UROLOGIC NURSING. Human Physiology Anatomy and Physiology of the Renal and Urinary System Kidneys Bean-shaped organs, weight-males- 145 gms,females-135. - презентация

1 UROLOGIC NURSING

2 Human Physiology

3 Anatomy and Physiology of the Renal and Urinary System Kidneys Bean-shaped organs, weight-males- 145 gms,females-135 gms Right kidney is lower than left because of the liver Located on either side of the vertebral column bet the 12th thoracic and 3rd lumbar in the posterior abdomen behind the peritoneum, fascia and fatty tissues hold them in place

4 Ureters –Extending from the renal pelvis to the urinary bladder –Transports urine from kidney to bladder via peristaltic waves of smooth muscles –Vesicoureteral sphincter prevents reflex of urine from bladder to ureter Bladder –Muscular, distentable reservoir for urine until it is excreted from the body –Total capacity: 1 litre –Urge to void normally occurs when ml of urine has accumulated Urethra –Extending from the base of the bladder to the urinary meatus approximateky 4 cm long in women, 20cm in men

5 CROSS SECTION OF THE KIDNEY

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8 Components of the Kidney Cortex: –Outer portion containing the glomerulus, tubules and part of the Loop of Henle Medulla –Middle portion containing part of the loop of Henle and collecting ducts Pelvis –Inner portion where urine is collected; narrowed portion becomes the proximal aspect of ureter as it approaches the Hilum Hilum –Area where nerves, blood vessels and ureter enter the kidney

9 Minor and Major Calices –Recesses of the pelvis that receives urine from the papillae of collecting ducts Renal column –Cortical tissue between pyramid in the cortex Pyramids –Collecting ducts which bases in the border between the cortex and medulla, apices from papillae as they extend towards the pelvis Papillae –Apices of the pyramids thru which urine travels to the renal pelvis Fibrous capsule –Outer covering that adheres to the renal parenchyma

10 Functions of Kidneys Excretion of waste products of protein metabolism thru the formation of urine Glomerular filtration (first step in blood processing) -water and solutes move from plasma in glomerulus into Bowmans capsule Tubular re-absorption (second step in urine formation) –molecules move from tubules into blood through tubule cells A.Proximal Tubules – reabsorb Na + and other major ions through active and passive transport B.Loop of Henle – reabsorbs through countercurrent mechanism; contents flow in opposite directions C.Distal Tubules – reabsorb Na + by active and passive in smaller amounts than proximal tubules D. Collecting ducts – prevent water from leaving filtrate; use active and passive reabsorption

11 Regulation of blood pressure –thru the activation of the renin-angiotensin mechanism when there is a decrease in BP - Renin - is an enzyme released into the blood from the kidney cortex in response to sodium loss - Angiotensin - an inactive substance formed by the action of renin on a protein in the blood plasma - Excessive productions of renin results in hypertensive kidney disease

12 Regulation of Water and Electrolytes –fluid volume regulation by the ADH and Aldosterone Erythropoietin Secretion –stimulates the bone marrow to accelerate the production of RBC Prostaglandins –are introduced in the renal medulla which are vasodilators and are prescribed to regulate renal blood flow and sodium re-absorption

13 Metabolize Vitamin D –Vit D3(cholecalciferol) is transformed in the liver and then metabolized to its active form in the kidney Degradation of Insulin –about 20% of insulin is degraded in the tubular cells. –diabetics with renal failure will therefore require less exogenous insulin

14 RENAL HORMONES AND ENZYMES Antidiuretic Hormone (ADH) - regulates urine volume by acting in distal tubule and collecting ducts to increase water reabsorption and urine concentration Atrial natriuretic hormone (ANH) - Aldosterone secreted by muscles fibers in atrium of heart - promotes loss of Na + via urine Aldosterone -- secreted by adrenal cortex - increases sodium absorption in distal and collecting tubules and controls potassium secretion – leading to osmotic imbalance that causes reabsorption of water a. increased serum K + level lead to increased aldosterone secretion b. increased aldosterone secretion increases Na + and water retention and depresses formationof renin

15 Renin - enzymes secreted by kidneys - helps regulate sodium retention and therefore blood pressure and fluid volume a. Renin-angiotensin system – converts angiotensin to angiotensin I in liver b. Angiotensin II – formed in lungs from angiotensin I; vasoconstrictor that stimulates adrenal cortex to produce aldosterone Erythropoetin - hormone produced by kidneys in response to low oxygen levels in atrial blood - travels to bone marrow and stimulates increased red blood cell production

16 URINARY EXCRETION Urinary Ureters - conduct urine Bladder – stores and excretes urine Urethra – tube that carries urine from bladder to exterior of body Urinary Meatus – exterior opening of the urethra Urination - an involuntary or voluntary reflex allowing urine to leave the body

17 - micturition reflex – parasympathetic response that stimulates relaxation and contraction of external sphincter – allowing urine to pass - internal sphincter muscle – helps control urine passage into urethra - relaxes in response to parasympathetic nerve fibers in bladder wall - external sphincter muscle – voluntary muscle that allows urine to pass into urethra - controlled by micturition reflex

18 CHARACTERISTICS OF NORMAL URINE Color - clear, pale amber Consistency - 95% water with many dissolved substances Output - 1,000 to 2,000 mL per 24-hour period - kidneys produce a minimum of 30 mL/hour under normal circumstances Specific Gravity - commonly to (range ) Odor - faint ammonia

