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The Urinary System
Anatomy and
Physiology
2014
Structure
KidneysUretersUrinary bladderurethra
Function
Maintains homeostasisControls blood and water
volumeMaintains blood pressureRegulates electrolyte levels
Eliminates protein wastes, excess salts and toxic materials from blood
Balances acid/base (PH)Secretes renin and
erythropoietin
Kidney Structure
2 reddish brown, bean-shaped organs
Located in small of the back at lower edge of ribs on either side of spine
“Retroperitoneal”
How the kidneys Regulate BP
ADH
RENIN
ALDOSTERONE
3 Parts
CortexMedullaPelvis
BecomeHealthyNow.com Home
Nephron
Functional units of the kidney
Cells that form urineOver 1 million nephrons in
each kidney
Glomerular Filtration
Tubular Reabsorption
Tubular Secretion
WORD WALL
1. Oliguria
2. Anuria
3. Dysuria
4. Polyuria
5. hematuria
Urine
Body excretes 1000-2000 ml of urine/day
Is normally sterileColor varies with hydration
Characteristics of Normal Urine
CLARITY
ODOR
SPECIFIC GRAVITY
THINK….
A STRONG, OFFENSIVE ODOR FROM FRESHLY VOIDED URINE IS SUGGESTIVE OF……..
Urinary Tract Infection
Composition of Normal Urine
WaterProtein wastes products
(urea, uric acid & creatinine)Excessive minerals from diet
(Na+,K+, Ca,sulfates & phosphates
ToxinsHormonesBile compoundsPigments from food/drugs
WORD WALL
FrequencyUrgency NocturiaEnuresisretention
Effects of Aging on the Urinary System
Ability to filter blood, reabsorb electrolytes & secrete wastes decreases
Less ability to return to normal after changes in blood volume
Decrease in number & size of nephrons
Decrease in GFRSmaller capacity of bladderWeaker bladder muscles
Incontinence
Not a normal consequence of age
Common due to many reasonsSee Chpter 23 for more
information on incontinence
Critical Thinking ChallengeCOMPARE & CONTRAST STRESS vs.
FUNCTIONAL
COMPARE & CONTRAST URGE vs. OVERFLOW
Nursing Assessmentof
The Urinary
System
HEALTH HISTORY
Chief complaintHistory of Present IllnessPast Medical HistoryFamily HistoryReview of Systems
Diagnostic & Laboratory Tests
Urinary System
URINE TESTS UA ( urinalysis )
C & S ( Culture & Sensitivity )
Creatinine Clearance (24 hr)
BLOOD TESTS
BUN ( blood urea nitrogen )
Serum Creatinine
Serum Electrolytes
Radiographic Studies
KUB ( flat plate ) IVP Arteriogram Renal Scan US
Invasive Procedures
1. Renal Biopsy
2. Cystoscopy
What are
Urodynamic Studies ??
What are common Therapeutic measures
Related to
“Catheterization”
Catheter Types
Foley
Ureteral
Suprapubic
Nephrostomy
Common Tubes and Catheters
Ureteral Catheter
Nephrostomy Tube
Urinary Stent
Pre-Op Care Urologic Surgery
Evaluate fluid status
Bowel cleansing
Enterostomal Therapist/Nurse
Counseling/Teaching
Post-Op Care Urologic Surgery
Report to MD U/O < 30 ml/hr
Pain Management
Mon. lung sounds
Assess for Paralytic ileus
Urinary Tract
Inflammation and Infections
Cystitis
Inflammation of the urinary bladder
Bacteria enters from the urethra, lymph nodes, infected kidneys
Women more suseptible
Causes
E-coliCandida AlbicansCoitusDiabetes mellitusSee Box 40-2 Risk Factors
for UTI’s
Signs & Symptoms
Dysuria, hematuriaFrequency, urgencyLow grade feverPelvic or abd. discomfortBladder spasms
Med. Dx & Tx
C&S and UA obtained Increase fluids 3-4 L / dayAntibiotics
(Cipro,Bactrim,SeptraAnalgesics(Pyridium)See Pt. Teaching pg. 898
Gerontologic Considerations
Watch for signs of mental confusion
Fever may be maskedSepsis develops quickly
Pyelonephritis
Bacterial infection of renal pelvis and kidney
Most common form of kidney disease
Often the result of reflux
Signs & Symptoms
Flank painChills, fever,N & VDysuria, fatiqueBladder irritation
Med & Nursing Considerations
Bedrest Increase fluids (8 8oz. Glasses
water/day) IV Monitor I + OProtein & Na+ restrictionsMon. for circulatory overload
Pharmacological TX
Antibiotics (Bactrim) or Cipro
AntipyreticsAnalgesics AntispasmoticsAntihypertensives
Glomerulonephritis
Autoimmune diseaseGlomerulus becomes
inflammedSymptoms dev. 1-3 wks after
respiratory infection cau by group A- hemolytic strep
Signs & Symptoms
Tea colored urineDecrease in u/oPeriobital edemaHTNHypervolemia
Medical Dx
Clinical PresentationUA ProteinuriaBUN, CrStrep. Antibody TestsRenal Biopsy or Ultrasound
Medical Treatment
Diuretics
Antihypertensives
Antibiotics
Nursing Considerations
Bedrest several weeksStrict I & O, daily weightsRestrict Fluids if orderedLow Na, low protein dietPrognosis is good
UA w/ RBC’s, Albumin, casts
protein
Treatment
Low Na, protein dietBedrestVS, BP…Strict I & ORestrict fluids
Condition may lead to pulmonary edema, increased BP,anemia,cerebral hemorrage, CHF and ultimately uremia or ESRD
In the absence of dialysis or kidney transplant, prognosis is poor.
