Formation of Urine
 Excretion or Conservation of Water
 Electrolyte Balance
 Acid-base Balance
 Activation of Vitamin D
 Production of Erythropoietin
 Production of Renin

Glomerular filtration
 Glomerular filtration rate
 Tubular reabsorption

› Include water and electrolytes
Tubular secretion
 Urine concentration

Renal Filtrate Kidneys form in 1 minute
 Averages 100-125 mL/minute


Renin-angiotensin-aldosterone system
› Role in blood pressure and sodium
reabsorption

Erythropoietin
› Role in RBC production
Vitamin D and calcium regulation
 Acid-base balance

Ureters: carry urine from kidneys to
bladder
 Bladder: temporary storage of urine and
its elimination
 Urethra: carries urine from bladder to
exterior

Amount: 1000-2000 mL/24 hours
 Color: straw or amber
 Clarity: clear
 Specific Gravity: 1.010-1.030

› Lower=Dilute; Higher=Concentrated

pH: 4.6-8.0

Constituents
› 95% water
› Waste products: Urea, Creatinine, Uric Acid







Renal Mass Smaller
Renal Flow Decreased 50%
Decreased Tubular Function
Bladder Muscles Weaken
Bladder Capacity Decreases
Voiding Reflex Delayed
Nephrons lost with aging
› Reduces kidney mass and GFR

Less urine concentration
› Risk for dehydration
Health History
 Pain/Burning with Voiding
 New Onset Edema, Shortness of Breath,
Weight Gain
 Fluid Intake
 Functional Ability

Color, clarity, amount of urine
 Difficulty initiating urination or changes in
stream
 Changes in urinary pattern
 Dysuria, nocturia, hematuria, pyuria

Vital Signs
 Lung Sounds
 Edema
 Daily Weights
 Intake and Output
 Skin Assessment


Urinalysis
› Common test
› Voided or Cath Specimen
 24 hour
 Clean catch
› 10 mL of urine collected
› Color, odor, clarity

Urine Culture
› Identifies bacteria present
› Urine collected before antibiotics
› Sensitivity test determines antibiotic that will
destroy bacteria

Renal Function Tests
› Serum Creatinine
› Blood Urea Nitrogen
› Uric Acid
› Creatinine Clearance Test

Kidneys-Ureter-Bladder
› Show tumors, swollen kidneys, kidney stones

Intravenous Pyelogram
› Dye injected
› Dye outlines renal structures
› Check allergies
› Increase fluids afterward

Renal Angiography
› Dye visualizes renal arteries
› Check allergies

Cystoscopy and Pyelogram
› Surgery: Cystoscope inserted in bladder
through urethra
› Pyelogram: dye injected in kidney pelvis
› X-rays taken
Noninvasive sound waves examine
anatomy of urinary tract
 Shows kidney enlargement, kidney
stones, chronic infection, tumors

Percutaneous or Open
 Before - NPO, Mild Sedative


After
› Vital signs
› Observe for bleeding
 Biopsy site, Urine
› Pressure dressing, sandbag
› Bed rest for 24 hours

Types
› Stress
› Urge
› Functional
› Overflow
› Reflex
 total
Postvoid residual urine
 Ultrasonic bladder scan
 Cystometrography
 Uroflowmetry


Medications
› Inhibit detrusor muscle contractions
› Increase bladder capacity
› Estrogen therapy

Surgery
› Bladder neck suspension
› Prostatectomy
Impaired Urinary Elimination
 Toileting Self-Care Deficit
 Social Isolation


Evaluating
› Keep voiding diary
› Identify wetting episodes
› Assess willingness to participate in social
activities

Teaching
› Home environment
› Voiding diary
› Therapies
Occurs when bladder cannot empty
 May be caused by obstructive or
functional problem

› Benign prostatic hypertrophy
› Surgery
› Drugs
› Neurologic diseases
› Trauma

Acute
› Anesthesia, medications, local trauma to
urinary structures

Chronic
› Enlarged prostate, medications, strictures,
tumors

Manifestations
› Overflow voiding
› Incontinence
› Firm, distended bladder
 May be displaced

