the underlying cause
• ACE inhibitors in combination with diuretics (reduces the degree of proteinuria)
• Anti –Neoplastic agents. E.g., cyclophosphamide, Azathioprine, chlorambucil, cyclosporine.
• If relapse occurs then steroids are added to antineoplastic Agents.

NURSING MANAGEMENT

Diet

• Provide patient with diet containing Low sodium
• Encourage the Liberal intake of potassium
• Restrict saturated Fat diet intake
• Encourage the intake of protein (0.8/kg/day) with emphasis on protein of high Biologic value(Diary products, egg, meat).

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OBSERVATIONS

• Monitor the patient Vital signs (B/P on standing)
• Monitor intake and output daily
• Assess the skin for oedema
• Check patient’s weight daily and measure abdominal girth or extremity size
• Assess the patient skin for pressure sores
• Observe for side effects of corticosteroids and Anti-Neoplastic Drugs.

OEDEMA

• Ensure dietary sodium restriction
• Assess skin for pitting oedema daily
• Monitor vital signs (increase B/P, Tachycardia, Tachypnoea, Dyspnoea, crackles)
• Meticulous skin care and treatment of pressure areas 4 hourly.
• Encourage patient to change position in bed frequently.
• Administer prescribed diuretic and observe for therapeutic and side effects.

PATIENT EDUCATION

• Explain the disease process to patient
• Explain the need for dietary restrictions
• Teach patient how to take medications
• Tell patient to stop using over the counter drugs.
• Because the patient with nephrotic syndrome is susceptible to infection, teach the patient to avoid exposure to persons with known infections.

Psychological care

• Support for the patient, in terms of coping with an altered body image, is essential because of the�embarrassment and shame often associated with the oedematous appearance��

COMPLICATIONS

• Infection (due to a deficient immune response)
• Thromboembolism (especially of the renal vein)
• Pulmonary emboli
• ARF (due to hypovolaemia)
• Accelerated atherosclerosis (due to�hyperlipidaemia).��