Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Fluids

and Electrolytes (Renal) Alteration V Continuation of Dialysis Lecture - Note the characteristics of the output
o o o o o
Topics Discussed Here Are: 1. Continuation of Hemodialysis 2. Renal Transplantation 3. Infections of Urinary Tract 4. Stone Formation 5. Benign Prostatic Hypertrophy

LOOKY HERE

Reddish to Pinkish is NORMAL Supposed to be LIGHTER and LIGTHER If continuous REDDISH output, IT IS BLEEDING! The DIALYSATE is expected to be CLEAR and NOT COLORLESS LIGHT YELLOWISH in color CLOUDY Presence of infection (Peritonitis)

IMPORTANT NURSING CARE

PreOp: Get BASELINE Vital Signs: TPR, BP, Weight, Serum Electrolytes InterOp: Monitor VS, Observe for complications! PostOp: Reassess VS, compare with BASELINE VS, and expect IMPROVEMENT!

HEALTH INSTRUCTIONS
Instruct client on how to care for the affected arm! Presence of THRILL/BRUIT is NORMAL o On the arm where the AV Shunt/Graft is attached NO CONSTRICTIONS on the arm Absence of THRILL/BRUIT ABNORMAL NO BP TAKING on affected arm If in the Event NO IV or BT or TPN on affected arm Thrill/Bruit is absent, GO TO THE HOSPITAL and the AV o AV Shunt MUST be PATENT Shunt will be FLUSHED with Heparinized Saline Solution Feel for bruit and thrill Use 2 or 3 fingers on top of the shunt and feel! Use a stethoscope to hear! Client must have a controlled DIET! o Na Diet o Protein Diet o K Diet Fluid intake is supposed to be RESTRICTED (800 mL 1 L/day) Avoid sources of INFECTION! If in the event: The client is responding favorably to the treatment, the doctor will suggest a higher form of management which is RENAL TRANSPLANTATION

RENAL TRANSPLANTATION
Involves TWO people o Donor: One who gives the kidney Donor has to be on a LEGAL AGE (On the signing of the consent) Donor should be FREE of disease which can be transmitted to the BLOOD STREAM (AIDS, Hepatitis, Malaria) Donor should be MENTALLY HEALTHY As much as possible: Closest GENETICALLY related person (Twin) Can be either a LIVING / NON-LIVING Donor Living Donor: Genetically Related or Non-Genetically Related o Genetically Related: Twin o Non-Genetically Related: Friends or Other People Non-Living Donor: NOT THE CADAVER!!! o The Donors circulation on the organs SHOULD BE NORMAL

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Recipient: The factor of AGE plays an important role of being a recipient Situation: Client is 80 YEARS OLD, no longer considered The Recipient should be FREE from other SYSTEMIC DISEASES! Like CANCER or MYOCARDIAL INFARCTION Renal Transplantation will involve TWO SETS of SURGERY o Which composes of Two Teams each having their own Doctors, Surgeons, Nurses and Anesthesiologist o
Operating Room 1 Donor Nephrectomy (Includes the Ureters and Blood Vessels) OPEN then CLOSE Perfusion Team The team that ASSESSES the condition of the donated KIDNEY If the kidney becomes ischemic, the procedure is DISCONTINUED Operating Room 2 Recipient If the kidney is healthy, it is the only time that the Recipient is OPENED UP >:] The Kidney is placed on ICE COLD NSS to promote HYPOTHERMIA, to DECREASE BODY METABOLISM

The surgical team does not REMOVE the old kidney! o Because there is too much manipulation o The NEW KIDNEY is placed on the LOWER PORTION, specifically on the ILIAC FOSSA o The Ureters are also placed o The length of the procedure is about 2 HOURS Disadvantages: o A DONOR is HARD to find! o VERY EXPENSIVE (1 million 1.5 million)

Nursing Care for Post Operational Renal Transplantation

Most Important NURSING CARE o STRICT Aseptic Technique! o STRICT REVERSE ASEPTIC Technique o NO VISITORS ALLOWED! o Get the Vitals Signs Temperature: If it is a cue of TISSUE REJECTION Blood Pressure: If it is a cue of TISSUE REJECTION Urine Output: Supposed to be INCREASED If Oliguric/Anuric it is a sign of TISSUE REJECTION Serum electrolytes o Instruct client to do early AMBULATION o Instruct client to take TWO DRUGS for the REST OF HIS/HER LIFE! Steroids (Anti-inflammatory Drugs: Prednisone, Decadron) Immunosuppresants ( Imuran) These drugs are taken to PREVENT TISSUE REJECTION o Emphasize on the client about REGULAR CHECK Ups! First 3 Months has to be a MONTHLY CHECK UP If has a stable VS: q2months, q3months Then 3 or 4 times a YEAR!~ o Patient SHOULD AVOID Body contact SPORTS Basket Ball, Volley Ball, Foot Ball May traumatize the transplanted kidney

