Nursing Care of Client
Experiencing
Kidney and Bladder
Disorders
Objectives for Class:
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Describe the anatomy and physiology of the upper and lower
urinary tract (self review)
Describe diagnostic studies used to determine upper and lower
urinary tract function and client education
Discuss the functions of the kidney
Discuss urinary retention & urinary incontinence
Discuss the causes, pathophysiologic changes, clinical
manifestations, management & nursing care for clients with
UTIs, glomerulonephritis, pyelonephritis, nephrotic syndrome,
renal calculi (kidney stones)
Describe nursing management of the client with dialysis
Discuss care of clients undergoing renal surgery
Develop a teaching plan for clients with acute/chronic renal
failure, UTIs, renal calculi (kidney stones)
Topics to be Considered

Common bladder & renal problems:
calculi
 infections
 neoplasms
 diverticuli
 pyleonephritis (review pediatric content)
 neurogenic
 incontinence
 kidney failure /dialysis (presentation)
 transplant

This is material you are required to know some is from 3rd year
It is testable in N405 & RNs
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Review changes in the urinary tract due to aging
Review common laboratory findings:
 Creatinine
 BUN
 ratio
Urinalysis lab profile
Preparing clients for tests involving contrast media
Follow up care after Renal Biopsy
Preventing UTIs
Readings:
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In your text Chapters 43, 44, 45
Recommended readings
Websites
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Kidney foundation
Canadian Society of Nephrology
College of Family Physicians of Canada
Elimination System
http://www.youtube.com/watch?v=zEpUQkQuKM&feature=related

The structures of this system precisely maintain the internal
chemical environment of the body (Smeltzer & Bare, 2007, pg. 1255)
Comprised of:

Upper urinary tract
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Kidneys: “balance the urinary excretion of substances against
the accumulation within the body through ingestion or
production”.(Balck Hawkes & Keene, 2001, p.732)
Ureters: connect the kidney from the renal pelvis to the bladder.
Lower urinary tract
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Bladder: hollow elastic organ that holds urine
Urethra: extends from base of bladder to the surface of the
body.
Anatomy Renal Pyramid of the Kidney
http://www.youtube.com/watch?v=Pz5DHAv_Mw4
Nephron and Associated Vascular Structures
http://www.youtube.com/watch?v=glu0dzK4dbU&feature=related
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Major Functions: Kidneys
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Urine formation
Excretion of waste
products
Electrolyte
regulation
Water balance
Acid Base Balance
Blood Pressure
regulation
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Renal clearance
Blood component
production
(RBC’s)
Vitamin D
synthesis
Prostaglandin
secretion
Why do
problems
occur with
the
bladder?
Why do
problems
occur with
the kidney?
Changes related to Aging:
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Nocturia
Decreased Bladder Capacity
Weakened sphincter & shortened
urethra in women
Tendency to retain urine
Decreased glomerular filtration rate
Hydration
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ensure adequate hydration
administer nephrotoxic drugs with care
Assessment
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Health history
Risk factors
Unexplained anemia - why
Pain
Changes in voiding
GI symptoms ?
Physical Exam
Risk Factors
Risk Factors
Bladder Palpation
Genitourinary Pain
Changes in Voiding
Changes in Voiding
Urine Color
Diagnostic Evaluation
(See Plan of Nursing Care Pg. 1424)
Urinalysis and Urine Culture
 Renal Function Tests (P. 1419 table
43-4)
 X-ray and other imaging modalities
 Urological Endoscopic Procedures
 Biopsy
 Urodynamic Tests

Goal of Clean Catch Urine
(Mid Stream)
To minimize
contamination of the
specimen by organisms
on the skin
Do you remember how to collect
a midstream sample ???
A 12 or 24 hr specimen??
Renal Function Tests: Table 43-4
BUN (Bld urea nitrogen)
(table 43-4)
Urea forms in the liver, along with CO2, constitutes the final
product of protein metabolism. The amount of excreted urea
varies directly with dietary protein intake. The test for BUN
which measures the nitrogen portion of urea is used as an index
of glomerular function in the production & excretion of urea.
Thus, serves as an index of renal functioning.
A marked increase in BUN = severe impaired renal function


