The Urinary System

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The Urinary System

• Jennifer Brewster RN, MSN

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Kidney Blood Flow
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Kidneys

• Role is to maintain body fluid volume and
  composition, filter waste products for
  elimination.
• Regulate blood pressure
• Participate in acid-base balance
• Produce erythropoietin for RBC synthesis
• Metabolize vitamin D to an active form

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• 2 kidneys behind peritoneum
• 4 to 5 inches long
• 2 to 3 inches wide
• 1 inch thick
• Weighs 8 oz.
• Left longer and narrower than the right

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• Kidneys receive 20-25 of the total cardiac
  output.
• Renal blood flow varies from 600-1300ml/min.
• Blood supply from the renal artery.
• Nephron is the working unit of the kidney,
  urine is formed here
• One million nephrons per kidney

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• 2 types of nephrons-
• Cortical
• Juxtamedullary

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Kidneys

• Regulatory functions-
• Control fluid, electrolyte and acid base balance
• Hormonal functions-
• Control red blood cell formation, blood pressure
  and vitamin D activation

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Regulatory

• Glomerular filtration- first step in urine
  formation.
• Blood and albumin should not be in urine-
  particles too large to filter through
• Normal GFR 125 ml/min.
• Tubular reabsorption- second process in urine
  formation.
• Prevents dehydration- tubules bring 99 of
  filtered water back into the body.

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• Tubular secretion- third process in urine
  formation.
• Allows substances to move from the blood into the
  urine.

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Hormonal

• Renin
• Prostaglandins
• Bradykinin
• Erythropoietin
• Vitamin D activation

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Ureters

• Each kidney has a single ureter-connects renal
  pelvis with urinary bladder.
• ½ inch diameter
• 12 to 18 inches in length

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Urinary bladder

• Muscular sac
• Men- in front of rectum
• Women- in front of the vagina
• Temporary urine storage site
• Provides continence
• Enables voiding
• Voiding- voluntary act

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Urethra

• Narrow tube- mucous membranes and epithelial
  cells
• Men- 6 to 10 inches
• Women- 1 to 1.5 inches
• Tube for eliminating urine from the body.
  Urination removes bacteria from the urethra.

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Renal changes in older adult

• Changes occur as part of the aging process.
• Kidney smaller by 80 yr/old
• Function decreases with aging.
• Decreased bladder capacity
• Reduced ability to retain urine.

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Patient history

• Family history for risk
• Personal history- age, previous renal problems,
  prescription drugs, OTCs, work exposure
• Diet history- intake or appetite changes
• Changes in urination pattern or continence

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Physical assessment

• Inspection
• Auscultation
• Palpation
• Percussion

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Lab tests

• Serum creatinine
• Blood urea nitrogen
• Urine culture and sensitivity
• 24 hr urine
• Urine- Creatinine clearance

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UA Strip
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Urinalysis

• Color, odor, turbidity
• Specific gravity
• pH
• Glucose
• Ketones
• Protein
• Leukoesterase
• Nitrites
• Sediment

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Radiology

• Kidney, Ureter, Bladder x-rays
• Intravenous urography (IVP)
• CT, US
• VCUG
• Renal scan
• Cystoscopy

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IVP
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Renal biopsy

• Determine cause for renal dysfunction and direct
  treatment
• Percutaneous with US or CT
• Monitor for bleeding, vital signs, hematuria,
  increasing pain or discomfort
• Bed rest 2-6hrs

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Cystitis

• Inflammation of the bladder
• Infection- bacteria, virus, fungus, parasites
• Interstitial cystitis
• Most common causes from intestinal tract
• Perineal area- organisms move as result of
  irritation, trauma or catheterization

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Factors for UTI

• Obstruction
• Stones
• Vesicoureteral reflux
• DM
• Urine
• Gender
• Age
• Sexual activity

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Clinical manifestations

• Frequency
• Urgency
• Dysuria
• Lower back pain
• Nocturia
• Hematuria
• Suprapubic tenderness
• Fever, chills, malaise, nausea, flank pain
• OLDER ADULT- may be different

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Nursing diagnosis

• Acute pain related to bladder spasms
• Knowledge deficit
• Risk for impaired skin integrity
• Risk for sepsis

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Treatment

• Depend on causative source
• Medication-quinalones, PCN, Sulfa, urinary
  antiseptic, analgesic, antispasmodic
• Diet- fluids

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Patient education

• 1-3 liters of fluid daily
• Adequate sleep and nutrition
• Women- clean from front to back
• Avoid irritating substance to perineal area
• Empty bladder regularly and before and after
  intercourse
• Complete medication therapy

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Incontinence

• Stress- most common
• Urge
• Overflow
• Mixed
• Transient
• Permanent

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Nursing diagnosis

• Stress urinary incontinence related to weak
  pelvic muscles and structural supports
• Urge urinary incontinence related to decreased
  bladder capacity, bladder spasms, diet and
  neurologic impairment
• Mixed urinary incontinence related to many causes

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Additional diagnosis

• Social isolation related to altered state of
  wellness or fear of embarrassment
• Risk for impaired skin integrity related to
  excessive moisture from urinary excretions
• Disturbed body image related to odor, need to
  wear protective supplies
• Risk for infection related to retained urine

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Management

• Diary, behavioral intervention, medications
• Exercise- pelvic floor exercises for stress
  incontinence
• Weight reduction
• catheterization
• Surgical

