Download The Urinary System

The Urinary System
Mandy Vichas, RN,
BSN, NPS
The Urinary System
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Kidneys
Ureters
Bladder
Urethra
Function of the Urinary System
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The primary function of the urinary system is
to maintain homeostasis
Regulate fluids and electrolytes
Eliminate waste products
Maintain BP
Involved with RBC production
Involved with bone metabolism
Kidneys
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Paired
Located retroperitoneally on the posterior
wall of the abdomen from T12-L3
The average adult kidney weighs 4.5oz
The right kidney sits lower in the abdomen
due to liver placement
An adrenal gland sits on top of each kidney
Kidney Anatomy
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Each kidney has two parts
The renal medulla is the inner portion
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consists of renal pyramids which are collecting
ducts that drain into renal pelvis
Once urine leaves the renal pelvis the
composition or amount of urine does not change
The Cortex is the outer portion
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contains nephrons
Kidney Anatomy
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Nephrons
Glomerulus
Glomerular Capillaries
Bowman’s Capsule
Bowman’s Space
Tubules
Proximal Tubule
Loop of Henle
Distal Convoluted Tubule
Collecting Tubule
Cortical Collecting Tubule
Calyx of renal pelvis
Blood Supply to the Kidneys
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Blood Supply = 25% of cardiac output to kidneys
The renal artery arises from the abdominal aorta
Renal Artery = provides into progressively smaller
branches down to afferent arteriole
Each afferent arteriole branches down to glomerulus
Blood flow leaves the glomerulus through the
efferent arteriole and eventually back to the inferior
vena cava
Glomerulus
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The glomerulus is the blood vessel where filtration occurs
Nephron
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Each kidney has approximately 1 million
nephrons
If the function is less than 20% replacement
therapy is usually initiated
The nephron is responsible for the initial
formation of urine
KIDNEY FUNCTIONS
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Urine formation
Excretion of waste products
Regulation of electrolytes
Regulation of acid-base balance
Control of water balance
Control BP
Regulation of RBC production
Synthesis of vitamin D to active form
Secretion of prostaglandins
Regulation of calcium and phosphorus balance
Urine Formation
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Urine is formed in the nephrons in a three step process
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Glomerular filtration
Tubular reabsorption
Tubular secretion
Glomerular Filtration produces ultrafiltrate which enters the
tubules
Selective reabsorption of H2O & solutes occurs in tubules
Selective secretion of solutes occurs in tubules
99% of ultrafiltrate is reabsorbed into the bloodstream
1000-1500mL of urine is produced each day
Excretion of Waste Products
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The kidney is the body’s main excretory organ
The major waste product of protein metabolism is
urea
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25-30g are produced and excreted daily
Other waste products include:
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Creatinine
Phosphates
Sulfates
Uric acid
Drug metabolites
Regulation of Electrolytes
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In normally functioning kidneys the amount of electrolytes
excreted per day is equal to the amount ingested
Sodium
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Linked to blood volume and pressure
Significant effects on osmotic pressure
90% of Na in ultrafiltrate is reabsorbed in the proximal tubules and
loops of Henle
Aldosterone causes kidneys to reabsorb sodium
Potassium
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The kidneys excrete more than 90% of K intake to maintain a
normal serum balance
Aldosterone causes the kidneys to excrete potassium
Regulation of acid-base balance
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Normal serum pH is 7.35-7.45
Normal urine pH is 4.6-8
Kidneys 3rd line of defense in acid-base balance
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respiratory & other buffer systems respond more rapidly
kidneys require several hours to a day or more to readjust
balance
Reabsorb bicarbonate from ultrafiltrate
Excrete large quantities of acid in the urine
(phosphoric and sulfuric acids) by buffering with
ammonia
Control of water balance
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The human body is made up of 60% water
Regulated by Antidiuretic hormone (ADH) or
vasopressin
Secreted by the posterior pituitary in response to
serum osmolality
ADH increases reabsorption of water to return serum
osmolality to normal
Decreased water intake stimulates ADH release
ADH controls volume & concentration of urine by
regulating permeability of distal tubule to H2O
Control BP
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The kidney secrets the hormone renin when there is
a decrease in BP
Renin converts angiotensinogen to angiotensin I
Angiotensin I converts to angiotensin II
Angiotensin II is a powerful vasoconstrictor and
causes BP to increase
Increase in BP stops the excretion of renin
The adrenal cortex also releases aldosterone in
response to increasing serum osmolality or poor
perfusion to increase BP
BP Regulation
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Renin-Angiotensin System
renin excreted by the juxtaglomerular apparatus
(macula densa cells) in response to renal ischemia
renin then acts with angiotensin produced by the
liver to make angiotensin I
angiotensin I + converting enzyme = angiotensin II
angiotensin II causes peripheral vasoconstriction &
secretion of aldosterone
BP Regulation
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K Control
increased levels of serum K---increased
excretion
aldosterone also increases tubular secretion,
increased serum K stimulates the adrenal
cortex to increase aldosterone
acid-base imbalances also effect K
Regulation of RBC production
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The kidneys release erythropoietin when
they sense a decrease in oxygen in the blood
Erythropoietin stimulates the bone marrow to
produce RBCs
Vitamin D Synthesis
