21/10/15

The Urinary System

Bones can break, muscles can atrophy,
glands can loaf, even the brain can go to
sleep without immediate danger to survival.
But should the KIDNEYS failneither
bone, muscle, gland nor brain could carry
on.

KIDNEYS

ANATO MY

21/10/15

CO
LU

M
NS

HILUS

MEDULLA
CALYCES
PYRAMIDS

RENAL ARTERY AND VEIN

1.Outer renal fascia

2.Middle adipose capsule
3.Inner renal capsule

RENAL PELVIS
URETER

CORTEXjA

Distinct Regions:
RENAL
MEDULLA

1.Outer Renal cortex

2.Inner Renal medulla

RENAL
CORTEX

SUMMARY

21/10/15

NEPHRONS
Functional and
Structural Unit
of the Kidneys
Each kidney contains
800 thousand to 1.2
million nephrons

Renal Corpuscles
Renal Tubules

CLASSIFIED as:
A.Cortical
B. Juxtamedullary

o Glomerulus
clusters of capillaries;
Site of Filtra1on

o Bowmans capsule
cup-shaped upper
e n d o f t h e r e n a l
tubules

Podocyte with
Basement
Membrane
Glomerulus

Bowmans Capsule

21/10/15

Renal Corpuscles
Renal Tubules

These are canals that

reabsorbs selected
materials back into
the blood and secrete,
collect, and conduct
urine.

Filters plasma at the glomerulus

Reabsorbs and secretes dierent
substances along tubular structures
Filters a ltrate of protein free plasma
Regulates the ltrate to maintain body
uid volume, electrolytes and pH within
acceptable limits

21/10/15

1. To regulate the volume or control

uid and electrolyte balance
2. To excrete waste products from the
body
3. Controls of acid-base balance
Major Functions of the Kidneys

4.Regula1on of Arterial Blood Pressure/

H2O Balance
5.Produc1on of erythropoie1n
6.Ac1va1on of Vitamin D

Major Functions of the Kidneys

URINE FORMATION

1. Filtration (Blue Arrow) is the movement of

materials across the ltration membrane into the
lumen of the Bowmans capsule to form ltrate

21/10/15

2.Reabsorption
Solutes are reabsorbed (purple arrow) across the
wall of the nephron by transport processes, such as
active transport and cotransport.
Water is reabsorbed (green arrow) across the wall
of the nephron by osmosis.

3. Secretion Solutes are secreted (orange

arrow) across the wall of the nephron into
the ltrate.

21/10/15

Color: Clear- Amber Yellow

hematuria,diluted,concentrated etc
Appearance: Clear
hazy/cloudy etc
pH: 4.6 8.0
indicates ability to maintain balanced pH
Odor: AromaMc

Specic Gravity: 1.005 1.030
reects urine concentra1on

Ketones: NegaMve
Protein: None
Glucose: None
RBC: None
WBC: None
Bacteria: NegaMve

pH

6.0

pH

6.8

Appearance

Clear

Appearance

Hazy

Color

Light Yellow

Color

Amber

Odor

AromaMc

Odor

AromaMc

Spec. Gravity

1.0015

Spec. Gravity

1.0020

Protein

None

Protein

Trace

RBCs
WBCs

None
2/hpf

RBCs
WBCs

2/hpf
15/hpf

URETERS

21/10/15

Ureterovesical JuncEon

Ureteropelvic JuncEon

Urinary Bladder

URETHRA

Assessment of Renal Function

21/10/15

...Biographical Data

BIOGRAPHICAL AND
DEMOGRAPHIC DATA

Age
Gender
Marital Status
Race
OccupaMon
Geographical LocaMon
Sexual preferences/pracMces

...Symptom Analysis

CURRENT HEALTH, CHIEF

COMPLAINT AND SYMPTOM
ANALYSIS

Changes in Urinary Volume

a)Anuria
b)Oliguria
c) Polyuria

...Symptom Analysis
Changes in Urine CharacterisMcs
a) Concentrated
b) Diluted
c) Hematuria
d) Pyuria
e) Proteinuria
f) Pneumaturia

