The Urinary System
Anatomy and
Physiology
(rev. 4/08)
Involved in waste removal
Filtration & removal plant
Greatly influences the body’s homeostasis
Structure
 Kidneys
 Ureters
 Urinary bladder
 urethra
Function
Maintains homeostasis
Controls blood and water volume
Maintains blood pressure
Regulates electrolyte levels
 Eliminates waste from blood
 Balances acid/base (PH)
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”
 4 inches long x 2 inches wide and 1 inch thick
 Extremely vascular
 Cushioned by renal fascia & adipose tissue
 Hilum on medial surface
Kidney Function
o
Regulate electrolyte levels
o
Control volume of body fluids
o
Balances the pH of blood
o
Eliminates protein wastes, excess salts, and toxic materials
o
Secretes renin & erythropoietin
Regulation of Blood Pressure
 ADH
 RENIN
 ALDOSTERONE
3 Parts
Cortex
Medulla
Pelvis
Cortex
Extends from renal capsule to bases of renal pyramids
Holds the larger portion of Nephron
Medulla
Inner, collecting portion of kidney
Contains collecting tubules shaped like cones renal pyramids
Pyramid tips point to pelvis
Pelvis
Funnel-shaped basin at upper end of ureter
Nephron
Functional units of the kidney
Cells that form urine
Over 1 million nephrons in each kidney
Ureters
Narrow tubes 1/5 inch in diameter ; 10-12 inches long
Receive urine from renal pelvis and empty urine into urinary bladder
Bladder
 Hollow muscular sac
 Lies behind symphysis pubis
 Extends up into abdominal cavity when full
•
Desire to void with 200-400 mls
•
May hold > 1000mls
Urethra
Tube leading from bladder
Urine passes through urethra to the outside
Opening to outside  “urinary meatus”
Urethra
Women
1. 1.5 inches long
2. Passageway for urine only
Urethra
Men
1. 8 inches long
2. Passageway for sperm and urine
Definitions
1. Oliguria
2. Anuria
3. Dysuria
4. Polyuria
5. hematuria
Characteristics of
NORMAL
URINE
Urine
 Body excretes 1000-1500 ml of urine/day
 Is normally sterile
 Color varies with hydration
 CLARITY
 ODOR
 SPECIFIC GRAVITY
THINK….
A STRONG, OFFENSIVE ODOR FROM FRESHLY VOIDED URINE IS SUGGESTIVE OF……..
Urinary Tract Infection
Composition of
Normal Urine
Water
Protein wastes products (urea, uric acid & creatinine)
Excessive minerals from diet (Na+,K+, Ca,sulfates & phosphates
Toxins
Hormones
Bile compounds
Pigments from food/drugs
Commom GU Terms
Frequency
Urgency
Nocturia
Enuresis
retention
Effects of Aging on
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 GFR
Smaller capacity of bladder
Weaker bladder muscles
Incontinence
Not a normal consequence of age
Common due to many reasons
See Chpter 23 for more information
Nursing Assessment
of
The Urinary
System
HEALTH HISTORY
 Chief complaint
 History of Present Illness
 Past Medical History
 Family History
 Review 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