19 Interpreting Changes in Urine Color ColorPossible Meaning Pale yellowNormal YellowConcentrated Urine AmberBile in Urine OrangeAlkaline or Concentrated Urine Red-orangeAcidic urine, medication effect RedBlood, menses PinkDiluted Blood BurgundyLaxatives TeaMelanin, hematuria Dark GrayMedications, dyes BlueDyes, medication

20 Renal System Differences Between Child and Adult Fluid is more important to body chemistry of infants and small children – it constitutes a larger fraction of total body weight During first 2 years of life, kidneys are less efficient at regulating electrolyte and acid-base balance – infants are more prone to fluid volume excess and dehydration Bladder capacity increases from 20 to 50 mL at birth to 700 mL in adulthood Innervation of "stretch receptors in bladder wall, which initiates urination and control of bladder sphincters (does not occur before age 2) – children under 2 cannot maintain bladder control Urethra is shorter in children than in adults and may contribute to frequency of urinary tract infections in children Kidneys are more susceptible to trauma in children because they do not have as much fat padding

21 DIAGNOSTIC TESTS AND ASSESSMENTS OF THE URINARY SYSTEM PHYSICAL ASSESSMENT - appearance of meatus - normal position - lack of redness, swelling - voiding pattern - frequency, amount, hesitancy, dysuria URINE STUDIES - Urinalysis - Clean-catch specimen - Sterile urine specimen - Urine culture - Twenty-four-hour urine specimen

22 a. creatinine b. creatinine clearance c. protein d. urea nitrogen - Urine Osmolality Renal Scan - IV radioactive substance is injected – observed passing through kidneys; evaluates renal blood flow, nephron and collecting system function and renal structures Radiographic Studies - KUB radiography – shows kidney size, position and structure - Renal angiography – detects abnormalities such as cyst, renal artery stenosis, and renal infarction - Renal venography – detects renal vein thrombosis

23 - Retrograde cystography - helps diagnose ruptured or neurogenic bladder and other conditions - Voiding cystourethrography Computerized Tomography (CT) scan -identifies masses and other lesions Magnetic Resonance Imaging (MRI) - produces 3D images of renal tissue Ultrasonography - evaluates kidney size, shape, and position

24 Blood Studies -BUN – measures nitrogenous urea in blood -Serum Creatinine – measures renal damage more reliably than BUN Intravenous pyelography (IVP) Cystoscopy or Cystourethroscopy Percutaneous renal biopsy

25 Cystoscopy

26 IVP

27 Common Urinary Problem Urinary reflux - backward flow of urine from the bladder into the ureter and renal pelvis - Incidence - boys during infancy, girls between 3-7 y.o. - Etiology - Due to incompetency at the vesicoureteral junction but can also occur at the urethrovesical junction - Predisposing factors –Congenital malformations –UTI –Neuromuscular dysfunction –Bladder neck obstruction

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29 - Manifestations Residual urine s/s of UTI ( flank pain, fever, chills, dysuria, measles, cloudy/bloody urine) Increased WBC count - Management Prepare the patient for surgical reimplantation of the ureter,if indicated Post-op care: monitor urethral catheter patency - Health teachings Take measure regularly, increased fluid intake to 3-4 L/day Importance of frequent and complete bladder emptying Hygienic measures( cotton undies, wiping front to back Acidify urine with acid-ash diet (increase intake of meats, cranberry juice, ascorbic acid)

30 URINARY RETENTION - retention of urine in the bladder in the presence of normal urine production, with the inability to release it when when the micturition reflex is activated Etiology - BPH, urethral stricture, calculi or foreign body in urethra, urethritis, tumor, trauma, fecal impaction, psychogenic retention Signs and symptoms - Inability to void, urgency, hesitancy, dribbling, lower abdominal pain/discomfort, restlessness, diaphoresis, visible or palpable bladder distention, dullness on bladder, s/s of lower UTI

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32 Urgency –Frequent desire to urinate Hesitancy –Reluctance or indecision to urinate Dribbling –To pass urine in drops especially after the main quantity of urine has been voided

33 Management –Facilitate bladder emptying thru providing privacy, running water, assume a normal voiding position and pain relief –If aeg cant void, perform intermittent catheterization to prevent over distention of the bladder –Administer prescribed meds to decreased sphincter resistance to outflow (phenoxybenzamine) and reduce pain –If indicate prepare patient for surgery( e.g dilation of urethra, cystoplasty )

34 URINARY INCONTINENCE - inability of the urinary sphincters to control release of urine Types 1. Enuresis (bedwetting) - usually a childhood problem 2. Stress incontinence - dribbling resulting from any kind of physical or emotional stress (coughing, sneezing, laughing, common in women) 3.Urgency incontinence - inability to hold back urine flow when feeling the urge to void 4. Paradoxical incontinence - urine retention with overflow, marked by involuntary voiding of small amounts) 5.Continuous incontinence - completely uninhibited micturition reflex, with an unpredictable voiding pattern