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The kidneys convert inactive vitamin D to
1,25-dihydroxycholecalciferol
Vitamin D is necessary for calcium balance
Regulation of calcium and phosphorus
balance
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1,25-dihydroxycholecalciferol is necessary
for absorption of calcium and phosphorus
absorption from the small intestine
Secretion of prostaglandins
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The kidneys produce prostaglandin E and
prostycyclin
Prostaglandin E
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Like hormones. They act as chemical messengers. Only
work within the cells where they are synthesized.
Activation of the inflammatory response, production of pain,
and fever.
Prostaglandins are produced when tissues are damaged,
WBCs flood to the site to try to minimize tissue destruction.
Causes increased blood flow in kidneys
Prostycyclin
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prevents platelet formation and vasodilation
Ureters
• 1 ureter per kidney
• Long fibromuscular tubes that connect each
kidney to the bladder
• Enter bladder at an oblique angle to prevent
flow blockage
• Propel urine to bladder through peristalsis
Bladder
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Hollow, muscular organ behind the pubic bone
Anatomic capacity is 1500-2000mL
Wall of the bladder contains four layers
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Adventitia—Outer layer/connective tissue
Detrusor—smooth muscle
Submucosal layer—loose connective tissue
Mucosal lining—Inner layer/impermeable to water
Bladder neck forms Internal sphincter which is
composed of smooth muscle
Urethra
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Female = 4 cm. (1.5”), Opens anterior to the vagina
Male = 20 cm. (8”) 3 sections
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prostatic = 1”, superior end joins bladder & internal
involuntary sphincter; dilatable at this point & larger; has 2
ejaculatory ducts
membranous = 1-2 cm (.5”) has voluntary internal sphincter
& Cowper’s or bulbourethral glands on either side
Cavernous = 15 cm. in central cavernous body of penis; has
urethral orifice at end
Surrounded by prostate just below the bladder neck
Urination
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approximately 150-350 mL of urine triggers stretch
receptors & stimulates afferent nerves sending
signal to CNS
Functional Capacity of bladder is 350mL
The efferent pelvic nerve stimulates the bladder to
contract, relaxing the urethral sphincter. The
decrease in urethral pressure and contractions of the
detrusor muscle opens the proximal urethra and
leads to flow of urine
reflex action however external sphincter can be
contracted with voluntary control
Terminology
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Micturation—Urination
Frequency—Frequent voiding >every 3hours
Urgency—Strong desire to void
Hesitancy—Delay or difficulty in initiating voiding
Nocturia—Excessive urination at night
Oliguria—Output <400mL/day
Anuria—Output <50mL/day
Polyuria—Increased volume of urine voided
Hematuria—RBCs in urine
Dysuria—Painful or difficult voiding
Enuresis—Involuntary voiding during sleep
Incontinence—Involuntary loss of urine
AGE & RENAL FUNCTION
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infants’ kidneys immature; renal blood flow & glomerular
filtration rate are lower; their ability to excrete Na, H2O & acids
is limited
35 - 40 yrs. the renal blood flow & glomerular filtration rate
decrease until age 85 (50% function)
age 40 = 600ml/min renal blood flow = 120ml/min GFR
age 85 = 300 ml/min renal blood flow = 60-70ml/min GFR
ability to reabsorb glucose decreases with age as well as ability
to dilute & concentrate urine
kidneys react more slowly to acid base balance with age
serum creatinine levels do NOT increase with age (muscle
mass also decreases with age)
Urinalysis
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Urine color
Urine clarity and odor
Specific gravity—Concentrating ability (normal=1.003-1.030)
Urine pH (normal= 4.5-8.0)
Protein—(Proteinuria up to 150mg/day is normal)
WBC (normal=0-4)
RBC (normal =0-3)
Glucose—(Gylcosuria)
Ketone bodies—(Ketonuria)
Casts—(molds of renal tubules)
Bacteria—(Bacteriuria)
Crystals—(Crystalluria)
Pus—(Pyuria)
Urinalysis
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clean, dry container, sterile if C & S ordered
Provide pt with skin cleanser to prevent
contamination
Pt voids in to container mid-stream
specimens delivered immediately or
refrigerated
24 Hour Urine Collection
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Empty bladder prior to start of collection &
discard
Record time collection started
Keep specimen refrigerated or on ice
Caution!! = some tests require acid as a
stabilizer and it is put in the collection
container. Warn men NOT to void directly
into container
Osmolality
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Most accurate measurement of kidney’s
ability to dilute & concentrate urine
Serum: 275 – 300 mOsm/kg.
Urine: 50 – 1200 mOsm/kg.
24 hr. urine: 300 – 900 mOsm/kg,
Creatinine Clearance
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(24 hr.) measures renal
function (GFR)
(Urine Volume x Urine
creatnine)/Serum
creatnine
Age
Male
Female
<30
88-146
81-134
30-40
82-140
75-128
40-50
75-133
69-122
50-60
68-126
64-116
60-70
61-120
58-110
70-80
55-113
52-105
Serum Tests
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Blood urea nitrogen (BUN) (normal= 10-20 mg/dL)
Serum Creatinine (normal= 0.7-1.4mg/dL)
HCT (normal=35-52%)
Electrolytes
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Calcium (normal=8.6-10.2mg/dL)
Sodium (normal=135-145mEq/L)
Potassium (normal=3.5-5.0mEq/L)
Phosphorus (normal=2.5-4.5mg/dL)
KUB
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X-ray of the kidneys, ureters, & bladder
Delineates size, shape, & positioin of kidneys
to reveal any abnormalities
Calculi, hydronephrosis, cysts, tumors, or
kidney displacement may be seen
Ultrasonography
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General Ultrasonography is used to detect
abnormalities such as fluid accumulation,
masses, congenital malformations, changes
in organ size, & obstructions
Bladder Ultrasonography is used to measure
urine volume in the bladder (need to know if
women have hx of hysterectomy)
Non-invasive procedure
CT & MRI
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Produce excellent cross images of kidney &
urinary tract
Evaluation for masses, nephrolithiasis,
