Lecture 9 Urinary System

Urinary System

Urinary System • •

Essential to life Every head to toe assessment must include… –

urinary tract function

Anatomy: Kidney • Kidneys – Vascular – Shape • Bean

– Color • Brown-red

– How many / # •2

Anatomy: Kidney •

3 areas – – –

Cortex

Medulla

Cortex Medulla Renal Pelvis

Renal Pelvis

Kidney: Cortex • Contains – Nephrons • Functional unit of the kidneys • Glomeruli / glomerulus • Filters blood • Creates urine

Kidney: Medulla • Function – Drain urine from the Nephrons to the renal pelvis

Kidney: Renal Pelvis • Ureter • Renal artery • Renal Vein

Anatomy: Nephrons • FYI – Functional unit* – 1 million Nephrons in ea. Kidney – Adequate renal function with 1 kidney

Urine flow • • • •

Nephrons  Medulla (pyramids)  renal pelvis  ureter

Anatomy: Ureters • • •

•

Long narrow muscular tube Moves urine via peristaltic waves Extends from renal pelvis  bladder Two

Anatomy: Bladder BLADDER • Description – –

•

Location –

•

Muscular hollow sac

Behind pubic bone

Function –

Reservoir for urine

Anatomy: Bladder • Normal capacity – 300-500 ml of urine

Anatomy: Urethra •

Carries urine from the bladder & expels it from the body

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 process

Anatomy: Nephrons • Nephron – Glomerulus – Bowman’s capsule • Proximal convoluted tubule • Loops of Henle • Distal convoluted tubule

Regulation of water excretion •

The amt. of urine formed is r/t the amt. of fluid intake – –

h fluid intake  volume urine •

h

•

Characteristic –

– –

Dilute

i fluid intake  volume of urine • •

i Characteristic –

Concentrated

Excretion of waste products •

Urea, (waste product) –

Blood Urea Nitrogen •

•

h BUN = renal dysfunction

Creatinine – –

The creatinine clearance compares the level of creatinine in urine with the levels in the blood i Creatinine clearance = renal dysfunction

Excretion of waste products • Primary means of ridding the body of Drug metabolism

Small Group Question 1. Describe the flow of urine from formation to excretion 2. What is the functional unit of the urinary system? What does it do? 3. Increased or decreased fluid intake has what effect on volume of urine and its characteristics 4. What two main waist products do the kidneys rid the body of?

Assessment: • Urine – Color – Odor – Amount

• Difficulty urinating • Fluid intake • Painful urination – dysuria

Assessment • Urinating at night – Nocturia

• Blood in the urine – Hematuria

• Cloudy urine – Pyuria

• Discharge?

Assessment • Pain – Abd – Suprapubic – Flank

Assessment: Health history • • • • • •

Symptoms Associated symptoms Hx of UTI’s Meds Smoking or Alcohol Females – Pg

Physical Assessment • Urine sample – Clean-catch

• V/S • Skin – Color – Moisture – Edema

• Palpate abd • Percuss kidney for tenderness

Physical Exam •

Abdomen, supropubic region, genitalia and lower back, the lower extremities

Physical Exam • Palpation of bladder – Performed after voiding if suspect urinary retention

Urinalysis: normal • Color – Light straw – amber – Clear

• Specific gravity – 1.005 – 1.030

• pH – 4.5 – 8.0

• Protein – Neg - trace

Urinalysis: normal • Glucose – -

• Ketones – -

• RBC – 1-2

• WBC – 3-4

• Casts – -

• Bacteria – -

Specific Gravity • •

The weight of urine 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: Urine Culture and Sensitivity • • •

ID microorganism(s) Sensitivity report Time –

2-3 days (48-72 hours)

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

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.

I&O Intake

•

Oral liquids – – – –

•

Milk Tea Juice Broth

Liquid at room temp – –

• •

Output

Ice cream Jello

NGT/GT IV

• • • •

Urine GI suction Emesis Drainage – Chest tubes – Wound tubes

• Healthy person • Fluid output = • Fluid input

• If the client takes in more fluid than they excrete  – edema

S&S Edema • Weight –h

• Swelling – – – –

Feet Ankles Face Fingers

• Urine output – i

• Fluid pooling – Lungs – Abd • Ascites

• Pitted edema is tested by pressing & holding your finger into the swollen tissue over a bony area for 5 seconds. If there is an indentation left behind when you remove your finger it is pitted edema. • To classify the pitted edema you measure the depth of pitting & compare the measurement to the following scale; • +1 = 2mm of pitting • +2 = 4mm of pitting • +3 = 6mm of pitting • +4 = 8mm of pitting

What is the nursing diagnosis for a client with edema? • Fluid Volume Excess

• If a client excretes more fluid than they take in  – dehydration

Dehydration S&S • Thirst • Constipation • Urine output –i

• BP – i

• Pulse – Weak –h

• Mentation – Confused – Lethargy

• Skin – Dry

• Mucus membranes – Dry

• Weight –i

1. Describe the nursing assessment of a client who is complaining of voiding issues? 2. What dx test do you expect the doctor to order for a client with renal failure 3. What does a UA measure & what should not be found in the blood. 4. Increased & decreased fluid intake have what effect on specific gravity 5. Describe how to get a clean catch and a sterile urine specimen?