...Symptom Analysis
IrritaMve/ObstrucMve ManifestaMons


5. Dysuria
1.Frequency
6. Nocturia
2.Urgency
3.Hesitancy

7. InconMnence
8. Dribbling

4.RetenMon

21/10/15

Pain
TYPE

PAIN

LOCATION CHARACTER

CVA; Flank
KIDNEY
URETERAL Radiates to
abdominal area/
umbilicus
BLADDER Suprapubic
URETHRAL Along Urethra

Dull, Constant
Severe, Sharp, Stabbing,
Colicky in nature
Dull, conMnuous
Intense with vodiing
Variable, may be during
or ager voiding

FAMILY HISTORY
CHILDHOOD DISEASES
PAST HEALTH
HISTORYLIFESTYLE,
DIET, AND WORK
HISTORY

Physical Assessment
(Urinary System)

Lower Abdomen should be at and

nondistended, no masses
Urethral orice should be pink and without
discharge and lesions
Physical Assessment

10

21/10/15

The bell of the stethoscope maybe used
to auscultate over CVA and upper
abdominal quadrants.
The abdominal aorta and renal arteries
are auscultated for a bruit.

Physical Assessment

Tenderness in the Flank Area may be

detected by st percussion (kidney
punch)
Normally, a rm blow in the ank area
should not elicit pain.

Physical Assessment

A l a n d m a r k u s e f u l i n
locaMng the Kidneys is the
c o s t o v e r t e b r a l a n g l e .
(Formed by the rib cage and
the vertebral column)
Lower pole of Right Kidney
is maybe palpable, smooth
and non tender, no masses
LeV Kidney is non palpable.

Laboratory Tests
Urine Studies
Blood Studies

rinalysis
U
CreaMnine Clearance
Urine Culture

11

21/10/15

Creatinine Clearance

Urinalysis
I t d e t e r m i n e / e x a m i n e t h e
p r o p e r M e s o f u r i n e
microscopically.

Also called 24 Hour Urine CollecMon

A laboratory test for esMmaMng
glomerular ltraMon rate of the kidney.
Normal Urine CreaMnine:
14-26mg/kg in 24 hours

Procedure
Collect 24 hour urine specimen
Discard rst urinaMon when test is started.
Save urine from all subsequent urinaMons for
24 hour
Instruct paMent to urinate at the end of 24

Ensure that the serum CreaMnine is

determined during the 24 hour urine
collecMon

hour and add the specimen to collecMon

Urine Culture

Is an asepMc collecMon of urine

commonly used to diagnose urinary
tract infecMon.

Male

Female

1. Wash hands
2. Cleanse the labia from front
to back
1. Wash hands
3. While keeping the labia
separated, void a small
2. Cleanse the meatus
amount into the toilet
3. Void a small amount
4. Without interrupMng the
into the toilet
urine stream, void directly
into the specimen container
4. Void directly into

the specimen
container

12

21/10/15

Blood Studies
Serum CreaMnine
Normal: 0.6-1.2mg/dL (males)
0.4-1.0mg/dL (females)
BUN
Normal: 6-20mg/dL (Adults)

Diagnostic Tests
Non Invasive
Invasive

Radiography

a)Kidneys , Ureters, Bladder

b)Intravenous Pyelography

KUB
Is an x-ray examinaMon which provides informaMon
regarding the structure, size, and posi1on of abdominal
organs.
Urinary System - CalcicaMons of the renal calyces or
renal pelvis as well as any radiopaque calculi present in
the urinary tract may be visualized.

There are NO food, uid, medicaMon restricMons unless
by medical direcMon.

13

21/10/15

IVP
A test which uses IV radiopaque
contrast medium/dye to visualize
kidneys, ureters, bladder and
renal pelvis.