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38 Etiology –Stress, inflammation, certain medication (narcotics, tranquilizers, sedatives, diuretics) –Bladder lesions, spinal cord injury/tumor, multiple sclerosis, complications of pelvic surgery, CVA, weak abdominal and perineal muscles due to obesity/sedentary lifestyle Signs and Symptoms –Clothing/bedding wet with urine –Reports of dribbling, urgency, hesitancy, inability to get to the bathroom before voiding starts –Express anxiety, frustration, depression, poor self-esteem or other psychological effects of incontinence

39 Management –Protect patients skin by keeping it dry –Changing clothings or linens if necessary –Provide bladder training –Fluid intake of L/day if not contraindicated –Perineal or Kegels exercise to help improve muscular control –Check patients drugs that could contribute to incontinence –Refer patient for psychological evaluation

40 Urinary Tract Infection inflammation and infection of urinary tract structure which are classified as upper and lower UTI - Upper UTI - Pyelonephritis - inflammation of the kidneys - Acute - bacterial infection - Chronic - related to other factors (retention) Pathophysiology –Infection-from lower urinary tract to kidneys - UTI (E. coli, Proteus, Klebsiella)

41 Signs and Symptoms –Flank pain, fever,chills,headache,dysuria,malaise, –frequency/urgency, possibly bloody/cloudy urine, HPN –Increased WBC, + bacteria in the urine Management –Force fluids-3L/day –Antibiotics –Instruct female patient to wipe from front to back –Instruct female patient to void after intercourse

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44 Lower UTI Ureteritis Inflammation of the ureters Cystitis Bladder wall (most common type) Urethritis Urethra –Infection ascends from urethra to bladders and ureters

45 Signs and Symptoms - Foul smelling urine - suprapubic pain - burning sensation on urination, malaise - fever, chills, N/V, flank pain, - hematuria, dysuria - inflammed swollen meatus in urethritis Laboratory Findings Urinalysis - bacteriuria CBC - increase WBC

46 Management Antimicrobials Acid-ash diet with recurrent UTI (cranberries, meat) Sulfonamides Fluid intake 3L/day Void after sexual intercourse Avoid bubble baths/perfumed soaps Avoid tight clothing which traps heat in perineal area

47 GENITOURINARY TUBERCULOSIS Caused by Mycobacterium tuberculosis from lungs via the blood stream Signs and Symptoms Hematuria, bladder irritation (burning on urination, frequency, nocturia) slight afternoon fever, loss of weight, anorexia Diagnostics IVP - reveal lesions, Cystoscopy Management Drugs (Rifampicin, Isoniazid, Ethambutol) Adhere to medication regimen Maintain good health practices

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49 OBSTRUCTIVE DISORDERS A. Hydronephrosis - abnormal dilation of the renal pelvis and the calices of one or both kidneys Etiology - obstruction of urine flow in the GU tract (due to BPH, calculi, strictures)

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51 Hydronephrosis

52 Signs and Symptoms Colicky renal flank pain Decreased urine output Hematuria, pyuria, dysuria Nausea and vomiting due to abdominal fullness Pain on urination Dribbling, hesitancy and other signs of UTI Diagnostics IVP/Ultrasound

53 Management –Surgery: remove obstruction ( dilation of urethra, prostatectomy) –Diet: decreased protein, sodium, potassium to stop progression of renal failure –Nephrostomy tube –for decompression and drainage of kidney: check for bleeding and patency –Administer antibiotics –Routine medical check-ups (especially for older men who are prone to BPH)

54 Complications –Infection; pyelonephritis –Paralytic ileus with acute obstruction –If unilateral hydronephrosis - prone to affect other kidney, atrophy of renal parenchyma (as one kidney undergoes gradual destruction), the contralateral kidney gradually enlarges - compensatory hypertrophy-impairment of renal function

55 B. URETHRAL STRICTURES Narrowing of the lumen and loss of distensibility of the urethra caused by scar tissue formation and contraction Etiology –Injuries-straddle injury, auto accidents, pelvis fracture and direct injury to urethra, instrumentation –Congenital Signs and symptoms –Diminution in force and size of urinary stream –UTI and retention –dysuria, urgency

56 Diagnostics –IVP –Cystogram - show the bladder's position and shape Management –Treat urethral infection promptly –Utilize utmost care in urethral instrumentation –Avoid prolonged urethral catheter damage –Surgical excision –Urethroplasty (repair of urethra)

57 Kidney Stones

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60 Presence of stone in the GU system Calculi are formed by deposits of crystalline susbtances (calcium, phosphate, Ca oxalate, uric acid) excreted in urine Factors favoring stone formation –Obstruction and urinary stasis (precipitation of salts from urine) –Immobilization - slowing of renal drainage and altered calcium metabolism –Infection (proteus vulgaris) –Dehydration and urine concentration - salt precipitation –Foreign bodies in urinary system

61 Signs and symptoms –Flank pain –Nausea and vomiting –hematuria, fever and chills Management –Force fluids to at least 3000cc/day –Record I and O –Strain all urine for stones - send to lab for analysis –Antibiotics (especially when stone block urine flow) –Diet therapy –Place heating pad on affected area –Ambulate to prevent urinary stasis

62 Surgery –Ureterolithotomy - removal of stones from ureters –Pyelolithotomy - removal of stone from kidney pelvis –Nephrectomy - removal of the kidney – lithotripsy - disintegration of stone through laser

