GUT Part 3 - Infections, Stones and Other Disorders

Urinary Tract
Disorders
IFLAMMATION & INFECTIONS
• Ureteritis = inflammation of ureter
(maybe caused by stone in the ureter)
• Cystitis = inflammation of bladder
(caused by ascending bacterial infection
usually E. coli)
• Urethritis = inflammtion of urethra (may
lead to prostatitis and epididymitis)
caused by bacterial infection (STD)
Urethritis
Urethritis
• Is an inflammation of the urethra
commonly associated with sexually
transmitted diseases and may occur with
cystitis
• In men, urethritis most often is caused by
gonorrhea or chlamydial infection
• In women urethritis most often is caused
by feminine hygiene sprays, perfumed
toilet paper or sanitary napkins,
spermicidal jellies, UTIs, or changes in the
vaginal mucosal lining
Urethritis
Assessment
Males
Burning in urination, frequency, urgency,
nocturia, difficulty voiding, discharge
from the penis
Females
Frequency, urgency, nocturia, painful
urination, difficulty voiding, lower
abdominal discomfort
Urethritis
Nursing Interventions
Encourage fluid intake
Prepare the client for testing to determine
if a sexually transmitted disease is present
Administer antibiotics as prescribed
Instruct the client in the administration of
sitz baths
If stricture occurs, prepare the client for
dilation of the urethra with instillation of
anesthetic and an antiseptic solution
Urethritis
Instruct the client to avoid intercourse
until the symptoms subside or treatment
of the sexually transmitted disease is
complete
Instruct the female client to avoid the
use of perfumed toilet paper or sanitary
napkins and feminine hygiene sprays
Urinary Tract Infection
(Cystitis)
Urinary Tract Infection (UTI)
• Inflammation of the bladder from
infection or obstruction of the urethra
• The most common causative organisms
are Escerichia coli (54.7%),
Enterobacter, Pseudomonas and
Serratia
• More common in women because of
shorter urethra than men, and location of
the urethra in women is close to the
rectum
• Inflammation of the bladder
by substances or
microorganisms moving up
the urethra
Contributing factors
– Obstructions, calculi
– Vesicoureteral reflux
– Diabetes
– Alkalotic urine
– Gender/age/sexual activity
– Catheters
Predisposing factors include
2. Sexually active and pregnant women
in hormonal changes influencing
alterations in vaginal flora
3. Allergens or irritants, such as soaps,
sprays, bubble bath, perfumed
sanitary napkins
4. Bladder distention
5. Poor hygiene
5. Synthetic underwear and pantyhose
6. Wet bathing suits
7. Urinary reflux
8. Indwelling urethral catheters
9. Invasive urinary tract procedures
10. Loss of bactericidal properties of
prostatic secretions in the male
11. Poor fitting diaphragms
12. Use of spermicides
13. Residual urine, urinary stasis
14. Dehydration
PATHOPHYSIOLOGY
The invading organism ascends the
urinary tract, irritating the mucosa and
causing characteristic symptoms
– Urethra=Urethritis
– Bladder= cystitis
– Ureter= ureteritis
– Pelvis= Pyelonephritis
PAIN ASSESSMENTS
Inflammatory Manifestations:
Pain during and after urination =
cystitis
Pain after urination = urethritis
Inguinal pain = ureteritis
Flank pain = pyelonephritis
Manifestations:
– Dysuria, burning on
urination
– Frequency, urgency
– Incomplete emptying
of the bladder,
retention, voiding
small amounts
– Inability to void
– Hesitancy
– Nocturia
– Incontinence
Manifestations:
– Low back pain
– Bladder spasms
– Rare: fever, chills,
N/V, malaise, flank
pain
– Hematuria
– Urine: cloudy, dark,
foul smelling, blood
Laboratory and Diagnostics
– Urinalysis (100,00 colonies/ml &/or pyuria)
– Urine culture (gold standard)
– CBC with differential counts
– Blood culture
– KUB, Ultrasound, CT scan, cystoscopy (If
an obstruction is suspected)
Pharmacology
2. Systemic antibiotics
- Ampicillin, cepaholosporins,
aminoglycosides
2. Sulfonamides
- Sulfisoxazole (Gantrisin),
sulfamethoxazole (Gantanol), trimethophrim-
sulfamethoxazole (Bactrim)
– Highly concentrated in the urine
– Effective against E. coli!
