PN-114-3 Urinary system

Anatomy of the urinary system

\-2 kidneys

\-2 ureters channel urine to bladder

\-Bladder-muscular sac that stores urine

\-Urethra

\-Kidneys from urine, and the rest of the system eliminates it

\-Urine formation is to help remove potential toxic products from the blood

Nephron

\-Functional and structural unit of the kidney

\-Urine is formed in approximately 1 million nephrons per kidney

\-Composted of a renal corpuscle and a renal tubule

\-Renal corpuscle consists of capillaries called glomerulus

\-Tubular system contains the PCT loop of Henle, DCTs, & collecting tubule

Glomuler filtration

\-first step of urine production from nephrons. BP forces water and small solutes out of the glomeruli and into Bowman's capsules. This fluid is called renal filtrate. Renal filtrate then enters the renal tubules

\-Glomerular filtration rate (GFR)= the amount of blood filtered by the glomeruli in a set amount of time (Norm= 125L/min)

tubular reabsorption

second step of urine production from the nephrons. is the recovery of useful materials (water and solutes) from the renal filtrate and their return to the blood

tubular secretion

third step of urine production from the nephrons. substances are actively secreted from the blood into the filtrate "Kidneys are organs most responsible for maintaining the normal pH of blood and tissue fluid

Normal urine amount

normal urinary output is 1000-2000 ml/24 hrs. Want to secrete 30 ml/hr. minimum

Normal color of urine

straw or amber. If diluted will be a lighter color. If cloudy could indicate infection

Normal specific gravity of urine

measure of dissolved materials in urine. Norm is 1.005 to 1.030

normal pH of urine

range of urine is 4.6-8.0 with average of 6.0; diet has the greatest influence on urine pH

normal constituents of urine

normal are urea, mineral salts, uric acid, creatinine, water. Abnormal \=sugar (ketones), pus, bacteria, acetone, albumin, blood, bile, nitrates

Aging and the urinary system

\-With age, number of nephrons in the kidneys decrease often to half of the original number by age 70-80

\-Renal flow decreases by 50%

\-GFR decreases

\-Urinary bladder decreases in size and tone decreases

\-Increased frequency and nocturia

\-Older adults more prone to infections of the urinary tract

\-Meds are excreted through kidneys (slows the excretion of some meds as people age)

Health history and the urinary system

\-age, gender, occupation, habits, medical history, urinary problems, new onset of symptoms, diet and fluid intake

\-Want a complete head to toe assessment

\-Pain in the flank or abdominal areas can be an indicator of renal problems or disease

Daily weights and the urinary system

weight is best indicator for fluid balance in the body; with renal disease often have fluid imbalances. Weighed at same time each day on same scale

Skin and the urinary system

inspected; can be yellow or gray cast with chronic disease. Presence of crystals on the skin is called uremic frost and is a late sign of waste products building up in the blood (uremia)

Intake and output and the urinary system

patient with kidney disease will be on fluid restriction. I/O needs to be carefully monitored

urinalysis

may be collected at any time of day, but first morning specimen is the best. Run it through machine to test for abnormalities. Clean perineum before collecting specimen. Collect urine mid-stream

Urine culture and sensitivity

determines number of bacteria and identifies organism. Sensitivity determines the most effective antibiotic to use. Clean catch or cath.

Urine creatinine clearance

best test of overall kidney function, amount of creatinine cleared from blood in 24 hours and determines renal function

first step of urine creatinine clearance

At start, patient is directed to void and discard that urine

Second step of urine creatinine clearance

Urine is collect for 24 hours in a large container. Keep refrigerated

Third step of urine creatinine clearance

24 hours after test; patient needs to void again. This urine is added to collection container

Fourth step of urine creatinine clearance

Lab collects serum creatinine during this 24 hour period

BUN

blood, urea, nitrogen; waste products of protein metabolism- increased BUN can indicate kidney disease, renal failure can be affected by increased protein diet, dehydration, GI bleed (norm- 8-21 mg/dl)

Serum creatinine

creatinine is waste product from muscle metabolism and is released into bloodstream (norm\=0.61-1.21 mg/dl- males; 0.51-1.11mg/dl- females). Good indicator of kidney function

Serum electrolytes

Na+, K+, Ca+

Cyastatin C

sensitive marker that reflects glomerular filtration rate (increases with impaired renal disease)

