Genital-Urinary System

1
Genital-Urinary System

• Renal System Part 1

2
Behavioral Objectives

• Review the anatomy and physiology of the
  genito-urinary systems
• Describe the physical assessment of the GU
  systems
• Discuss the application of the nursing process as
  it relates to patients with disorders of the GU
  system
• Describe the purpose and methods for collecting
  sterile and clean-catch urine specimens.
• Discuss the importance of monitoring and
  maintaining intake and output and appropriate
  documentation
• Discuss common diagnostic tests, procedures and
  related nursing responsibilities for the patient
  with GU disorders.
• Explain the purpose of dialysis and differentiate
  between peritoneal and hemodialysis

3
Introduction

• Essential to life
• Every head to toe assessment must include
• Upper lower urinary tract function

4
Anatomy Kidney

• Kidneys
• Shape
• Bean
• Color
• Brown-red
• How many /
• 2

5
Anatomy Kidneys

• Kidneys
• Location
• Posterior wall of the abdomen
• Base of the rib cage
• Surrounded by renal capsule
• Right kidney is lower than the left

6
Anatomy kidney

• Do You Remember?
• What lies on top of each kidney?
• Liver
• Pancreas
• Meat balls
• Adrenal gland

7

• What hormones do the adrenal glands secrete?
• (Not a multiple choice question!)
• Hint
• Sugar, Sex Salt
• Glucocorticoids
• Androgens
• Mineralcorticoids - aldosterone

8
Anatomy Kidney

• Two distinct regions
• Renal parenchyma
• Renal pelvis
• Renal parenchyma
• Divided into 2 parts
• Cortex
• Medulla

9
Renal parenchyma

• Medulla
• Inner portion
• Contain
• Loops of Henle
• Vasa recta
• Collecting ducts

10
Renal parenchyma

• Medulla
• Collecting ducts connect to Renal pyramids
• Shape
• Triangle
• Point toward
• Hilum / pelvis
• Ea. Kidney contains
• 8-18 pyramids

11
Anatomy Kidney

• Medulla
• Function
• Drain urine from the Nephrons to the renal pelvis

12
Renal parenchyma

• Divided into 2 regions
• Medulla
• Cortex
• Contains
• Nephrons
• Functional unit of the kidneys

13
Anatomy Kidney

• Renal pelvis
• Ureter
• Renal pyramids drain urine into the ureter
• Renal artery
• Renal Vein

14
Blood supply to the kidney

• Aorta ?
• Renal artery ?
• Afferent arteriole ?
• Glomerulus
• Capillary bed
• Efferent arteriole ?
• Venules and veins
• Inferior Vena Cava

15
Can you do it?

• Place the following in order to best describe
  blood flow threw the kidney.
• Afferent arteriole
• Aorta
• Efferent arteriole
• Glomerulus
• Inferior Vena Cava
• Renal artery
• Vein
• Venules
• B-F-A-D-C-H-G-E

16
QUESTION????

• Where in the flow of blood threw the kidney does
  filtration take place?
• Afferent arteriole
• Aorta
• Efferent arteriole
• Glomerulus
• Inferior Vena Cava
• Renal artery
• Vein
• Venules

17
Anatomy Nephrons

• Functional unit
• FYI
• 1 million Nephrons in ea. Kidney
• Adequate renal function with 1 kidney

18
Anatomy Nephrons

• Nephron
• Glomerulus
• Bowmans capsule
• Proximal convoluted tubule
• Loops of Henle
• Distal convoluted tubule

19
Anatomy Ureters

• Urinenephrons ? renal pyramids ? renal pelvis ?
  ureter,
• a long narrow muscular tube
• Extends from renal pelvis ? bladder
• Two
• Upper urinary tract

20
Anatomy Ureters

• 3 narrowed areas
• promotes efflux
• prevents reflux
• micturition
• Propensity for obstruction by renal calculi

21
Anatomy Ureters

• lining urothelium
• prevents reabsorption of urine
• The movement of urine is facilitated by
  peristaltic waves