– SE: Can cause CRYSTALLURIA and
photosensitivity reaction
Pharmacology
3. Antibiotics
- Nitrofurantoin (Macrodantin), methenamine
mandelate (Mandelamine) nalidixic acid
(NegGram), Quinolones (Not given to less than
18 because they can cause cartilage
degradation)
4. Antispasmodics: Cystospaz
5. Urinary Tract Analgesic: Phenazopyridine
(Pyridium)
- Direct anesthetic to bladder mucosa
- Can cause urine discoloration
Prevention of UTI in Females:
Teach pregnant women to void every 2
hours
Instruct the client to void and drink a
glass of water after intercourse
Instruct the female client to avoid bubble
bath and tub baths and avoid vaginal
deodorants or sprays
Teach the female client good perineal
care and to wipe from front to back
“Bad Stroke”
Prevention of UTI in Females:
Instruct the female client to wear cotton
pants and to avoid wearing tight clothes
or pantyhose with slacks and to avoid
sitting in a wet bathing suit for prolonged
periods of time
Encourage menopausal women to use
estrogen vaginal creams to restore pH
Instruct the female client to use water-
soluble lubricants for coitus, especially
after menopause
Nursing interventions
Obtain urine specimen for culture and
sensitivity if prescribed, to identify
bacterial growth before administering
prescribed antibiotics
Instruct the client to increase fluids up to
3L a day, especially if the client is taking
sulfonamide because these medications
can form crystals in concentrated urine
• Administer medications as prescribed
which include analgesics, antiseptics
antispasmodics, antibiotics, and
antimicrobials
• Maintain an acid urine pH (5.5) by an
acid-ash diet; instruct the client in foods
to consume on acid-ash diet
• Use strict aseptic technique when
inserting a urinary catheter into a client.
• Note that if the client is prescribed an
aminoglycoside, sulfonamide, or
nitrofurantoin (Macrodantin), the actions
of these medications are diminished by
acidic urine
• Maintain closed urinary drainage
systems and provide meticulous perineal
care for the client with an indwelling
catheter
• Provide warm sitz bath. Provide heat for
the abdomen if with abdominal pain
• Force fluids. Nurses may give 3 liters of
fluid per day unless contraindicated
• Encourage measures to acidify urine
(cranberry juice, acid-ash diet).
Types of Diet:
Acid-Ash Diet
Diet decreases the pH of the urine
Diet makes the urine more acidic
Foods to include:
Bread, cereal, whole grains
Cheese, eggs, corn and legumes
Cranberries, prunes, plums, tomatoes
Meat, fish, oysters, poultry
Pastries
Types of Diet:
Alkaline-Ash Diet
Diet increases the pH of the urine
Diet reduces the acidity of the urine
Foods to include:
Fruits except cranberries, plums, and
prunes
Milk, rhubarb
Most vegetables
Small amounts of beef, halibut, veal, trout,
and salmon
Discourage caffeine products such as
coffee, tea, cola and alcohol
Instruct client to take antibiotics on
schedule and take the entire course of
medications as prescribed for 10-14 days
Importance of follow-up urine culture
following treatment
Provide client teaching and discharge
planning concerning
a. Avoidance of tub baths
b. Avoidance of bubble baths that
might irritate urethra
c. Importance for girls to wipe
perineum from front to back
d. Increase in foods/fluids that
acidify urine.
