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Location of kidneys—retroperitoneal, b/w 12th thoracic and 3rd lumbar vertebra
Right kidney sits a little lower than the left d/t liver
Filter approx 180L of fluid per day
Vascular—receive about 20% of resting cardiac output; renal blood flow about
1200mL/min
Protected by a layer of fat, ribs, tough outer covering
Urine: kidneys  ureter  bladder  urethra  outside
Ureter: urine to bladder via peristaltic waves
Bladder: capacity 500-600mL in normal adult
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Ppl with chronic renal insufficiency are asymptomatic at first. When you are admitting a
pt, get a good history.
Who’s at risk for renal failure?
• Elderly
• Non-whites: especially African-Americans, Hispanics, and Native Americans
• Men
• Diabetics
• Hypertension
• Diabetics and hypertensives make up about 2/3 of all people with renal insufficiency
Ask questions like:
• Urinary frequency and urgency
• Pain on urination—now or ever
• Difficulty urinating
• Is it hard to initiate urinating
• What color is urine
• Flank pain
• Ever had a UTI or STD
• Are you taking herbal, prescription, OTC, or recreational drugs
• Family history of CV disorders, diabetes, cancer, or other chronic illness; PKD is an
inheritable condition
• Psychosocial history—stresses can affect the way ppl deal with illness and how they
feel
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Blood carries protein to cells. After cells use protein, the remaining waste product is
returned to the blood as urea.
Urea is formed from ammonia in the liver
Healthy kidneys take the urea out of the blood and dump it in the urine for excretion
Lower BUN levels may suggest liver disease
Evaluate BUN with Cr
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BUN:Cr ratio give a more accurate picture of what is going on
With GI bleed, BUN:Cr is especially helpful if there are no overt signs of bleeding
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A KUB is just a plain, contrast free xray showing kidneys and bladder, can’t see ureters
Pt needs to be lying supine for this
Good for seeing stones
Also sometimes used as a follow up for device placement such as urinary stents, NG
tube or to detect other GI disorders like bowel obstruction or gall stones
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May need to be NPO
A water-based conducive gel is used, then a probe placed on abdomen
Top picture is a normal kidney
Bottom picture is a kidney with cysts
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No contrast—okay to eat and drink
Contrast—NPO for at least 4 hours
Pt might feel a hot flash, feel like they are urinating, or have a metallic taste in mouth
IV contrast enhances the images of blood vessels and tissue structure of organs
Oral contrast is used to enhance organs of abdomen and pelvis
Notes of Caution with Contrast:
• Check allergies—any allergy to iodine, shellfish, or previous contrast media? If so,
may or may not receive contrast—some facilities do have protocols in place, such as
Benadryl and Solumedrol, some may have aggressive hydration
• Can result in contrast induced nephropathy
• Diabetics on metformin (Glucophage): hold metformin for 48 hours.
• Why? The IV dye can temporarily decrease renal function, which can cause
levels of metformin in the blood to rise, which can lead to lactic acidosis
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BE SAFE!!!! Of course, only on TV would someone walk away from this.
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Quick—usually done in 5-10 minutes; dye usually moves into calyces and pelvises within
3-5 minutes
NPO for 6-8 hours
Hydration!
Check for allergies
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Pyelonephritis
• Caused by bacteria or virus—e coli most common cause
• Bacteria/virus can move up from bladder or enter kidney through bloodstream
• Those at risk for pyelo: those with cystitis, and those with a structural/anatomic
problem in the urinary tract
• S/S
• Fever and/or chills
• Nausea and/or vomiting
• Back, side, groin pain
• Frequent, painful urination
• Complications: usually none if treated appropriately with antibiotics
• Kidney scarring, which can lead to chronic kidney disease, hypertension,
and/or renal failure—this usually only happens if person has structural defect,
kidney disease, or repeated pyelo infections
• Sepsis
• Diagonsis: UA/culture, US, CT
• Treatment: antibiotics, hospitalization for severely ill (hydrate)
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• S/S
• Fever and/or chills
• Nausea and/or vomiting
• Back, side, groin pain
• Frequent, painful urination
• Complications: usually none if treated appropriately with antibiotics
• Kidney scarring, which can lead to chronic kidney disease, hypertension,
and/or renal failure—this usually only happens if person has structural defect,
kidney disease, or repeated pyelo infections
• Sepsis
• Diagonsis: UA/culture, US, CT that help in the evaluation of acute pyelonephritis by
revealing calculi, tumors, or cysts
• Treatment: antibiotics, hospitalization for severely ill (hydrate). After antibiotics
therapy, a reculture of urine one week after therapy.
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Lead to about 8 million medical office visits annually. In fact, 1 in 5 women will develop
a UTI during her lifetime
Most bacteria enter the urinary tract by way of the urethra, that among women may
result from the shortness of the female urethra
Under normal circumstances, these bacteria are flushed out during urination
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S/S cont…burning during urination, pressure in the lower abdomen, blood in urine,
malodorous urine, cramps or spasms of the bladder, itching, and possibly urethral
discharge in males. Other common features include low back pain, malaise, nausea,
abdominal pain or tenderness over bladder area, flank pain, chills.
Diagnosis cont….lower counts do not necessarily rule out infection, if the patient is
voiding frequently, the bacteria require 30-45 minutes to reproduce in urine.
Treatment cont…….pyridium is a urinary tract analgesic, turns urine orange. Increase
fluids to 2 L per day. Sitz baths to relieve pain in the perineum. Educate about risk
factors, need for increased fluid intake, hygiene and taking medications as prescribed
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Signs and symptoms cont…..can be caused by the same organisms that infect the
bladder, including E. coli. Also some sexually transmitted diseases cause urethral
infection such as herpes simplex, chlamydia,
Diagnosis cont….approx. 30% of women with painful and frequent urination do not have
a significant number of bacteria in their urine this indicates that the inflammation may
be in the urethra or may not be a result of a bacterial infection.