63 Wilms Tumor (Nephroblastoma) - cancerous unilateral tumor of the kidney - most common type of renal Ca in kids Signs and symptoms –Classic triad (late sign and symptoms) Hematuria Pain - from distension of renal capsule, invasion of surrounding tissues Palpable mass in flank –Low grade fever –GI symptoms-due to reflex action/encroachment on intraperitoneal organs

64 Wilm's Tumor

65 Diagnostics –IVP –Ultrasound –CT scan –Cystoscopy – endoscopy of the urinary bladder via the urethra Management –Radical nephrectomy –Chemotherapy –Hormonal therapy (progesterone) antitumor effect –Interferons (glycoproteins produced by human cells in response to viral infection) - antitumor effect

66 –Immunotherapy - stimulate hosts defense system –Renal artery embolization - use of embolizing material (gelfoam/steel coins) to occlude/close tumor then Nephrectomy –Pscyhological support

67 Neurogenic Bladder Dysfucntion

68 Dysfunction of the bladder due to impaired neurologic control secondary to central / peripheral nervous system lesions Etiology –Spinal cord injury –Herniated intervertebral disk –CVA and other central disorders –Neurologic disorders such as multiple sclerosis, diabetes mellitus, syphillis –Congenital anomalies ( e.g. spina bifida, myelomenigocele) –Infection

69 Types A.Spastic Neurogenic Bladder - upper motor neuron lesion –Loss of conscious sensation and cerebral motor control –Reduced bladder capacity and marked bladder wall capacity –Incomplete pattern of spontaneous, uncontrolled voiding

70 B. Flaccid Neurogenic Bladder - lower motor neuron lesion –Inability of the bladder to contract, allows to fill until it becomes grossly distended –When intrabladder pressure reaches a certain point, small amount of urine dribble from the urethra –Sensory loss may make the patient unaware of incontinence –Extreme, prolonged bladder distention can result to damage to bladder musculature, urine stasis and infection

71 Complications –UTI –Hydroneprhosis –Urolithiasis –renal failure Management –Bladder re-training –Bladder catheterization –Fluid intake (2-2.5 L/day) –Intervene depending on type and cause of neurogenic bladder

72 Injuries to the Kidneys Trauma to the abdomen, flank or back may produce renal injury Types of Injuries –Contusion -bruise, ecchymosis, hemorrhage into and beneath the skin –Laceration - cut or wound –Rupture - tearing of a part

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74 Major Problems following injuries control of hemorrhage injuries to other organs late complications Signs and Symptoms –Hematuria, pain, nausea and vomiting (abdominal fullness) –abdominal rigidity (due to retroperitoneal bleeding) –Shock (severe/multiple injuries)

75 Renal Injuries Diagnostics –IVP-define extent of injury Management –Urinalysis - hematuria –Bedrest to minimize bleeding –Monitor V/S especially B/P and pulse for shock –Antibiotics to discourage infection –Maintain urinary drainage –Monitor for complications (hemorrhage, infection, stone formation, loss of renal function) –Prepare for surgery if with penetrating injury –Activity restricted 1 month ff trauma to decrease bleeding

76 Conditions of the Prostate Benign Prostatic Hyperplasia –Hypertrophy of lateral & subcervical lobes of prostate gland –injury compressing the urethra & can cause overt Prostate –Size of walnut -15 gm; 4-6 cm long –2 cm posterior to symphysis pubis –Base(superior) located at neck of bladder,apex( inferior)- suspended by urogenital diaphragm, posterior area is in close contact with rectal wall & can be palpated –Urethra runs thru the prostate & ejaculatory duct; a median furrow divides lower part into L & R lobes; middle lobe (ejaculatory duct & urethra) by contracting during ejaculation

77 Prostate Gland Function manufacture of prostatic secretion –To eject prostatic secretion thru ejaculatory ducts; secretion aids in passage of sperms & helps keep them alive, supplying them with emergency food if needed –Seminal vesicle - found in upper side of prostate - stores semen prior to discharge Testicle produces sperm; located in scrotum –Manufactures and secretes testosterone (male sex hormone)

78 BPH

79 Pathophysiology –As patient ages & experience endocrine changes (dihydroxytestosterone in prostate- hormones produced in the testes and adrenal glands - normal function of this is to regulate the growth of the prostate cells, however, in cancer cells this regulation is compromised; testosterone stimulate local growth hormones) --- abnormal increase of cell in prostate compress surrounding prostate tissue --- form an overgrowth of smooth muscle & connective tissue BPH urinary obstruction – renal insufficiency

80 Signs and Symptoms –Urinary dysfunction( urgency, frequency, burning on urination, hesitancy, dribbling –Hematuria, retention, nocturia –Signs and symptoms of UTI –Decrease force of urine Diagnostics –Rectal exam (DRE) –Increase BUN, creatinine, cystoscopy (enlarged prostate gland), uirinary stasis

81 Management –Force fluids ( large amount) to keep urine diluted & minimize infection –Monitor I and O, Signs –Intermittent catheterization –Antibiotics - s/s of UTI –Psychological support –Cystostomy drainage of bladder –Teaching: surgery for BPH doesnt cause impotence, but may cause retrograde ejaculation (to the bladder)