Infections of the Urinary Tract

Females are more prone for UTI due to their shorter urethra UTI can affect: o Urethra Urethritis o Urinary Bladder Cystitis o Ureteritis Ureters

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RISK FACTORS: 1. Presence of any obstruction on the flow of urine May be due to stone formation which will cause a back flow of urine and stasis of urine Stagnant urine is a good source of INFECTION 2. Presence of Vesicoureteral Reflux Backflow of urine Muscles of urinary bladder gets TRAUMATIZED 3. Presence of certain disorders Diabetes Mellitus More at risk for UTI Due to glucose, and glucose is a good medium of multiplication of microorganisms Changes of pH in the urine Alkalotic Urine and Concentrated Urine is a RISK FACTOR for UTI An Alkalotic urine promotes bacterial growth as opposite to an ACIDIC environment Instruct client to DRINK CRANBERRY JUICE! To ACIDIFY the urine 4. Gender: Females are more prone 5. Age: Older males are more at risk for UTI due to BPH!! 6. Sexual Activity: People who are sexually active are more at risk due to the constant irritation on the perineum 7. Use of Antibiotics Antibiotics destroy microorganisms, and the body contains NORMAL FLORA, if the antibiotics destroy also the normal flora, it would make the client more at risk for infection! Overdose!! = DESTROYED Normal Flora

Cystitis
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Inflammation of the CYST XD JOKE

Inflammation of the URINARY BLADDER More commonly brought about by the microorganism E.coli

Manifestations: a. Frequency of voiding b. Urgency c. Dysuria d. Foul smelling urine Diagnostic Findings: Urinalysis Category Transparency WBC Pus Management:
Preventive measures o Instruct client to VOID FREQUENTLY! (q3 Hours) To WASH out the urinary bladder and urethra o Fluid intake o Good perineal hygiene! More important among women, FRONT to BACK o Use cotton underwear o Instruct to AVOID BUBBLES BATHS / BATH TUBS If patient wants, first has to clean self! o DEFINITIVE MANAGEMENT: Antibiotics: Will have to be given for 7 10 DAYS to completely ERADICATE the microorganism

Normal Clear Negative ( - ) Negative ( - )

Abnormal Cloudy / Turbid More than 3 Positive

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Stone Formation

A. Cause: 1. Increased excretion of insoluble urinary constituents a. Calcium (Hypercalcemia) 1. Food HIGH in Ca 2. Prolonged immobilization 3. Bone disorders 4. Hyperparathyroidism b. Uric Acid 1. Food HIGH in URIC ACID (Internal Organs: Liver, intestines or Sardines) 2. Kidney Disorders ( Uric Acid, Gouty Arthritis) 3. Due to Other Diseases 2. Physical changes in the urine Conditions that bring about INCREASED CONCENTRATED URINE Due to FLUID INTAKE 3. Nidus Formation a. A core / nucleus upon which precipitates would adhere to b. Composed of PUS and WBC c. Associated with CHRONIC UTI B. Assessment: Manifestations Small Stone: Initially ASYMPTOMATIC but has STONE , different cases goes undetected Pain is ON and OFF, but BEARABLE Bleeding: There is not COMPLETE DISCOLORATION of the urine, but there would be MICROSCOPIC HEMATURIA (Normal color urine, but [+] for RBC) Infection (Presence of CLOUDY / TURBID urine) Stone Gets BIGGER Pain is CONSTANT and SEVERE! Bleeding is now GROSS HEMATURIA Infection: Shows FEVER! Decreased URINE OUTPUT Instruct client to INCREASE FLUID C. Plan of Care: INTAKE or have ADEQUATE 1. Conservative Management: HYDRATION. About 3 4 LITERS a. Relief of Pain of Water PER DAY! Objective: To relieve pain! Two causes of pain from STONE FORMATION a. Trauma: USE ANALGESICS! b. Spasms (In the Ureters): Use ANTI SPASMODIC DRUGS b. c. Attempts to dissolve the stones Allopurinol Therapy (Zyloprim) Increased FLUID INTAKE by dissolving the urine To know if management is SUCCESSFUL~ a. Collect the clients URINE b. Filter it in a FUNNEL with a CLOTH c. Check for presence of SAND Materials on the funnel d. Document the presence of the SANDY material 2. Surgery:

Lithiasis Process of stone formation (Calculi) Cystolithiasis In the Urinary Bladder Ureterolithiasis In the Ureters Pyelolithiasis In the Renal Pelvis (Staghorn) Nephrolitiasis In the Kidneys~

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a. Non-Invasive Lithotripsy Extracorporeal Shockwave Lithotripsy (ESWL) Uses the forms of SHOCKWAVE / ULTRASOUND Sound that travels at a VERY FAST SPEED, the machine hits the stone to BREAK IT Patient is STRAPPED to hit the appropriate site! Advantages: NON INVASIVE Less prone to develop INFECTION due to no INCISIONS were done b. Invasive 1) Pyelolithotomy: Removal of stones from the RENAL PELVIS 2) Ureterolithotomy: Removal of stones from the URETERS 3) Cystolithotomy: Removal of stones from the URINARY BLADDER 4) Nephrectomy: Removal the KIDNEY due to STAGHORN CALCULI Staghorn Calculi IS VERY HARD, if attempted to be removed, may risk the client for BLEEDING

Benign Prostatic Hypertrophy (BPH)

It is the ENLARGEMENT of the PROSTATE GLAND, but is BENIGN The enlargement develops over the years, commonly seen on men ages 55 years old and above Signs and Symptoms of BPH and Prostatic Cancer are ALMOST THE SAME! But! o BPH = BENIGN o Prostatic CA = MALIGNANT

Causes: - Unknown - Aging Process o Degenerative process - Hormonal Imbalance Signs and Symptoms: Nocturia Gets up during the night, and urinates 2 3 times Wetting of pants while voiding (Force of stream is DECREASED) Frequency: o Client increase in number of voiding o But does not mean that the urine is increased in voiding Hesitancy: Urge to void is there, but difficulty initiating the urine Hypogastric Pain: Due to DISTENDED BLADDER Hematuria: Rupture of BLOOD VESSEL at the neck of the urinary bladder and urethra causes blood to come out REMEMBER: PATIENT IS MORE AT RISK FOR INFECTION DUE TO STAGNANT URINE!!!! Diagnostic Test: Digital Rectal Examination (DRE) o Most CHEAP! o IF THE MD PALPATES: Soft = BPH! Hard = Prostatic Cancer Management: 1. Conservative Management: a. Relief of bladder distention

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2.

Catheterization Can cause TRAUMA and INFECTION If in the Event: Infection has set in, LIMIT catheterization b. Prevent / Control of infection Surgery (Prostatectomy Removal of the Prostate Gland) a. Types: 1. TURP (Transurethral Resection Prostatectomy) LEAST traumatic approach to BPH 2. Suprapubic Prostatectomy and Retropubic Prostatectomy Suprapubic Prostatectomy and Retropubic Prostatectomy are both incisions on the low abdomen Difference: How was the PROSTATE GLAND REMOVED Suprapubic Prostatectomy: Prostate Gland was removed through an OPEN URINARY BLADDER Retropubic Prostatectomy: Prostate Gland was removed through the ANTERIOR PROSTATIC CAPSULE Perineal Prostatectomy: Prostate Gland was removed through an INCISION BETWEEN THE RECTUM and SCROTUM LEAST DONE Due to INCONTINENCE and IMPOTENCE!!

POST PROCEDURE of PROSTATECTOMY

Two possible tubes may be attached to the client (Cystoclysis) o Indwelling Catheter o Cystostomy Tube 1 and Inches long attached to the abdomen Between the umbilicus and symphysis pubis Attached to saline solution Infused in the urinary bladder to wash off clotted blood!!

Continuous Bladder Irrigation

REMEMBER: The more A THREE lumen tube devices attached to a client, The tube has a: more prone to infection! o Small Lumen: Used to inflate the balloon o Medium Lumen: Used as an irrigating channel o Large Lumen: Used for the passage of urine How Is IT Done? The chamber drip is regulated The solution gets in the patient (Through the medium sized lumen) and flushes out blood clots from the urinary bladder The urine passes through the LARGE lumen and then to the drainage bag Situation: 1800 mL URINE IF PATIENT has NURSING CARE: PROFUSE BLEEDING, Monitor VS: 1200 mL INFUSED HE/SHE MUST TPR, BP RETURN TO THE OR! 600 mL Assess presence of bleeding Collect urine, put on bottle 1 and bottle 2 at separate times, then compare, after three hours do the same again Color of urine output should be LIGHTER and LIGHTER in color If continuous RED it is BLEEDING Monitor Intake and Output! Measure WHOLE amount on drainage bag then SUBTRACT amount infused If discharged home, patient may resume sexual activity 3 4 weeks after surgery

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