The Urinary System
Anatomy and
Physiology
2014
Structure
 Kidneys
 Ureters
 Urinary
 urethra
bladder
Function
 Maintains
homeostasis
 Controls blood and water
volume
 Maintains blood pressure
 Regulates electrolyte levels
 Eliminates
protein wastes,
excess salts and toxic
materials from blood
 Balances acid/base (PH)
 Secretes renin and
erythropoietin
Kidney Structure
2
reddish brown, beanshaped organs
 Located in small of the back
at lower edge of ribs on
either side of spine
 “Retroperitoneal”
How the kidneys
Regulate BP

ADH
 RENIN
 ALDOSTERONE
3 Parts
 Cortex
 Medulla
 Pelvis
BecomeHealthyNo
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Nephron
 Functional
units of the
kidney
 Cells that form urine
 Over 1 million nephrons in
each kidney
 Glomerular
Filtration
 Tubular
Reabsorption
 Tubular
Secretion
WORD WALL
1.
2.
3.
4.
5.
Oliguria
Anuria
Dysuria
Polyuria
hematuria
Urine
 Body
excretes 1000-2000 ml
of urine/day
 Is normally sterile
 Color varies with hydration
Characteristics of
Normal Urine
 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
WORD WALL
 Frequency
 Urgency
 Nocturia
 Enuresis
 retention
Effects of Aging on the
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 on incontinence
Critical Thinking
Challenge
COMPARE & CONTRAST
 STRESS vs.
FUNCTIONAL
COMPARE & CONTRAST
 URGE vs. OVERFLOW
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
Arteriogram
Renal Scan
US
Invasive Procedures
1.
2.
Renal Biopsy
Cystoscopy
What are
Urodynamic Studies ??
What are common
Therapeutic
measures
Related to
“Catheterization”
Catheter Types
Foley
Ureteral
Suprapubic
Nephrostomy
Common
Tubes and Catheters
 Ureteral
Catheter
 Nephrostomy
 Urinary
Stent
Tube
Pre-Op Care 
Urologic Surgery

Evaluate fluid status

Bowel cleansing

Enterostomal Therapist/Nurse

Counseling/Teaching
Post-Op Care
Urologic Surgery

Report to MD U/O < 30 ml/hr

Pain Management

Mon. lung sounds

Assess for Paralytic ileus
Urinary Tract
Inflammation and
Infections
Cystitis
 Inflammation
of the urinary
bladder
 Bacteria enters from the
urethra, lymph nodes,
infected kidneys
 Women more suseptible
Causes
 E-coli
 Candida
Albicans
 Coitus
 Diabetes
mellitus
 See Box 40-2 Risk Factors
for UTI’s
Signs & Symptoms
 Dysuria,
hematuria
 Frequency, urgency
 Low grade fever
 Pelvic or abd. discomfort
 Bladder spasms
Med. Dx & Tx
 C&S
and UA obtained
 Increase fluids 3-4 L / day
 Antibiotics
(Cipro,Bactrim,Septra
 Analgesics(Pyridium)
 See Pt. Teaching pg. 898
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
Signs & Symptoms
 Flank
pain
 Chills, fever,N & V
 Dysuria, fatique
 Bladder irritation
Med & Nursing
Considerations
 Bedrest
 Increase
fluids (8 8oz.
Glasses water/day)
 IV
 Monitor I + O
 Protein & Na+ restrictions
 Mon. for circulatory overload
Pharmacological TX
 Antibiotics
(Bactrim) or
Cipro
 Antipyretics
 Analgesics
 Antispasmotics
 Antihypertensives
Glomerulonephritis
 Autoimmune
disease
 Glomerulus becomes
inflammed
 Symptoms dev. 1-3 wks after
respiratory infection cau by
group A- hemolytic strep
Signs & Symptoms
 Tea
colored urine
 Decrease in u/o
 Periobital edema
 HTN
 Hypervolemia
Medical Dx
 Clinical
Presentation
 UA  Proteinuria
 BUN, Cr
 Strep. Antibody Tests
 Renal Biopsy or Ultrasound
Medical Treatment
 Diuretics
 Antihypertensives
 Antibiotics
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
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 400-600ml
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

Urinary Tract
Obstructions
RENAL CALCULI
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 low in calcium
Signs & Symptoms
 Size
& location of stone
affects degree of pain
 Spasm = “colic”
 Hematuria
N & V
Medical Treatment
 Opioids
 NSAIDS
 Antispasmodics
 IV
Fluids
 Antibiotics
Surgical Management
 Lithotripsy
(ESWL)
 Urethroscopy
 Nephrolithotomy
 See Post-Op Care Goals pg.
906
Nursing Considerations
 Strain
all urine & pain relief
 Send gravel or stones to lab
 Monitor of s/s infection
 Give antispasmodics
 Encourage fluids ; IV
 Manage Pain
Hydronephrosis
 Distention
of kidney
 Can cause permanent damage
 Maintain accurate I & O
 Strain all urine
 Send all stones for analysis
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”
/cahe/respcared/cyberc
as/dialysis/franvasc.ht
ml
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. 924
 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)
 Colon conduit,
ureterosigmoidostomy
 Cutaneous ureterostomy
 Internal ileal reservoir, aka:
“Kock pouch” or “continent
ileostomy”
Nursing Interventions
•
•
•
•
•
•
VS
I&O
Patency of tubes
BS, stoma appearance
Special skin care
Signs of infection