chronic renal infections, trauma, metastatic
disease, and soft tissue abnormalities
Contrast may be used to enhance
visualization
Nuclear Scans
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Injection of radioisotope (iodine or hippurate)
Monitor isotope as moves through blood
vessels of kidneys
Provides information about kidney function
such as GFR
Post-procedure the pt is encouraged to drink
fluids to eliminate the radioisotope
Intravenous Urography
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Includes tests such as excretory urography,
IVP, & infusion drip pyelography
A radiopaque contrast agent is administered
May be used as the initial assessment of
many urologic problems especially lesions in
the kidney and ureters
Infusion Drip Pyelography
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IVP shows the kidneys, ureter and bladder via x-ray
imaging as the dye moves through the urinary
system
Provides an indication of renal function
Requires IV infusion of a large volume of dilute
contrast agent.
Images are obtained at specified intervals after the
start of the infusion
Nephrotomogram
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May be included as part of IVP to visualize
different layers of kidney & diffuse
structures within each layer
Used to differentiate solid masses or lesions
from cysts in the kidneys or urinary tract
Retrograde Pyelography
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Catheters are advanced through the ureters
into the renal pelvis by means of cystoscopy
A contrast agent is injected
Performed if IV urography provided
inadequate visualization of collecting
systems
Cystoscopy
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A catheter is inserted into bladder
Contrast media is instilled
Aids in evaluating backflow of urine from the
bladder back into the ureter(s) and bladder
injury
Can be a frightening procedure
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increased tension & spasms
warn pt of sensation of desire to void
Voiding Cystourethrography
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Uses fluoroscopy to visualize the lower
urinary tract
A urethral catheter is inserted
contrast agent instilled in bladder
when bladder is full & pt. feels urge to void
catheter removed & pt. voids
Renal Angiography
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Provides an image of the renal arteries
A catheter is inserted into femoral artery then
passed through the aorta or renal artery
Dye injected & renal arteriogram done
Used to evaluate renal blood flow
Pre-Procedure Care
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Bowel cleansing to prevent obstruction on xray
Approach sites (groin or axilla) may be
shaved
Peripheral pulse sites (radial, femoral and
dorsalis pedis) are marked
The patient is advised of possible brief
sensation of heat when dye is injected
Post-Procedure Care
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Pressure dressing over injection site
Injection site monitored frequently
VS monitored
Peripheral CMS
Urine color changes with dye used
Liberal fluid intake decreases irritation
Monitor I&O
Monitor for sx of infection
Cystoscopic Examination
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Used to visualize the urethra and bladder
Cystoscope inserted through the urethra has a optical lens for
visualization and allows pictures to be taken
Small ureteral catheters can be passed through the cystoscope
to visualize the ureters and pelvis of each kidney
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The patient is usually conscious (no more uncomfortable than
catheterization) if the lower urinary tract is being visualized
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Biopsy and urine samples can be obtained
Calculi can be removed
Viscous lidocaine is injected in the urethra
Sedation is often used if the upper urinary tract is being
visualized
Post-Procedure Care
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Liberal fluid intake decreases irritation
Voiding may be PAINFUL for 24 hr.
Mild hematuria not uncommon
Analgesics & sitz baths for pain
Monitor for sx. of infection
Monitor for frank hematuria
Monitor I&O
Renal & Ureteral Brush Biopsy
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Cystoscopic examination followed by biopsy
brush passed through catheter
Suspected lesion brushed lesion brushed
back & forth to obtain cells & surface tissue
Post Procedure
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IV fluids to help clear kidneys & prevent clot
formation
Blood should clear form urine in 24 – 48
hours
May need to medicate for pain r/t postop
renal colic
Percutaneous Kidney Biopsy
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A small section of the renal cortex is obtained by
needle biopsy
Location of needle may be verified via ultrasound or
fluoroscopy
Sedation may be used
Pt placed prone over sandbags or firm pillow, bent at
diaphragm with spine straight & shoulders on bed
local anesthetic injected
Pt must hold breath for procedure & pain may be felt
Pre-Procedure Care
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Clotting studies r/t risk of bleeding post
biopsy
IV established
Urine sample obtained for comparison postprocedure
NPO for 6-8h prior to the procedure
Catheter placement?
Post Procedure Care
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Direct pressure held for 20 min. then pressure
bandage
Pt must remain supine & motionless for 4 hr.
May have small pillow under head
BP & pulse √ every 15 min. x 1 hr., then every 30
min. x 1 hr. then every 1 hr.
Bed rest for 24 hr. or until urine clear
Encourage fluids
I&O
√ for hematuria
Open Kidney Biopsy
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Small incision made over kidney to obtain
biopsy
Pre-procedure and post-procedure care
similar to that for any major abdominal
surgery
Assessment
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History
Present condition
Elimination patterns
Frequency
Urgency
Incontinence
Nocturia
Pain
Color
Smell
Volume
Physical Exam
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VS including postural BP
Edema
Lung sounds
Symptoms of electrolyte imbalance
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tingling
arrhythmias
tetany
weakness
confusion
Hct. (unexplained anemia)
Skin color & turgor
Pruritis
Mucous membranes
Urinary Incontinence
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More than 17 million adults in the US have
urinary incontinence
Affects people of all ages for a variety of