22
Anatomy Bladder

• BLADDER
• Description
• Muscular
• hollow sac
• Location
• Behind pubic bone
• Function
• Reservoir for urine

23
Anatomy Bladder

• Normal capacity
• 300-500 ml of urine
• Capable of holding
• 1500-2000 ml
• CNS stim. need to void
• 150-200 ml urine

24
Anatomy Bladder

• Neck of the bladder
• Internal urinary sphincter
• Involuntary control

25
Anatomy Urethra

• Carries urine from the bladder expels it from
  the body
• External urinary sphincter
• voluntary control

26
Physiology of the Urinary System

• Function of the kidneys
• Urine formation
• Excretion of waste products
• Regulation of
• Electrolytes
• Acid-base control
• RBC production
• Ca Ph

• Control
• water balance
• blood pressure
• Renal clearance
• Synthesis of Vit. D

27
Physiology of the Urinary System

• Urine formation
• The nephrons form urine through a complex 3-step
  process
• Glomerular filtration
• Tubular reabsorption
• Tubular secretion

28
1. Glomerular filtration

• Step 1
• Most of the elements of blood, except
• large molecules
• blood cells
• forced out of the blood ? capillaries of the
  glomerulus ? Bowmans capsule ? filtrate
• High capillary BP in the glomerulus.

29
1. Glomerular filtration

• Filtration at Glomerulus
• Water
• Na
• Cl-
• Bicarbonate
• K
• Glucose
• Urea
• Creatinine
• Uric Acid

30
1. Glomerular filtration

• Glomerular filtration
• Factors that can alter process
• Blood flow
• Blood pressure

31
2. Tubular reabsorption

• Step 2
• Filtrate ? Proximal convoluted tubule ?
• Reabsorption (back into blood)
• Most
• Water
• Na
• Cl-
• Bicarb
• K
• Uric Acid
• All of the glucose
• None of the Creatinine

32
3. Tubular Secretion

• Elements secreted from blood into tubule for
  excretion in urine
• Some
• Water
• Na
• Cl-
• Bicarbonate
• K
• Uric acid
• Most Urea

33

• Filtrate ?
• Tubules ?
• Collecting duct ?
• Renal pelvis?
• Ureter ?
• Bladder ?
• Urethra

34
Glucose

• Normally all the glucose filtered through the
  glomeruli will be reabsorbed back into blood
• No glucose in the urine
• Glycosuria
• Diabetes mellitus
• h serum glucose levels overwhelm the nephrons
  ability to reabsorb glucose

• Sweet pea!

35
Protein

• Filtered by glomeruli returned to the blood by
  tubular reabsorption.
• Slight proteinuria
• OK
• globulin, albumin
• Persistent proteinuria
• Glomerular damage

36
Anti-diuretic hormone (ADH)

• AKA
• Vasopressin
• Secreted by
• Posterior Pituitary
• Secreted in response to
• changes in blood osmolality

37
Anti-diuretic hormone (ADH)

• Normally
• Water intake i ?
• Blood osmolality ?
• h
• Stim. pituitary to
• ADH
• h
• ADH receptor site ?
• Kidney
• Action
• h reabsorption of H2O
• i urine volume/output
• ? returns blood osmolality to normal

38
Anti-diuretic hormone (ADH)

• Normally
• Water intake h ?
• Blood osmolality ?
• i
• Stim. pituitary to
• ADH
• i
• ADH receptor site Kidney
• Action
• i reabsorption of H2O
• h urine volume (diuresis)
• ? returns blood osmolality to normal

39
Osmolarity Osmolality

• Osmolarity
• of particles dissolved in solution
• Osmolality
• Thickness of solution
• Urine
• Serum / blood

40
Regulation of water excretion

• The amt. of urine formed is r/t the amt. of fluid
  intake
• h fluid intake ?
• volume urine
• h
• Characteristic
• Dilute
• i fluid intake ?
• volume of urine
• i
• Characteristic
• Concentrated
• Normally kidneys rid the body of about 75 of
  fluids taken in