Monitor
› Urine output
› Bladder distention
› Bladder Scan
 Residual volume of 150-200 cc urine
 Indicates need for treatment

Complications
› Hydronephrosis
› Acute renal failure
› Urinary tract infection

Diagnostic tests
› Portable bladder scan

Treatment depends on cause
› Surgery
› Medications
› Stimulation techniques
› Catheterization
Identify clients
 Take measures to promote urination


Indwelling Catheters
› Justifiable reasons
 Shock
 Urinary tract obstruction
 Neurogenic bladder
› Urinary incontinence is NOT justification

Urinary catheters result in infection

Intermittent catheterization
› Best
› Reduces risk of infection
› Patients may self-cath

Suprapubic Catheter
› Indwelling catheter inserted through incision
in lower abdomen into bladder
Invasion of urinary tract by bacteria
 Women > Men
 Aging

› Older men due to enlarged prostate
› Women due to declining estrogen
› Nosocominal infections common
Stasis of urine
 Contamination in Perineal/Urethral area
 Instrumentation
 Reflux of urine
 Previous UTIs

Dysuria
 Urgency
 Frequency
 Cloudy, foul-smelling urine

Urethritis: inflammation of urethra
 Cystitis: inflammation/infection of
bladder wall
 Pyelonephritis: infection of the kidneys

Dysuria, flank pain, fever, chills, malaise
 Urine examined for cloudiness, blood,
foul odor
 Predisposing factors
 Urinalysis and culture results

Urinalysis
 Urine culture & sensitivity
 CBC with differential
 IP
 Voiding cystourethrography
 Cystoscopy

Acute pain
 Impaired urinary elimination
 Risk for injury
 Knowledge deficit

Monitor symptoms
 Monitor intake and output
 Pain control
 Teaching

› Medications: take all antibiotics – 3-7 days
› Prevention
Obstruction of urine flow is always
significant
 Backup of urine destroys kidney


Urethral Strictures
› Urethra lumen narrowing due to scar tissue

Renal Calculi
› Hard, generally small stones
› Kidney stones
 Nephrolithiasis
Urolithiasis most common cause of
obstructed urine flow
 Calculi

› Masses of crystals formed from materials
normally excreted in urine
› Most made from calcium

Etiology
› Heredity
› Chronic dehydration
› Infection
› Immobility
› Men > Women

Kidney/Pelvis
› May be asymptomatic
› Dull, aching flank pain

Ureter
› Acute severe flank pain, may radiate
› Nausea/vomiting
› Pallor
› Hematuria

Bladder
› May be asymptomatic
› Dull suprapubic pain
› Hematuria

Diagnosis
› Kidney-ureter-bladder x-ray
› Intravenous Pyelogram (IVP)
› Renal ultrasound
› Urinalysis
Small stones passed
 IV fluids
 Pain control
 Thiazide diuretics
 Allopurinol
 Lithotripsy

Medications
 Dietary management
 Surgery

› Lithotripsy
› ESWL
› Cystoscopy
› Nephrolithotomy
› Nephrectomy

Prevention
› Foods
› Hydration
› Exercise

Complications
› UTIs
› Hydronephrosis

Nursing Diagnosis
› Acute pain
› Risk for infection
› Deficient knowledge
Monitor symptoms
 Strain all urine
 Intake and output
 Pain control
 Hydration
 Teaching

Abnormal dilation of renal pelvis and
calyces
 Results from urinary tract obstructions or
backflow of urine
 Manifestations depend on how rapidly it
develops


Diagnosis
› Ultrasound
› CT scan
› Cystoscopy

Treatment
› Stents

Signs and symptoms
› Frequency
› Urgency
› Dysuria
› Flank and back pain
› Renal failure
Treat cause
 Urinary catheter
 Stents
 Nephrostomy tube

› Intake and output
› No clamping

Focuses on prevention and ensuring
urinary drainage
Most common urinary tract cancer
 Men > Women
 Ages 50-70 years
 Etiology

› Smoking
› Industrial pollution

Signs and symptoms
› Early
 Painless
 Hematuria

Signs and symptoms (cont’d)
› Late
 Pelvic pain
 Lower back pain
 Dysuria
 Inability to void