Pyelonephritis
Ureteritis
Inflammation of the ureter commonly
associated with pyelonephritis
Chronic pyelonephritis causes the
ureter to become fibrotic and
narrowed by strictures
Pyelonephritis
• Inflammation of renal pelvis &
parenchyma commonly caused by
bacterial infection
• Maybe unilateral or bilateral, acute or
chronic
• Acute Pyelonephritis- occurs after
bacterial contamination of the urethra or
following an invasive procedure of the
urinary tract (catheter or cystoscope)
- usually ascends from lower urinary tract
Pyelonephritis
• Chronic Pyelonephritis- most commonly
occurs following chronic obstruction with
uretrovesical reflux or chronic disorders
with infected urine backing up into ureters
and renal pelvises
- result of recurrent urinary tract infections
- slow and progressive, leads to fibrosis
and scarring with loss of nephrons,
eventual parenchymal deterioration and
possible renal failure
Pyelonephritis
• Escherichia coli is the most common
bacterial causative organism
• Pathophysiology: bacteria enters renal

pelvis-> inflammatory response->
increase WBC-> edema & tissue
swelling -> parenchymal deterioration
-> scar tissue-> impaired renal
function -> renal failure
Acute and Chronic
Pyelonephritis
Acute Pyelonephritis
• Usually follows a short course that
recurs as a as a new infection or
relapse of a previous infection
• Can progress to abscess formation,
bacteremia or chronic pyelonephritis
Assessment:
fever and chills
nausea
flank pain and groin on the affected
side
Acute Pyelonephritis
Assessment:
costovertebral angle tenderness
(pathognomonic)
headache, muscular pain, fatigue
dysuria, frequency and urgency,
nocturia
cloudy, bloody, or foul-smelling urine
increased WBCs in the urine
tachycardia, tachypnea
Chronic Pyelonephritis
• Is a slow, progressive disease usually
associated with recurrent acute
attacks
• Causes contraction of the kidney and
dysfunction of the nephrons, which
are replaced by scar tissue
• Can lead to renal failure
• Frequently diagnosed incidentally
when a client is being evaluated for
hypertension
Chronic Pyelonephritis
Assessment:
Hypertension
Pyuria, Nocturia, Proteinuria
Azotemia
Anemia
Acidosis
Increased sodium loss
Hyperkalemia
Pyelonephritis
Diagnostics:
Urinalysis: +WBC, + bacteria
Urine & blood for culture
CBC with differential counts
Renal Ultrasound (other studies if
indicated) and other radiograph
imaging
IVP and renal US used in diagnosis of
Chronic pyelo: shows scaring, and a
smaller than normal kidney
Pyelonephritis
Medical Management:
Acute
– Antibiotics for 2 weeks
– Antibiotics: initially will use broad
spectrum antibiotics (ampicillin,
vancomycin) combined with an
aminoglycoside (gent, tobramicin) then
switch when sensitivities are
documented: main drugs are: Bactrim,
septra (trimethoprim-
sulfamethoxazole) Cipro
Pyelonephritis
Medical Management:
Acute
– Antispasmodics (Cystospaz)
– Urinary analgesics: phenazopyridine
(Pyrdium)
– NSAIDS: use cautiously
– Surgical removal of any obstruction
– Increase fluid intake
Pyelonephritis
Medical Management:
Chronic
– Antibiotics for 2-4 weeks
– Urinary antiseptics (sulfonamides,
nitrofurantoin)
– Urinary analgesics
– NSAIDS: use cautiously
– Surgical correction of structural
abnormality if possible
– Increase fluid intake
Pyelonephritis
Nursing Interventions:
Acute
– Provide adequate comfort and rest
– Monitor I and O
– Administer antibiotics as ordered
– Provide client teaching and discharge
planning concerning:
a. Medication regimen
b. Follow-up cultures
c. Signs and symptoms of recurrence
and need to report
Pyelonephritis
Chronic
– Administer medications as ordered
– Provide adequate fluid intake and nutrition
– Support client/significant others and
explain possibility of dialysis, transplant
options if significant renal deterioration
occurs
Pyelonephritis
Monitor vital signs
Monitor intake and output
Monitor weight
Encourage fluid intake up to 3000ml a
day
Encourage adequate rest
Instruct the client in a high-calorie, low
protein diet
Pyelonephritis
Provide warm, moist compresses to the
flank area
Encourage the client to take warm
baths