KUB

x-ray of kidneys, ureter, bladder. Looks at size, shape, and stones

IVP

intravenous pyelogram; IVP dye will outline kidneys and follow urine flow; checks kidney function. Enemas may be given the night before to empty colon

retrograde pyelogram

small catch placed into ureter during a cystogram and dye injected; checks urine flow

cystogram

cath inserted or cystoscope, dye is injected into bladder and evaluates bladder filling and emptying, distention, reflux, obstruction

Renal ultrasound

diagnosis of congenital abscesses, hydronephrosis, tumors, kidney stones

Renogram

radioactive substance injected to detect lesions. The amount of dye filtered and drained by the kidneys can be analyzed by a computer. Perfusion, function and drainage of the kidney can be determined

cytoscopy

Surgical procedure that views the urethra, bladder, ureteral openings by scope. May remove small bladder tumors, polyps, stones, treat enlarged prostate or congenital abnormalities

Nursing interventions for cystoscopy

Give post-op analgesics, encourage fluid intake, dysuria for 24 hours and initial voiding to be blood tinged. Measure urine output to detect retention from swelling of meatus

Complications from cystoscopy

UTI, urine retention, bladder perforation

Renal biopsy

\-Diagnose or provides information about kidney disease such as benign and malignant masses, causes of renal disease, transplant rejection

\-A CT scan or ultrasound is done first to locate the kidney for biopsy

\-A small section of the renal cortex is obtain for the lab either percutaneously or with small flank incision

What patient's are not eligible for renal biopsy

bleeding tendencies, uncontrolled hypertension, or a solitary kidney

Nursing considerations for renal biopsy

\-NPO 6-8 hrs. prior

\-No anticoagulants

\-Mild sedative given

\-Prone position with sandbag under abdomen

\-Monitor VS post-op

\-Monitor for bleeding 24 hours post-op

\-No heavy lifting for 2 weeks

Urinary incontinence

involuntary leakage of urine; very common

Management of urinary incontinence

\-Keep voiding diary

\-Refer to urologist to identify cause/treatment

\-Incontinence that cannot be treated is managed by the use of padding and absorptive products

Stress incontinence

\-Involuntary loss of less than 50 ml of urine associated with increasing abdominal pressure during coughing, sneezing, laughing, or other physical activities

\-Common in women after child birth and menopause

\-Common in men with prostatectomy and radiation

\-Taught Kegel exercises to increase perineal muscle tone; do sets of 10 three times per day

\-Void at frequent intervals (q 2 hrs.)

\-Use urge inhibition techniques

Urge incontinence

\-Involuntary loss of urine associated with abrupt and strong desire to voids

\-Patient usually cannot make it to the bathroom in time

\-Most common type of urinary incontinence in older adults

\-Taught Kegel exercises to increase perineal muscle tone; do sets of 10 3x per day

\-Use urge inhibition techniques

Functional incontinence

\-Inability to reach the toilet because of the environmental barrier, physical limitations, loss of memory, or disorientation

\-Usually dependent on others and have no other urinary problems

\-Common in people who are often institutionalized

\-Teach patients to wear clothing that is not restrictive and easy to remove (sweat pants)

\-Provide appropriate urinary receptacles (commode, urinal)

Overflow incontinence

\-Involuntary loss of urine associated with over-distention of the bladder

\-It occurs with acute or chronic urinary distention with dribbling of urine

\-Bladder is unable to empty normally despite frequent urine loss

\-Spinal cord injuries or enlarged prostate may cause overflow incontinence

Total incontinence

\-Continuous and unpredictable loss of urine

\-Usually results from surgery, trauma, or malformation of ureter

\-Bladder training is ineffective

\-Patient is often neurologically impaired

\-Goal is to keep patient dry and clean

Management of urinary retention

\-Urine retention is the inability to empty the bladder completely during attempts to void

\-Many factors can cause this

\-Can be acute/chronic

\-Can palpate bladder to see if distended

\-Use bladder scanner; scan assesses the volume of urine in the bladder

\-Painless; non-invasive

\-Normally bladder contains less than 50 ml after urination

\-Residue volume of 15-200 ml of urine indicates need for treatment of urine retention

Indwelling catheters

\--Inset for various reasons

\--Short term use because of UTIs

\--Bacteria enter 1) around catheter up urethra into bladder 2) through outlet at the end of the collection bag contaminating urine; which goes back into bladder