Adult: 7-18 mg/dl or
2.5-6.4 mmol/L
Elderly 8-20 mg/dl or
2.9-7.5 mmol/L

Child 5-18 mg/dl or
1.8-6.4 mmol/L
Urine Creatinine (table 43-4)
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Amino acid waste product derived from muscle creatine (a product of
protein metabolism)
All creatinine filtered by kidneys in a certain timeframe goes into the
urine, creatinine levels thus are equal to the glomerular filtration rate.
Disorders of kidney interfere with normal secretion of creatinine
Thus creatinine measures effectiveness of renal functioning (serum
Creatinine)
Keep in mind that rate normally decreases as we age
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urine creatinine men 0.8 -1.8 g/24h
urine creatinine women 0.6 - 1.6 g/24h
blood creatinine: 0.4-1.5 mg/dl
Renal Function Tests: Table 43-4
Creatinine Clearance
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Decreased
Impaired kidney function
Kidney Disease
Shock & dehydration
COPD
CHF
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Increased
State of high cardiac
output
Pregnancy
Burns
Carbon monoxide
poisoning
What causes them?
Who is at risk?
What helps prevent UTIs?
Classifications of UTI

Lower UTI
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Cystitis, prostatitis, urethritis
Upper UTI

Acute pyelonephritis, chronic
pyelonephritis, renal abcess,
interstitial nephritis, perirenal
abcess
Classifications of UTI

Uncomplicated Lower or Upper UTI


Community acquired
Complicated Lower or Upper UTI

Often nosocomial related to catheterization,
urologic abnormalities, pregnancy,
immunosuppression, diabetes, obstructions
Risk Factors: UTI
See Chart 45-2 Pg. 1483
Pathophysiology
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Bacterial invasion: colony
count 10^5 per ml/L urine
Reflux
Most common cause is gram
negative organisms – E.coli,
Klebsiella, Enterobacter &
Proteus
Males & catheterizedpsuedomonas & enterococcus
Routes of infection- urethra,
bloodstream, fistula
Pathophysiology of E.Coli UTI
Clinical Manifestations
Uncomplicated Lower UTI
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Dysuria (burning pain on urination)
Frequency
Urgency
Voiding in small amts. or inability to void
Nocturia
Incontinence
Pain
Cloudy urine & hematuria
Gerontologic considerations-generalized fatigue,
change in cognitive functioning
Medical/Nursing Interventions
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Inhibit bacterial growth with antibacterials – often
short course
Pain: urinary tract anesthetics – Pyridium
Modify diet – avoid foods that irritate such as
caffeine, alcohol, tomatoes
Increase fluid intake (3-4 litres/day)
Education:
 risk factors, early symptoms
 Use of antibiotics (self-care)
 Health promotion: p. 1488 table 45-4
Nursing Diagnoses
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Acute pain
Altered health maintenance
PC: sepsis
PC: Renal failure
Goal is to prevent renal damage
Catheterization
 Indwelling
devices and infections
 Suprapubic catheterization
 Bladder retraining
 Intermittent self-catheterization
Suprapubic Catheterization
Catheter inserted
through an incision
or puncture made
above the pubis
May be inserted:
When urethral
route is
impassable
After abdominal
or gynecologic
surgery
Pelvic fractures
Preventing Infection in the
Catheterized Patient

Chart 45-9 Page 1500
KNOW!!
Condom Drainage and Leg Bag
Urethritis
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Inflammation of the urethra
Commonly associated with
STIs (gonorrhea, chlamydia),
feminine hygiene products,
scented toilet paper,
spermicidal jellies
S & S include pain & pyuria
Management includes
removing the cause,
antibiotics (if bacterial) and
drinking plenty of fluids, use
of lubricants with intercourse,
teaching re STI
Pyelonephritis
Is a bacterial infection causing
inflammation of
the renal pelvis, tubules, and interstitial
tissue of one or both kidneys.
 Common cause is E. coli
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May also be caused by candidiasis.
May be acute
 Usually enlarged kidney, maybe
abscesses, & possibly destruction of
glomeruli
May be chronic
 Kidneys scarred, contracted, &
nonfunctioning
Acute Pyelonephritis
Clinical manifestations
Appears acutely ill
 Fever, chills, flank pain, nausea, headache,
muscle pain, dysuria, urgency, frequency
 Urine cloudy, bloody, foul smelling, increased
WBC & casts
Diagnosis
Ultrasound or CT to check for obstruction
Urine C & S
X-ray (KUB), MRI

