Post on 23-Feb-2016
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Urinary SystemCh 45-47
Zoya Minasyan RN MSN-Edu
Structures and Functions of Urinary System
Assessment of Urinary System
Assessment of Urinary System
Diagnostic Studies of Urinary System
Diagnostic Studies of Urinary System; Cystoscopic examination
Diagnostic Studies of Urinary System
Ch 45, table 45-8 Page 1114-1119
Diagnostic study
Bladder and its contents are free of bacteria in most healthy patients.
Escherichia coli most common pathogen Fungal and parasitic infections can cause
UTIs. Patients at risk
◦ Are immunosuppressed◦ Have diabetes◦ Have undergone multiple antibiotic courses◦ Have traveled to certain Third World countries
Urinary Tract Infection
Upper versus lower Upper tract
Renal parenchyma, pelvis, and ureters Typically causes fever, chills, flank pain Example
Pyelonephritis: inflammation of renal parenchyma and collecting system
Lower urinary tract Usually no systemic manifestations Example
Cystitis—Inflammation of bladder wall
Classification
Classification of UTI
Complicated versus uncomplicated◦ Uncomplicated
Occurs in otherwise normal urinary tract Usually involves only the bladder
◦ Complicated Those with coexisting presence of
Obstruction Stones Catheters Existing diabetes/neurologic disease Pregnancy-induced changes Recurrent infection
Classification
Bacterial persistence◦ Occurs when
Bacteria develop resistance to antibiotic agent. Foreign body in urinary system allows bacteria to survive
Unresolved bacteriuria◦ Occurs when
Bacteria are resistant to antibiotic Drug is discontinued before bacteriuria is completely
eradicated Antibiotic agent fails to achieve adequate
concentrations in bloodstream or urine to kill bacteria
Classification
Urinary tract above urethra normally sterile Defense mechanisms exist to maintain
sterility/prevent UTIs.◦ Complete emptying of bladder
Etiology and Pathophysiology
Defense mechanisms◦ Acidic pH◦ High urea concentration
Alteration in defense mechanisms increases risk of contracting UTI. Predisposing factors
◦ Factors increasing urinary stasis Examples: BPH, tumor, neurogenic bladder,stones
◦ Foreign bodies Examples: Catheters, instrumentation
◦ Anatomic factors Examples: Obesity, congenital defects, fistula
◦ Compromising immune response factors Examples: Age, HIV, diabetes
◦ Functional disorders Example: Constipation
◦ Other factors Examples: Pregnancy, multiple sex partners (women)
Etiology and Pathophysiology
Organisms are introduced via the ascending route from the urethra.
Less common routes ◦ Bloodstream
Lymphatic system Hospital-acquired UTI accounts for 31% of
all nosocomial infections.◦ Causes
Often: E. coli Seldom: Pseudomonas
◦ Catheter-acquired UTIs Bacterial biofilms develop on inner surface of
catheter.
Etiology and Pathophysiology
Symptoms related to bladder storage or bladder emptying◦ Bladder storage
Urinary frequency Abnormally frequent (> every 2 hours)
Urgency Sudden strong desire to void immediately
Incontinence Loss or leakage of urine Nocturia
Waking up ≥2 times at night to void Nocturnal enuresis
Complaint of loss of urine during sleep◦ Bladder emptying
Weak stream Hesitancy Difficulty starting the urine stream Intermittency
Interruption of urinary stream while voiding Postvoid dribbling
Urine loss after completion of voiding Urinary retention Inability to empty urine from bladder Dysuria
Difficulty voiding◦ Pain on urination
Flank pain, chills, and fever indicate infection of upper tract. Pyelonephritis
Clinical Manifestations
Older adults◦ Symptoms are often absent. ◦ Experience nonlocalized abdominal discomfort
rather than dysuria◦ May have cognitive impairment◦ Are less likely to have a fever
Patients over age 80 years may experience a slight decline in temperature.
Clinical Manifestations
History and physical examination Dipstick urinalysis
◦ Identify presence of nitrates, WBCs, and leukocyte esterase.