Post-Test
Force uids.
Assess venipuncture site for
bleeding
Monitor V/S ; U/O

Pretest
Assess for iodine sensi1vity.
Obtain consent
Inform client he will lie on a table throughout
procedure.
Administer enema the night before.
Keep the client NPO for 8 hours pretest.
Inform client about possible side eects like
throat irritaMons, ushing of face, warmth or a
salty taste that may be experienced during the
test

...MRI
It is used to visualize the Urinary
System.
It is very sensiMve in dierenMaMng
between cysts and neoplasm.
It creates a vascular map of arteries
a n d v e s s e l s w h e n u s e d
preoperaMvely.

14

21/10/15

...Ultrasonography
It can be used to evaluate the size of
the kidneys and diagnose solid
tumors and cysts.
It helps in localizing and mapping the
kidneys before biopsy.

...Urodynamic Studies
Are used to evaluate manifestaMons
of voiding dysfunc1on/abnormali1es
related to pathology of the lower
urinary tract. (Bladder and Urethra)

...Urodynamic Studies
Residual Urine (Post void Residual)
urine leV in the bladder aVer voiding

Uroowmetry
measures volume of urine voided/sec
Cystometrogram (CMG)
Evaluate bladder capacity and neuromuscular

fxns of the bladder, urethral pressures and

causes of bladder dysfunc1ons

15

21/10/15

...Endoscopy
It is used to evaluate and treat condi1ons
in the urinary tract.
Provides direct visualiza1on of the lower
urinary tract - areas not usually visible
with x-ray procedures.

Post Test
1. Observe for bright red bleeding, which is not
normal
2. Explain that burning on urinaMon, pink-Mnged
urine and urinary frequency are expected
eects.
3. Oer warm sitz baths, and mild analgesics to
relieve discomfort.

Pretest
NPO/Restrict food and uids for 8
hours.
Make sure a wri_en informed
consent has been signed prior to the
procedure and before administering
premedicaMons.

...Renal Angiography
Test which uses a radiopaque
iodine contrast material
Allows x-ray visualiza1on of the
large and small arteries of the
renal vasculature and parenchyma
or the renal veins and their
branches.

16

21/10/15

Preparation/ Procedure
Establish intravenous access. AnMcoagulants are
disconMnued.
Client should remove jewelry/metal objects
Client is posiMoned supine.
Arterial site is cleansed: Femoral artery
A radiopaque contrast material is injected through
a catheter
Rapid and series of radiographic lms are taken to
record circulaMon.

Post Test

Apply pressure over the site for 15

minutes. Apply pressure dressing.
Monitor catheter site for bleeding,
inammaMon, hematoma formaMon.
Monitor vital signs and urine output.

...Renal Biopsy
It is the excision of a 1ssue sample
from the kidney for microscopic
a n a l y s i s t o d e t e r m i n e c e l l
morphology and the presence of
1ssue abnormali1es.

17

21/10/15

Pre Test

Make sure that a wrijen consent has been signed prior

the procedure and before administering medicaMons.
NPO for 6-8 hours.
Obtain history of paMents immune system and any
bleeding disorders based on previously performed
laboratory tests (especially bleeding Mme, complete
blood count, platelets, PT, PTT, BUN and CreaMnine)
Obtain medicaMon history especially paMents who are
taking anMcoagulant.

PHARMACOLOGY

Post Test
Apply pressure to the site for 5-20 minutes. Observe
site for bleeding.
Tissue samples are placed in formalin soluMon.
Closely monitor vital signs.
Blood maybe seen in the urine ager the rst few post
procedural voiding.
Monitor I and O.
Administer medica1ons. (analgesics and anMbioMcs)

DIURETICS

DIURETICS
URINARY ANALGESIC
URINARY ANTI INFECTIVES

Ac=on:
Inhibits reabsorpMon of water, potassium,
sodium and chloride in the ascending Loop of
Henle
Increasing water excreMon.