Acute Pyelonephritis
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Medical management
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May be outpatient or inpatient treatment
Antibiotic therapy based on C & S, usually for
7-10 days, up to 2 weeks for outpatients
Analgesics
Follow up urine C&S 2 weeks after completing
therapy
Chronic Pyelonephritis
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Likely to occur after repeat acute bouts of Acute
Progressive with recurrent attacks
Clinical Manifestations
No symptoms of infection , unless acute
exacerbation
May have fatigue, headache, poor appetite,
polyuria, excessive thirst, weight loss
Lab values are abnormal
Complications
ESRD, Hypertension, Renal calculi
Chronic Pyelonephritis
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Medical management
Goal is prevention of further renal damage
Antibiotics - cautious use depending on
degree of renal function
High fluid intake may be contra-indicated
Control hypertension
Chronic pyelonephritis
Nursing care
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Monitor fluid balance, may require IV fluids
(nausea, IV antibiotics)
Monitor blood work
Address pain: analgesic & 3-4L fluids unless
contraindicated ?
V/S – T q4h
Bedrest
Client education
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Follow-up urine cultures
Appropriate use of antibiotics
Perineal hygiene
Acidification of urine by drinking cranberry
juice or taking ascorbic acid
Frequent emptying of bladder
Adequate fluid intake
Early detection of infection
Primary Glomerular Diseases
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Definition: “a group of kidney diseases caused by
inflammation of the capillary loops in the glomeruli of
the kidney” (Hogan & Maydayag, 2004)
Caused by an immunologic reaction to an antigen,
causing inflammatory response that damages the
glomeruli
IgG can be found in glomerular capillary walls
Often preceded by group B hemolytic strep infection
Primary presenting feature is hematuria
Includes: acute & chronic glomerulonephritis, rapidly
progressive glomerulonephritis, & nephrotic syndrome
Manifestations: proteinuria, hematuria, decreased GFR,
alterations in sodium excretion
Acute Glomerulonephritis
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Primarily in children over 2, but can occur
at any age
Most cases preceded 2-3 weeks by group
A strep infection of throat
May follow impetigo or viral infections
Medications or other foreign substances
may cause
Group A Streptococcus
Occasionally, autoimmune
Clinical Manifestations
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Hematuria – may be micro or macroscopic
Urine may be cola coloured due to RBC casts
Proteinuria - albuminuria,
Headache, malaise, flank pain in severe form
Tenderness over CVA
Elderly may experience circulatory overload
Some edema & hypertension in 75%
Atypical: confusion, somnolence, seizures
Diagnostics & Assessment
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May require renal biopsy
Poststreptococcal – usually elevated
serum antistreptolysin O or anti-DNase B
titres
Over half have elevated serum IgA &
normal complement
About 70% of adults recover
Complications
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Hypertensive encephalopathy - therapy
aimed at decreasing blood pressure
without impacting renal function
Heart failure
Pulmonary edema
Optic neuropathy - rare
Medical treatment
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Treat symptoms
Preserve kidney function
Prevent complications
Drugs for cause & symptoms
Restrict protein with elevated BUN
Restrict sodium as necessary
Nursing Management
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Most uncomplicated are treated at home
High carbohydrates
Fluid replacement as per losses & body
weight – remember insensible loss
Usually diuresis begins 1 week after onset
Client education – fluid/diet restrictions,
aware of symptoms of renal failure, S&S
infection, medication knowledge
Follow up assessments
Medical management
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Reduce inflammation
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Plasmapheresis in conjunction with
corticosteroids & immunosuppressive agents
Antibiotic therapy
Dialysis
Chronic Glomerulonephritis
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May be due to repeated episodes of acute
 Hypertensive nephrosclerosis
 Hyperlipidemia
 Chronic tubulointerstitial injury
 Hemodynamically mediated glomerular sclerosis
Kidneys shrink, surface rough & irregular, glomeruli &
tubules scarred, branches of renal artery thickened
Results in ESRD
Clinical Manifestations
Some may have no symptoms for many years and may be
secondary diagnosis
 Malaise, weight loss, edema, increasing irritability,
nocturia (kidney’s inability to concentrate urine),
headache, dizziness and digestive disturbances
 Edema increases as heart failure increases & serum
albumin decreases
 Severe anemia
 S&S of renal insufficiency & chronic renal failure as
disease progresses
 Peripheral neuropathy & neurosensory changes
Diagnostics & Assessment
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Many lab abnormalities as GFR decreases
CXR cardiac enlargement & pulmonary
edema
EKG may be normal or abnormal
Chronic Glomerulonephritis
Medical Management
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Reduce inflammation
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Plasmapheresis in conjunction with corticosteroids &
immunosuppressive agents.
Antibiotic therapy
Maintain fluid & electrolyte balance
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Volume overload & HT are treated with diuretics,
antihypertensives & restriction of Na & H2O
Monitor vs, intake & output, wt
Careful assessment for complications
Medical treatment
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Treat symptoms – especially UTI
Hypertension – treat
Restrict sodium as necessary
Weigh daily
Diuretics
High value protein, adequte calorie intake
Dialysis – use early
Nursing Management
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Assess fluid & electrolyte status
Assess for indications of decreasing renal
function
Report changes in cardiac or neurologic
status also
Psychosocial support
Client education – fluid/diet restrictions,
aware of symptoms of renal failure, S&S
infection, medication knowledge, dialysis
Follow up assessments
Nephrotic Syndrome:
Cluster Clinical Findings
Nephrotic Syndrome
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Marked increase of protein in urine
(proteinuria)
Decrease in albumin in blood
(hypoalbuminemia)
Edema
High serum cholesterol and
hyperlipidemia
Any condition that damages the
glomerular capillary membrane causing
increased permeability
Nephrotic Syndrome
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Low albumin levels in the blood lead to edema,
stimulates retention of Na & H2O as fluids move
into interstitial spaces
Hyperlipidemia: increased lipoprotein probably
response of liver to low serum albumin
Anemia depending on amount of renal failure
Manifestations:
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Massive edema
Waxy pallor
Anorexia, malaise, irritability, abnormal menses.
Large amt protein in urine & low serum albumin
Nephrotic Syndrome
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Goal of treatment is to preserve renal function
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Maintain fluid/electrolyte balance: weight QD, girth
measurements, intake/output
Loop diuretics (Lasix) – use caution
Plasma volume expanders such as albumin, dextran,
plasma to increase oncotic pressure
Mild sodium restriction
Good skin care (edema disrupts cellular nutrition)
Steroid therapy & anticoagulants (reduce inflammation &
prevent renal vein thrombosis) – especially if infection
High protein, low sodium, high potassium, low saturated
fat diet
Education
Nursing Care:
Priority Diagnoses
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Fluid volume excess
Altered nutrition: less than body
requirements
Risk for impaired skin integrity
Risk for infection
Fatigue
Knowledge of therapeutic regimen
Renal Transplantation
Organ Donation
 Preoperative Management
 Postoperative Management

