Genital-Urinary System
Renal System Part 1
Behavioral Objectives:
• Review the anatomy and physiology of the genito-urinary systems
• Describe the physical assessment of the GU systems
• Discuss the application of the nursing process as it relates to patients with
disorders of the GU system
• Describe the purpose and methods for collecting sterile and “clean-catch”
urine specimens.
• Discuss the importance of monitoring and maintaining intake and output
and appropriate documentation
• Discuss common diagnostic tests, procedures and related nursing
responsibilities for the patient with GU disorders.
• Explain the purpose of dialysis and differentiate between peritoneal and
hemodialysis
Introduction
•
•
Essential to life
Every head to toe
assessment must
include…
–
Upper & lower
urinary tract
function
Anatomy: Kidney
• Kidneys
– Shape
• Bean
– Color
• Brown-red
– How many / #
•2
Anatomy: Kidneys
Kidneys
•
Location
–
–
–
–
Posterior wall of the
abdomen
Base of the rib cage
Surrounded by renal
capsule
Right kidney is lower
than the left
Anatomy: kidney
Do You Remember?
•
What lies on top of each kidney?
A.
B.
C.
D.
Liver
Pancreas
Meat balls
Adrenal gland
• What hormones do the adrenal glands
secrete?
– (Not a multiple choice question!)
– Hint
• Sugar, Sex & Salt
– Glucocorticoids
– Androgens
– Mineralcorticoids - aldosterone
Anatomy: Kidney
•
Two distinct regions:
–
–
•
Renal parenchyma
Renal pelvis
Renal parenchyma
–
Divided into 2 parts
•
•
Cortex
Medulla
Renal parenchyma
• Medulla
– Inner portion
– Contain
• Loops of Henle
• Vasa recta
• Collecting ducts
Renal parenchyma
• Medulla
– Collecting ducts connect
to Renal pyramids
• Shape:
– Triangle
• Point toward
– Hilum / pelvis
• Ea. Kidney contains
– 8-18 pyramids
Anatomy: Kidney
• Medulla
– Function
• Drain urine from the
Nephrons to the renal
pelvis
Renal parenchyma
• Divided into 2 regions
–Medulla
–Cortex
• Contains
–Nephrons
»Functional unit of
the kidneys
Anatomy: Kidney
•
Renal pelvis
– Ureter
•
Renal pyramids
drain urine into the
ureter
– Renal artery
– Renal Vein
Blood supply to the kidney
•
•
•
•
Aorta 
Renal artery 
Afferent arteriole 
Glomerulus
– Capillary bed
• Efferent arteriole 
• Venules and veins
• Inferior Vena Cava
Can you do it?
•
Place the following in order to best describe blood
flow threw the kidney.
A.
B.
C.
D.
E.
F.
G.
H.
•
Afferent arteriole
Aorta
Efferent arteriole
Glomerulus
Inferior Vena Cava
Renal artery
Vein
Venules
B-F-A-D-C-H-G-E
QUESTION????
•
Where in the flow of blood threw the kidney does
filtration take place?
A.
B.
C.
D.
E.
F.
G.
H.