41
Regulation of Electrolytes Excretion

• Sodium
• Normally serum Na
• 135 - 145 mmol/L
• Na filtered from the blood reabsorbed from the
  tubule back into the blood
• Na excretion is controlled by Aldosterone
• h Aldosterone ? h Na retention ?
• __?__ Serum Sodium level
• h serum sodium level
• Na most abundant electrolyte found outside the
  cells (extracellular)

42
Regulation of Electrolytes Excretion

• Potassium
• K is the most abundant electrolyte found inside
  the cells (intracellular).
• h Aldosterone ? h K excretion ?
• __?__ serum K level
• i serum K level

43
Regulation of Electrolytes Excretion

• Kidneys not functioning normally
• Na K will not be adequately filtered from the
  blood
• Retention of K is the most life-threatening
  effect of renal failure
• Renal failure
• Retention of K ?
• Hyperkalemia ?
• Cardiac dysrhythmias ?
• Death

44
Regulation of acid excretion

• Proteins are broken down into acids
• phosphoric acid
• sulfuric acid.
• Acids in the blood ?
• i pH
• Normally kidneys
• Filter acids from the blood
• Tubular filtration
• Chemical buffer mechanism

45
Regulation of acid excretion

• Tubular filtration
• Acid is excreted into the urine through tubular
  secretion
• Used until the bladder acidity
• pH 4.5
• Any excess acid must be neutralized

46
Regulation of acid excretion

• Neutralize acids
• binding them to chemical buffers
• Be excreted without altering the pH
• Important buffers
• Phosphate ions
• Ammonia
• NH3

47
Regulation of Red Blood Cell Production

• Kidneys measure O2 tension of the blood (PaO2)
• i PaO2 ?
• (Hormone) h erythropoietin ?
• (Receptor site) bone marrow ?
• (Action) h production of RBC ?
• h Hgb ?
• h PaO2

48

• Normal RBC-Erythrocytes
• Male 4.7 - 6.1 million/mm3
• Female 4.2 - 5.4 million/mm3
• Normal Hemoglobin
• Male 14 - 18 g/dL
• Female 12 - 16 g/dL

49
Vitamin D Synthesis

• Kidneys activate ingested Vitamin D ?
• Aid absorption of calcium

50
Excretion of waste products

• Urea, (waste product of protein metabolism)
• Blood Urea Nitrogen
• h BUN renal dysfunction
• Other waster products of metabolism are
• Creatinine
• Phosphates
• Sulphates
• Ketone
• Along with BUN the serum Creatinine level is
  usually ordered whenever the MD suspects renal
  disease

51
Excretion of waste products

• Uric acid (purine metabolism)
• Hyperuricemia
• gout,
• Kidneys also are the primary means of ridding the
  body of Drug metabolism

52
Auto-regulation of Blood Pressure

• Vasa recta constantly monitor the blood pressure
• i blood pressure ?
• h Renin
• h angiotensin 2
• h vasoconstriction ?
• h blood pressure.
• h B/P
• i Renin
• Vasa recta failure to recognize h BP stop/halt
  Renin secretion ? primary causes of hypertension.

53
Gerontological Considerations

• Function of the urinary tract declines.
• GFR declines
• Prone to develop hypernatremia fluid volume
  deficit
• At risk for adverse drug effects

54
Assessment

• Risk Factors
• h age
• Instrumentation of urinary tract
• Immobility
• Diabetes mellitus
• HTN
• Gout, hyperparathyroidism, Crohns disease
• Benign prostatic hypertrophy
• Obstetric injury

55
Assessment Health history

• Chief complaint
• Pain
• Hx of UTIs
• Fever or Chills
• instrumentation
• Dysuria
• Hesitancy, straining
• Urinary incontinence
• Hematuria