\---Routine catheter care done

\---Encourage fluid intake

\---Maintain closed system

\---Secure to patients leg

\---Remove asap

Intermittent catheterization

\--For pt. who is unable to void

\--Best for patients post-op, neurologic disorder, or urine retention

\--Reduces the risk of infection as long as the bladder is not allowed to overfill

\--Cath every 3 hours to empty bladder

\--Maybe taught to self-Cath at home

suprapubic catheter

\-Used for long term situations

\-Indwelling Cath that is inserted through a surgical incision in the lower abdomen directly into the bladder

\-Need to keep the area clean and dry, changing dressing, keep it taped to prevent tension

Urinary tract infection (UTI)

\-refers to the invasion of the urinary tract by bacteria

\-Urinary tract is sterile above the urethra

Most common bacterial disease and Hospital acquired infection

UTI

Lower UTI

urethritis, prostatitis, and cystitis

Upper UTI

pyelonephritis and urethritis

Path of UTI

caused most often by an ascending infection, starting at the external urinary meatus and progressing towards the bladder and kidneys

What causes most UTI infections

E. Coli

Risk factors for UTIs

\-Incomplete bladder emptying

\-Contamination in perineal and urethral areas

\-Instrumentation infection

\-Faulty valves causing reflux of urine

\-Previous UTIs

\-Female anatomic and genetic differences

\-Pregnancy

\-Age and urinary tract

Signs and symptoms of UTI

\-Dysuria

\-Urgency

\-Frequency

\-Incontinence

\-Nocturia

\-Hematuria

\-Back pain

\-Cloudy, foul smelling urine

\-Fatigue (common in elderly)

\-Decline in mental status

\-Fever

Urethritis

inflammation of the urethra that may result from a chemical irritant, bacterial infection, trauma, or STDs (gonorrhea and chlamydia)

Common irritants leading urethritis

\-Bubble baths/salts common urethral irritants

\-Spermicidal agents

Signs and symptoms of urethritis

frequency, urgency, dysuria, discharge from penis

How is urethritis diagnosed?

UA or urine culture

Treatment for urethritis

based on cause

Pyridium

urinary analgesic, is often used to treat dysuria (turns urine orange)

If sexually transmitted urethritis

partner must be treated

Cystitis

inflammation and infection of the bladder wall

cause of cystitis

bacteria, viruses, fungi, or parasites

How do organisms cause cystitis

first grow in the perineal area then ascend into bladder

Signs and symptoms of cystitis

dysuria, frequency, urgency, cloudy urine

Types of Cystitis

complicated and uncomplicated

How is cystitis diagnosed

urinalysis

Cystitis treatment

uncomplicated cystitis-sulfa meds (Bactrim, Septra, or macrodantin)

Nursing care for cystitis

patients must finish all prescribed meds regardless or symptoms, force fluids, and follow up with appointments

pyelonephritis

infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys

What causes pyelonephritis

Begins with colonization and infection of lower urinary tract; small abscesses throughput kidney and gross enlargement of the kidney

What type of conditions are already existing to cause pyelonephritis

obstruction, strictures, stones

Risk factors for for pyelonephritis

urological surgery, lymphatic infection, urinary stasis, and decreases immunity

Signs and symptoms of pyelonephritis

fatigue, urgency, frequency, dysuria, flank pain, fever, chills, costovertebral tenderness pain, cloudy urine with RBCs, nitrates

Diagnostic tests of pyelonephritis

will help differentiate pyelonephritis from cystitis. Urinalysis will show casts in kidney infection, have more than 100k colonies of bacteria

Treatment for pyelonephritis

antibiotics, antispasmodic agents

Nursing interventions for pyelonephritis

\-Force fluids 2-3 L (3k ml) per day

\-Avoid caffeine, alcohol

\-Empty bladder

\-Encouraging voiding q 3 hrs.