Afferent arteriole
Aorta
Efferent arteriole
Glomerulus
Inferior Vena Cava
Renal artery
Vein
Venules
Anatomy: Nephrons
• Functional unit*
• FYI
– 1 million Nephrons in
ea. Kidney
– Adequate renal
function with 1
kidney
Anatomy: Nephrons
• Nephron
– Glomerulus
– Bowman’s capsule
– Proximal convoluted
tubule
• Loops of Henle
• Distal convoluted
tubule
Anatomy: Ureters
•
•
•
•
•
Urine:nephrons 
renal pyramids 
renal pelvis  ureter,
a long narrow
muscular tube
Extends from renal
pelvis  bladder
Two
Upper urinary tract
Anatomy: Ureters
• 3 narrowed areas
– promotes efflux
– prevents reflux
• micturition
– Propensity for
obstruction by renal
calculi
Anatomy: Ureters
• lining urothelium
– prevents
reabsorption of urine
• The movement of
urine is facilitated by
peristaltic waves
Anatomy: Bladder
BLADDER
• Description
–
–
•
Location
–
•
Muscular
hollow sac
Behind pubic bone
Function
–
Reservoir for urine
Anatomy: Bladder
• Normal capacity
– 300-500 ml of urine
• Capable of holding
– 1500-2000 ml
• CNS stim. “need to void”
– 150-200 ml urine
Anatomy: Bladder
• Neck of the bladder
– Internal urinary
sphincter
– Involuntary control
Anatomy: Urethra
•
•
Carries urine from
the bladder & expels
it from the body
External urinary
sphincter
–
voluntary control
Physiology of the Urinary System
•
Function of the
kidneys
–
–
Urine formation
Excretion of waste
products
Regulation of
–
•
•
•
•
Electrolytes
Acid-base control
RBC production
Ca+ & Ph
– Control
• water balance
• blood pressure
– Renal clearance
– Synthesis of Vit. D
Physiology of the Urinary System
•
Urine formation
–
The nephrons form
urine through a
complex 3-step
process
1. Glomerular filtration
2. Tubular
reabsorption
3. Tubular secretion
1. Glomerular filtration
Step 1
•
Most of the elements of
blood, except
–
–
•
•
large molecules
blood cells
forced out of the blood
 capillaries of the
glomerulus 
Bowman’s capsule 
filtrate
High capillary BP in the
glomerulus.
1. Glomerular filtration
• Filtration at Glomerulus
–
–
–
–
–
–
–
–
–
Water
Na+
ClBicarbonate
K+
Glucose
Urea
Creatinine
Uric Acid
1. Glomerular filtration
• Glomerular filtration
– Factors that can alter
process:
• Blood flow
• Blood pressure
2. Tubular reabsorption
Step 2
•
Filtrate  Proximal convoluted
tubule 
•
Reabsorption (back into blood)
–
Most
•
•
•
•
•
•
–
–
Water
Na+
ClBicarb
K+
Uric Acid
All of the glucose
None of the Creatinine
3. Tubular Secretion
• Elements secreted from
blood into tubule for
excretion in urine
– Some
•
•
•
•
•
•
Water
Na+
ClBicarbonate
K+
Uric acid
– Most Urea
• Filtrate 
–
–
–
–
–
–
Tubules 
Collecting duct 
Renal pelvis
Ureter 
Bladder 
Urethra
Glucose
•
Normally all the glucose
filtered through the glomeruli
will be reabsorbed back into
blood
–
•
No glucose in the urine
Glycosuria
–
–
Diabetes mellitus
h serum glucose levels
overwhelm the nephron’s ability to
reabsorb glucose
Sweet pea!
Protein
•
•
Filtered by glomeruli &
returned to the blood by
tubular reabsorption.
Slight proteinuria
–
–
•
OK
globulin, albumin
Persistent proteinuria
–
Glomerular damage
Anti-diuretic hormone (ADH)
•
AKA
–
•
Secreted by
–
•
Vasopressin
Posterior Pituitary
Secreted in response
to
–
changes in blood
osmolality
Anti-diuretic hormone (ADH)
Normally
• Water intake i 
• Blood osmolality 
– h
• Stim. pituitary to
– ADH
• h
• ADH receptor site 
– Kidney
• Action
– h reabsorption of H2O
– i urine volume/output
–  returns blood osmolality to normal
Anti-diuretic hormone (ADH)
Normally
• Water intake h 
• Blood osmolality 
– i
• Stim. pituitary to
– ADH
• i
• ADH receptor site Kidney
• Action
– i reabsorption of H2O
– h urine volume (diuresis)
–  returns blood osmolality to normal
Osmolarity & Osmolality
• Osmolarity
– # of particles
dissolved in solution
• Osmolality
– Thickness of solution
• Urine
• Serum / blood
Regulation of water excretion
•
The amt. of urine formed is r/t
the amt. of fluid intake
–
–
h fluid intake 
volume urine
•
h
•
Characteristic
–
–
–
i fluid intake 
volume of urine
•
•
i
Characteristic
–
•
Dilute
Concentrated
Normally: kidneys rid the body of
about 75% of fluids taken in
Regulation of Electrolytes Excretion
•
Sodium
–
Normally serum Na+:
•
–
–
–
Na+ filtered from the blood & reabsorbed from the
tubule back into the blood
Na+ excretion is controlled by Aldosterone
h Aldosterone  h Na retention 
•
•
–
135 - 145 mmol/L
__?__ Serum Sodium level
h serum sodium level
Na+ most abundant electrolyte found outside the
cells (extracellular)
Regulation of Electrolytes Excretion
• Potassium
– K+ is the most abundant electrolyte found
inside the cells (intracellular).