82 Surgical procedures A.suprapubic prostatectomy - from an abdominal incision thru bladder to anterior aspect of prostate B. retropubic prostatectomy - incision thru lower abdomen to approach prostate C. Perineal - incision thru scrotum & rectum D. Transurethral resection( TUR) Resectoscope is passed thru urethra to excise & cauterize the excessive prostatic tissue, most common approach

83 E. Radical prostatectomy - done to resect cancer of prostate Prostatic gland, seminal vesicle & the cuff of bladder neck are removed by retropubic or transpubic route After surgey - patient will be impotent & possibly experience incontinence

84 Prostatitis Inflammation of prostate gland due to bacteria, virus, UTI Signs and Symptoms –Cloudy urine with foul odor –Increased WBC –High fever, chills –Dysuria, urethral discharge –Tender prostate –Low back pain –retention

85 Management –Antibiotics ( tetracycline), analgesic (for back pain) –Hot sitz bath (for relaxation) –Stool softeners, antipyretics –Increase fluid intake, monitor I and O for signs of retention –Avoid food and drinks that have diuretic action or prostatic irritants and increase prostatic secretions - tea, coffee, chocolate, cola, alcohol, spices

86 Hydrocele Collection of fluid in the tunica vaginalis (covering membranes) of the testes Causes –Due to defective/inadequate reabsorption of normally produced hydrocele fluid –Secondary to local injury –Secondary to infection –Complication to tumor of testicle –Edematous states such as CHF, cirrhosis of liver –following epididymitis or orchitis

87 Hydrocele

88 Signs and symptoms –Enlargement of scrotum –Usually painless until fluid accumulation is large enough to cause pressure Management –Surgery Hydrocelectomy (excision of tunica vaginalis of testis) for removal of fluid & control swelling Periodic aspiration of hydrocele fluid in poor risk patient Open operation for eversion of hydrocele sac or removal of hydrocele sac –Scrotal support

89 Varicocele A mass of varicose veins in the scrotum,usually part of the spermatic cord Signs and symptoms –Subfertility may occur-may suppress spermatogenesis due to vascular & temperature changes or more likely to reflux of adrenal corticosteroids to testes because of intercommunication of their venous circulations –A dragging sensation in the scrotum is usually the patients chief complaint –Varicocele on the R may indicate retroperitoneal tumor

90 varicocele

91 Diagnostics –Palpation of intrascrotal mass (with patient on upright position) that disappears in a short time after he has been lying down Management –Scrotal support to relieve discomfort –Surgery - varicelectomy (ligation & excision of veins) –Post-op Apply ice bag for 1st few hours to relieve edema Apply scrotal support for comfort

92 Epididymitis An infection of the epididymis that usually descends from an infected prostate or urinary tract Epididymis - collects sperm from testicle Causes –Prostatic infection (most common cause) complication of infected urine containing pyogenic bacteria –Trauma ; urethral stricture –Complication of prostatectomy & urethral catheterization –Specific causes : gonorrhea, and other related STD

93 Signs and symptoms –Localized scrotal pain & tenderness –Edema, redness & tenderness of scrotum –Fever and chills –Pyuria/bacteria Diagnostics –Urinalysis --- pus(+), bateria( +) –Increased WBC –Epididymitis aspiration –Staining of urethral discharge

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95 Management –Antimicrobial therapy, stool softeners –Bed rest in acute phase –Scrotal support for enlarge testicle( to relieve edema, discomfort & improve venous discharge) –Infiltration of spermatic cord with local anesthesia to relieve pain –Analgesics for pain relief –Intermittent cold compress to scrotum during initial period for pain relief –Use local heat or sitz bath later to hasten resolution of inflammation

96 IMPOTENCE( Erectile Dysfunction) Inability to achieve or maintain an erection sufficient to accomplish intercourse Chronic or complete erectile dysfunction, partial or brief erections. Incidence - increases with age

97 Etiology –Psychogenic causes Anxiety, fatigue, depression & undue pressure to perform sexuality –Organic cause Occlusive vascular diseases Endocrine conditions (DM, pituitary tumors, hypogonadism) Genitourinary conditions ( prostatectomy) Hematologic disorders (Hodgkins disease, leukemia) Neurologic disorders (neuropathy, parkinsonism) Genital trauma Alcohol & drug abuse Medications (antipsychotics, anticholinergics, anti HPN)

98 impotence

99 Physiology of Erection The physiological process of erection begins in the brain and involves the nervous and vascular systems. Neurotransmitters in the brain (e.g., epinephrine, acetylcholine, nitric oxide) are some of the chemicals that initiate it. Physical or psychological stimulation (arousal) causes nerves to send messages to the vascular system, which results in significant blood flow to the penis. Two arteries in the penis supply blood to erectile tissue and the corpora cavernosa, which become engorged and expand as a result of increased blood flow and pressure. Because blood must stay in the penis to maintain rigidity, erectile tissue is enclosed by fibrous elastic sheathes (tunicae) that cinch to prevent blood from leaving the penis during erection. When stimulation ends, or following ejaculation, pressure in the penis decreases, blood is released, and the penis resumes its normal shape.

