Alterations in Renal and Genitourinary Function

Learning Objectives

• Explore risk factors that contribute to clients experiencing alterations in urinary elimination or renal function.
• Differentiate the clinical presentation of clients with urinary or renal alterations.
• Examine the nurse’s role in caring for clients with renal or urinary disorders.

Overview of Common Urinary Conditions

• Urinary Tract Infections (UTIs)
• Urinary Incontinence
• Urinary Retention
• Benign Prostatic Hyperplasia (BPH)

Urinary Tract Infections (UTIs)

Classifications

• Uncomplicated: isolated, otherwise‐healthy urinary system.
• Asymptomatic bacteriuria: bacterial colonization with no symptoms.
• Healthcare-associated: linked to catheters, procedures, hospital stays.
• Affects the urethra, bladder, or kidneys.

Diagnostics

• Urine dipstick: positive nitrates indicate bacteria.

Risk Factors

• Female anatomy (short urethra).
• Indwelling urinary catheter.
• Poor perineal hygiene.
• Sexual intercourse.
• Frequent pelvic exams; diaphragms or condoms with spermicidal foam.
• Diabetes Mellitus (DM) or other immunocompromised states.

Pharmacologic Treatment

• Antibiotics: Bactrim, Sulfatrim (Trimethoprim/Sulfamethoxazole).
• Non-opioid urinary analgesic: Pyridium (Phenazopyridine).
• Cranberry juice (adjunct, not primary therapy).

Client Education

• Wipe front → back.
• Use gentle soaps for perineal cleansing; avoid harsh chemicals.
• Prefer showers over baths.
• Maintain adequate hydration.
• Complete the entire course of prescribed antibiotics.

Urinary Incontinence

Types

• Urge: sudden, strong need to void.
• Stress: leakage with coughing, sneezing, laughing.
• Overflow: constant dribble from over-distended bladder.
• Other: functional, neurological, mixed.

Treatment & Therapies

• Bladder training (scheduled voiding, urge suppression).
• Pelvic-floor (Kegel) muscle training.
• Pharmacology:
  • Urinary antispasmodics.
  • Bladder relaxants.

Urinary Retention

• Etiologies: obstruction, infection, neurologic or other causes.
• Post-void residual (PVR) by bladder ultrasound:
  • $\ge 200\,\text{mL}$ = inadequate emptying.
  • $\ge 400\,\text{mL}$ = urinary retention.

Benign Prostatic Hyperplasia (BPH)

• Non-cancerous enlargement of prostate tissue (males >50).
• Compresses urethra → obstructed urine flow.

Continuous Bladder Irrigation (CBI)

• Ordered post-urologic surgery to flush clots.
• Nurse responsibilities:
  • Maintain accurate I&O.
  • Assess color/clarity/volume of output.

Indwelling Catheters

• Materials: silicone or latex.
• Sizing: French (Fr); larger number ⇒ wider tube.
• Balloon sizes: typically $10 – 60\,\text{mL}$ (marked on inflation port).
• Three-way catheter (for CBI):
  • Port 1 = balloon inflation.
  • Port 2 = bladder drainage.
  • Port 3 = irrigation inflow.

Sterile Specimen Collection

• Do NOT sample from collection bag.
• Use catheter sampling port:
  • Clean with alcohol.
  • Withdraw urine via Luer-lock syringe into sterile cup.

External & Specialty Catheters

• Condom catheters.
• Wick devices (female external).
• Suprapubic catheter: long-term retention, post-surgery; ↑ comfort, ↓ infection risk, easier self-care.

Disorders of Kidney Function

• Pyelonephritis
• Polycystic Kidney Disease (PKD)
• Glomerulonephritis
• Renal Calculi (kidney stones)
• Acute Renal Failure / Acute Kidney Injury (AKI)
• Chronic Kidney Failure (CKF)

Pyelonephritis

• Infection/inflammation of renal pelvis, calyces, medulla (ascending UTI).
• Pathologic changes: scarring, ↓ filtration, reabsorption, secretion.

Classes

• Acute: interstitial inflammation, tubular necrosis, abscesses; temporary function loss.
• Chronic: repeated infections → permanent scarring; associated with obstruction, anomalies, vesicoureteral reflux.

Risk Factors

• Women >65, young sexually active females.
• Older men with prostate issues.
• Chronic stones, spinal cord injury, pregnancy, congenital anomalies.
• Bladder tumors, DM, HTN, chronic cystitis, other chronic illness.

Diagnostics

• Urinalysis (UA) & culture: dark/cloudy, foul odor, bacteria, WBCs/RBCs; \text{WBC} >10{,}000.
• Positive blood cultures.
• Elevated: serum creatinine, BUN, CRP, ESR.
• Imaging: KUB, IV pyelogram, Gallium scan.

