Review normal A&P of male/female urinary systems in textbook & syllabus handouts

Review Diagnostic tests associated with urinary function in Lab/Dx book and in syllabus

Urine control

F&E control

Acid Base Balance

Excretion of wastes

BP regulation

RBC production

Regulation of CA+/Phosphate metabolism

Propel urine from the kidney into the bladder

Collecting bag for urine

Transports urine from bladder to external meatus

STERILE

Infections can occur anywhere along the urinary tract

Let's start at the top…...

An inflammation of the kidney caused by a bacterial infection

Most often occurs as an extension of infectious process located elsewhere in the UT ( Most typically the bladder)

The bacterial spread to the kidney primarily by traveling up the ureter to the kidney

Blood & lymphatic circulation also provide channels for the organism to travel

Ureteral Reflux--which allows infected urine back into the ureter

AND

Obstruction--which causes urine to stagnate & allows organisms to multiply

An acute inflammation of the upper UT that produces pain & edema in the kidney, renal pelvis, and surrounding structures

Characterized by development of abscesses & eventually scar tissue

Inflammation results in destruction & atrophy of the tubules & glomeruli

May cause minimal sx or pt may be completely asymptomatic

Typically, however, pt seems in acute distress

S&S may be minimal to severe

High fever & chills

N & V

flank pain on the affected side

headache

CVA tenderness (percussion/deep palpation)

Increased WBC count

Bacterial & WBCs in urine

Sx of lower UTI such as

dysuria -frequency

urgency -cloudy urine

bloody urine -foul-smelling urine

Frequently the pt has experienced the lower UTI sx for several days before seeking tx & identification of a problem higher in the urinary tract

UA--bacteria, WBCs, possibly blood

Urine C&S

CBC

IVP--determines presence of obstruction and/or kidney enlargement

BUN & Creatinine

Aimed at identification of infection & preventing future episodes

Most common cause is E-coli

Antibiotics

initially broad spectrum

then based on C&S results

usually IV X 3-5 days until pt afebrile for 24 - 48 hours

then oral ABCs for next 2 - 4 weeks

usually continued for 2 weeks after a negative urine C &S (recurrence is common)

Antipyretics

to control fever/discomfort

Surgery

may be necessary to correct any obstruction (calculus, tumor, etc.)

Assessment

Nursing Diagnoses

Goals

Interventions

A slowly progressive disease usually associated with recurrent acute attacks

Kidneys eventually become scarred & contracted from recurrent bouts of acute pyelonephritis

However……no history of acute pyelonephritis is possible

The number of functioning nephrons decreases and they are replaced by scar tissue

Renal failure may result

Has no specific sx of its’ own

Sx associated with an acute process, renal failure, kidney stones, and/or hypertension

Fatigue, poor concentration

Headache

Poor appetite

May/may not be bacteria/WBCs in urine

Many times pt presents with elevated BP

H/O repeated episodes of acute pyelonephritis

BP is elevated b/o

sodium retention

volume overload

stimulation of renin-angiotensin system

Extent of Disease Process is determined by

BUN

Serum Creatinine

Creatinine Clearance (urine)

IVP, KUB

Urine C&S may be clear

Aimed at decreasing further renal damage

renal damage is NOT reversible

Determination of specific bacterial presence & tx with sensitive ABC

Urinary antiseptics

****Remember……compromised renal fx alters the excretion of antimicrobial agents & necessitates careful monitoring of renal function especially with such antibiotics such as Gentimicin & Tobramycin

Tx of hypertension (if indicated)

Important to prevent further renal damage

Prevention of stone development

Prevention of dehydration

Assessment

Nursing Diagnoses

Goals

Interventions

(Essentially the same as for acute pyelonephritis)

Distention of the renal pelvis & calices by an obstruction to normal urine flow

If the obstruction is in the urethra or bladder, the back pressure affects both kidneys

If the obstruction is in one of the ureters (b/o a stone, kink, tumor, etc.) only one kidney is involved (initially)

Urine production is NOT impaired & urine is trapped proximal to the obstruction

The occlusion may be caused by:

calculus

inflammation, trauma

tumor

scar tissue

kink in the ureter

enlarged prostate

congenital structural defects

Whatever the cause of the occlusion, the accumulating urine exerts pressure on the renal pelvis wall

At low to moderate pressures, the kidney may dilate with no obvious loss of function

BUT………..

OVER TIME…….

Sustained or intermittent high pressure causes irreversible nephron destruction

In a matter of hours, the vasculature & renal tubules can be damaged extensively

Pyelonephritis is always a risk b/o urinary stasis

May be asymptomatic if onset is gradual and only 1 kidney is involved

If BOTH kidneys are involved…..