100 Pathophysiology - Pathologic processes are diverse but commonly involve decreased blood flow to the penis, altered nerve conduction or decreased hormonal secretion - Impotence may be partial or full, intermittent or constant, transient, selective for partners and of sudden or gradual onset

101 ERECTILE FUNCTION TEST Duplex ultrasound - used to evaluate blood flow, venous leak, signs of artherosclerosis, and scarring or calcification of erectile tissue. - Erection is induced by injecting prostaglandin, a hormone -like stimulator produced in the body. Ultrasound is then used to see vascular dilation and measure penile blood pressure (which may also be measured with a special cuff). - Measurements are compared to those taken when the penis is flaccid.

102 Prostate examination - An enlarged prostate, which can be detected with a digital rectal examination (DRE), can interfere with blood flow and nerve impulses in the penis. Penile nerve function - bulbocavernosus reflex test - to determine if there is sufficient nerve sensation in the penis. Nocturnal penile tumescence (NPT) - Snap gauge - involves wrapping three plastic bands of varying strength around the penis. Erectile function is assessed according to which bands break - Strain gauge - involves placing special elastic bands at the base and tip of the penis. These bands stretch during erection and register changes in circumference.

103 Treatment Sex Therapy Medical Treatment - Oral Medication Surgical Treatment - Penile Implants - Vascular Reconstructive Surgery - involves bypassing blocked veins or arteries by transferring a vein from the leg and attaching it so that it creates a path to the penis that bypasses the area of blockage. - Venous ligation - performed to prevent venous leak

104 Sexual Dysfunctions Impotence –inability to achieve or maintain penile erection Frigidity –Inability of a woman to achieve arousal or orgasm during sexual intercourse Priapism –An abnormally persistent erection of the male organ Hyposexuality –Inhibited sexual excitement in which sexual arousal can be achieved only with great difficulty

105 Anorgasmia –Recurrent and persistent inability to achieve orgasm despite normal sexual stimulation Vaginismus –Vaginal muscles contract strongly during intercourse, making coitus difficult or impossible Dyspareunia - painful or difficult sexual intercourse Erectile impotence - cannot sustain an erection Ejaculatory impotence - man cannot achieve orgasm in womans vagina, erection and orgasm by other methods Premature ejaculation - before or immediately after entering vagina TREATMENT - SEX THERAPY

106 Renal Parenchyma A.Glomerulonephritis Acute Glomerulonephritis - common bilateral inflammation of the capillary loops in the glomeruli due to streptococcal infection of respiratory tract or impetigo Chronic Glomerulonephritis - slowly progressive disease characterized by inflammation of the renal glomeruli; usually irreversible leading to renal failure

107 Etiology and Incidence –Group A beta hemolytic strep in URTI, skin infections (impetigo) –autoimmune process (SLE) - glomerulonephritis symptoms appear 7-14 days after the infection Pathophysiology –Infection-produce antibodies-entrapment & collection of antigen-antibody in capillary loops of glomeruli – swelling -obstruction-decrease filtration especially of Na and water

108 Signs and symptoms –Edema (leg, face or generalized) –HPN, dyspnea –Oliguria –Circulatory congestion (slight cardiac enlargement –Hematuria - RBCs are allowed to pass thru the impaired glomerular capillary wall –Fever, malaise –Transient anemia

109 Diagnostics - renal biopsy, CBC, urinalysis, throat culture, KUB Management: –Penicillin for residual infection –Diuretics and anti-HPN –Diet - CHON restriction or gms/day (if oliguria is severe) Increased CHO to spare CHON K restriction Na restriction for HPN & CHF; if diuresis is great, Na replacement maybe necessary Vitamin replacement

110 Management –Fluid restriction –CBR during acute onset, start activity when BP & BUN are normal 1-2 weeks –Monitor V/S continuously –Verbalize feeling due to edema, loss of health, fear of death –Monitor I and O, weight –Evaluate for signs and symptoms of renal failure (oliguria, azotemia, acidosis) –Complications - cardiac failure - acute renal failure

111 Nephrotic Syndrome Renal disease characterized by edema and albuminuria, hypo-albuminemia, hyperlipidemia Pathophysiology –Increased permeability to CHON of the glomerulus due to a group of glomerular diseasehypoalbuminemia intravascular oncotic pressure --- loss of fluid into interstitial space --- reduced plasma volume aldosterone secretion water and Na retention --- edema –Loss of fluid in interstitial spaces edema

112 Nephrotic syndrome (NS) - is a condition that is often caused by any of a group of diseases that damage the kidneys' filtering system, the glomeruli. - The structure of the glomeruli prevents most protein from getting filtered through into the urine. - Normally, a person loses less than 150 mg of protein in the urine in a 24-hour period. - Nephrotic-range proteinuria - the urination of more than 3.5 grams of protein during a 24-hour period, or 25 times the normal amount, is the primary indicator of NS.