Immunosuppressive therapy
 Rejection
 Infection
 Urinary Function
 Complications

Renal Transplantation
URINARY CALCULI
Urinary calculi (urolithiasis)
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Form primarily in the kidney
(nephrolithiasis) but can form or migrate
to lower urinary system.
Usually asymptomatic until they pass into
lower tract.
Primary causes are 1) urinary stasis, 2)
supersaturation of urine with poorly
soluble crystalloids (leads to precipitation
of crystals).
Risk factors
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Infections
Dehydration
High mineral content in water
Prolonged indwelling catheterization
Neurogenic bladder
Previous history
Foreign bodies
Failure to empty bladder completely
Metabolic disorders (I.e. hypercalcemia)
Obstruction in urinary tract
Female genital mutilation
Abnormalities of Urine Sediment in
Client With Renal Calculi
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ABNORMALITY
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Red cells
White cells
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Protein
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Pus + bacteria
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SIGNIFICANCE
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Suggests injury to urinary
tract
suggests inflammation or
infection
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Suggest glomerular injury

Infection
Types of Stones
Calcium, Oxalate, Struvite,
Uric acid, Cystine
Manifestations
 Severe sharp pain
 Renal colic flank pain on
side of affected kidney
radiating to groin
 May have nausea, vomiting,
pallor, grunting respirations,
elevated BP, pulse,
diaphoresis & anxiety
 Elevated WBC & temp

Calculi
Staghorn Calculis
Medical Management
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Increase fluids
Reduce pain
Prevent stone recurrence
Dietary changes – see next slide
Medications
Surgery
Nursing Management
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Pain
Impaired urinary elimination
Effective management of therapeutic
regimen
Risk for infection
Urinary retention
KIDNEY STONES & PAIN
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OPIODS
NSAIDs
ANTISPASMODICS
RELAXATION
IMAGERY
THERAPEUTIC/HEALING
TOUCH
BREATHING
TECHNIQUES
Surgery
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Lithotripsy: laser and ESWL
Nephroscopic removal
Pyelolithotomy
Nephrolithotomy
Lithotripsy
Extracorporeal Shock Wave Lithotripsy
Nephroscopic Removal of Kidney Stones
Pyelolithotomy Removal of Kidney Stones
Nephrolithotomy Removal of Kidney Stones
to the Urinary Tract
Bladder Trauma
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blunt or penetrating injury to bladder that
may cause bladder rupture.
Often the result of car accidents, seat belt
pressure against distended bladder.
Urine spills into peritoneal cavity, causing
peritonitis & pelvic cellulitis.
Manifestations: hematuria, pain, difficulty
voiding.
Usually require surgery, post-op have a
urethral or suprapubic catheter.
Ureteral trauma

usually the result of
surgical accident.
Other causes gunshot
or stabbing


Symptoms include flank
pain, hematuria,
eventually paralytic
ileus, sepsis
Treatment is surgical
repair
Urethral trauma
• May result from pelvic fracture (falling on
object such as bar on bike)
•Symptoms include inability to void or
altered stream, swelling in groin, scrotum
or inguinal area, may lead to sepsis and
necrosis.
•Complications include urethral strictures
or impotence in men.
•Treatment may be medical (catheter for
several weeks or surgery)
Renal trauma
Renal Trauma