Example:
Furosemide (Lasix)
Bumetanide (Bumex)

Ac=on:
Blocks Sodium reabsorpMon in the DCT, which
prevents water reabsorpMon;
Increases urine output;
Decreases blood volume
Potassium maybe also excreted
Example:
Chlorothiazide (Diuril)

18

21/10/15

Ac=on:
Acts by blocking aldosterone receptors in the
kidneys, thus causing excreMon of water and
sodium and potassium retenMon.
Example:
Spironolactone (Aldactone)

Ac=on:
Promotes renal excreMon of sodium,
potassium, bicarbonate and water in the renal
tubules
Example:
Acetazolamide (Diamox)

DescripEons
Exert an anMbacterial eect on renal Mssue,
ureters, and bladder
Used to treat local UTI
Available in oral and IV
preparaMons

Ac=on
Acts by increasing osmo=c
pressure in the glomerular
ltrate inside the renal tubules.
This causes less reabsorpMon of
uid and electrolytes by tubules
and increased loss of uid,
chloride, and sodium.
Example:
Mannitol (Osmitrol)

A resin that exchanges sodium ions for

potassium ions in the large intesMnes.
Used in the treatment of hyperkalemia.
Example:
Polystyrene Sulfonate
(Kayexalate)

Example:
Nitrofurantoin (MacrodanMn)
Sulfonamides (Sulfadiazine)
Side eects:
n/v; skin rash; CNS disturbances
Blood dyscrasias

19

21/10/15

Descrip=on
An dye excreted in the urine
which provides a topical
analgesic eect to the
urinary tract.

Example:
Phenazopyridine (Pyridium)
Side Eects
Urine may become reddishorange and can stain fabrics
Stop drug if sclera or skin
turn yellow a sign of drug
accumulaMon

URINARY TRACT INFECTION

Etiology and Risk Factors

Most commonly due to infection

by the bacteria Escherichia coli.

Risk Factors
Female
Short, straight urethra
Proximity of meatus to vagina
to anus
Sexual Intercourse
Use of diaphragm/spermicidal
compounds for birth control
Pregnany

20

21/10/15

Risk Factors
Female
Male
Uncircumcised
ProstaMc hypertrophy
Anal intercourse

Risk Factors
Both
Aging
Urinary Tract ObstrucMon
Neurogenic bladder dysfuncMon
Vesicoureteral reux
GeneMc Factors
CatheterizaMon

PYELONEPHRITIS
It is the inammaEon of the renal pelvis
and parenchyma caused by bacterial
infecEon.

Two Main Types
a. Acute
b. Chronic

oWomen pregnant, practice poor genital

hygiene, sexually active, anatomic difference
(urethra is shorter and urinary meatus is closer to
rectum.)
oMen may arise as a complication of prostate
enlargement

Pathophysiology
Bacteria enters the renal pelvis
Causing Inflammatory Response
Edema, Swelling,

Increased in WBC

Spreading to the Cortex

oUrinary Obstruction
oCystitis, Neurogenic bladder
oCatheterization, Cystoscopy,
Urologic instrumentation

Caliceal abnormalities and cortical

scarring
Decreased number of functioning
nephrons

21

21/10/15

Clinical Findings

Subjective

Objective
vNausea and vomiMng
vLab data:
oBlood - increased WBC
oUrine increased WBC,
h e m a t u r i a , p r o t e i n u r i a ,
p o s i M v e c u l t u r e s , f o u l
smelling
oIVP may manifest structural
changes

vPain:
vank, one or both sides; dysuria, pyuria
Clinical Findings
vLoss of appeMte
vFever, chills
vUrinary frequency and urgency
vUrine cloudy, bloody, malodorous

Diagnostic Tests/Lab
Findings
1.Urinalysis and
Culture and sensitivity, (+) bacteria
2. CBC (+) WBC
3. X-ray; KUB
4. BUN, Creatinine
5. IVP, UTZ

Nursing Diagnosis
1. Altered urinary eliminaMon related
to kidney disease/infecMon
2.Pain related to inammaMon/kidney
damage

3 . H y p e r t h e r m i a r e l a t e d t o
inammaMon

Pharmacology
1. AnMbioMcs depending on the
culture and sensiMvity result
2. Analgesic (Pyridium)
3. AnMpyreMc

Nursing Outcomes/Goals
Overall goals:
1.
2.
3.
4.
5.