• Nocturia
• Hx of kidney stones
• Hx of STDs
• Tobacco, alcohol, drugs
• Meds
• Females
• types of deliveries
• Hx vaginal infections

56
Physical Exam

• Abdomen, supropubic region, genitalia and lower
  back, the lower extremities
• Palpate kidney
• Feel the rounded lower border of the kidney
• Right kidney

57
Physical Exam

• Palpation of bladder
• Performed after voiding if suspect urinary
  retention

58
Terms - matching

1. Urgency
2. Pyuria
3. Proteinuria
4. Polyuria
5. Oliguria
6. Nocturia
7. Incontinence
8. Hesitancy
9. Hematuria
10. Frequency
11. Euresis
12. Dysuria
13. Anuria

1. Frequent voiding more than every 3 hours
2. Strong desire to void
3. Painful or difficult voiding
4. Delay, difficulty in initiating voiding
5. Excessive urination at night
6. Involuntary loss of urine
7. Involuntary voiding during sleep
8. Increased volume of urine voided
9. Urine output less than 400 ml/day
10. Urine output less than 50 ml/day
11. Red blood cells in the urine
12. Abnormal amounts of protein in the urine
13. Pus in the urine

59

• The presence of peritoneal fluid build up is
  described as which one of the following?
• Im so nervous I have to void phenomenon
• Bruits
• Generalized edema
• Peritoneal dialysis
• Ascites

60
Diagnostic EvaluationUrinalysis

• Color clarity odor urine pH and specific
  gravity
• Colorless to pale yellow
• dilute (diuretics, alcohol, diabetes Insipidus,
  excess fluid intake)
• Yellow to milky white
• Pyuria, infection
• Bright yellow
• Multiple vitamin
• Pink to red
• RBC, menses, Bladder or prostate surgery, beets,
  meds
• Blue, blue green
• dyes, meds
• Orange to amber
• Dehydration, bile, excess bilirubin or carotene,
  meds
• Brown to black
• Old red blood cells, dehydration,

61
Diagnostic Evaluation Urine Culture and
Sensitivity

• ID microorganism(s)
• Sensitivity report
• Time
• 2-3 days (48-72 hours)

62
Specific Gravity

• The weight of urine
• The specific gravity of distilled water
• 1.000
• Normal urine specific gravity
• 1.003 1.030
• Urine specific gravity is related to the level of
  hydration.
• h fluid intake ? h H20 excretion ? i specific
  gravity
• i fluid intake ? i H20 excretion ? h specific
  gravity

63
Diagnostic EvaluationSterile urine specimens

• Safety
• Standard precautions
• Biohazard bag for transport
• Collection
• Indwelling Foley Catheter
• Not from the drainage bag
• Aspiration port
• Catheter straight cath
• A small amount of urine is allowed to run out of
  the catheter into a basin, then the urine is
  allowed to run into a sterile specimen bottle.

64
Diagnostic Evaluation Clean-catch or
Clean-voided specimen

• Clean-voided
• uncontaminated by skin flora.
• Female
• Cleanse front to back
• Male
• Cleanse tip of the penis downward
• Collect a "clean-catch"
• Start to void
• Midstream catch
• Collect 1 to 2 oz of urine

65
Renal Clearance

• Purpose
• Assess the Kidneys ability to clear solutes from
  the plasma
• Procedure
• 24 hr urine collection
• 12 hr serum Creatinine level
• Creatinine
• waste product of skeletal muscle contraction

66
Renal Clearance

• One function of the kidney is to excrete
  Creatinine. If the Creatinine clearance level
  (the amount of Creatinine excreted by the kidney)
  decreases, what does that tell you about the
  function of the kidney?