reasons
Can be very embarrassing and expensive
Age, gender and number of vaginal
deliveries are risk factors
Stress Incontinence
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Caused by coughing, sneezing, or changing
position
Predominantly affects women who have had
vaginal deliveries
Thought to be r/t decreasing pelvic floor support
of urethra & decreasing or absent estrogen
within urethral walls & bladder base
May also affect men
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experienced after a radical prostatectomy
Urge Incontinence
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Involuntary loss of urine associated with
strong sudden urge to void that can’t be
controlled
Caused by an uninhibited detrusor
contraction
May occur in those with neurological
dysfunction
Reflex Incontinence
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Involuntary loss of urine r/t hyperreflexia in
the absence of normal voiding sensations
Commonly occurs in patients with spinal cord
injury
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Lack of motor control of the detrusor
No sensory awareness of need to void
Overflow Incontinence
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Involuntary loss of urine associated with over
distention of bladder
Often r/t neurologic abnormalities & factors
that obstruct outflow of urine
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Spinal cord lesions
Tumors
Prostate enlargement
Functional Incontinence
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Lower urinary tract function is intact
Often r/t cognitive impairment or physical
impairments that make it difficult or
impossible to reach the bathroom
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Alzheimer’s
Developmental Delays
BLE Amputation
Iatrogenic Incontinence
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Involuntary loss of urine r/t intrinsic factors,
such as medications
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Alpha-adrenergic agents for HTN
Sedatives
ETOH
Muscle relaxants
Analgesics
Causes of Transient Incontinence
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Delirium
UTI
Atrophic vaginitis
Urethritis
Psychological factors (depression, regression)
Excessive urine production
Restricted activity
Stool Impaction
Medical Management
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Incontinence is often reversible & treatable
Provide encouragement and support
Behavioral therapy is first choice
Kegel exercises
Keep a voiding diary
Biofeedback
Verbal instructions (prompting voiding)
Physical therapy
Patient Education
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Avoid diuretics after 4pm
Avoid bladder irritants such as caffeine,
alcohol, and aspartame
Avoid constipation
Drink adequate fluids
Void regularly every 2-3 hours
Perform Kegels as instructed
Smoking cessation
Pharmacological Management
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Medications work best when done in combination with behavior
therapy
Anticholinergics inhibit bladder contraction
Depress uninhibited detrusor contractions
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Tricyclic antidepressants decrease bladder contractions
Inhibitory effect on the detrusor
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Propantheline (Pro-Banthine)
Flavoxate(Urispas)
Dicyclomine (Bentyl)
Tolterodine (Detrol)
Oxybutynin (Ditropan)
Imapramine
Stress incontinence may be treated with Sudafed which causes
urinary retention
Estrogen therapy is controversial r/t long term risks
Surgical Management
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Most procedures involve lifting & stabilizing bladder or urethra
to restore normal urethrovesical angle or to lengthen urethra
Anterior vaginal repair, retropubic suspension, or needle
suspensions to reposition urethra
Periurethral bulking agents such as artificial collagen compress
urethra & increase resistance to urine flow
Artificial urinary sphincter
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Periurethral cuff
Cuff inflation pump
Men may have transurethral resection or artificial sphincter,
possible injection of bulking agents
Urinary Retention
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Inability to empty bladder completely during
micturation
residual urine is what remains in bladder
after voiding
< 60 yrs. complete emptying should occur
> 60 yrs. 50 – 100 ml. residual may remain
May be assessed via catheterization or
bladder ultrasound
Urinary Retention Causes
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Diabetes
Prostate enlargement
Uretral pathology
Trauma
Pregnancy
Neurological disorders
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stroke
spinal cord injury
MS
Parkinson’s
Urinary Retention Complications
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Renal calculi
Pyelonephritis
Sepsis
Hydronephrosis
Urinary tract infections
Nursing Management
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Provide the most natural environment
possible
Run H2O in sink
Run H2O over meatus
Run hands under warm H2O
Pain management
Catheterization if necessary
Lower Urinary Tract Infections
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Cystitis, prostatitis and urethritis
Most common organism is E. Coli from the rectum
Risk factors
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Urinary retention
Obstruction
Impaired immune system
Instrumentation
Inflammation
Lower Urinary Tract Infections
Symptoms
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Urgency
Frequency
Dysuria
Hematuria
Bladder spasms
Suprapubic or back pain
Cloudy urine
Proteinuria
Increased WBC on UA
Confusion in the elderly
May be afebrile
Diagnosis
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UA with C & S if indicated
Clinical Exam
Subjective Data
Medical Management
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Antibiotics initiated empirically and then
based on C & S results
Short course of antibiotic therapy for
uncomplicated UTI
Complicated UTI treated with antibiotics for
resistant strains of bacteria
Analgesics
Patient Education
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Decrease caffeine intake to decrease diuretic effect
& frequency
Cranberry juice can lower pH if taken in large
quantities
Citrus juice does NOT work
Encourage fluid intake to flush out bacteria
Educate pt that frequency is temporary because of
inflammation
Empty bladder regularly
Sitz baths
Patient Education
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