◦ Table 45-8, page 1114
Diagnostic Studies
Urine for culture and sensitivity (if indicated)◦ Clean-catch sample preferred◦ Specimen by catheterization or suprapubic needle
aspiration more accurate Determine susceptibility of bacteria to antibiotics Imaging studies
◦ IVP(IV pyelogram)◦ Antegrade pyelogram◦ Retrograde pyelogram◦ Abdominal CT when obstruction suspected◦ Renal ultrasound for recurrent UTIs
Diagnostic Studies
◦ IVP(IV pyelogram) Visualizes urinary tract after IV injection of contrast media. Size, shape, position
of kidneys, ureters, bladder, tumor, cysts, lesions, obstructions Nursing
Check for iodine sensitivity Warmth, a flushed face and salty taste during injection of contrast media Force fluid after procedure to flush out contrast media.
◦ Antegrade pyelogram If pt has allergy to contrast media or decreased renal fx or no passage to
ureteral catheter -contrast media inserted into renal pelvis or via nephrostomy tube
◦ Retrograde pyelogram-X ray If pt has allergy to contrast, cyctoscope is inserted and ureteral catheter are
inserted through it into renal pelvis and contrast is inserted through catheter◦ Abdominal CT when obstruction suspected
Visualization of kidneys Masses, tumor Iv contrast to differentiate masses
◦ KUB- Kidneys, ureters, bladder Bowel prep if needed X-ray of abdomen for the size, shape and position of the kidneys Stones and foreign bodies can be seen
◦ Renal ultrasound for recurrent UTIs To detect mass
Diagnostic Studies
•Teach women •To wipe the periurethral area from front to back using a moistened, clean gauze sponge (no antiseptic is used, as it could contaminate the specimen and cause false-positives)
• tell them to collect the specimen 1 to 2 seconds after voiding starts.
•Instruct men to wipe the penis around the urethra. The specimen is collected 1 to 2 seconds after voiding begins.
•Refrigerate urine immediately on collection
Diagnostic Studies
◦ Trimethoprim/sulfamethoxazole (TMP/SMX) Used to treat uncomplicated or initial Inexpensive Taken twice a day
◦ E. coli resistance to TMP-SMX ◦ Nitrofurantoin (Macrodantin)
Given 3 or 4 times a day Long-term use
Pulmonary fibrosis Neuropathies
◦ Fluoroquinolones Treat complicated UTIs Example: Ciprofloxacin (Cipro)
◦ Pyridium Used in combination with antibiotics Provides soothing effect on urinary tract mucosa Stains urine reddish orange
Can be mistaken for blood and may stain underclothing OTC
Collaborative Care: Drug Therapy
Health history ◦ Previous UTIs, calculi, stasis, retention,
pregnancy, STDs, bladder cancer◦ Antibiotics, anticholinergics, antispasmodics◦ Urinary hygiene◦ N/V, anorexia, chills, nocturia, frequency, urgency◦ Suprapubic/lower back pain, bladder spasms,
dysuria, burning on urination
Nursing Management: Nursing Assessment
Objective data◦ Fever◦ Hematuria, foul-smelling urine, tender, enlarged
kidney◦ Leukocytosis, positive findings for bacteria, WBCs,
RBCs, pyuria, ultrasound, CT scan, IVP
Nursing Management: Nursing Assessment
Impaired urinary elimination Ineffective self-health management
Nursing ManagementNursing Diagnoses
Patient will have◦ Relief from lower urinary tract symptoms◦ Prevention of upper urinary tract involvement◦ Prevention of recurrence
Nursing ManagementPlanning
Health promotion ◦ Recognize individuals at risk.