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Traffic accidents & falls most
common cause
Five categories
Complications include hemorrhage,
abscess, fistula, HT
Treatment may be medical or
surgical- watch & see
Manifestations:
 Type of injury is key
 May have hematuria, shock,
flank pain, palpable mass,
paralytic ileus, bruising
over flank
Renal Cancer
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85% of renal tumors are malignant
Most common between ages of 50 and 70
Cause unknown but some links between chemicals and
cancer, I.e. smoking, exposure to lead.
Tumor starts in renal cortex and lead to obstruction,
renal failure, hemorrhage invasion of surrounding tissue
Symptoms: painless hematuria, flank pain, palpable
mass (often delayed diagnosis – 35% have mets when
diagnosed)
Renal cell carcinoma with venous
invasion.
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Stage I: confined to kidney
capsule; survival rate 65%
Stage II: extends beyond
capsule into fatty tissue; S.R
40%
Stage III: regional lymph
nodes, renal vein, possibly
IVC
Stage IV: distant mets, often
lungs & mediastinum
Survival rare in III and IV
Management
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Surgery: partial or radical nephrectomy is
usual treatment
Radiation therapy: with chemotherapy
and/or surgery. Pre-op to shrink tumor or
post-op for residual cells or mets
Chemotherapy: seems to be less effective
b/c of slow growth rate. Vinblastine is most
effective single agent with response rate of
25%
Immunotherapy: fairly new, stimulates
immune system
Renal surgery
Nursing Management
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Pre-op teaching and emotional support
Post-op there is high risk for hemorrhage, monitor
for signs of bleeding (may be incisional or
internal). Also risk for pneumothorax.
Post-op care requires:
 DB & C (how can you help??)
 Monitor urine output
 Pain Management
 Monitor GI status (watch for ileus)
Bladder Cancer



Appears to be the result of exposure of
bladder wall to carcinogens – smoking,
asbestos, radiation & chemo
Gross hematuria is often the first sign.
Identified through cystoscopy, IVP, CT,
MRI, blood work (CEA)
Treatment includes surgery, radiation
therapy and chemo
Just read on own
Cystoscopy
Surgery


Transurethral resection, partial
cystectomy, radical cystectomy & urinary
diversion
Urinary diversion procedures:




Ileal conduit
Indiana pouch
Neobladder
Palliative procedures: percutaneous
nephrostomy or pyelostomy (tube in renal
pelvis), ureterostomy
Indiana Pouch Procedure
Indiana Pouch



Urine is removed by
inserting a thin tube
(catheter) into the stoma
when the pouch is full.
A bag is not required and
the patient simply wears a
bandage over the stoma.
The patient is then taught
to catheterize the reservoir
to drain urine at regular
intervals during the day.
Hypertension
May be cause of renal failure or effect
e.g. Renal artery stenosis decreases blood flow to
the kidney. This activates the renin-angiotensinaldosterone system which increases BP. Renal
hypertension results from the kidney’s inability
to excrete salt and water.
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Sustained high BP causes nephrosclerosis &
damages arteries and arterioles
Renal vascular disorders

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Renal artery disease
Renal vein disease
Congenital
Abnormalities
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May involve abnormalities in
number, position or size.
Agenesis: means absence of
one or both kidneys
Sizes: small with or without
functioning tissue
Horseshoe kidney: both
kidneys are joined, in lower
lumbar region

Susceptible to hydronephrosis,
infection and calculus formation
Polycystic Kidneys
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Hereditary disease
characterized by cyst
formation & massive
enlargement – affects both
adults & children.
Disease is slow & progressive
results in CRF
No cure so management is
conservative, supportive
medical treatment
Eventually needs dialysis or
transplant
Renal Transplantation
Renal Transplantation
Organ Donation
 Preoperative Management
 Postoperative Management

Immunosuppressive therapy
 Rejection
 Infection
 Urinary Function
 Complications

Renal disorder website

http://www.merck.com/mmhe/sec
11.html