How serious is….cont….but if caused by an untreated STD, can lead to more serious
problems, such as PID, stricture of urethra, prostatitis, epididymitis, sterility, meningitis
and inflammation of the heart.
Treatment cont….for a chlamydia infection, an antibiotic such as tetracycline. For
gonorrhea, PCN.
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Most likely to occur in young women.
Signs and symptoms cont…
Persistent, urgent need to
urinate, nocturia, burning, pain, pelvic pain, pain during sexual intercourse
Diagnosis cont….cystoscopy reveals bladder hemorrhage
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Treatment: medications may improve the s/s such as ibuprofen, tricyclic antidepressants
such as amitriptyline may help relax the bladder. PENTOSAN (elmiron) the only oral drug
approved by the FDA specifically for interstitial cystitis. How it works is unknown, but it
may restore the inner surface of the bladder, which protects the bladder wall from
substances in urine that could irritate it. Nerve stimulation a TENS unit uses mild
electrical pulses to relieve pelvic pain Bladder distention some notice temporary
improvement in symptoms after undergoing cystoscopy with bladder distention
medications instilled into the bladder such as silver nitrate which will reduce
inflammation and possibly prevent muscle contractions that cause frequency, urgency
and pain. May need to be repeated weekly and then have a maintenance treatment.
Surgery is rarely used, and only considered after all other treatments have failed.
Bladder augmentation is the damaged portion of the bladder is removed and replaced
with a piece of the colon, though pain remains and the bladder may be emptied many
times a day with a catheter. Fulguration (burn off ulcers that are present) Resection (to
cut around any ulcers)
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Causes:
• Dehydration
• Infection: infected, scarred tissue provides a place for calculi development
• Changes in urine pH: constantly acidic or alkalitic urine provides good medium for
calculi to develop
• Obstruction: urinary stasis allows for calculus constituents to collect and adhere
• Immobilization: allows calcium to be released into circulation and eventually to be
filtered by kidneys
• Metabolic factors: hyperparathyroidism, renal tubular acidosis, elevated uric acid;
defective oxalate metabolism, excessive intake of calcium or vitamin D
S/S:
• PAIN—hallmark symptom, usually occurs when large calculi obstruct opening of
ureter and increases the frequency and force of peristaltic contractions. Located in
the side and lower back. Sometimes people report a constant dull pain
• n/v may accompany severe pain
• Fever/chills
• Hematuria from where the stone abrades the ureter
• Abdominal distension
• oliguria
Treatment:
• Drink lots of fluid (>3L/day)
• Drug therapy: for infection, pain; diuretic to prevent urinary stasis and more stone
formation, thiazides to decrease calcium excretion in urine
• Misc: cystoscopy to remove lodged stone, lithotripsy; percutaneous nephrostomy
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Cerebral disorders, such as stroke, tumor, Parkinson’s, MS. Spinal cord disease or
trauma. Acute infectious diseases such as transverse myelitis, heavy metal toxicity,
chronic alcoholism, to name a few.
Complications cont…..urinary infection, stone formation, and renal failure.
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Diagnosis cont….a voiding cystourethrography evaluates bladder neck function and
continence. Cystometry evaluates bladder nerve supply, muscle tone and pressures
during bladder filling and contraction.
Treatment cont….techniques of bladder evacuation include Valsalva’s method, Crede’s
method (pressing over lower abdomen) though taught correctly not always able to
eliminate the need for catheterization Intermittent self-catheterization which is more
effective than the 2 mentioned techniques, this allows for complete emptying of the
bladder. Drug therapy may include bethanechol (urecholine) and phenoxybenzamine
(dibenzyline) to facilitate bladder emptying and dicyclomine (bentyl), imipramine
(tofranil) to facilitate urine storage. When conservative treatment fails, surgery may
correct the structural impairment (urethral dilatation, external sphincterotomy or
urinary diversion procedures)
Nursing interventions cont……explain all procedures/tests, use strict sterile technique
during insertion of catheter, BID peri care, watch for signs of infection, instruct on plenty
of fluids to prevent calculus formation and infection from urinary stasis. If urinary
diversion is to be performed, consult ET RN.
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Pathophys: increased estrogen levels prompt androgen receptors in prostate to
increase, which causes an overgrowth (hyperplasia) of normal cells around urethra.
Overgrowth causes areas of poor blood flow and necrosis in prostatic tissue. As prostate
enlarges, it may extend into bladder and decrease urine flow by compressing the urethra
Causes:
• Androgen-estrogen imbalance
• Tumor
• Arteriosclerosis
• Inflammation
• Metabolic or nutritional deficiencies
When is bph no longer benign?
• When prostate is so large that it blocks the urethra from draining urine—urine is
blocked up into bladder
• UTI
• Calculi
• Acute or chronic renal failure (this is a post renal cause of RF)
Other complications:
• Bladder muscle can thicken and create diverticuli—little pouches that retain urine
after bladder emptied
• Incontinence
• Hydronephrosis
Nursing assessment:
• Decreased urine stream size and force
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Nsg Dx: Pain, Impaired Urinary Elimination, Knowledge Deficit, Risk for Infection, Risk for
Injury (r/t DVT)
Post Procedure:
• Foley, maybe CBI; to cleanse and drain bladder of clots
• DVT prevention
Discharge instructions:
• Avoid strenuous activity, heavy lifting (nothing over 10 pounds), constipation, sexual
activity for 6 weeks
• Drink plenty of fluid
• Get up and move every hour while awake
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