Hygiene principals of clean to dirty
Avoid nylon underwear & tight clothing
Avoid bath oils, bubble baths & perfumes
Avoid harsh soaps for skin & clothes
Avoid prolonged activity which increases perineal
pressure
Drink 8 glasses fluid/day
Empty bladder after intercourse
Do NOT ignore pain or discharge
Neurogenic Bladder



Dysfunction that results from lesion on
nervous system
May be caused by spinal cord injury, spinal
tumor, herniated vertebral disk, MS, spina
bifida
2 types
–
–
Flaccid bladder
Spastic (reflex ) bladder
Flaccid Bladder




A lower motor neuron disorder commonly
resulting from trauma also increasingly r/t
diabetes mellitus
The bladder continues to fill, becomes
distended & overflow incontinence occurs
bladder muscle doesn’t contract forcefully
sensory loss may also occur so pt. feels no
discomfort
Spastic Bladder




More common
Caused by spinal cord lesion above the
voiding reflex arc
There is a loss of conscious sensation &
cerebral motor control
The bladder empties on reflex with minimal
or no ability to control its activity
Management









Empty the bladder regularly and completely
Maintain urine sterility
Prevent overdistention of the bladder
Prevent reflux
Catheterization
Encourage mobility and activity
Bladder retraining
Fluid intake
Urecholine may increase detrusor contraction
Acute Glomerulonephritis


Inflammation of the glomerular capillaries
Causes
–
–

Following Group A beta hemolytic strep of the
throat (2 - 3 wks. Later)
Acute viral infections
Antigen-antibody complexes clog glomeruli
Acute Glomerulonephritis

Symptoms include
–
–
–
–
–
–
Hematuria
Edema
Azotemia (concentration of urea & other
nitrogenous wastes in the blood)
Proteinuria
HTN
Headache, malaise, & flank pain (severe disease)
Acute Glomerulonephritis






Complications
Hypertensive encephalopathy
Heart failure
Pulmonary edema
ESRD
Approximately 60% of patients recover
completely
Acute Glomerulonephritis



Treatment
Antibiotics therapy
Symptom management
–
–
–
–
–
–
–
Antihypertensives
NA restriction
Corticosteroids
Immunosuppressant
Loop diuretics
Dialysis
Dietary restrictions of fluid & protein
Acute Glomerulonephritis




High carbohydrate diet provides energy &
reduces catabolism of protein
I&O
fluids administered based on fluid losses and
body wgt.
Diuresis begins about 1 week after the onset
of symptoms
Chronic Glomerulonephritis




May be due to repeated episodes of acute
glomeulonephritis
The kidneys are composed largely of fibrous tissue
Can lead to ESRD
Symptoms vary
–
–
–
Elevated BUN & creatnine
HTN
Sudden nosebleed, stroke or seizure
Chronic Glomerulonephritis

UA results
–
–
–






Urinary casts
Specific gravity 1.010
proteinuria
Hyperkalemia
Metabolic acidosis
Anemia
Hypoalbuminemia
Decreased serum calcium (to compensate for
elevated phosphorus)
Mental status changes
Chronic Glomerulonephritis