Diagnosis
› Urinalysis
 Telomerase
› Urine for Cytology, Culture
› Cystoscopy and Transurethral Biopsy
› IVP

Therapeutic Interventions
› Chemotherapy
› Bacille Calmette-Guérin Vaccine
› Photodynamic Therapy

Therapeutic Interventions
› Surgery
 Cystoscopy & Pyelogram with Fulguration
 Laser
 Robotic Laparoscopic Radical Cystectomy
 Urinary diversion

Therapeutic Interventions
› Incontinent urinary diversion
 Ileal conduit
› Continent urinary diversion
 Kock pouch
› Othotopic bladder substitution
 Studer pouch
 Hemi-Kock pouch
 Ileal W-Neobladder

Nursing Care
› WOC Nurse
› Monitor urine output
› Education
› Preop and postop care
Uncommon
Renal cell carcinoma most common
primary tumor
 Risk factors


›
›
›
›
›
›
›
›
Smoking
Obesity
Renal calculi
Hypertension
Long term kidney dialysis
Radiation exposure
Asbestos
Industrial pollution
Most arise from tubular epithelium
 Can occur anywhere
 Often metastasize
 Often silent


Later signs and symptoms
› Hematuria
› Dull pain in flank area
› Mass
IVP
 Cystoscopy and Pyelogram
 Ultrasound
 CT scan
 MRI
 Renal biopsy


Therapeutic Interventions
› Radical Nephrectomy
› Nephron-sparing surgery
› Radiation therapy
› Immunotherapy
› Chemotherapy

Nursing Management
› Monitor urine output
› Education
› Preop and postop care
Pain
 Ineffective breathing pattern
 Risk for impaired urinary elimination
 Anticipatory grieving

Flank pain
 Hematuria
 Treat injury


Nursing Care
› I&O
› Vital signs
› IV fluids
› Pain control
Multiple cysts in the kidney
 Signs and symptoms

› Dull heaviness in flank/back
› Hematuria
› Hypertension
› UTI
Progressive
 No treatment

Long-term complication of diabetes
 Most common cause of renal failure
 Atherosclerotic changes decrease blood
to kidney
 Smaller doses of insulin as progresses
 Chronic renal failure develops

Inflammatory condition of glomerulus
 Acute or chronic
 Primary kidney disorder or secondary to
systemic disease

Affects structure and function of
glomerulus
 Damages capillary membrane

› Blood cells and proteins escape into filtrate
› Hematuria, Proteinuria, Azotemia
Usually follows infection of group A betahemolytic Streptococcus
 Manifestations develop abruptly
 Hematuria, proteinuria, edema,
hypertension, fatigue
 Anorexia, nausea, vomiting, headache
 Elevated BUN and serum creatinine

Older adults may show less characteristic
manifestations
 Symptoms may subside spontaneously
 Some may develop chronic
glomerulonephritis

Usually end-stage kidney damage
 Slow, progressive destruction of glomeruli
 Gradual loss of nephrons
 Kidneys decrease in size
 Symptoms develop slowly





ASO titer
ESR
BUN
Serum creatinine




Serum electrolytes
Urinalysis
KUB x-ray
Kidney scan or
biopsy

Signs and symptoms
› Oliguria
› Hypertension
› Electrolyte imbalances
› Edema
› Flank pain
Focus is on identifying and treating
underlying disease process and
preserving kidney function
 Medications
 Plasma exchange therapy
 Dietary management
 Renal failure treatment

Vital signs
 Symptom support
 Rest
 Fluid, sodium, protein restrictions
 Renal failure care
 Education

Preventing acute renal failure is goal of
care
 Diagnostic tests

› Serum creatinine, BUN
› Creatinine clearance
› Serum electrolytes, ABGs, CBC
› Urinalysis
› Kidney biopsy
Kidneys unable to remove waste
products from blood
 Acute or chronic
 Azotemia

› Waste products accumulate

Fluid, electrolyte, acid-base imbalances
› Oliguric
Rapid decline in function
 Abrupt onset
 Often reversible with treatment
 Risk factors

› Major trauma, surgery, infection,
hemorrhage, severe heart failure, lower
urinary tract obstruction
› Older adults at risk