– h Aldosterone  h K excretion 
• __?__ serum K+ level
• i serum K+ level
Regulation of Electrolytes Excretion
• Kidney’s not functioning normally
– Na+ & K+ will not be adequately filtered from the blood
• Retention of K+ is the most life-threatening effect
of renal failure
• Renal failure
–
–
–
–
Retention of K+ 
Hyperkalemia 
Cardiac dysrhythmias 
Death
Regulation of acid excretion
•
Proteins are broken
down into acids
–
–
•
Acids in the blood 
–
•
phosphoric acid
sulfuric acid.
i pH
Normally kidneys
–
Filter acids from the
blood
•
•
Tubular filtration
Chemical buffer
mechanism
Regulation of acid excretion
• Tubular filtration
– Acid is excreted into
the urine through
tubular secretion
– Used until the
bladder acidity
• pH 4.5
– Any excess acid must
be neutralized
Regulation of acid excretion
Neutralize acids
– binding them to
chemical buffers
– Be excreted without
altering the pH
• Important buffers
– Phosphate ions
– Ammonia
• NH3
Regulation of Red Blood Cell Production
•
Kidneys measure O2 tension of the
blood (PaO2)
– i PaO2 
– (Hormone) h erythropoietin 
– (Receptor site) bone marrow 
– (Action) h production of RBC 
– h Hgb 
– h PaO2
• Normal RBCErythrocytes
– Male: 4.7 - 6.1
million/mm3
– Female: 4.2 - 5.4
million/mm3
• Normal Hemoglobin
– Male 14 - 18 g/dL
– Female 12 - 16 g/dL
Vitamin D Synthesis
•
•
Kidneys activate
ingested Vitamin D

Aid absorption of
calcium
Excretion of waste products
•
•
•
Urea, (waste product of protein metabolism)
– Blood Urea Nitrogen
– h BUN = renal dysfunction
Other waster products of metabolism are
– Creatinine
– Phosphates
– Sulphates
– Ketone
Along with BUN the serum Creatinine level is usually
ordered whenever the MD suspects renal disease
Excretion of waste products
• Uric acid (purine metabolism)
– Hyperuricemia
• gout,
• Kidneys also are the primary
means of ridding the body of
Drug metabolism
Auto-regulation of Blood Pressure
•
•
•
•
Vasa recta constantly monitor
the blood pressure
i blood pressure 
–
h Renin
–
h angiotensin 2
–
h vasoconstriction 
–
h blood pressure.
h B/P
–
i Renin
Vasa recta failure to recognize
h BP & stop/halt Renin
secretion  primary causes
of hypertension.
Gerontological Considerations
–
–
–
–
Function of the urinary tract declines.
