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Pathophys Renal Lec

What is the major role of the renal system? waste management
Where is tenderness most likely noted? CVA- costovertebral angle
What muscles are near the kidneys? quadratus lumborum and psoas (directly behind quadratus and some what behind psoas)
Where is the kidneys in relaiton to the ribs? just behind the las few ribs
Where is the bladder? in the pelvic area behind the symphysis pubis
What happens in the renal cortex and medulla? exchange takes place in bauman's capsule
What types of balance are amintained with the renal syst? fluid balance (urine production) and chemical balance
Describe the waste products of chemical balance and what ions are regulated? Urea nitrogen- from protein metabolism Creatinine- from muscle Normal cellular environment by regulating various ions e.g.. Na+, K+, Ca2+, Mg2+, PO4
What two lab values are important for us to know? creatine and BUN
What can cause BUN to increase? Increases with: Dehydration High protein diet Blood in the gastrointestinal tract Catabolic states:Injury, Infection, Fever, Steroids
What is a more accurate determination of renal function? creatine
What is creatine a waste product from? (men vs women( liberated from muscle at a constant rate, women slightly less than men to decreased muscle mass
What implications are there for increased sodium Increased Sodium- cell shrinkage/swelling Central and peripheral nervous system most susceptible Changes in mental status
What implications are there for increased potassium? Increased Potassium- abnormal neuromuscular function Heart most susceptible- arrhythmias, cardiac arrest Weakness, irritability
Bricker hypothesis states that in the even there are two types of nephrons... Affected----nonfunctional Unaffected---function normally
What happens to the disease free nephron? hypertrophy until late renal failure
How many nephrons can you lose before you start increasing BUN/Creatine 75%, can happen over hours or years (poison vs. diabetes)
What is acute renal failure? what happens to BUN/Creatine? and etiology of ARF? Abrupt onset – usually reversible Elevated BUN/Creatinine Etiology: Shock--ischemia Trauma Toxicity-anesthesia, street drugs, contrast dye Obstruction Infection
Why are women more at risk for UTI? shorter urethra, close to vagina and rectum
Why is UTIs common in pregnancy? Dilatation of upper urinary system Decreased ureteral peristalsis Displacement of bladder from pelvic to abdominal position
Why are UTIs common in the elderly? Immobility-decreased bladder emptying-stasis Constipation Decreased activity of prostatic secretions
What other things can cause UTIs Catheterization Instrumentation Sexual intercourse Obstruction-urinary stasis, reflux (Outflow-enlarged prostate, calculi)
What are some clinical manifestations of UTIs? Dysuria- burning Frequency Urgency Incontinence Fever Chills, malaise Muscle weakness or spasms above baseline (esp with Multiple sclerosis and Spinal cord injury) Change in mental status (elderly)
What other Lower Urinary tract infections can occur? Prevalence? Cystitis-bladder infection Urethritis Prevalence: Geriatric 20% (F), 10% (M) home 25% (F), 20% (M) institutionalized
Pyelonephritis Upper urinary tract infection of renal parenchyma and renal pelvis Acute-bacterial infection Chronic
Types of pain with pyelonephritis lumbar or abdominal, tenesmus (pain and burning with urination), and CVA tenderness
DIagnosing a UTI Urinalysis – wbc, bacteria Culture->100,000 bacterial org/ml CBC – increased wbc X-ray, ultrasound, CT scan- r/o stones, obstruction
Treatment of a UTI Antibiotics Inc. fluid intake Bladder washings
What to discuss with pt about UTI possibilty of UTI if symptoms noted
If symptoms noted do what? contact MD suggest urinanalysis and culture
When to stop therapy due to a UTI? Fever >101 F Change in mental status N/V
Stage 1 kidney disease kidney damage with normal GFR (>/=90)
Stage 2 kidney disease kidney damage with mildly decreased GFR, 60-89
Stage 3 kidney disease moderate decreased GFR, 30-59
Stage 4 kidney disease severel decreased GFR 15-29
stage 5 kidney disease kidney failure, GFR <15, HD(hemodialysis)
Ways to diagnose chronic renal failure Ultrasonography—shows bilateral small kidneys X-rays-osteodystrophy due to hyperparathyroidism CRF—decrease Vit D prod.– decrease Ca absorp. – Parathy. Feed back to increase PTH-- leaching of Ca from bone----- OSTEODYSTROPHY
uremia and uremic syndrome Constellation of signs and symptoms and physiochemical changes that occur with renal failure
general manifestations of CRF Fatigue, weakness, decreased alertness, inability to concentrate
skin manifestations of CRF Pallor, ecchymosis, pruritus, dry skin & mucous membranes, thin/brittle fingernails, urine odor on skin
Hematologic manifestation of CRF Anemia, tendency to bleed easily
Manifestation of CRF in body fluids Polyuria, nocturia, dehydration, hyperkalemia, metabolic acidosis, hypocalcemia, hyperphosphatemia
manifestation of CRF in eyes, ears, nose, and throat Metallic taste in mouth, nosebleeds, urinous breath, pale conjunctiva
pulmonary manifestation of CRF Dyspnea, rales, pleural effusion
cardiovascular manifestations of CRF Dyspnea on exertion, hypertension, friction rub, retrosternal pain on inspiration
GI manifestations of CRF Anorexia, nausea, vomiting, hiccups, GI bleeding
Genitourinary manifestations of CRF Impotence, amenorrhea, loss of libido
skeletal manifestations of CRF Osteomalacia, osteoporosis, bone pain, fracture, metastatic calcification of soft tissues
Neurologic manifestations of CRF Recent memory loss, coma, seizures, muscle tremors, parethesis, muscle weakness, restless legs, cramping
PT implication for neural changes short simple directions, use visual aids, involve family and PCAs, freq. rest period, foot drop---orthosis