Administer analgesics, antipyretics,
antibiotics, urinary antiseptics, ad
antiemetics as prescribed
Monitor for signs of renal failure
Bacteremia- Urosepsis
Bacteremia-Urosepsis
Urosepsis is a gram-negative bacteremia
originating in the urinary tract
The most common Causative Agent
-Escherichia coli - Gram negative bacteria
Predisposing Factors:
More prevalent in institutionalized clients
Presence of an indwelling urinary catheter
Untreated UTI in a client who is medically
compromised
Bacteremia -Urosepsis
Pathophysiology:
• Bloodstream invasion of bacteria seeded
from the urinary tract
• The major problem is the ability of this
bacterium to develop resistant strains
• Urosepsis can lead to septic shock if not
treated aggressively -> Death
Assessment:
Fever is the most common and earliest
manifestation
Tachycardia, tachypnea
Weakness, malaise, fatigue
Nausea and vomiting
Hypotension, shock, oliguria, anuria
Narrowed pulse pressure
Change in level of consciousness and
sensorium
• Obtain a urine specimen for urine culture
and sensitivity before giving antibiotics
• For urosepsis give aminoglycosides
• Administer antibiotics intravenously as
prescribed, usually until the client has been
afebrile for 3 to 5 days
• Administer oral antibiotics as prescribed
after the 3 to 5 day afebrile period to
complete 2 to 4 weeks
Bacteremia –Urosepsis
Other Nursing Interventions:

Increase fluids
Acidify urine (offer cranberry juice)
Warm sitz bath
Monitor for hypotension, fever, narrow pulse
pressure, neurological vital signs for signs of
impending shock
Implementation Steps for
selected problems
Provide PAIN relief
Assess the level of pain
Administer medications usually narcotic
ANALGESICS
selected problems
Maintain Fluid and Electrolyte
Balance
Encourage to consume at least 2 liters of
fluid per day except for cases of ARF,
limit fluid as directed
Weigh client daily to detect fluid retention
selected problems
Ensure Adequate urinary elimination
Encourage to void at least every 2-3 hours
Promote measures to relieve urinary
retention:
– Alternating warm and cold compress
– Bedpan
– Open faucet
– Provide privacy
– Catheterization if indicated
Nephrolithiasis /
Urolithiasis
“Lithiasis”
• Nephrolithiasis = kidney stone
• Ureterolithiasis = ureter stone
• Cystolithiasis = bladder stone
• Urethrolithiasis = stone at the urethra
• The stone is usually calcium phosphate
and uric acid/oxalate
Urinary Calculi - Stone
Nephrolithiasis/Urolithiasis
Urolithiasis
Formation of urinary stones anywhere in
the urinary tract
Urinary calculuses are commonly formed
in the kidneys followed by ureters
Nephrolithiasis
A form of urolithiasis associated with
formation of kidney stones
Kidney stones are formed in the renal
parenchyma (major and minor calyces)
• Calculuses or stones can form anywhere
in the urinary tract; however, the most
frequent site is the kidneys
Complications:
Pain
Obstruction
Tissue trauma (scar)
Secondary hemorrhage
Infection
Predisposing Factors
a. Diet: large amounts of calcium, vitamin
D, milk, protein, oxalate, purines or alkali
b. Elevated uric acid levels such as in gout
c. Sedentary life-style, immobility
d. Family history of gout or calculi
e. Hyercalcemia and hyperparathyroidism
f. Obstruction and urinary stasis
Predisposing factors
g. Dehydration
h. Use of diuretics which can cause
volume depletion
i. Urinary Tract infections and prolonged
urinary catheterization
Pathophysiology
Calculuses occludes the ureter and blocks the flow
of urine -> OBSTRUCTION
Ureter dilates -> HYDRONEPHROSIS
Urinary stasis results in INFECTION
Impairment of renal function on the side of blockage
KIDNEY DAMAGE
Assessment Findings
2. Flank pain
3. Renal colic which originates in the
lumbar region and radiates toward the
genitalia and thigh
4. Sharp, severe pain of sudden onset
(highest nursing priority in emergency)
5. Dull aching pain in the kidney
6. Cool, moist skin
7. Nausea and vomiting, pallor, and
diaphoresis during acute pain
Assessment Findings
2. Urinary frequency with alternating
retention
3. Signs of UTI
4. Low-grade fever
5. High numbers of red blood cells, white
blood cells, and bacteria in the urinalysis