67
Renal Clearance

• i renal function ?
• i Creatinine clearance
• Creatinine clearance evaluates
• glomerular filtration rate (GFR)
• Detects and evaluates progression of renal
  disease

68
Can you Critical Think????

• Mrs. Notafeela Sowell had a renal clearance test
  done 3 times this week. Is her renal disease
  getting better or worse?
• Monday Renal clearance 70 ml/min
• Wednesday Renal clearance 80 ml/min
• Friday Renal clearance 90 ml/min

69
Diagnostic Evaluation Intake and Output

• IO
• All fluids taken orally
• Form
• Time
• Amount
• Output
• Urine
• drainage from nasogastic tube
• drainage tubes
• Chest tubes
• Wound tubes

70
Apply it!

• Mr. Noah Awl is recovering from Prostatectomy due
  to benign hypertrophy of the Prostate. Mr. Awl
  is on strict intake and Output. He requests a
  cup of ice chips because his throat hurts (due to
  intubation). You give him a 200cc cup of ice
  chips and he eats them all. How much to you make
  on the Intake?
• 100cc
• 150 cc
• 200cc
• 300 cc
• 400 cc

71
Dialysis Overview

• Purpose
• Remove fluids and waste products from the body
• Definition
• Mechanical means of removing waste from the blood
  
• Types
• Hemodialysis
• Peritoneal dialysis

72
Dialysis Process

• Process
• Diffusion and osmosis across a semi permeable
  membrane into a dialysate solution
• prescribed specific to the individual clients
  needs

73
Dialysis process

• Diffusion
• Toxins wastes are removed by diffusion
• Move from an area of higher concentration to an
  area of lower concentration

74

• This photo shows the diffusion of fluids. I added
  a few drops of blue food coloring in a vase of
  water, and took a picture after a few seconds.
  Diffusion is the process of a substance moving
  from high concentration to low concentration. The
  cause of diffusion is random molecular motion of
  the fluids, in other words, molecules of both the
  food coloring and the water move at random
  causing them to mix. In this case, the diffusion
  of the food coloring goes from high concentration
  to low concentration. 

75

• Osmosis
• Excess water is removed by osmosis
• Water move from an area of higher solute
  concentration (blood) to an area of lower solute
  concentration (dialysate)

76
Hemodialysis

• A machine with an artificial
  semi-permeable membrane used for the filtration
  of the blood.

77
Hemodialysis

• A graft or fistula is surgically prepared to
  access the clients circulatory system

78
Hemodialysis

• With each hemodialysis treatment, the catheter is
  inserted into the graft of fistula

79
Hemodialysis

• The clients blood is circulated past the semi
  permeable membrane
• Excess fluids are removed by osmosis

80
Hemodialysis

• Waste products are removed from the blood by
  diffusion

81
Hemodialysis

• Nursing interventions
• Weighted before and after
• Strict asepsis technique

82
HemodialysisNursing interventions

• Assess fistula or graft
• A thrill
• felt
• A bruit
• heard
• Pulse peripheral
• Protect Grafts
• Not an IV port!
• No BP in graft arm

83

• The nurse is preparing to teach a client about
  his new shunt for hemodialysis. What should be
  included in this teaching?
• Avoid overusing the arm with the shunt to protect
  from accidental harm.
• Always use this arm for blood pressure readings
• If you feel any vibrations over the skin of the
  shunt, call the doctor.
• Theres nothing special to the care of the shunt.
  Pretend it isnt there.

84
HemodialysisNursing interventions

• Meds are given after
• Usually performed 3 time a week
• Usually take 3-6 hours

85
Peritoneal Dialysis

• Uses the peritoneal lining of the abdominal
  cavity

86
Peritoneal Dialysis

• A catheter is placed by the MD into peritoneal
  space

87
Peritoneal Dialysis

• The dialysate,
• In sterile container similar
• Instilled aseptically into the abdominal cavity.
• The container remains connected to the catheter
• rolled up
• dialysate remains in the abdominal cavity for a
  specified length of time.
• The container is then unrolled and lowered
• below the abdominal cavity
• Dialysate drains back into the container

88
Peritoneal Dialysis

• Usually 2 liters of dialysate
• Less expensive, easier to perform and less
  stressful
• Complication
• INFECTION
• Usually 4 x day 7day/wk