Pain caused by stretching of kidney tissues & compression of adjacent structures

Pain may be dull flank pain or may be colicky pain

If BOTH kidneys are involved….

N/V

feeling of need to void but much difficulty doing so (maybe)

bladder distention (maybe)

sx of infection------fever, chills, pyuria, dysuria

Hematuria

Bladder may be palpated above the symphysis pubis & percussed with dull sound noted

If prostate enlargement is the cause, urinary frequency & nocturia may be 1st symptom

Sx of Chronic Renal Failure (CRF)

IVP

KUB

CT

US of Kidney

UA

Urine C&S

Once considerable kidney destruction has occurred, serum creatinine & BUN may be increased

Serum electrolytes may be altered

Metabolic acidosis

Tx aimed at relieving the obstruction & preventing/treating infection

Antimicrobial therapy

SP catheter for urethral obstruction

Urinary diversion

Pain relief

analgesics

antispasmodics

Urispas

Ditropan

Monitor for fluid depletion associated with reflexive diuresis

Nephrectomy

Assessment

Nursing Diagnoses

Goals

Interventions

Kidney stones

Also called

urinary calculi

urolithiasis

Stones can form anywhere in the urinary tract, but most frequent site is the kidney

Stones can travel down the urinary tract with or without resultant damage

Stones are formed by the deposit of crystalline substances (calcium, oxalate, uric acid, phosphates) excreted in the urine

Stones vary in size from minute pieces the size of a grain of sand to bladder stones the size of an orange

Concentrated urine with precipitation of urinary salts (dehydration)

Infection (changes urine pH)

Urinary stasis

Immobility

Bone demineralization leading to CA+ and Phosphorus in serum & urine

Excessive intake of CA+ and Vitamin D

Certain medications ---e.g., corticosteroids, certain antacids, sodium bicarb intake

High serum uric acid levels

Hyperparathyroidism

Large intake of oxalate - forming foods

green leafy vegetables

celery tea

rhubarb coffee

beets cola

spinach fruit juices

asparagus peanuts

chocolate

Many times no cause can be found

Occurs most often ages 30 - 50

Affects more men than women

Pts who have had stones tend to have recurrences

Approximately 80% of the stones are composed of Ca+ salts (calcium phosphate or calcium oxalate)

Calcium Stones

range in size from very small (sand or gravel size) to giant staghorn calculi

Staghorn calculi may fill up the entire renal pelvis and extend up into the calices

Calcium stones caused by

immobility

increased vitamin D level

diffuse bone diseases

increased Ca+ intake in diet

hypercalcemia

not dependent on pH

Pyuria

Diarrhea

Sometimes NO pain/other symptoms but only the "clink" in the toilet!!!!!

Pain

Obstruction (stone, inflammation)

Tissue trauma (irregular shaped stones)

Hemorrhage

Infection

Hydronephrosis/Hydroureter

History

Serum calcium, uric acid, creatinine, BUN

Urine for calcium, uric acid, creatinine clearance, 24 hour urine for total volume

Primary aim is to preserve renal fx

Pain control with

narcotics

urinary antispasmodics

Antiemetics

FF to 3000-4000 ml/day

I&O

Ambulation to encourage urinary peristalsis (especially if stone is in ureter)

Cystoscopy

Other surgeries

Lithotripsy

Tx of infections

Prevention of stone recurrence

Diet

Meds

uric acid stones------Allopurinol

Phosphate stone-----aluminum hydroxide

Treat other underlying causes

Preop care

Postop care

Assessment

Nursing Diagnoses

Goals

Interventions

The impairment of kidney function

Classified as either acute or chronic

Acute renal failure is a potentially reversible condition

Chronic renal failure is irreversible

Chronic renal failure often leads to a complete loss of kidney function

Insidious in nature

Kidneys are able to fx (filtrate/excrete, etc.) until approximately 75% of nephrons are destroyed

At 80 - 90% nephron loss, pt is obviously symptomatic

Irreversible & progressive destruction of the kidneys

Caused by a number of conditions and leads to multisystem failure

Occurs when the GFR is 25% of normal

BUN and creatinine leves are increased

S/S include

fatigue weakness

headache nausea

pruritus polyuria

nocturia

ESRD

Uremic phase

Occurs when GFR is less than 5 - 10% or normal

As CRF progresses, the retained substances cause the body’s organs to deteriorate leading to multisystem failure

See H.O.