Symptom management is the cornerstone of
treatment
–
–
–
–
–
Diuretics
Antihypertensives
Balanced diet with proteins
Sodium and fluid restriction
Dialysis
Pyelonephritis



Kidney infection
Caused by bacteria spread thru blood,
lymph, or ascending from the bladder
Damage & scarring to the kidney can occur
in chronic infections
Pyelonephritis


Symptoms include fever, chills, severe
(costavertebral) flank pain, hematuria, bacturia,
dysuria, and frequency
Diagnosis
–
–
–
–

UA with C&S (f/u UA is done 2 weeks after ABX therapy)
CT
Ultrasound
Less commonly IVP
Tx.
–
–
–
–
antibiotics
bed rest
Analgesics
hydration
Calculi






Urolithiasis—Urinary tract stones
Nephrolithiasis—Kidney stones
More frequent in males
Occurs predominantly in 3rd – 5th decades of life
Formation of calculi is dependent upon amount of substance,
ionic strength & pH of urine
Chemical analysis is done when stones are recovered
–
–
–
–

oxalate
uric acid
calcium
cystine
75% are calcium based
Calculi Symptoms










Flank pain, may begin as a dull pain progressing to sharp renal
colic
Pain can radiate to groin, labia & testicles
Pain moves as stone moves
Fever
N&V
Diarrhea
Hematuria
Crystaluria
UTI
Nocturia
Calculi

Diagnosis is done by
–
–
–
–
–
KUB,
Ultrasound
IV urography
Blood chemistries
24 hour urine collection
Treatment




Nutrition therapy
Opiod analgesics
NSAIDs
Increased fluids 3500-4000ml/day
–
–
H2O preferred
includes fluids at night
Treatment

Ureteroscopy
–
–

A laser of other instrument is passed through
ureteroscope to fragment and remove the stone
A stent may be inserted & left in place for 48 hrs.
to keep ureter patent
Extracoroporeal Shock Wave Lithotripsy
(ESWL)
–
–
A noninvasive procedure to break up stones to
size of grains of sand
Ultrasonic shock waves aimed at stones located
with fluoroscopy fragment the stone
Nursing Management






Strain urine for calculi/crystals
Observe for signs of obstruction
Pain management
Observe for signs of infection
Fluids
Nutrition
Electrohydraulic Lithotripsy





Used to extract stones that cannot be removed with
other methods
A nephroscope may be introduced percutaenously
into kidney parenchyma
Stone(s) may be extracted with forceps or a basket
A lithotriptor may be passed through the scope to
fragment the stone
A nephrostomy tube is placed to prevent edema
and/or clots
Chemolysis




Use of alkylating or acidifying agents
Used for high risk patients with other dx.
Percutaneous nephrostomy is performed and
warm chemical solution flows onto stone
Solution exits via means, ureter or
nephrostomy tube
Surgical Management





Used as a last resort (1-2% of cases)
Pyelolithotomy (incision into renal pelvis)
Nephrolithotomy (incision into kidney
parenchyma)
Cystotomy (incision into bladder)
Cystolitholapaxy (stone crushed by an
instrument passed through the urethra into
the bladder)
Renal Failure

Acute renal failure
–
–
–

Prerenal failure
Intrarenal failure
Postrenal failure
Chronic renal failure
–
End stage renal disease (ESRD)
Acute Renal Failure

The initiation period
–
–

The oliguria period (10-20 days)
–
–

An increase in the serum concentration of urea, creatnine, and
electrolytes
The minimum amount of urine needed to rid the body of normal
metabolic waste products is approx 400mL/day
The diuresis period
–
–
–

Begins with the initial insult
Ends with the onset of oliguria
Gradual increase in output
Labs plateau
Pt continues to have uremic symptoms
The recovery period
–
–
May take 3-12 months
Labs WNL
Acute Renal Failure

Management
–
–
–
Maintain fluid balance
Underlying causes are identified and treated when possible
Diuretics

–
–
Dialysis
Acid-base balance

–
may impede healing
Sodium bicarbonate
Electrolyte balance

Kayexelate for hyperkalemia (exchanges sodium ions for
potassium ions in the intestines)
Chronic Renal Failure





Progressive irreversible deterioration in kidney
function
The greater the buildup of waste products, the more
sever the symptoms
Stages 1-5 are based on glomerular filtration rate
(GFR)
GFR is the amount of plasma filtered through the
glomeruli (see slide 40)
Normal GFR=125mL/min/1.73m2
Chronic Renal Failure

Neurologic
–
–
–

–
–

–
HTN
Edema
Musculoskeletal
–
–
Cramps
Bone pain/fx
Pulmonary
–
–
–

Pruritis
Dry skin
Ecchymosis
Cardiovascular
–

Confusion
Weakness
Seizures
Integument
–

GI
–
–
–

Anorexia
N/V
Constipation or diarrhea
Hematologic
–

Crackles
SOB
Decreased cough reflex
Anemia
Reproductive
–
–
Infertility
Decreased libido
Chronic Renal Failure