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Urolithiasis

• Calculi in the urinary tract
• Nephrolithiasis- stones in the kidney
• Ureterolithiasis- stones in the ureter
• Hypercalcemia
• Hyperoxaluria
• Hyperuricemia
• Struvite
• cystinuria

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Kidney Stones
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Kidney Stones
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Kidney Stones
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Physical assessment

• Renal colic
• Pain most intense when stone moving or ureter
  obstructed
• Nausea, vomiting, pallor, diaphoresis
• Obstruction is emergency
• KUB or CT to determine

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Nursing diagnosis

• Acute pain related to presence of stone in
  urinary tract
• Fear related to potential recurrence of stone
• Risk for renal injury related to obstruction

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Interventions

• PAIN RELIEF
• Lithotripsy
• Hydration
• Strain urine-to determine cause of stone
• Surgical- if too large
• Stent
• Percutaneous nephrolithotomy

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Lithotripsy
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Acute and chronic renal failure

• Onset-sudden
• Percent of nephrons involved- approx 50
• Duration-2-4 wk
• Prognosis-good with supportive care, can be fatal
• Affects many body systems

• Onset- gradual
• Percent of nephrons involved-90-95
• Duration- permanent
• Prognosis- fatal without dialysis or transplant
• Affects every body system

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Acute renal failure

• Rapid decrease in renal function- leads to
  collection of metabolic wastes in the body.
• Prerenal
• Intrarenal
• Postrenal
• Can occur in any patient
• Increasing BUN, Creat and abnormal electrolytes

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Nursing diagnosis

• Excess fluid volume related to compromised
  regulatory mechanisms
• Potential for pulmonary edema
• Potential for electrolyte imbalances

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Renal failure and electrolytes

• Potassium
• Sodium
• Phosphate
• Calcium
• Hydrogen
• Bicarbonate
• Magnesium

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Interventions

• Fluid and electrolyte monitoring and replacement
• Drug therapy
• Diet therapy
• Dialysis

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Chronic renal failure

• Progressive, irreversible kidney injury
• No return of kidney function
• ESRD- kidney function too poor to sustain life
• Stage I- diminished renal reserve
• Stage II- renal insufficiency
• Stage III- end stage renal disease

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Body changes

• Elevates blood pressure
• Increased triglycerides, total cholesterol and
  LDL levels
• Heart failure
• Anemia
• GI upset

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Patient education for prevention

• Observe for changes in urine- color, amount,
  discomfort
• Adequate amount of fluids
• Know family history
• Control DM, HTN
• Take medication as prescribed

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Interventions

• Nutrition therapy
• Protein restriction
• Sodium restriction
• Potassium restriction
• Vitamin supplementation
• Drug therapy
• Fluid restriction

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Hemo vs peritoneal

• More efficient clearance
• Shorter treatment time
• Muscle cramps
• Hemodynamic changes
• Vascular access route
• Specially trained nurses
• Vascular access care
• Restricted diet

• Easy access
• Few hemodynamic complications
• Hyperglycemia
• Bowel perforation
• Peritoneal adhesions
• Intra-abdominal catheter
• Simple
• Less complex training
• More flexible diet

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HD system

• Dialyzer
• Dialysate
• Vascular access route
• HD machine
• Anticoagulation

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Types of access for HD

• AV fistula
• AV graft
• Tunneled catheter
• Hemo catheter
• AV shunt
• Subcutaneous device

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Care of the access

• NO !!!! Blood pressure readings, venipunctures or
  IV lines in extremity with access
• Assess for bruit and thrill frequently
• Evaluate extremity for CMS and ROM
• No heavy lifting with accessed arm
• Observe for infection

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Care of HD patient

• May hold medications until after treatment
• Monitor for side effects of treatment
• Weigh before and after treatment
• Assess access before and after treatment
• Observe access for bleeding after treatment

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Peritoneal dialysis

• Occurs in the peritoneal cavity
• Slower than HD- more time needed for same effect
• For hemodynamically unstable and cannot tolerate
  anticoagulation
• Not if pt. has abdominal adhesions or extensive
  intra-abdominal surgery

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• Diffusion and osmosis across semipermeable
  membrane and capillaries.
• Solutes and water move from area of higher
  concentration in the blood to an area of lower
  concentration in the dialyzing fluid (diffusion)
• Dialysate prescribed based on patient's fluid
  status
• Heparin to tube to prevent clotting
• Potassium and antibiotics in Dialysate

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Care of PD patient

• Mask self and patient
• Sterile gloves
• Observe Dialysate for color
• Frequent vital signs
• Weigh before and after treatment
• Strict I/O

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Kidney Transplant
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Kidney transplant

• Treatment for ESRD
• Candidates selected based on medical problems and
  risks
• Donors- living related, living non-related,
  cadaveric
• Immunosupressive medications long term

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Post operative

• Ongoing physical and renal assessment
• I/O strict
• Complications-
• Rejection
• Thrombosis
• Infection
• Urinary tract complication

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Rejection

• Hyperacute-
• Within 48 hrs of surgery
• Increased temp
• Increased BP
• Immediate removal of kidney

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• Acute rejection-
• 1wk to 2 yr
• Oliguria or anuria
• Temp over 100F
• Increased BP
• Elevated creat, BUN, K
• Increased doses of immunosuppressive drugs

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• Chronic rejection-
• Gradual over months to years
• Fluid retention
• Changes in electrolytes
• Conservative treatment until dialysis needed