Cystitis • Inflammation of the urinary tract – Bladder – UTI

• Etiology – Bacteria

Cystitis: S&S • • • • • • •

Dysuria Frequency Urgency Nocturia Pyuria Hematuria Lower abd discomfort

Gerontologic considerations • • • •

Few S&S Fatigue Alt cognitive function drop in temp

Defense Mechanism • Who is more likely to get a UTI A. Male B. Female

• Why? – Shorter urethra

Pyelonephritis • Inflammation of the renal pelvis & parenchyma • Etiology – Bacteria • E-coli

Pyelonephritis: S&S • S&S of Cystitis –+

• • • •

Flank pain Vomiting / diarrhea Fever / chills Malaise

Assessment & Dx findings • Urinalysis – UA

• Culture

Medical management/ pharmacological therapy • Antibiotic • Urinary analgesic

Nursing Process: UTI • Assessment – – – –

S&S Voiding patterns Sexual intercourse Urine

Nursing: health promotion • Fluid intake –h

• Void when you feel the need – Q3-4 hours

• Female – Clean front to back

• Void after intercourse

• Avoid – bubble bath – Feminine hygiene – Douching

• Cotton underwear • Shower not bath

Nrs Dx: Pain • • •

Assess pain Admin. Analgesics, antibiotics per order Teach non-Rx – Heating pad – Warm showers

• Cranberry juice • Vitamin C • Avoid excess milk, fruit juice

1. What are the S&S of cystitis? 2. Differentiate with cystitis & Pyelonephritis 3. What are the gerontological considerations for a client with a UTI? 4. What would you teach a client about preventing further UTI’s

Glomerulonephritis • Inflammation of the glomerulus – Damage  • Blood • Protein • escapes into tubule

Glomerulonephritis • Etiology – Acute • Bacterial infection

– Chronic • Diabetes • Lupus

Nephrotic syndrome •

Group of symptoms (glomerulonephritis) • • • •

Protein in the urine i serum albumin Edema h serum cholesterol

Nephrotic syndrome –

Clinical Manifestation • • • • •

#1 – edema Malaise H/A Irritability Fatigue

Glomerulonephritis •

Assessment and diagnostic findings – – – – –

Edema Proteinuria Hyperlipidemia Hypoalbuminemia Azotemia •

Increased waste product in the blood –

(Urea, Creatinine etc.)

Glomerulonephritis • Complications – Renal Failure – Embolism

Glomerulonephritis • Medical Management – Edema • Diuretic

– Inflammation • Glucocortioids • NSAID

– Infection • Antibiotics

– Diet • Sodium – i

• protein – h – Azotemia i

• Fat – i

Glomerulonephritis • Nursing Management - Edema – qD weight – I&O – Abd. Girth – Clean skin – Diet per order

Kidney stones /Renal Calculi • Risk factors – – – –

Dehydration Urinary stasis Infection Immobility

Renal calculi or nephrolithiasis • Clinical Manifestations – Pain • Abd / flank • Severe • N&V

– Hematuria

Renal calculi or nephrolithiasis •

Assessment and diagnostic findings – – – –

UA X-ray CT-scan/MRI Cystoscopy

Renal calculi • Cystoscopy – Lighted scope to inspect bladder – Gen anesthesia

Renal calculi •

Medical management –

Pain relief • •

– –

Opioid analgesic NSAIDs

Diuretics? Antibiotics?

Renal calculi •

Medical management –

Diet • • •

Fluids i protein i Sodium

Renal calculi or nephrolithiasis •

Surgical Management – –

If > 4mm will not pass through ureter If not pass spontaneously or if complications  surgery

Nrs Dx: Acute Pain / Deficient knowledge to prevent recurrence of renal stone • Admin Meds – opioid agents – NSAIDS

• Position of comfort • Amb. • Heat to flank

• Fluids –h

• • • •

Assess urine I&O Strain urine – gauze Avoid dehydration

Small Group Questions 1. What are the classic clinical manifestations fro a client with Glomerulonephritis 2. What causes Glomerulonephritis 3. What are the medical interventions for a client with Glomerulonephritis 4. What are the specific nursing interventions of this client 5. What are the S&S of renal calculi 6. How is a renal calculi treated?

Cancer of the urinary tract •

Pathophysiology –

Most common site •

–

Bladder

Carcinogen •

– –

#1 Tobacco

Metastasize early 1/3 have metastasis at time of diagnosis

Cancer of the urinary tract • Clinical Manifestations – Initial • Painless hematuria

– Late • Frequency • Dysuria

Cancer of the urinary tract • Medical treatment – Goal: • Eradicate before metastasis – Surgery » Cystectomy » Nephrorectomy

• Radiation • Chemotherapy

Renal Failure • Kidneys unable to remove accumulated waste products from the blood – Acute – End-stage

What is the medical term for accumulation of waste product in the blood? • Azotemia

Acute Renal Failure • Abrupt onset • Often reversible • Etiology – Trauma – Infection

Acute Renal Failure: S&S • Oliguria – Urine < 400 mL/day

• BUN –h

• GFR –i

• Azotemia – Confusion – Na+ & H2O retention • Edema • HTN

– Hyperkalemia

End Stage Renal Failure • Gradual kidney destruction

End Stage Renal Failure: S&S • Uremia – – – – –

(Urine in the blood) N/V Weakness Fatigue Confusion

Renal Failure: Tx • No nephrotoxic drugs – NSAID’s

• Antihypertensives • Diuretics • Fluid – Restriction

• Sodium – Restriction

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

• Osmosis – Excess water is removed by osmosis

Hemodialysis •

A machine with an artificial semipermeable membrane used for the filtration of the blood.

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 • Frequency – 2-3 times a week – Total • 9-12 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 • Complication – INFECTION

• Usually 4 x day – 7day/wk