precautions for neurological changes decreased sensation, careful with modality use
PT implication for cardiac problems -BP w/ pos changes, teach pt to move slow, encourage to adhere on fluid restrictions, suck on hard candy, albumin reflects nutritional status, report chest pain or other signs and sx to MD, check EKG and electrolytes to rule out significant hyperkalemia
PT implication for visual impairment large print, corrective lenses in session
PT implications for dermal changes avoid trauma to skin, avoid falls
PT implications for respiratory syst. changes report worsening signs and symptoms
PT implication for GI syst problems report any signs or symptoms to MD make not of any blood in vomitus or stools
Summary of PT implications Report signs and symptoms to MD Make note of s/s to patient Note worsening S/S Monitor BP, HR, RR Use perceived exertion rating scales Slow position changes Frequent rest periods Hard candy for thirst Avoid skin trauma, falls
What do note when doing ROM? bony end feels, dont force through
Other things to note (how to give instructions, family involvement, other tests to check?) Simple instructions in large print Involve family Check EKG-T-waves, heart rate Electrolytes-K, Na, BUN, Cr, Ca; albumin X-ray—bone formation around joints
What is the treatment of choice for end stage renal disease? renal replacement (transplant or dialysis)
what is dialysis? Hemodialysis Peritoneal dialysis IPD- intermittent peritoneal dialysis CCPD-continuous cycle assisted CAPD- continuous ambulatory dialysis
Step 1 of dialysis Blood travels to dialyzer through cellophane tubing (semipermeable membrane)
Step 2 of hemodialysis Dialyzing fluid contains varying concentrations of electrolytes and chemicals which facilitate proper movement of H2O and solutes
step 3 of hemodialysis Unwanted substances in the blood pass into the dialysate fluid
last step of hemdialysis Clean blood flows back into the body
Two types of access for hemodialysis Intravascular Subclavian Femoral jugular Peripheral Arterial-venous fistula Arterial-venous graft
How is peritoneal dialysis used? Membrane which lines the peritoneal cavity is used as the semipermeable membrane.
process of peritoneal dialysis Dialysate fluid passed into the abdomen through surgically placed catheter --filtering takes place over several hours--fluid is drained out. Cycle repeated.
What is CAPD? CAPD-no machine used. 4 bags/day
What is CCPD? CCPD-machine automatically fills and drains dialysate from abdomen. Usually overnight.
What is IPD? IPD-extended CCPD usually in hospital, 36-42hr/wk.
Dialysis complications Hypo/hypertension Bleeding/clot formation/anemia Graft site infection Peritonitis (PD): Redness, swelling around catheter Abdominal pain Fever, n/v Cloudy dialysate
What is dialysis dementia? Dialysis dementia-aluminum accumulation -disturbed speech, myoclonus, behavioral changes, dementia. Progressive.
What is dialysis disequilibrium? Dialysis Disequilibrium-occurs near end of dialysis treatment or after. Osmotic gradient produced across the blood brain barrier—cerebral edema—h/a, n/v agitation, twitching, confusion, seizure.
ESRD management between dialysis Medications: anticoagulants, antihyperentensives Diet: low protein (1g/kg/d), low sodium (1500-200mg/d) Low potassium (1000-2760mg/d) Calories 35kcal/kg of ideal body weight Fluid restriction (0.5-1 liter/d)
Implications for PT with dialysis BP-no ex for >200/100mmHg Encourage pt to adhere to schedule Most pt prefer ex. day after dialysis
What is a neurogenic bladder? some causes? Urinary dysfunction due to interruption of the sensorimotor innervation to the bladder Lesions above sacral area—spastic bladder, detrussor-sphincter dyssynergia Lesions at sacral area/peripherally-flaccid
Neurogenic bladder abnormalities Diminished bladder capacity-due to spasticity of detrussor muscle Constricted external sphincter Atonic bladder Hyperactive detrussor Loss of perception of bladder fullness
What are some manifestations of neurogenic bladder abnormalities partial/complete retention, incontinence, urgency, frequency
Neurogenic bladder management Urodynamic studies—assess bladder function Radiologic tests to assess anatomic status, presence of stones. Treatment: Catheterization Meds-to relax sphincter/contract detrussor Bladder retraining-timed voiding, adequate fluid intake, biofeedback
Complications for Neurogenic bladder UTIs Vesicoureteral reflux Urinary stones
Neurogenic bladder implications for PT Be familiar with and report signs of complications Exercise and behavioral interventions where appropriate for urge incontinence
Types of urinary incontinence Functional incont- normal bladder, mobility prob (can’t get to the bathroom) Stress incont-urine loss with inc. intra-abdominal pressure—coughing, lifting, laughing Urge incont-sudden urge to go Dyssynergia Freq and urgency Overflow -leaking (full blad)
Risk factors for UTI Pelvic floor muscle weakness History of myelomeningocele History of benign prostatic hyperplasia (BPH) Fecal impaction-outflow obstruction Med use, including diuretics, tranquilizers, & decongestants Pelvic surgery Bladder irritation Imprd mobility
DIagnosis of UI history (voiding pattern, meds, reproductive hx, operations) Urinalysis, Ucx-r/o infection Urodynamics studies
Treatment of UI Stress: Pelvic floor muscle training (Kegel ex.s), surg. Meds- inc. sphincter tone Urge: timed voiding meds, catheterization, urge inhibition via pelvic floor exercises Overflow: meds, catheterization
UI implication for PTs Ask about urinary pattern: H/o leaking with activity, nocturia, frequency, fluid intake, constipation Report new onset incontinence to MD Can teach pelvic floor muscle exercises Timed voiding Home eval- min. mobility barriers (night lights, no obstacles)
Created by: 696592119
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