Debilitated persons Older adults Underlying diseases (HIV, diabetes)
◦ Taking immunosuppressive drug or corticosteroids◦ Emptying bladder regularly and completely◦ Evacuating bowel regularly◦ Wiping perineal area front to back◦ Drinking adequate fluids
Nursing ManagementNursing Implementation
Health promotion (cont’d) ◦ Cranberry juice or cranberry essence may help
decrease risk.◦ Avoid unnecessary catheterization and early
removal of indwelling catheters.◦ Aseptic technique must be followed during
instrumentation procedures.◦ Wash hands before and after contact.◦ Wear gloves for care of urinary system.◦ Routine and thorough perineal care for all
hospitalized patients◦ Avoid incontinent episodes by answering call light
and offering bedpan at frequent intervals
Nursing ManagementNursing Implementation
o Adequate fluid intake Patient may think will worsen condition because of discomfort. Dilutes urine, making bladder less irritable Flushes out bacteria before they can colonize
◦ Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods. Potential bladder irritants
◦ Emphasize taking full course of prescribed drugs despite disappearance of symptoms. Second or reduced drug may be ordered after initial course in
susceptible patients. Instruct patient about drug therapy and side effects. Instruct
patient to watch urine for changes in color and consistency and decrease in cessation of symptoms.
◦ Application of local heat to suprapubic or lower back may relieve discomfort.
◦ Counsel on persistence of lower tract symptoms beyond treatment; onset of flank pain or fever should be reported immediately
Nursing Management: Nursing Implementation
Ambulatory and home care◦ Emphasize compliance with drug regimen.
Take as ordered.◦ Maintain adequate fluids.◦ Regular voiding (every 3 to 4 hours)◦ Void after intercourse.◦ Instruct on follow-up care.◦ Recurrent symptoms typically occur
1 to 2 weeks after therapy.
Nursing ManagementNursing Implementation
Use of nonanalgesic relief measures Appropriate use of analgesics Passage of urine without urgency Urine free of blood Adequate intake of fluids
Nursing ManagementEvaluation
Inflammation of renal parenchyma(consisting of the nephrones) and collecting system
Caused most commonly by bacteria, Fungi, protozoa, or viruses.
Acute Pyelonephritis
Acute Pyelonephritis
Fig. 46-2. Acute pyelonephritis. Cortical surface shows grayish white areas of inflammation and abscessformation (arrow).
Urosepsis◦ Systemic infection from urologic source
Can lead to septic shock and death
Septic shock: Outcome of unresolved bacteremia involving gram-negative organism
Usually begins with colonization and infection of lower tract via ascending urethral route
Frequent causes ◦ Escherichia coli◦ Proteus◦ Klebsiella◦ Enterobacter
Etiology and Pathophysiology
Hospitalization for patients with severe infections and complications ◦ Such as nausea and vomiting with dehydration
•Signs/symptoms typically improve within 48 to 72 hours after therapy is started.
•The patient with mild symptoms may be treated as an outpatient with antibiotics for 14 to 21 days.
•When initial treatment resolves acute symptoms and the patient is able to tolerate oral fluids and drugs, the person may be discharged on a regimen of oral antibiotics for an additional 14 to 21 days.
Collaborative Care
Health history ◦ Nausea, vomiting, anorexia, chills, nocturia,
frequency, urgency Suprapubic or lower back pain, bladder
spasms, dysuria, burning on urination Objective data
◦ Fever◦ Hematuria, foul-smelling urine, tender, enlarged
kidney◦ Leukocytosis, positive findings for bacteria, WBCs,
RBCs,ultrasound, CT scan, IVP
Nursing Management: Nursing Assessment
Nursing Diagnoses Acute pain Impaired urinary elimination Planning
◦ Patient will have Relief of pain Normal body temperature No complications Normal renal function No recurrence of symptoms
Nursing Management
Health promotion◦ Early treatment for cystitis to prevent ascending
infection Patient with structural abnormalities is at high risk
Stress the need for regular medical care. Ambulatory and home care
◦ Need to continue drugs as prescribed◦ Need for follow-up urine culture◦ Identification of risk for recurrence◦ Encourage adequate fluids. ◦ Rest to increase comfort◦ Low-dose, long-term antibiotics to prevent re infections
Nursing ManagementNursing Implementation
Appropriate use of analgesics Passage of urine without urgency Urine free of blood Adequate intake of fluids
Nursing ManagementEvaluation
The nurse identifies the patient with the greatest risk for a urinary tract infection as a:
1. 37-year-old man with kidney stones.2. 26-year-old pregnant woman who has a history
of urinary tract infection.3. 69-year-old man who has urinary retention
caused by benign prostatic hyperplasia.4. 72-year-old woman hospitalized with a stroke
who has a urinary catheter because of urinary incontinence.