113 Nephrotic syndrome

114 Signs and Symptoms Hypoalbuminemia (low level of albumin in the blood) – due to proteinuria Edema (swelling) Hypercholesterolemia (high level of cholesterol in the blood)

115 Diagnosis Blood analysis - high cholesterol levels and low albumin. Urinalysis Kidney biopsy

116 Management –Correct underlying cause –Diet - protein replacement( 1.5g CHOn/KG body weight), restrict sodium intake –Diuretics for edema, antibiotics for infection –8week course of corticosteroid (prednisone) - to decrease edema –Monitor I and O –Give good skin care - due to edema –Encourage activity and exercise –provide anti-embolic stockings - to avoid thrombophlebitis

117 Renal Failure Loss of kidney function A. Acute Renal Failure: is the rapid breakdown of renal function that occurs when high levels of uremic toxins accumulate in the blood. occurs when the kidneys are unable to excrete the daily load of toxins in the urine. B. Chronic Renal Failure: Renal tissues progressively stops functioning, irreversible loss of function Develops gradually (several years)

118 Etiology A.Acute Renal Failure (ARF) Prerenal ARF - characterized by inadequate blood circulation to the kidneys, which leaves them unable to clean the blood properly. - Symptoms Dizziness Dry mouth Low blood pressure (hypotension) Rapid heart rate Slack skin Thirst Weight loss

119 Postrenal ARF - is caused by an acute obstruction that affects the normal flow of urine out of both kidneys. - The blockage causes pressure to build in all of the renal nephrons. - The excessive fluid pressure ultimately causes the nephrons to shut down. - seen most often in elderly men with enlarged prostate glands that obstruct the normal flow of urine.

120 Intrinsic renal ARF - involves damage or injury within both kidneys - Vascular disease - Glomerulonephritis and vasculitis - Renal artery obstruction (atherosclerosis, thrombosis) - Renal vein obstruction (thrombosis) - Diseases of tubules and interstitium - Amyloidosis - Interstitial nephritis - Acute tubular necrosis - Ischema (lack of blood flow to an organ) - Toxins

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122 Acute renal failure Oliguric phase - initial s/s of failure being oliguria as the cardinal sign - stage may begin as soon as 24 hrs after the cause - s/s: urine < 400 ml/day,volume overload, Increase BUN & creatinine, electrolyte abnormalities, uremia, metabolic acidosis - ( normal H2CO3,dec HCO3) Diuretic Phase - output increases, 5L/day, for the duration of the phase, up to 3 weeks

123 Recovery/Convalescent stage - Major recovery within 2 weeks up to a year - BUN stabilizes & patient returns to normal activity - Altered urine output - HPN/hypotension - Tachypnea - s/s of fluid overload or ECF depletion - Anemia

124 Diagnostics: blood chemistry UTZ retrograde pyelogram - visualization of the bladder, ureters, and renal pelvis. KUB Urinalysis IVP renal scan

125 Management Acute Renal Failure Monitor urine output, I and O, weight Verbalize concerns & altered body image Provide mouth care Diet: increase calories, decrease CHON, Na, K, restrict fluids Hyperkalemia: dialysis, hypertonic glucose, insulin Monitor electrolyte Assess for infection Monitor anemia-BT Aseptic technique-infection

126 Chronic renal failure 1. Decreased renal reserve - renal function is impaired( % functioning) - homeostasis maintained - metabolic wastes do not accumulate in the blood - BUN is normal 2. Renal insufficiency - renal function 20-40% normal - decrease GRF - metabolic wastes begin to accumulate in the blood - Slight increased in BUN

127 3.End stage renal disease (UREMIA) - Less than 10% function-kidney loses its ability to maintain homeostasis - Scanty urine output - Severely disturbed electrolyte balance - Accumulation of nitrogenous wastes - Altered urine output - Weak, easily fatigued, drowsy - Headache, slight breathlessness & lethargy - Restlessness & insomnia - Dry skin & mucous membranes - Halitosisurineferous breath - Loss of appetite, nausea & v - CNS: anxiety, irritability, hallucination, mental wandering, muscle twitching, coma & convulsion, HPN, anemia, edema

128 Management Chronic renal failure Fluid overload(500ml/day) Diet: decrease CHON, Na, K, increase calorie intake ( sugar,vCHO) like candy,vbutter balls Electrolyte replacement, monitor HPN & heart failure Prepare client for dialysis or kidney transplantation

129 TREATMENTS A. Catheterizations Purposes Relieve acute/chronic urinary retention Pre-op & post-op urinary drainage Determine amount of residual urine after voiding Common types Whistle tip/Olive tip/Round tip/Foley triple lumen (self-retaining), Foley double lumen-air and drainage/Condom catheter

130 Management Put patient at ease supine with knees flexed & feet resting on bed Observe aseptic technique drape patient Direct light for visualization moisture-proof of pad under buttocks Lubricate catheter ask patient to strain to relax sphincter

131 Cystoclysis A continuous bladder irrigation performed by instilling saline solution hung from an IV pole thru one lumen of the urinary catheter or suprapubic catheter Purposes - Empty urine from the bladder following bladder, prostate or vaginal surgery - Relieve urinary tract obstruction - Permit urinary drainage in patient with neurogenic bladder dysfunction/urinary retention - Determine accurate measurement of urinary drainage in critically ill patient Note: In the male patient, indwelling catheter is taped to the abdomen to straighten the angulation of the penoscrotal junction, thus reducing pressure on the urethra exerted by the catheter

132 Cystoclysis

133 Cystostomy( Suprapubic Drainage) Method of establishing drainage from the bladder by inserting a catheter or tube thru the suprapubic area into the bladder by either a stab incision or puncture with a needle or trocar Purposes: –Drain the bladder via a tube placed in the bladder thru the suprapubic area –Divert urine flow from the urethra –Obtain urine specimen for culture CLINICAL USEFULNESS: When urethral route is impassable-urethral strictures, injuries Following gynecologic operations - vagina hysterectomy, vaginal repair Following bladder surgery Pelvic fractures