6. Gross hematuria
Urolithiasis / Nephrolithiasis:
Pain Assessments
• Pain assessment will be dependent on the site
of stone
• Flank pain = kidney or ureter
• Groin pain = ureter
• Pelvic and perineal pain = bladder and urethra
• Descending stone may scratch the membrane
irritating the membrane leading to inflammation
and bleeding
• Adhesions may follow after healing leading to
secondary obstruction
Diagnostic Tests
1. Kidney Ureter Bladder Ultrasound & X-ray:
pinpoints location, number & size of stones
2. Intravenous Pyelogram: identifies specific
site of obstruction and presence of non-
radiopaque stones
3. Urinalysis: indicates presence of bacteria,
increased protein, WBC and RBC (hematuria)
4. Computed Tomography scan & Renal
Ultrasonography: indicates soft tissue
inflammation, and parenchymal scars
Diagnostic Tests
5. Stone Analysis- done after passage in the
urine (urine straining) to determine the type of
stone and assist in determining treatment
Types:
a. Calcium Phosphate stones
b. Calcium Oxalate stones
c. Struvite stones
d. Uric acid stones
e. Cystine stones
Types of Stones
Types of Stones
1. Calcium Phosphate stones
- are caused by supersaturation of urine
with calcium and phosphate
2. Calcium Oxalate stones
- are caused by supersaturation of urine
with calcium and oxalate
3. Uric acid stones
- are caused by excess dietary purine or
from gout
- tend to form in acidic urine
Types of Stones
4. Struvite Stones
- also are called triple phosphate stones
and are composed of magnesium and
ammonium phosphate
- are caused by urea splitting bacteria
- tend to form in alkaline urine
5. Cystic Stones
- caused by cystine crystal formation
- tend to form in acidic urine
Medical Management of Kidney Stones
• Medications prescribed for calcium stones
may include Phosphates, Thiazide
diuretics, and Allopurinol (Zyloprim)
• Pyridoxine or magnesium oxide may be
prescribed for clients with oxalate stones
• Allopurinol (Zyloprim) may be prescribed
for clients with oxalate and uric acid stones
• Long term use of antibiotics may be
prescribed for struvite or cystine stones
Management Summary
Medical Management
Narcotics and NSAIDs for pain
management
Antibiotics prophylactically
Antispasmodic (Probanthine)
Rowatinex to dissolve stone
I & O, strain urine (any catched stone
must be submitted to lab to identify type
of stone)
Surgical Management
1. Surgery of Kidney Stones
A. Cystoscopy
• May be done for stones located in the
bladder or lower ureter
• No incision is made
• One or two ureteral catheters are inserted
past the stone
• The stone may be manipulated and
dislodged by the procedure
Surgical Management
1. Surgery of Kidney Stones
A. Cystoscopy
• Catheters are left in place for 24 hours to
drain the urine trapped proximal to the
stone and to dilate the ureter
• A continuous chemical irrigation may be
prescribed to dissolve the stone
• The catheters may guide the stones
mechanically downward as they are
removed
Surgical Management
2.Surgery of Kidney Stones
B. Extracorporeal Shock Wave
Lithotripsy
• Is a noninvasive mechanical procedure for
breaking up stones that are located in the
kidney or upper ureter using sound waves or
light so that they can pass spontaneously or
be removed by other methods
• Fluoroscopy is used next to visualize the
stone
• No incision and no drains are placed
ESWL
Conscious
sedation
Used to break
up stones for
easier
excretion
ESWL
Surgical Management
Lithotripsy
• Ultrasonic waves are delivered through a
bath of warm water to the areas of the
stone to disintegrate it
• Stones are passed in the urine within a few
days
• Preprocedure: Maintain client on NPO
status for 8 hours before the procedure
Surgical Management
Lithotripsy
• Postprocedure: Monitor vital signs, intake
and output, bleeding, pain and signs of
urinary obstruction
- Instruct the client to increase fluid intake
to wash out the stone fragments
- Inform the client that ambulation is
important
Surgical Management
C. Percutaneous Lithotripsy
• Performed for stones in the bladder, ureter
or kidney
• Is an invasive procedure in which a guide
is inserted under fluoroscopy near the area