Question
Involves progressive, irreversible loss of kidney function
Disease staging based on decrease in GFR ◦ Normal GFR 125 mL/min, which is reflected by
urine creatinine clearance◦ Last stage of kidney failure
End-stage renal disease (ESRD) occurs when GFR <15 mL/min
Chronic Kidney Disease (CKD)
Defined as presence of ◦ Kidney damage
Pathologic abnormalities Markers of damage
Blood, urine, imaging tests ◦ Glomerular filtration rate (GFR)
<60 mL/min for 3 months or longer
Chronic Kidney Disease
Leading causes of ESRD◦ Diabetes◦ Hypertension
Chronic Kidney Disease
Polyuria◦ Results from inability of kidneys to concentrate
urine ◦ Occurs most often at night
Oliguria ◦ Occurs as CKD worsens◦ 300-500 ml/day
Anuria ◦ Urine output <40 mL per 24 hours
Clinical ManifestationsUrinary System
Waste product accumulation◦ As GFR ↓, BUN ↑ and serum creatinine levels ↑
BUN ↑ Not only by kidney failure but by protein intake, fever,
corticosteroids, and catabolism N/V, lethargy, fatigue, impaired thought processes, and
headache may occur. Altered carbohydrate metabolism
◦ Caused by impaired glucose use From cellular insensitivity to the normal action of insulin
Defective carbohydrate metabolism◦ Patients with diabetes who become uremic may require
less insulin than before onset of CKD. Insulin dependent on kidneys for excretion
Clinical ManifestationsMetabolic Disturbances
Elevated triglycerides◦ Hyperinsulinemia stimulates hepatic production of
triglycerides.◦ Altered lipid metabolism
↓ levels of enzyme lipoprotein lipase Important in breakdown of lipoproteins
Clinical Manifestations Metabolic Disturbances
Potassium◦ Hyperkalemia
Most serious electrolyte disorder in kidney disease Fatal dysrhythmias
Sodium◦ May be normal or low◦ Because of impaired excretion, sodium is retained.
Water is retained. Edema Hypertension CHF
Calcium and phosphate alterations Magnesium alterations
Clinical ManifestationsElectrolyte/Acid-Base Imbalances
Metabolic acidosis◦ Results from
Inability of kidneys to excrete acid load (primary ammonia)
•Defective reabsorption/regeneration of bicarbonate• The average adult produces 80 to 90 mEq of acid
per day. This acid is normally buffered by bicarbonate.
• In kidney failure, plasma bicarbonate, which is an indirect measure of acidosis, usually falls to a new steady state at around 16 to 20 mEq/L (16 to 20 mmol/L).
Clinical Manifestations Electrolyte/Acid-Base Imbalances
Hematologic System Anemia
◦ Due to ↓ production of erythropoietin From ↓ in functioning renal tubular cells
Bleeding tendencies Defect in platelet function Infection
◦ Changes in leukocyte function◦ Altered immune response and function◦ Diminished inflammatory response
Clinical Manifestations
Cardiovascular System Hypertension Heart failure Left ventricular hypertrophy Peripheral edema Dysrhythmias Uremic pericarditis
Clinical Manifestations
Respiratory System Kussmaul respiration Dyspnea Pulmonary edema Pleural effusion Predisposition to respiratory infection
Clinical Manifestations
Gastrointestinal System Every part of GI is affected.
◦ Due to excessive urea Mucosal ulcerations Stomatitis
with exudates and ulcerations, a metallic taste in the mouth, and uremic fetor (a urinous odor of the breath)
Uremic fetor (urinous odor of breath) GI bleeding
• Anorexia, nausea, vomiting• may develop if CKD progresses to ESRD and is not
treated with dialysis.