GFR declines
Prone to develop hypernatremia & fluid volume
deficit
At risk for adverse drug effects
Assessment
Risk Factors
•
h age
•
Instrumentation of urinary
tract
•
Immobility
•
Diabetes mellitus
•
HTN
•
Gout, hyperparathyroidism,
Crohn’s disease
•
Benign prostatic
hypertrophy
•
Obstetric injury
Assessment: Health history
•
•
•
•
•
•
•
•
•
Chief complaint
Pain
Hx of UTI’s
Fever or Chills
instrumentation
Dysuria
Hesitancy, straining
Urinary incontinence
Hematuria
•
•
•
•
•
•
Nocturia
Hx of kidney stones
Hx of STD’s
Tobacco, alcohol, drugs
Meds
Females
– # & types of deliveries
– Hx vaginal infections
Physical Exam
•
•
Abdomen,
supropubic region,
genitalia and lower
back, the lower
extremities
Palpate kidney
–
Feel the rounded
lower border of the
kidney
•
Right kidney
Physical Exam
• Palpation of bladder
– Performed after voiding
if suspect urinary
retention
Terms - matching
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Urgency
Pyuria
Proteinuria
Polyuria
Oliguria
Nocturia
Incontinence
Hesitancy
Hematuria
Frequency
Euresis
Dysuria
Anuria
A. Frequent voiding – more than every 3
hours
B. Strong desire to void
C. Painful or difficult voiding
D. Delay, difficulty in initiating voiding
E. Excessive urination at night
F. Involuntary loss of urine
G. Involuntary voiding during sleep
H. Increased volume of urine voided
I. Urine output less than 400 ml/day
J. Urine output less than 50 ml/day
K. Red blood cells in the urine
L. Abnormal amounts of protein in the urine
M. Pus in the urine
• The presence of peritoneal fluid build up is
described as which one of the following?
A.
B.
C.
D.
E.
“I’m so nervous I have to void” phenomenon
Bruits
Generalized edema
Peritoneal dialysis
Ascites
Diagnostic Evaluation:
Urinalysis
–
Color; clarity; odor; urine pH and specific gravity
•
Colorless to pale yellow
»
•
Yellow to milky white
»
•
dyes, meds
Orange to amber
»
•
RBC, menses, Bladder or prostate surgery, beets, meds
Blue, blue green
»
•
Multiple vitamin
Pink to red
»
•
Pyuria, infection
Bright yellow
»
•
dilute (diuretics, alcohol, diabetes Insipidus, excess fluid intake)
Dehydration, bile, excess bilirubin or carotene, meds
Brown to black
»
Old red blood cells, dehydration,
Diagnostic Evaluation:
Urine Culture and Sensitivity
•
•
•
ID microorganism(s)
Sensitivity report
Time
–
2-3 days (48-72 hours)
Specific Gravity
•
•
The weight of urine
The specific gravity of distilled water
–
•
Normal urine specific gravity
–
•
1.000
1.003 – 1.030
Urine specific gravity is related to the level of
hydration.
–
–
h fluid intake  h H20 excretion  i specific gravity
i fluid intake  i H20 excretion  h specific gravity
Diagnostic Evaluation:
Sterile urine specimens
•
Safety
–
–
•
Standard precautions
Biohazard bag for transport
Collection
–
Indwelling Foley Catheter
•
•
–
Not from the drainage bag
Aspiration port
Catheter – straight cath
–
A small amount of urine is allowed to run out of the catheter into
a basin, then the urine is allowed to run into a sterile specimen
bottle.
Diagnostic Evaluation:
Clean-catch or Clean-voided specimen
• Clean-voided
– uncontaminated by skin flora.
– Female
• Cleanse: front to back
– Male
• Cleanse: tip of the penis downward
• Collect a "clean-catch"
– Start to void
– Midstream catch
– Collect 1 to 2 oz of urine
Renal Clearance
•
Purpose
–
•
Procedure
–
–
•
Assess the Kidney’s ability to
clear solutes from the plasma
24 hr urine collection
12 hr serum Creatinine level
Creatinine
–
waste product of skeletal muscle
contraction
Renal Clearance
• One function of the kidney is to excrete
Creatinine. If the Creatinine clearance level
(the amount of Creatinine excreted by the
kidney) decreases, what does that tell you
about the function of the kidney?
Renal Clearance
• i renal function 
– i Creatinine clearance
• Creatinine clearance
evaluates
– glomerular filtration rate
(GFR)
• Detects and evaluates
progression of renal
disease
Can you Critical Think????