Thorough HX

S/S

Hypocalcemia

Elevated BUN & Creatineie

Elevated K+

Low/Elevated NA+

Decreased RBCs

KUB

IVP

CT

Renal Angiography

Goals

Slow/prevent further deterioration of renal fx

Correct F&E imbalances

Reduce/prevent sx of uremia

Pharmacology

diuretics to incr K+ loss & decr BP

antihypertensives

Na+ bicarb to control acidosis

Ca+ supplements

Kayexalate enemas

Folic Acid & Iron

Assessment

Nursing Diagnoses

Goals

Interventions

Diet & Fluids

fluid restriction

Increase Ca+ foods

Decrease protein diet

Decrease K+ foods

Dialysis

peritoneal dialysis

hemodialysis

Renal transplantation

Predisposing Factors

vaginal/fecal contamination

catheters

obstructions

ignoring urge to void

alkaline urine

sexual intercourse

Predisposing Factors

Diabetes Mellitus

Pregnancy

Bubble baths

Nylon underwear/pantyhose

Feminine hygiene sprays

Hot tubs

Antibacterial Defenses:

Free urinary flow

Large urine output

Acidic urine pH

If any of these are altered, invasion of bacteria is likely to occur

Classic symptoms

frequency, urgency

dysuria (can be severe)

hesitancy

hematuria (can be severe)

burning during/after urination

Other S/S

fever

cloudy urine (pus usually present)

low abdominal discomfort

foul smell to urine

UA …bacteria, WBC, possibly blood

increased serum WBC

anxiety d/t alteration in voiding pattern

Hx of SX

UA

Urine C&S

IVP

Voiding Cystourethrogram

Antibiotics/Urinary Antiseptics

Septra (Sulfonamide)

Cepahlosporins

Ampicillin (Penicillin)

Gantrisin

Macrodantin

Noroxin

Urinary Analgesics

Pyridium

AzoGantrisin

Antispasmodics

Urispas

Ditropan

Detrol

Decrease bladder spasms & increase bladder emptying

Follow-up urine C&S 5 - 14 days after start of treatment

Frequent UTI recurrence either with a new organism or a relapse of the original organism

Assessment

Nursing Diagnoses

Goals

Interventions

Interventions...

Types

See H.O.

Complications Associated with Neurogenic Bladder….

Hydronephrosis

Urolithiasis

Mainly symptomatic

BUN, serum Creatinine, Creatinine Clearance to determine renal status

Cystogram

Cath for residual

Goals:

evacuate the bladder

prevent infection

provide continence

Intermittent Cath after pt voids

Pt taught to self-cath

Methods to stimulate mictuation

lean forward, push on abd

breathe deep to force diaphragm down (valsalva)

Crede’ maneuver

Catheter freedom

External caths for men

Limit stimulants such as coffee, colas

Limit fluids after 6 pm

Toileting

Teaching

Occurs most freq between age 50-70’s

occurs more often in men than women

occurs more in African Americans 2X greater than caucasions

Predisposing Factors

Rarely know exact cause

Carcinogen exposure (active/passive cigarette smoke, dyes, paints, coffee?, artificial sweetener?

Predisposing Factors

Recurrent UTI

Bladder calculi

Exposure to Cytoxin

Primary S/S

painless hematuria (usually intermittent)

Urinary frequency, urgency

Nocturia

Dysuria

Pain may or may not be present

Hematuria may cause anemia

Pain in bladder, rectum, pelvis, back or legs

Fever & flank pain suggest infection in UT

Edema of LE indicative of venous obstruction caused by an invasive tumor

HX, esp associated with predisposing factors

Cystoscopy

Pelvic Exam for females

BX of bladder

H&H

Bone Scan

IVP

CT

MRI

Liver

Bone

Lungs

As tumor progresses, it extends into the rectum, vagina, retroperitoneal structures

Ureteral/urethral orifices often blocked by bladder tumor

Chemo

Radiation

Surgery

type of surgical procedure depends on the type & stage of the cancer and the pt’s general health

Pre-op

Post-op

Care of the Urinary Diversions

Complications of Urinary Diversions

Benign neoplasms are rare

85% of renal tumors are malignant

When pt presents CA has probably already metastasized

Tumor growth goes on for some time before sx are noticed

The tumors can grow very large & tend to compress surrounding tissues

Tumor surrounds blood vessels & stenose them

Fever

Wt loss

Cachexia

Hypertension

Fatigue

Anemia

Thrombophlebitis

Nephrectomy

Radiation

Chemotherapy (renal CA is highly insensitive to chemo, possibly b/o slow growth rate)

Hemorrhage

Shock

Infection

Adrenocortical Insufficiency

causes lg H2O & sodium loss

Already covered!!!