Manifestations

• Fever, chills, flank/back/abdominal pain.
• N/V, fatigue.
• Dysuria, urgency, frequency, nocturia.
• Possible asymptomatic bacteremia.

Interventions

• Antibiotics, antipyretics, hydration.

Polycystic Kidney Disease (PKD)

• Genetic; numerous fluid-filled cysts.
• Progressive ↓ kidney function; $\approx 50\%$ reach ESRD by age 60.

Glomerulonephritis

• Acute or chronic inflammation of glomeruli.
• Damaged filtration ⇒ waste retention, electrolyte imbalance.
• Classic sign: cola-colored urine.
• Acute forms may progress to ESRD within weeks–months.

Renal Calculi (Kidney Stones)

• Mineral/salt aggregates lodging anywhere in urinary tract.
• S/S: severe pain, hematuria.
• Dehydration ↑ risk.
• $80\text{–}90\%$ pass spontaneously via urethra.

Acute Kidney Injury (AKI)

• Sudden, usually reversible decline in function.
• Three stages: Risk → Injury → Failure.

Etiologic Categories

• Pre-renal: ↓ renal blood flow (e.g., arrhythmias, tamponade, shock, HF, MI).
• Intra-renal: parenchymal damage (acute tubular necrosis, nephrotoxins, obstetric complications, inflammation, ischemia).
• Post-renal: obstruction distal to kidneys (infection, clots, calculi, edema, tumors, uric acid crystals, BPH, strictures).

Clinical Phases

1. Onset (hrs–days).
2. Oliguric (1–3 wks).
3. Diuretic (2–6 wks).
4. Recovery (up to 12 mos).

Systemic Impact

• Uremic toxins, acid–base & electrolyte imbalance.
• Inflammation, oxidative stress, neuro-hormonal dysregulation.
• Multi-organ effects: encephalopathy, CHF, arrhythmias, lung injury, hepatic/metabolic changes, GI dysbiosis, systemic immune activation.

Treatment

• Re-establish perfusion/function.
• Diet: high calories, low protein, low $\text{Na}^+$, low $\text{K}^+$, fluid restriction.
• Manage hyperkalemia: dialysis, sodium bicarbonate, hypertonic glucose + insulin.

Continuous Renal Replacement Therapy (CRRT)

• 24-hr modality for hemodynamically unstable ICU patients.

Chronic Kidney Failure (CKF / CKD)

• Permanent, progressive damage; common causes: DM, HTN.
• Five stages by estimated GFR (eGFR):
  • Stage 1 >90
  • Stage 2 $60\text{–}89$
  • Stage 3a $45\text{–}59$
  • Stage 3b $30\text{–}44$
  • Stage 4 $15\text{–}29$
  • Stage 5 <15 (ESKD)

Hormonal Considerations

• Erythropoietin: ↓ production in CKD → anemia; replacement drugs: Procrit, Epogen (Sub-Q).
• Renin: key in BP & fluid balance; dysregulated secretion possible.

Dialysis Modalities & Nursing Care

Hemodialysis

• Blood removed via access (fistula, graft, catheter), passes through dialyzer, returned cleaned.

Pre-Dialysis Nursing

• Assess access site: thrill & bruit for fistula/graft.
• Hold antihypertensives as dialysis can ↓ BP (may administer Midodrine if low BP anticipated).
• Obtain current vitals & weight; compare to “dry weight.”

Peritoneal Dialysis

• Dialysate infuses into peritoneal cavity; waste diffuses into fluid, which drains out.

CRRT (see AKI section).

End-Stage Renal Disease (ESRD) Diet

• Restrict:
  • Sodium
  • Potassium
  • Phosphorus

Kidney Transplant

• Definitive treatment for ESRD (slide referenced only).

Key Labs & Diagnostics Recap

• UA: positive nitrates ⇒ bacteria.
• Urine albumin.
• 24-hr urine collection.
• Blood Urea Nitrogen (BUN): $10\text{–}20\,\text{mg/dL}$.
• Serum Creatinine: <1.2\text{–}1.3\,\text{mg/dL}.
• eGFR (see CKD stages).
• Imaging: KUB X-ray (Kidney, Ureter, Bladder).

Ethical & Practical Considerations

• Catheter‐associated infection prevention (CAUTI) protocols.
• Education on antibiotic stewardship.
• Psychosocial support for lifestyle changes (dialysis schedules, diet restrictions).
• Informed consent and cultural sensitivity for transplant decisions.

Connections & Real-World Relevance

• Rising prevalence of CKD due to global diabetes/hypertension epidemic.
• Multidisciplinary approach: primary care, nephrology, urology, dietetics.
• Public-health focus on hydration and UTI prevention in long-term care facilities.
• Emerging technologies: home dialysis systems, wearable CRRT prototypes.