of the stone
• An ultrasonic wave is aimed at the stone to
break it into fragments
Surgical Management
• May be performed via cystoscopy or
nephroscopy (more common)
• The client may possibly have an indwelling
catheter
• A nephrostomy tube may be placed to
administer chemical irrigations to break up
the stone; nephrostomy tube may remain in
place for 1 to 5 days
Surgical Management
• Encourage the client to drink 3 to 4L of
fluid per day following the procedure
• Monitor for and instruct the client to
monitor for complications of infection,
hemorrhage, and extravasation of fluid into
the retroperitoneal cavity
Surgical Management
D. Ureterolithotomy
• Is an open surgical procedure performed if
lithotripsy is not effective
• It is performed if the location of the stone is
in the ureter
• Incision is made through a lower abdominal
or flank incision to remove the stone
• The client may have a penrose drain, a
ureteral stent catheter, and an indwelling
bladder catheter
Surgical Management
E. Pyelolithotomy
• An incision into the kidney via the flank or
lumbar approach is made to remove stones
from the renal pelvis
• A large flank incision is required
• The client may have Penrose drain and an
indwelling bladder catheter
Surgical Management
F. Nephrolithotomy
• Incision into the kidney is made to remove
the stone
• A large flank incision is required
• The client may have a nephrostomy tube
and an indwelling bladder catheter
Surgical Management
G. Partial or Total Nephrectomy
Performed for extensive kidney damage,
renal infection, or severe obstruction and
to prevent stone recurrence
POST-OP Interventions:
Monitor incision sitr, particularly if a
Penrose drain is in place, because it will
drain large amount of urine
Protect the skin from urinary drainage
Surgical Management
• Place an ostomy pouch over the Penrose
drain to protect the skin if urinary drainage
is excessive
• Monitor the nephrostomy tube, which may
be attached to a drainage bag for a free
flow of urine
• Do not irrigate catheters unless prescribed
Surgical Management
Monitor indwelling Foley catheter for
drainage
Encourage fluid intake to ensure a urine
output of 2500 to 3000ml or more per day
Monitor intake and output closely
Determine the composition of stone from
laboratory analysis
Surgical Management
Instruct the client in dietary restrictions if
required
Instruct the client about medications that
may be needed for long term to reduce the
development of calculuses
1. Monitor vital signs
2. Monitor intake and output
3. Assess for fever, chills and infection
4. Monitor for nausea, vomiting, and diarrhea
5. Encourage Fluid Intake up to 3000—4000

ml/day unless contraindicated, to facilitate
the passage of the stone and prevent
infection.
6. Strain all urine through gauze to detect
7. Send stones to the laboratory for
anlaysis
8. Provide warm baths and heat to the flank
area
9. Relieve pain by administration of
analgesics as ordered
10. Assess the client’s response to pain
medication
11. Administer fluids intravenously as
prescribed to increase the flow of urine and
facilitate the passage of the stone
12. Turn and reposition immobilized clients
and encourage ambulation to prevent stasis
13. Assist the client in performing relaxation
techniques to assist in relieving pain
14. Prepare the client for surgical
procedures if prescribed
15. Maintain urinary pH depending on the
type of stone
16. Instruct the client in the diet specific to
the stone composition
Types of Diet in Stones
Acid-Ash Diet
Diet decreases the pH of the urine
Diet makes the urine more acidic
Foods to include:
Bread, cereal, whole grains
Cheese, eggs, corn and legumes
Cranberries, prunes, plums, tomatoes
Meat, fish, oysters, poultry
Pastries
Types of Diet in Stones
Alkaline-Ash Diet
Diet increases the pH of the urine
Diet reduces the acidity of the urine
Foods to include:
Fruits except cranberries, plums, and
prunes
Milk, rhubarb
Most vegetables
Small amounts of beef, halibut, veal, trout,
and salmon
Provide modified diet, depending upon stone
consistency: Calcium phosphate, Calcium
oxalate, Uric acid, Struvite, or Cystine