\-Avoid bubble baths and scented toilet paper

\-Wear cotton underwear

\-Drink cranberry juice to prevent bacteria from sticking on the walls of bladder

\-Administer antispasmodic agents and antimicrobial therapy for pain and discomfort from inflammation

\-Monitor urinary elimination

\-Educate- finish all prescribed meds to prevent recurrent infections

Urethral structures

\-A narrowing of the lumen of the urethra caused by scar tissue

\-More prevalent due to rising incidence of STIs

\-Some result from trauma from insertion of catheters or surgical instruments, congenital abnormalities, or untreated gonorrhea

\-Diminished urinary stream and prone to UTIs

\-Usually seen in older men

Treatment for urethral stricture

mechanical dilation; if continues surgical repair (urethroplasty) with stent

renal calculi

\-Kidney stones made up of masses of crystals and protein that form when urine becomes supersaturated with a salt capable of forming solid crystals

\-Different types of stones

\-Diet and lifestyle can play a role in development

\-Stones may form in ureter or bladder, Stones less than 6 mm are readily passed in urine

\-Stones found in kidneys called nephrolithiasis

Etiology/ signs and symptoms of renal calculi

\-Family history

\-Chronic dehydration

\-Infection

\-Dietary factors

\-Meds may cause stone formation

\-Excruciating flank pain and renal colic

\-Costovertebral tenderness

\-N&V

\-Diarrhea

\-Hematuria

Prevention of renal calculi

\--Consult dietician

\--Encourage fluid intake

\--Encourage pt. to walk

Complications of renal calculi

\--Renal calculi increases the risk for UTIs

\--If untreated can result in retention of urine and damage to kidney (hydronephrosis)

Diagnostic tests for renal calculi

\-Helical CT without contrast

\-Urinalysis-hematuria

\-24 hour renal creatinine clearance-measures total urine

\-KUB-reveals most calculi

\-Ultrasound-identify stone in the renal pelvis, calyx, or ureter

\-Retrograde pyelography- identify the anatomic location of the stone

Therapeutic measures for renal calculi

\-Most small stones are flushed out of body during urination

\-Can pass stone if 5mm or smaller

\-All urine must be strained to detect passage of stone; pain meds

\-Lithotripsy- use of sound, laser, or dry shock waves to break stone in small fragments

\-Surgery-endoscopic or open surgery

hydronephrosis

\-Distention of the renal pelvis and calices

\-Results from untreated obstruction of urine flow in the urinary tract

\-Kidney enlarges as urine collects in the pelvis and kidney stones

\-Usually treatable

Signs and symptoms of hydronephrosis

\-commonly develop UTIs, have frequency, urgency, dysuria, flank and back pain

\-Treatment=want to remove obstruction; insert indwelling catheter, surgery, stents, or nephrostomy tube insertion (make sure there are no kinks or clamps with tubes to allow urine to flow)

Complications of hydronephrosis

UTI, urine retention, kidney failure

Most common cancer of the urinary tract

bladder cancer

Who primarily gets bladder cancer

Caucasian men around the age of 73

How does bladder cancer start

\-Starts as benign growth on the bladder wall that undergoes cancerous changes

\-Usually begins in the inner lining of the bladder

Causes of bladder cancer

Smoking, exposure to industrial pollution

Signs and symptoms of bladder cancer

\--Usually painless hematuria

\--Bleeding is intermittent, which causes a delay in seeking treatment

\--As progresses; frank hematuria

\--Bladder irritability

\--Urine retention from clots

\--Fistula formation

\--Pelvic pain

\--Painful urination, inability to void

Diagnostic tests for bladder cancer

\--Urinalysis

\--Urine culture

\--Cystoscopy

\--Cystoscopy

\--Transurethral biopsy

\--IV pyelogram

Therapeutic measures for bladder cancer

\-Treatment depends on type and staging of bladder cancer

\-Chemo instilled into bladder through a catheter for small/confined tumors

\-Photodynamic therapy

\-Surgery

\-Incontinent urinary diversion-complete removal of the bladder; urine leaves the body in different manner. Will have an ileal conduit=involved surgery with 6-8 inch section pf the ileum or colon removed and used as conduit for urine. The remaining portions of the bowel are stitched back together. Ileal conduit contains mucus, so will normally secrete mucus strands. Must wear an ostomy appliance at all times to collect urine

\-Continent urinary diversion-done for patient convenience. Kock pouch; segment of the ileum that has been made into a reservoir for urine

\-The ureters are implanted into the side of the reservoir. A special nipple valve is constructed and is the passageway through which the patient inserts a Cath at 4-6 hour intervals to drain urine

Nursing care for bladder cancer

\-Regular post-op care

\-Adequate urinary output and report any obstruction

\-Skin care around stoma

\-Patient teaching on how to care for Cath (urinary diversion) or by wearing an appliance

\-Body image disturbance may occur because of the change in body function

Risk factors for kidney cancer

genetics, smoking, obesity, hypertension, years of kidney dialysis, and exposure to radiation, asbestos, and industrial pollution