• Mrs. Notafeela Sowell had a renal clearance
test done 3 times this week. Is her renal
disease getting better or worse?
– Monday: Renal clearance = 70 ml/min
– Wednesday: Renal clearance = 80 ml/min
– Friday: Renal clearance = 90 ml/min
Diagnostic Evaluation:
Intake and Output
•
I&O
–
–
All fluids taken orally
Form
•
•
•
Time
Amount
Output
–
–
–
–
–
Urine
drainage from nasogastic tube
drainage tubes
Chest tubes
Wound tubes
Apply it!
• Mr. Noah Awl is recovering from Prostatectomy due to benign hypertrophy
of the Prostate. Mr. Awl is on strict intake and Output. He requests a cup
of ice chips because his throat hurts (due to intubation). You give him a
200cc cup of ice chips and he eats them all. How much to you make on
the Intake?
A.
B.
C.
D.
E.
100cc
150 cc
200cc
300 cc
400 cc
Dialysis: Overview
•
Purpose
–
•
Remove fluids and waste products from the
body
Definition
–
•
Mechanical means of removing waste from the
blood
Types:
–
–
Hemodialysis
Peritoneal dialysis
Dialysis: Process
• Process
– Diffusion and osmosis across a semi permeable
membrane into a dialysate solution
• prescribed specific to the individual clients needs
Dialysis: process
• Diffusion
– Toxins & wastes
are removed by
diffusion
– Move from an
area of higher
concentration to
an area of lower
concentration
• This photo shows the diffusion of fluids. I added a few drops of blue
food coloring in a vase of water, and took a picture after a few seconds.
Diffusion is the process of a substance moving from high concentration
to low concentration. The cause of diffusion is random molecular
motion of the fluids, in other words, molecules of both the food
coloring and the water move at random causing them to mix. In this
case, the diffusion of the food coloring goes from high concentration to
low concentration.
• Osmosis
– Excess water is removed
by osmosis
– Water move from an area
of higher solute
concentration (blood) to
an area of lower solute
concentration (dialysate)
Hemodialysis
•
A machine with an
artificial
semipermeable
membrane used for
the filtration of the
blood.
Hemodialysis
– A graft or fistula is
surgically prepared to
access the clients
circulatory system
Hemodialysis
– With each
hemodialysis
treatment, the
catheter is inserted
into the graft of
fistula
Hemodialysis
– The clients blood is
circulated past the
semi permeable
membrane
– Excess fluids are
removed by osmosis
Hemodialysis
• Waste products are
removed from the
blood by diffusion
Hemodialysis
• Nursing interventions
– Weighted before and
after
– Strict asepsis
technique
Hemodialysis
Nursing interventions:
• Assess fistula or graft
– A thrill
• felt
– A bruit
• heard
– Pulse peripheral
• Protect Grafts
– Not an IV port!
– No BP in graft arm
The nurse is preparing to teach a client about his new shunt for
hemodialysis. What should be included in this teaching?
A. Avoid overusing the arm with the shunt to protect from
accidental harm.
B. Always use this arm for blood pressure readings
C. If you feel any vibrations over the skin of the shunt, call the
doctor.
D. There’s nothing special to the care of the shunt. Pretend it
isn’t there.
Hemodialysis
Nursing interventions:
• Meds are given after
• Usually performed 3
time a week
• Usually take 3-6 hours
Peritoneal Dialysis
•
Uses the peritoneal
lining of the
abdominal cavity
Peritoneal Dialysis
– A catheter is placed
by the MD into
peritoneal space
Peritoneal Dialysis
• The dialysate,
– In sterile container similar
– Instilled aseptically into the abdominal
cavity.
• The container remains connected to the
catheter
– rolled up
– dialysate remains in the abdominal
cavity for a specified length of time.
• The container is then unrolled and
lowered
– below the abdominal cavity
– Dialysate drains back into the container
Peritoneal Dialysis
• Usually 2 liters of
dialysate
• Less expensive, easier to
perform and less
stressful
• Complication
– INFECTION
• Usually 4 x day –
7day/wk