Complications
Hyperkalemia
–

Pericarditis, pericardial effusion & Tamponade (compression of
the heart)
–

Sodium and water retention
Anemia
–

Retention of uremic waste
HTN
–

Decreased excretion, metabolic acidosis and excessive intake
Decreased erythropoietin production
Bone Disease
–
Retention of phosphorus, low serum calcium and abnormal vitamin
D metabolism
Chronic Renal Failure


Management
Calcium and phosphorus binders
–
–
–



Antihypertensives
Antiseizure agents
Erythropoietin
–
–

Given 3x weekly in ESRD
IV or SQ
Nutrition therapy
–

Bind dietary phosphorus in the GI tract
Os-Cal and PhosLo
High risk for hypercalcemia
Regulation of protein, sodium, potassium and fluid
Dialysis
Dialysis

Hemodialysis
–
–

Peritoneal Dialysis
–
–



Most common
A dialyzer serves as a synthetic semipermiable membrane
Sterile dialysate fluid is introduced into the peritoneal cavity
through a catheter
The peritoneal membrane serves as the semipermeable
membrane
Diffusion—solutes move from an area of higher
concentration to lower concentration
Osmosis—water moves from an area of higher
solute concentration to lower solute concentration
Ultrafiltration—water moves under high pressure to
an area of lower pressure
Hemodialysis Access

Vascular Access Device
–
–
–

Arteriovenous (AV) Fistula
–
–
–


Double-lumen large bore catheter
May be cuffed for LT use
Subclavian, Internal Jugular, or Femoral vein
Anastomosing of an artery to a vein
Usually in the forearm
Needs 14 days to mature
Arteriovenous (AV) Graft
Subcutaneous interposing graft material between an
artery and a vein
–
Created when the vessels are not suitable for a fistula
AV Fistula and Graft
Hemodialysis Complications





Hypotension
Muscle cramping
Dysrhythmias
Air embolism
Dialysis disequilibrium
–
Cerebra fluid shifts
Peritoneal Dialysis Complications

Peritonitis
–
–
–



Most common and severe
Pain and rebound tenderness
cloudy diasylate drainage
Leakage at catheter site
Bleeding
Risk for LT cardiovascular disease
Polycystic Kidney Disease




A genetic disorder characterized by the growth of numerous
cysts in the kidneys
When cysts form in the kidneys, they are filled with fluid
Can also cause cysts in the liver and problems in other organs,
such as blood vessels in the brain and heart
Autosomal recessive PKD
–
–

rare inherited form
Symptoms begin in the earliest months of life, even in the womb.
Autosomal dominant PKD
–
–
the most common inherited form.
Symptoms usually develop between the ages of 30 and 40 is a
Kidney Transplant


Tissue typing, blood typing and antibody
screening are done to determine
compatibility between donor and recipient
Immunosuppressive agents are administered
post-operatively and the patient will take
these as long as they have the transplanted
kidney
–
–
Cyclosporine
Tacrolimus (Prograf)
Kidney Transplant



Transplant patients are at increased risk for
infections
Monitor kidney function
Rejection
–
–
–
–
–
Oliguria
Edema
Fever
HTN
Increased serum creatnine
Genitourinary Trauma



10% of injuries in ED Ureteral Trauma
May occur during gynecologic surgery or
urologic surgery
Increased potential to develop fistula
Kidney Trauma



Rib Fractures
The kidneys receive half of the blood flow from the
aorta
Risk for bleeding!
–
–
–


Hematuria
Flank swelling
Ecchymosis
May need surgical intervention
Risk for renal artery thrombus
Bladder Trauma


Pelvic fracture or blow to lower abdomen
when bladder is full
Symptoms
–

contusion with ecchymosis
Complications
–
–
–
hemorrhage
shock
sepsis
Urethral Trauma


Pelvic fracture
Classic triad of symptoms
–
–
–
Blood at meatus
Unable to void
Distended bladder
Nursing Management






Assess frequently first few days for abdominal or
flank pain and swelling over flank
Adequate fluid intake
Monitor for hematuria or signs of decreasing kidney
function
Monitor for hypertension
Restrict activity for 1 month to minimize delayed or
secondary bleeding
Assess for sexual abuse
Renal Cancer







Accounts for 3% of all cancers in adults
More common in men than women
Linked to tobacco use
Occupational exposure to chemicals
Obesity
Unopposed estrogen therapy
Polycystic kidney disease
Renal Cancer






Most patients are asymptomatic
In 10% of patients classic triad of hematuria,
pain and flank mass are present
Diagnosis by CT, IV urography, cystoscopic
examination or renal angiograms
Surgery is primary treatment
Radiation for palliation
Biologic response modifiers such as IL-2 and
IFN
Wilm’s Tumor (neprhoblastoma)





Malignancy that occurs in kidneys or
abdomen
Occurs most often in girls
Age 3 is the peak age of occurrence
Metastasis is rare
Genetic link may play a role in development
Wilm’s Tumor (neprhoblastoma)