Prerenal Failure
› Decreased blood supply to kidneys

Intrarenal Failure
› Damage to nephrons

Postrenal Failure
› Obstruction

Nephrotoxins
› Diagnostic Contrast Media (Dyes)
› Medications
 IV Aminoglycosides, Tobramycin (Tobrex),
Amikacin (Amikin), Cisplatin (Platinol)
› Chemicals

Prevention
› Check serum BUN and creatinine prior to
dyes or meds
› Hydrate before/after contrast media
› Monitor peak/trough levels of nephrotoxic
drugs per institutional policy

Phases
› Oliguric
› Diuretic
› Recovery

Therapeutic Interventions
› Treat cause
› Supportive treatment
› Dialysis
› Continuous renal replacement therapy
Removes fluid continuously along with
Hemodialysis
 Remove fluid/solutes in controlled,
continuous manner in unstable patients
 Blood flows through Hemofilter, excess
fluids/solutes move into collection bag

Gradual decrease in kidney function
 Irreversible
 Slow, insidious process
 Final stage is end-stage renal disease
 Increasing in incidence
 Diabetic nephropathy and hypertension
leading causes in U.S.


Etiology
› Diabetic Nephropathy
› Nephrosclerosis
› Glomerulonephritis
› Autoimmune diseases


Nephrons destroyed by disease process
Remaining nephrons hypertrophy and have
increased workload
› Can compensate for a while
Renal insufficiency develops – 75% of
nephrons lost
 Further insult leads to ESRD

› Uremia develops



End-stage: 90% of nephrons lost
Uremia: urea in the blood
Affects all body systems

Often not identified until uremia
develops
› Nausea
› Apathy
› Weakness
› Fatigue
› Confusion
Fluid accumulation
 Electrolyte imbalance
 Waste products retained
 Acid-base imbalance
 Anemia


Diet
› High calorie
› Low protein (unless dialysis)
› Low sodium, potassium, phosphorus
› Increased calcium
› Vitamins

Fluid restrictions

Medications
› Diuretics
› Antihypertensives
› Phosphate binders
› Calcium/Vitamin D supplements
› Kayexalate prn

Dialysis
› Symptoms of fluid overload
› High potassium
› Neurological signs
› Uremia

Hemodialysis
› Artificial kidney removes waste products and
excess water from blood

Vascular Access
› Temporary
› LifeSite Hemodialysis Access System
› A-V Graft
› A-V Fistula

Vascular Access Care
› Thrill, Bruit
› Protect
› Postop
 NV checks, pain
 Elevate extremity
Continuous dialysis done by patient
 Peritoneal membrane is semipermeable
membrane, across which excess
wastes/fluids move from blood
 Peritoneal catheter
 Exchange process: fill, dwell time, drain

Excess fluid volume
 Imbalanced nutrition: less than body
requirements
 Risk for infection
 Disturbed body image
 Activity intolerance
 Impaired skin integrity
 Risk for injury


Excess fluid volume
› Monitor weight
› I&O
› Fluid restriction
› Monitor for fluid retention

Electrolyte imbalance
› Monitor levels
› Dietary restriction
› Monitor dysrhythmias

Waste products
› Oral care, skin care
› Lotion
› Protect from injury

Impaired hematological function
› Protect from injury/infection
BPH tends to occur in men over 40 years
of age
 Intervention is required when symptoms
of obstruction occur
 The most common treatment is
transuretheral resection (TURP)


PSA
› False high levels can be present for up to 12
days after a rectal examination or
instrumentation around the prostate gland
especially after a cystoscopy

Signs and symptoms
› Increased frequency with a decrease in
›
›
›
›
›
›
amount of each voiding
Nocturia
Hesitancy
Terminal dribbling
Decrease in size and force of stream
Acute urinary retention
Bladder distention

TURP
› Preop teaching
› Monitor urinary drainage system
› Provide pain relief
› Monitor urinary drainage system for clots
› Irrigate bladder as prescribed
› Monitor H &H
› Monitor v/s
Hematuria generally is present for at
least 23 hours following a TURP
 Monitor color & content of urinary output
 Care post catheter removal

› Monitor # of voids and amount
› Have client collect urine in specimen cups

Force fluids