stones
Calcium Phosphate Stones
• Provide acid-ash diet to acidify urine
(cranberry or prune juice, meat, eggs,
poultry, fish, grapes, and whole grains)
• Decrease intake of foods high in calcium
content like milk/dairy products
• Avoid excess vitamin D intake
Calcium Oxalate Stones
• Acid-ash foods because calcium stones
have an alkaline chemistry
• Avoid excess intake of foods/ fluids high in
oxalate to reduce urinary oxalate content
and the formation of stones (tea, almonds,
cashews, chocolate, cocoa, beans, rhubarb
and spinach)
• Avoid foods high in calcium
Uric acid stones
• Alkaline-ash foods
• Reduce foods high in purine (organ meats,
liver & kidneys, gravies, red wines,
sardines, beans, kidneys, shellfish, meat
soups, legumes)
• Allopurinol (Zyloprim) may be prescribed to
lower uric acid levels
Struvite Stones
• Acid-ash foods
• Limit high-phosphate foods such as dairy
products, red and organ meats, and whole
grains to reduce urinary phosphate content
Cystine Stones
• Alkaline-ash foods
• Dietary prescription is a low intake of
methatione, an essential amino acid that
forms cystine
• The client would be instructed to avoid
meat, cheese, and eggs
• Dietary measures also focus on
encouraging fluid intake up to 3L a day,
unless contraindicated, to help dilute the
urine and prevent cystine crystals from
forming
Nephrolithiasis/Urolithiasis:
Summary of Diet
Determine the type of stone (calcium
or uric acid) and specific diet
prescribed
• If its calcium phosphate, oxalate or struvite
then give cranberry juice (acid ash diet)
• If its uric acid then give milk and vegetables
(alkaline ash diet) or Allopurinol
• If its cystine then give also milk and
vegetables (alkaline ash diet)
• 17. Provide client teaching and discharge
planning concerning
- Prevention of Urinary stasis by
maintaining increased fluid intake
especially in hot weather and during
illness; mobility; voiding whenever the
urge is felt and at least twice during the
night
- Need for routine urinalysis (at least every 3—4
months)
- Need to recognize and report signs/ symptoms of
Glomerulonephritis
Glomerulonephritis
A variety of diseases
most of which are
caused by an
immunological
reaction
Usually resolves in
about 14 days, self-
limiting
• Most common cause of
chronic & end stage
renal failure
Glomerulonephritis
Glomerulonephritis
Predisposing Factors:
Immunological or autoimmune diseases
Autoimmune: autoantibodies are deposited in
the glomeruli causing inflammation which
creates scars
Streptococcal infection, group A B-hemolytic
History of pharyngitis or tonsillitis 2 to 3 weeks
before symptoms
Can also be caused by: drug exposure, toxins,
vascular and systemic disease,
Glomerulonephritis
Diagnostic Test:
Urinalysis reveals RBCs, WBCs, protein,
cellular casts
Urine specific gravity increased
BUN and serum creatinine increased
ESR elevated
Hgb and Hct decreased
Increased antistreptolysin O titer
Glomerulonephritis
Assessment:
• Gross hematuria, oliguria or anuria
• Dark smoky, cola-colored or red-brown urine
• Proteinuria that produces a persistent and
excessive foam in the urine
• Hypertension
• Urinary debris, low urinary pH
• Moderately elevated to high specific gravity
• Headache, chills and fever, fatigue & weakness
• Anorexia, nausea and vomiting, pallor
• Edema in the face, periorbital area, feet or
generalized edema
Glomerulonephritis
Assessment:
• Shortness of breath, ascites, pleural effusion,
and CHF
• Abdominal or flank pain
• Reduced visual acuity
• Increased blood urea nitrogen and creatinine
levels
• Increased antistreptolysin O titer (use to
diagnose disorders caused by streptococcal
infections)
Glomerulonephritis
Complications:
Heart Failure
Hypertensive encephalopathy
Pulmonary edema
Renal Failure
Glomerulonephritis
• Acute: occurs 2 to 3 weeks after a
streptococcal infection associated with abrupt
onset of hematuria, proteinuria, azotemia,
edema, hypertension (post-streptococcal)
• Rapidly progressive: renal insufficiency
occurs within days to weeks & renal failure
within months. Hematuria. (adults: often
unknown)
• Chronic: slowly progressive renal