Polycystic Kidney Disease
Congenital, familial, also may be acquired
Fluid-filled cystsAbdominal, low back or
flank pain and headache
Diagnosis
X-ray or sonogramBUN & CreatinineGoal of management is…..
Renal Failure
A.K.A. Uremia
May be Acute or Chronic
Renal Failure
Kidneys no longer meet everyday demands
Kidneys unable to filter waste products from blood
BUN & Creatinine levels elevate
Causes of Renal Failure
GlomerulonephritisIDDMAny condition which
decreases blood supply to kidneys
InjuryRecurrent UTIDrug overdosePoisoningNephrotoxic Drugs
Acute Renal Failure
CAUSED BY:
1. Prerenal Failure
2. Intrarenal Failure
3. Postrenal Failure
Acute Renal Failure
4 PHASES1.Onset2.Oliguria3.Diuresis4.Recovery
Medical & Drug Management
AntihypertensivesDiureticsCardiotonicsDialysis if needed
Diet & Fluids
Diet based on consideration of serum electrolytes and BUN. Adequate carbs to prevent breakdown of fat & protein.
Fluids calculated by adding 400-600ml to previous days output.
Nursing Considerations
Freq. BUN, Creatinine, Na & K levels
Usually Low Na, K and protein diet
Mon. I & O
Chronic Renal Failure“ESRD”
IrreversibleChronic abnormalities in
internal environment of kidney
Dialysis or kidney transplant necessary for survival
Signs & Symptoms• Azotemia • Hyperkalemia• Hypocalcemia• Metabolic acidosis• Hypernatremia and
hypervolemia• Insulin Resistance
Medical Treatment
IV Glucose and Insulin Calcium, Vitamin D and phosphates Fluid restriction & diuretics Beta blockers, calcium channel blockers
and ACE inhibitors Iron, folic acid and synthetic
erythropoietin High carb/low protein diet
Urinary Tract Obstructions
RENAL CALCULI
Urolithiasis
Calculus or stone formed in the urinary tract
Etiology is unknownCan occur in renal pelvis,
ureters, bladder or urethra
Contributing Factors
Infection & or DehydrationUrinary stasis ImmobilityRecurrent UTI’sDiet low in calcium
Signs & Symptoms
Size & location of stone affects degree of pain
Spasm = “colic”HematuriaN & V
Medical Treatment
OpioidsNSAIDSAntispasmodics IV FluidsAntibiotics
Surgical Management
Lithotripsy (ESWL)UrethroscopyNephrolithotomySee Post-Op Care Goals pg.
906
Nursing Considerations
Strain all urine & pain reliefSend gravel or stones to labMonitor of s/s infectionGive antispasmodics Encourage fluids ; IVManage Pain
Hydronephrosis
Distention of kidneyCan cause permanent damageMaintain accurate I & OStrain all urineSend all stones for analysis
Dialysis• Mechanical• Imitates the function of the
nephron• May be chronic or acute• Removes body wastes through
semipermeable membrane
Dialysis
PeritonealHemodialysis
HemodialysisBlood circulates through a
machine outside the bodySemipermeable membrane is
within machine“Artificial kidney”Performed 3x/wk for approx.
4 hrs
AV Shunts, fistula or cannula
All allow access to the arterial system
All must be assessed for patency by:
“Feel the thrill” & “listen for the bruit”
http://classes.kumc.edu/cahe/respcared/cybercas/dialysis/franvasc.html
Peritoneal Dialysis
Uses the peritoneal lining of the abd. Cavity as semipermeable membrane
Diffusion & osmosis occur through membrane
Performed 4x/day 7 days/wk
3 Phases of Peritoneal Dialysis
Inflow Dwell Drain All 3 phases comprise one exchange
CAPD
• Used in the home• Freedom from machines• Steady bld chemistry levels• Process is shorter• Less expensive
CCPD
Also called: Automated peritoneal dialysis
Requires a cycler Free from exchanges during
day Must take cycler if traveling
Nursing Considerations
Weigh before & after VS Observe for edema, resp.
distress Check bleeding at access
site
Acc. I & O, ? Fluid restriction High calorie Low protein, Na & K diet Strict asepsis Skin care ( s/s infection)
Kidney Transplant
Kidney Donation
Live donor or cadaverTissue and blood-typed Amendment to Social
Security ActWhy is counseling advised
for both donor and recipient?
Before surgery…
BP medications Immunosuppressant drugs Possible transfusion Dialyzed before transplantation Explore patient understanding Record VS Address questions
Surgery & Complications
See fig. 40-16 pg. 924ATN, rejection, renal artery
stenosis, hematomas, abscesses and leakage of ureteral or vascular anastomoses
Organ Rejection
Hyperacute Acute Chronic s/s fever, ^ BP, pain at site of new
kidney Immunosuppressant drugs
Why are they called:
Immunosuppressants????
What is the patient predisposed to???
Routine Nursing CareMonitor urine outputMonitor fluid intakeVSNote weight changesTC & DBControl pain
Bladder CA
Most common site of urinary system CA
Men bet. 50-70 yrsMost bladder tumors are
malignant
Risk Factors
Cigarette smokingLung cancerCaffeine intakeDyes found in industrial
compounds
Medical Treatment
Cytoscopic resectionFulgurationLaser photocoagulationSegmental resectionRadical cystectomy
Types of urinary Diversion
Ileal conduit (most common)Colon conduit,
ureterosigmoidostomy Cutaneous ureterostomy Internal ileal reservoir, aka:
“Kock pouch” or “continent ileostomy”
Nursing Interventions• VS• I & O• Patency of tubes • BS, stoma appearance• Special skin care• Signs of infection