Signs & Sx.
may cause frequency & urgency with compression or
renal structures
presents as an abdominal mass
Tx.
preoperative chemotherapy or radiation to decrease
tumor size
surgical removal
chemotherapy anywhere from 6 – 15 month
radiation for large tumors recurrent disease
Bladder Cancer







Most common site of urinary malignancy
Usually curable if bladder wall is not penetrated
More common in males
Most common from ages 50-70 yrs
Greatest risk factor is smoking
Diagnosis done by cystoscope, cytology of washings, excretory
urography, CT, ultrasound, & manual exam
Newer techniques are being developed such as
–
–
–

tumor antigens
nuclear matrix proteins
adhesion molecules
Visible, painless hematuria is the most common symptom
Bladder Cancer

Chemotherapy
–
–
–


Intravesical—instillation into the bladder
Intravenous
BCG—attenuated live strain of Mycobacterium bovis
(thought to produce a local inflammatory response and a
systemic immunologic response)
Radiation
Surgical treatment
–
–
Transurethral resection
Cystectomy with urinary diversion
Post-Surgical Nursing Management










Note location of incision (i.e. flank = breathing painful
lower abdomen, perineal or transthoracic)
√ for hemorrhage— Post-operatively & 8-10 days
later
Monitor urine & drain output every 1 hr.
I & O on all drains separately noted
VS
Note color of drainage
Turn, cough & deep breath
Protect skin from urine drainage
Restrict pm fluids
CUTANEOUS URINARY DIVERSIONS



Urine drains through an opening created in
the abdominal wall and skin
Ileal Conduit
Cutaneous Ureterostomy
Ileal Conduit



Oldest & most common of the urinary
diversions
The urine is diverted by implanting the ureter
into a 12cm loop of ileum that is led out
through the abdominal wall
A loop of sigmoid colon may also be used
Nursing Management









NG in place several days until bowel tones normal due to
disruption of GI tract
JP drains
I&O
Skin protection around stoma
Monitor for skin changes
When changing positions make sure drain not impeded
monitor urine volumes
urine outflow <30 ml/hr may indicate dehydration or obstruction
Stents are placed in the ureters to prevent occlusion secondary
to post-operative edema
Cutaneous Ureterostomy




Ureters are directed through abdominal wall
& attached to opening in skin
Used for pts. with ureteral obstruction
(advanced pelvic cancer) or previous
abdominal radiation
Urinary appliance is fitted immediately postoperatively
Nursing care similar to ileal conduit
CONTINENT URINARY DIVERSIONS

Indiana Pouch
–
–
–
–

Created for the patient whose bladder is removed or no
longer functions
Uses a segment of the ileum and cecum to form a reservoir
for urine
Urine collects in the pouch until a catheter is inserted
Urine is drained at regular intervals
Post-op the patient will have additional drainage
tubes (cecostomy catheter from pouch, stoma
catheter existing from stoma, ureteral stents,
Penrose, drain & urethral catheter)
Continent Urinary Diversions

Ureterosigmoidostomy
–
–
–
–

ureters are implanted into colon
Pt voids & defecates through the rectum
no appliance needed, colon is reservoir
special bowel prep before & low residue diet after
Catheter is placed in rectum post-op to drain
urine & prevent reflux
Nursing Management




need good skin care—remove catheter when
peristalsis returns
√ fluid & electrolytes
Instruct patient to use restroom every 2-3 hrs
Risk for infection
Kock Pouch




Variation of the continent urinary reservoir
U-shaped pouch constructed of ileum
Has a nipple-like one way valve
Must be drained at regular intervals with a
catheter
Charleston Pouch



Uses ileum & ascending colon as pouch
Appendix & colon junction serve as one way
valve mechanism
Must be drained at regular intervals with a
catheter
General Care Principles




Maintain adequate hydration
Fluids & electrolytes
Daily Weight
I&O
–
–

Record all output with urine separate, including all caths &
drains in urinary system
If incontinent record # of times bed or diaper wet & whether
damp or soaked
Maintaining Flow with Catheters
Catheters

Foley
–
–

Coude tip
–

–
–
Surgically inserted into bladder
Sutured in place not self retaining
Does NOT interfere with urethral voiding
Ureteral
–
–

makes it easier to thread the catheter past an enlarged prostate
Suprapubic
–

Most common
Passed through urethra into bladder
Never plug
Goes directly into ureter
Nephrostomy
–
Goes directly into kidney pelvis
Foley Catheters
Suprapubic Catheter
Catheter Care

Prevention of Infection
–
–
–

Irrigation
–
–
–
–
–
–
–

aseptic technique whenever system is open
prevent backflow
pericare with soap & H2O rinse
to remove sediment & clots or instill Rx.
I & O = note irrigant in & out in bag (difference = urine output)
√ level in drainage bag frequently
disconnect, treat ends aseptically
attach filled syringe to catheter
plug drain end
irrigate then reconnect
3-way
–
constant or intermittent