deterioration (autoimmune) or after an acute
phase with continued hematuria, proteinuria, &
resulting uremic syndrome
Acute Glomerulonephritis
Nursing Management:
Symptomatic relief
Rest
Restriction of Na and fluid intake
Restriction of protein
Diuretics
Antihypertensive medications
Antibiotics if infection is present
Corticosteroids, cytotoxic agents,
plasmapharesis
Glomerulonephritis
Monitor vital signs
Monitor intake and output and urine
closely
Monitor daily weight
Monitor for edema
Monitor for fluid overload, ascites,
pulmonary edema, and CHF
Restrict fluid intake as prescribed
Glomerulonephritis
Provide a high-calorie and low-protein
diet
Restrict sodium intake as prescribed if
edema is present
Provide bed rest and limited activity
Instruct the client to obtain treatment for
infections, specifically sore throats and
upper respiratory infections
Glomerulonephritis
Administer diuretics, antihypertensives,
and antibiotics as prescribed
Monitor for signs of complications:
renal failure, cardiac failure, and
hypertensive encephalopathy
Instruct the client to report signs of
bloody urine, headache, or edema
Nephrotic Syndrome
Nephrotic Syndrome
An autoimmune process leading to a
condition that seriously and diffusely
damages the glomerular membrane and
results in increased permeability to plasma
proteins particularly albumin
Course of disease consists of exacerbations
and remissions over a period of months to
years
Commonly affects children than adults, male
more often than female
Nephrotic Syndrome
Pathophysiology:
• Plasma proteins enter the renal tubule and
are excreted in the urine, causing proteinuria
• Protein shift causes altered oncotic pressure
and lowered plasma volume
• Hypovelemia triggers release of renin and
angiotensin, which stimulates increased
secretion of aldosterone
• Aldosterone increases reabsorption of water
and sodium in distal tubule
Nephrotic Syndrome
Pathophysiology:
• Lowered blood pressure also stimulates
release of ADH, further increasing
reabsorption of water; together with a
general shift of plasma into interstitial
spaces, results in edema
Prognosis:
Good unless edema does not respond to
steroids
Most serious complication:
Thromboembolism
Nephrotic Syndrome
Manifestations:
Massive proteinuria (>3.5gm/dL)
Hypoalbuminemia, Hyperlipidemia
Peripheral edema
Waxy pallor to the skin
Anemia
Anorexia, malaise, irritability
Amenorrhea or abnormal menses
Hematuria may be present
• Ascites and anasarca
Nephrotic Syndrome
Nephrotic Syndrome
Medical Management:
• Drug Therapy
• Corticosteroids to resolve edema
• Antibiotics for bacterial infections
• Thiazide diuretics in edematous stage
• Diuretics: Mannitol for brain edema
• Lipid-lowering agents: (Lovastatin)
• Anticoagulant therapy
Nephrotic Syndrome
• Monitor vital signs
• Monitor intake and output strictly
• Daily weights, maintaining skin integrity
• Bed rest is necessary if severe edema
• Diet modification: Low fat and normal to low
protein diet as prescribed with adequate
carbohydrate and calorie intake
• May provide high protein (100gm/day) and
low sodium diet during edema phase only if
ordered unless there is renal failure
• Small frequent meals
• Assess closely for infections
Nephrotic Syndrome
Monitor potassium level; potassium may be
restricted from the diet if the potassium rises
Administer diuretics cautiously as prescribed
Administer corticosteroids and cytotoxic
medications as prescribed
Administer plasma volume expanders, such as
albumin, plasma, and dextran, to raise osmotic
pressure
Administer anticoagulants as prescribed for
those clients who develop renal vein
thrombosis

GUT Part 3 - Infections, Stones and Other Disorders

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GUT Part 3 - Infections, Stones and Other Disorders

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Urinary Tract

• Pathophysiology: bacteria enters renal

Other Nursing Interventions:

Ureter dilates -> HYDRONEPHROSIS

Urinary stasis results in INFECTION

Impairment of renal function on the side of blockage

5. Encourage Fluid Intake up to 3000—4000

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