Normal renal funcMon

Normal body temperature
Prevent complicaMons
Relief from pain
Prevent recurrence of symptoms

22

21/10/15

Nursing Interventions
Goal:
Combat infecEons, prevent recurrence,
alleviate symptoms

MedicaMons
Fluids: 1500 2000ml/day
vto ush kidneys
v relieve dysuria
v reduce fever
vto prevent dehydraMon

Observe hydraMon status:

vI and O, daily weight; skin
turgor.
vurine check for protein
vB l o o d m o n i t o r f o r
hypertension, tachycardia
Hygiene
v MeMculous perineal care

Nursing Interventions
Cooling measures: TSB for fever

Diet:
vSucient calories and protein to
prevent malnutriMon
v Acid-ash diet to prevent renal
calculi
vIncrease uids

Nursing Interventions
Goal: Health Teaching
Medications:

Nursing Interventions
Goal:
qPromote physical & emotional rest

AcMvity:
v Bed rest or as tolerated;
encourage ADLs as tolerated
EmoMonal support
v Encourage expression of fears,
v Include family in care; answer
quesMons

Chronic Pyelonephritis
Causes about 2 to 3% of end-stage renal disease

v take regularly, watch out for side effects

Personal care:
v
v
v
v

perineal hygiene,
avoid urethral contamination;
avoid tub baths
Stress the need for frequent hand washing

Possible recurrence with pregnancy

Void at the first urge to prevent bladder
distention and stasis

Chronic pyogenic infecMon of the kidneys

Atrophy and calyceal deformity with overlying
parenchymal scarring

23

21/10/15

HYDRONEPHROSIS

HYDRONEPHROSIS

Is the distention of the renal pelvis and

calyces of a kidney due to pressure
from accumulating urine.

Is the distention of the renal pelvis and

calyces of a kidney due to pressure
from accumulating urine.

The pressure impairs, and may

eventually interrupt kidney function.

The pressure impairs, and may

eventually interrupt kidney function.

One or both kidneys may be affected.

One or both kidneys may be affected.

Pathophysiology
It is caused by urinary tract obstruction.
(Calculus, tumor, scar tissue, congenital
structural defects, and kink in the ureter)
Accumulating urine exerts pressure on the
renal pelvis wall

Over time, sustained or intermittent high

pressure causes irreversible nephron
destruction.
Infection is always a risk secondary to
urinary stasis.

Clinical Findings
The signs and symptoms depend on the site of
obstruction, the cause and the rapidity with
which the condition developed.
The person may complain of:
vintense flank pain,
vnausea and vomiting,
voliguria, anuria and hematuria.
Palpation and percussion of abdomen may reveal
distention of the kidneys.

24

21/10/15

Diagnostic Tests/Lab Findings

1. Serum Creatinine/BUN - Increased
2. Urinalysis and Culture (+)Infection
3. Serum Electrolytes Increased
4. IVP;UTZ Dilated ureters, kidneys

Nursing Outcomes
Treatment aims to:

Relieve obstruction and

Prevent infection
Treatment/Pharmacology:
Surgery to relieve obstruction and restore
adequate drainage

IVP
RESULT

Nursing Diagnosis
Risk for Altered Renal Perfusion
Pain
Risk for infection related to Urinary
Stasis

Antibiotics to prevent infection

Antispasmodics for colicky spasm

Nursing Interventions/
Patient Teaching

v Teach the importance of adequate fluids

v Explain the importance of notifying the
physician at the first sign of inability to void or
urinary infection
v Be sure the patient, family and caregiver
understands all medications prescribed
including dosage, route, action, and adverse
effects.
v Care of indwelling catheters.
v Explain measures to prevent UTI

25