Clinical Manifestations
Neurologic System Expected as renal failure progresses
◦ Attributed to ↑ nitrogenous waste products Electrolyte imbalance Metabolic acidosis Axonal atrophy
◦ Demyelination of nerve fibers ◦ Restless leg syndrome◦ Muscle twitching◦ Irritability◦ Decreased ability to concentrate◦ Peripheral neuropathy ◦ Altered mental ability◦ Seizures◦ Coma◦ Dialysis encephalopathy
Clinical Manifestations
Musculoskeletal System CKD mineral and bone disorder
◦ Systemic disorder of mineral and bone metabolism◦ Results in skeletal complications and extra-skeletal (vascular)
calcifications
• As kidney function deteriorates, less vitamin D is converted to its active form, resulting in decreased serum levels.
• To absorb calcium from the GI tract, activated vitamin D is necessary.
• Thus decreased active vitamin D levels result in less calcium absorption from the intestine, and therefore decreased serum calcium levels.
Clinical Manifestations
Integumentary System Pruritus
• includes dry skin, calcium-phosphate deposition in the skin, and sensory neuropathy.
• The itching may be so intense that it can lead to bleeding or infection secondary to scratching.
Clinical Manifestations
Reproductive System Infertility
◦ Experienced by both sexes Decreased libido Low sperm counts Sexual dysfunction
Female-decreased levels of estrogen, progesterone, and luteinizing hormone, causing an ovulation and menstrual changes
Men experience loss of testicular consistency, decreased testosterone levels, and low sperm counts
Sexual function may improve with maintenance dialysis and may become normal with successful transplantation.
Clinical Manifestations
Psychologic Changes Personality and behavioral changes Emotional ability WithdrawalDepression
• Changes in body image caused by edema, integumentary disturbances, and access devices (e.g., fistulae, catheters) may contribute to the development of anxiety and depression.
Clinical Manifestations
History and physical examination Dipstick evaluation(detects protein-
albumin) Albumin-creatinine ratio (first morning void) GFR Renal ultrasound Renal scan CT scan Renal biopsy
Diagnostic Studies
Nutritional Therapy Protein restriction
◦ Benefits are being studied. Water restriction Intake depends on daily urine output. Sodium restriction
◦ Diets vary from 2 to 4 g, depending on degree of edema and hypertension.
◦ Sodium and salt should not be equated. Salt substitutes should not be used because they contain
potassium chloride. Potassium restriction
◦ 2 to 3 g◦ High-potassium foods should be avoided.
Collaborative Care
Acute kidney failure Onset- sudden Cause-tubultar necrosis Dx-acute reduction in UO and/or elevation
of serum creatinin Mortality rate-high-60% Primary cause of death-infection TABLE-1,2 and3, ch 47, page 1165
Acute kidney Injury(AKI)
Movement of fluid and molecules across a semi permeable membrane from one compartment to another.
Two dialysis are available◦ Peritoneal ◦ Hemodialysis◦ Table 47-13, page 1182
Dialysis
UI is an uncontrolled leakage of urine◦ Cause: infection, urinary retention, restricted
mobility, fecal impaction, drugs, prostate inlargment
UR is the inability to empty the bladder◦ Cause: bladder outlet obstruction and /or
decreased the contraction strength of bladder muscle
Urinary incontinence and retention
Stress incontinence; coughing laughing, sneezing, lifting, exercising (Increase in intra abdominal pressure)
Urge incontinence :involuntary urination, periodic leakage but also frequent and in large amount
Overflow incontinence: distended bladder, small frequent urination
Reflex incontinence :Fequent, moderate and equally during the day and night
Incontinence after trauma or surgery: alteration in control of proximal and distal sphincter of urethra
Functional incontinence: loss of urine resulting from cognitive, functional or environmental factors
Urinary incontinence
Lifestyle modifications: weight reduction, smoking cessation, decrease caffeine intake, fluid modification, etc
Scheduling voiding regimens Pelvic floor muscle exercises or training:
Kegels Anti- incontinence devices: surgical
treatment Drugs
Urinary incontinence: Interventions
Minimize the risk:◦ avoid intake of large volumes of fluid over short
period of time, ◦ avoid alcohol, coffee intake and hot tea(it
increase the urgency of urination, distention of the bladder.
◦ Take warm shower or bath and attempt to urinate while in the bathtub or shower.
◦ Indwelling or intermittent catheterization- straight cath i/o.
Urinary retention