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135 DIALYSIS Is the removal of urea and other wastes products by peritoneal dialysis (peritoneum) or hemodialysis (machine) which serves as artificial kidneys PERITONEAL DIALYSIS –Involves putting dialysis fluid into the peritoneal cavity PERITONEUM - is the dialyzing membrane - as blood flows pass the peritoneal membrane, wastes products are taken out of the blood and into the peritoneal cavity. This happens because the concentration of wastes products is higher in the blood than in the dialyzing fluid in the peritoneal cavity. The draining fluid carries away the bodys chemical waste products

136 PROCEDURES A. Preliminary procedures Secure consent Abdominal preparation Warm dialyzing fluid into body temperature in order to dilate blood vessels in the peritoneum Empty bladder before the procedure Weigh patient prior to procedure B. Performance phase Incision is made below the umbilical area Trocar is inserted thru the incision into the peritoneal cavity Obturator is removed & tip of catheter is placed on the lowest part of the abdominal cavity to ensure good flow of fluid

137 PERIODS OF PERITONEAL DIALYSIS 1. INSTILLATION Catheter is connected to administration tubing & a dialysis cycle is begun. The inflow clamps are open & dialysate infuses rapidly into the peritoneal cavity & then clamp is closed. Dialyzing rate of 2.5 L inflow period is 5-10 mins. 2. EQUILIBRIUM Osmosis, diffusion & filtration take place. Lasts for 20 mins 3. DRAINAGE Outflow clamp is opened & dialysate drains from the peritoneal cavity. Outflow period is 20 mins.

138 NURSING RESPONSIBILITIES - Nurse is responsible for cycling the fluid - Observe the color of the outflow - Accurate recording of each dialysis cycle on a flowsheet - Monitor V/S frequently,weight and gen condition - Prevention of complications - Check for tubing patency - Keep physician abreast COMPLICATIONS - Displacement or plugging of the catheter - Perforation of the bladder or bowels - Infection ( contaminated catheter tubing or solution) - Breathing difficulties ( Increased fluid in abdomen) - Pain ( when fluid is instilled and withdrawn)

139 HEMODIALYSIS Process of removing accumulated metabolic wastes products from a patients blood & restoring water, electrolytes, acid-base balance by extremely circulating the patients blood through an artificial kidney

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142 Types of Dialyzers 1. Coil dialyzer/Kolff twin Dialyzer –Requires pump to propel the blood thru them. It cause blood hemolysis, air embolism, hemorrhage. Takes 5 hours of dialysis 2. Parallel flow/Kill Dialyzer –A pump is not necessary –It takes hours 3. Capillary dialyzer –Made of tiny hollow capillary fibers in a parallel arrangement thru the patients blood flow. It has little resistance. Takes 4 hours of dialysis

143 ARTERIOVENOUS FISTULA( AV-shunt) – Fistula is created surgically by connecting or joining (anastomosis) an artery to a vein by side or end to end. Takes about 4-6 weeks to be ready for use. Types of Shunts 1. Teflon Silastic Cannula (temporary AV shunt) Painless, easy access to patients bloodstream. Patient is prone to infection, phlebitis, clotting, accidental separation of cannula 2.Subcutaneous Arterio-venous Fistula Surgical anastomosis of one cephalic vein and one radial/brachial artery is done. Due to the fistula, a large amount of blood is shunted into the venous circulating producing venous engorgement with high rate of blood flow. A necessity of venipuncture for each dialysis & strict immobilization of limb during dialysis is needed 3.Subclavian AV Shunt: shunt is performed beneath the clavicle

144 Reactions during Dialysis –Marked decrease in B/P –Dizziness –upset stomach (due to electrolyte disturbance) –Chest pain or squeezing pressure on the chest (electrolyte disturbance) –Sudden chills or heavy sweating –Severe, unusual pain of any kind

145 Nursing Responsibilities Observe aseptic technique Weigh patient before and after procedure Regularly check the B/P, pulse and temperature Check the palpable bruit before the procedure ( shunt is ripe for dialysis) Avoid taking B/P readings, injections, IVs, blood sampling on the arm with shunt to prevent trauma Make patient comfortable Diet: foods should be rich in calcium & phosphorus, fluid intake of 500 ml/day

146 Methods of Heparinization 1.Intermittent 2.Constant 1 hour: 0.5 cc heparin---if bleeding 1 hour: 1 cc heparin ----no bleeding

147 TRANSPLANTATION Factors that determine the suitability of patient for renal transplantation – Age: children should be transplanted than old – Potential for good health – Functional goals: active patient may go back to work and lifestyle – emotional reliability SOURCES OF DONORS: Living donors (preferably relatives) Cadaver donors

148 Nursing Responsibilities –Explain consent –Secure consent –Prepare patient holistically for surgery –Post-op Monitor threatened rejection –Pain & tenderness of graft –Inc B/P & creatinine –Dec urine output –Weight gain, apprehension, fever

149 Nursing responsibilities –Post-op Prevent infection –Protective isolation due to dec immune system response –Asepsis should be observed –Regular skin and oral care Maintain fluid and electrolyte balance –Monitor I & O –Weigh once a day –Monitor serum and urine electrolytes Prevent complications –Acute renal failure, GI ulceration & bleeding, hyperactive rejection, suicide