The Urinary System

Anatomy and

Physiology

2014

Structure

KidneysUretersUrinary bladderurethra

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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

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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