Angiogram

Renal Scan

US
Invasive Procedures
1.
Renal Biopsy
2. Cystoscopy
What are
Urodynamic Studies ??
What are common Therapeutic measures
Related to
“Catheterization”
Common
Tubes and Catheters
 Ureteral Catheter
 Nephrostomy Tube
 Urinary Stent
Renal Disease
Unavoidable if disease processes exist in other systems
Obstructive Disorders
Urolithiasis
Calculus or stone formed in the urinary tract
Etiology is unknown
Can occur in renal pelvis, ureters, bladder or urethra
Contributing Factors
Infection & or Dehydration
Urinary stasis
Immobility
Recurrent UTI’s
Diet rich in calcium
Signs & Symptoms
Size & location of stone affects degree of pain
“colic”
hematuria
Nursing Considerations
 Strain all urine
 Send gravel or stones to lab
 Monitor of s/s infection
 Give antispasmodics
 Encourage fluids ; IV
 Manage Pain
Pharmacological
Bromide (Pro-Banthine)
Antibiotics
Zyloprim
Calcibind
Surgical Management
Lithotripsy (ESWL)
Urethroscopy
Nephrolithotomy
Ureterolithotomy
Nephrolithiasis
Calculi in the kidney
Percutaneous Nephrolithotomy
Hydronephrosis
 Distention of kidney
 Can cause permanent damage
 Maintain accurate I & O
 Strain all urine
 Send all stones for analysis
Infectious Diseases
Of the Urinary Tract
Cystitis
Inflammation of the urinary bladder
Bacteria enters from the urethra, lymph nodes, infected kidneys
Women more suseptible
Causes
E-coli
Candida Albicans
Coitus
Prostatitis
Diabetes mellitus
Signs & Symptoms
Dysuria
Frequency
Burning
Hematuria
Chills, fever
Nursing Considerations
C&S and UA obtained
Increase fluids
Antibiotics (Cipro,Bactrim,Septra
Analgesics(Pyridium)
Gerontologic Considerations
Watch for signs of mental confusion
Fever may be masked
Sepsis develops quickly
Pyelonephritis
Bacterial infection of renal pelvis and kidney
Most common form of kidney disease
Often the result of reflux
Bacteria ascend from bladder, up through ureter & into kidney
Obstruction in ureter
Pyelonephritis :
May be acute or chronic
If chronic, may cause high BP &/or chronic renal failure
Signs & Symptoms
Flank pain
Pyuria
Chills, fever,N & V
dysuria
Bacteruruia w/ WBC’s
Nursing Considerations
Bedrest
Increase fluids
IV
Monitor I + O
Daily weights
Pharmacological TX
Sulfonamides (Bactrim) or Cipro
Antipyretics
Analgesics
Glomerulonephritis
Autoimmune disease
Glomerulus becomes inflammed
Symptoms dev. 1-3 wks after respiratory infection cau by group A- hemolytic strep
Acute
Symptoms may go unnoticed at first
Puffy face
Edema
Mild to severe HTN
Tea colored urine
Hematuria
Severe headaches
Irritability
Hypervolemia
Nursing Considerations
Bedrest several weeks
Strict I & O, daily weights
Restrict Fluids if ordered
Low Na, low protein diet
Prognosis is good
UA w/ RBC’s, Albumin, casts
protein
Pharmacological TX
Penicillin
Diuretics (Lasix)
Antihypertensive medications
Chronic
Much more serious than acute
May permanently damage the kidney by destroying nephrons
Signs & Symptoms
Disease flares up at intervals
General malaise
Albumin in urine
Pale/dilute urine
Hypertension w/ headaches
Marked edema
Treatment
Low Na, protein diet
Bedrest
VS, BP…
Strict I & O
Restrict 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 cysts
Abdominal, low back or flank pain and headache
Diagnosis
X-ray or sonogram
BUN & Creatinine
Goal 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
 Glomerulonephritis
 IDDM
 Any condition which decreases blood supply to kidneys
 Injury
 Recurrent UTI
 Drug overdose
 Poisoning
 Nephrotoxic Drugs
Acute Renal Failure
CAUSED BY:
1. Prerenal Failure
2. Intrarenal Failure
3. Postrenal Failure
Acute Renal Failure
4 PHASES
1.Onset
2.Oliguria
3.Diuresis
4.Recovery
Medical & Drug Management
Antihypertensives
Diuretics
Cardiotonics
Dialysis 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 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”
Irreversible
Chronic 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
Dialysis
•
Mechanical
•
Imitates the function of the nephron
•
May be chronic or acute
•
Removes body wastes through semipermeable membrane
Dialysis
Peritoneal
Hemodialysis
Hemodialysis
Blood circulates through a machine outside the body
Semipermeable 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”
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 cadaver
Tissue and blood-typed
Amendment to Social Security Act
Why 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. 879
ATN, 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 Care
Monitor urine output
Monitor fluid intake
VS
Note weight changes
TC & DB
Control pain
Bladder CA
Most common site of urinary system CA
Men bet. 50-70 yrs
Most bladder tumors are malignant
Risk Factors
Cigarette smoking
Lung cancer
Caffeine intake
Dyes found in industrial compounds
Medical Treatment
 Cytoscopic resection
 Fulguration
 Laser photocoagulation
 Segmental resection
 Radical cystectomy
Types of urinary Diversion
Ileal conduit (most common)
Sigmoid conduit
Ureterostomy
Nephrostomy
Continent internal ileal reservoir (Kock pouch)
Nursing Interventions
•
VS
•
I&O
•
Patency of tubes
•
BS, stoma appearance
•
Special skin care
•
Signs of infection
Catheter Types
Foley
Ureteral
Suprapubic
Nephrostomy
1.Foley Catheter
-into bladder
-balloon
2.Ureteral Catheter
-surgical incision through back
3.Suprapubic Catheter
-incision into low abdomen
-directly into bladder
4.Nephrostomy Catheter
-incision directly into renal pelvis through back