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Anatomy & Physiology Tri-State Business Institute Micheal H. McCabe, EMT-P.

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1 Anatomy & Physiology Tri-State Business Institute Micheal H. McCabe, EMT-P

2 The Urinary Tract: Kidneys Kidneys Ureters Ureters Urinary Bladder Urinary Bladder Urethra Urethra Urinary Meatus Urinary Meatus

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4 Kidneys: Located: Retroperitoneal space, base of rib cage, adjacent to “floating ribs” Located: Retroperitoneal space, base of rib cage, adjacent to “floating ribs” Right kidney usually lower than the left Right kidney usually lower than the left The left and right renal arteries provide blood flow from aorta to the kidneys. The left and right renal arteries provide blood flow from aorta to the kidneys.

5 Internal Structure: Cortex – outer layer of kidney Cortex – outer layer of kidney Medulla – internal portion of kidney Medulla – internal portion of kidney Pyramids – triangular divisions of medulla Pyramids – triangular divisions of medulla Papilla – long & narrow end of pyramid. Papilla – long & narrow end of pyramid. Calyses – divisions of renal pelvis Calyses – divisions of renal pelvis

6 Internal Structure:

7 Microscopic Structure: Nephrons are microscopic functional units of kidney function Nephrons are microscopic functional units of kidney function Each nephron serves as a filter that removes toxins and nitrogenous waste from the blood. Nephrons also help maintain the fluid balance, regulate chemical levels, and secrete renin – a hormone that regulates blood pressure. Each nephron serves as a filter that removes toxins and nitrogenous waste from the blood. Nephrons also help maintain the fluid balance, regulate chemical levels, and secrete renin – a hormone that regulates blood pressure.

8 Internal Structure: Each nephron has two primary components: 1.Renal Corpuscle 2.Renal Tubule

9 Renal Corpuscle: Consists of Bowman’s capsule with its glomerulus Consists of Bowman’s capsule with its glomerulus Bowman’s Capsule – the cup-shaped top. Bowman’s Capsule – the cup-shaped top. Glomerulus – network of blood capillaries surrounded by Bowman’s Capsule. Glomerulus – network of blood capillaries surrounded by Bowman’s Capsule.

10 Renal Tubule: Proximal convoluted tubule – first segment Proximal convoluted tubule – first segment Loop of Henle – extension of proximal tubule; consists of descending limb, loop, and descending limb. Loop of Henle – extension of proximal tubule; consists of descending limb, loop, and descending limb. Distal Convoluted Tubule – extension of ascending limb of loop of Henle Distal Convoluted Tubule – extension of ascending limb of loop of Henle Collecting Tubule – straight extension of distal tubule. Collecting Tubule – straight extension of distal tubule.

11 Functions: 1. Excretes toxins and nitrogenous waste. 2. Regulates levels of many chemicals in the blood 3. Maintains water balance 4. Helps regulate blood pressure by secretion of renin

12 Formation of Urine: Occurs by a series of three processes that take place in successive parts of the nephron. Occurs by a series of three processes that take place in successive parts of the nephron. Control of urine volume is regulated mainly by anti-diuretic hormone which suppresses it. Control of urine volume is regulated mainly by anti-diuretic hormone which suppresses it.

13 Filtration Process: Is continuous as long as blood flows through the kidney. Is continuous as long as blood flows through the kidney. Blood pressure in glomerulus causes water and dissolved substances to filter out of glomeruli into Bowman’s capsule. Blood pressure in glomerulus causes water and dissolved substances to filter out of glomeruli into Bowman’s capsule. Normal filtration rate is 125 ml per minute. Normal filtration rate is 125 ml per minute.

14 Re-absorbtion: Movement of substances out of renal tubules into blood in peritubular capillaries. Movement of substances out of renal tubules into blood in peritubular capillaries. Water, nutrients, and ions are reabsorbed into bloodstream. Water, nutrients, and ions are reabsorbed into bloodstream. Water is reabsorbed by osmosis in proximal tubules. Water is reabsorbed by osmosis in proximal tubules.

15 Secretion: Movement of substances into urine in the distal and collecting tubules from blood in peritubular capillaries Movement of substances into urine in the distal and collecting tubules from blood in peritubular capillaries Hydrogen ions, potassium ions, and certain drugs are secreted by active transport. Hydrogen ions, potassium ions, and certain drugs are secreted by active transport. Ammonia is secreted by diffusion. Ammonia is secreted by diffusion.

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17 Characteristics of Urine: Color: Transparent yellow / amber / or straw colored Color: Transparent yellow / amber / or straw colored Odor: slight odor Odor: slight odor pH: 4.6 to 8.0 pH: 4.6 to 8.0 Specific Gravity: 1.001 to 1.035 Specific Gravity: 1.001 to 1.035

18 Composition of Urine: Mostly water Mostly water Normally contains mineral ions including Na, Cl, and K. Normally contains mineral ions including Na, Cl, and K. Nitrogenous waste including ammonia, creatinine, urea, and uric acid Nitrogenous waste including ammonia, creatinine, urea, and uric acid Suspended solids (sediment) Suspended solids (sediment) Urine Pigments Urine Pigments

19 Abnormal Characteristics: Abnormal color or cloudiness indicating blood, bile, bacteria, drugs, food pigments, or high-solute concentrate. Abnormal color or cloudiness indicating blood, bile, bacteria, drugs, food pigments, or high-solute concentrate. Acetones, ketones, nitrites Acetones, ketones, nitrites Albumin (protein) Albumin (protein) Glucose Glucose High specific gravity can lead to precipitates that form kidney stones. High specific gravity can lead to precipitates that form kidney stones.

20 Typical Lab Values for Urine: Acetone – normally none; acetone in urine can indicate fasting, starvation, or diabetic ketoacidosis Acetone – normally none; acetone in urine can indicate fasting, starvation, or diabetic ketoacidosis Acetoacetate – normally none Acetoacetate – normally none Albumin – normally trace amounts; albumin may indicate hypertension, kidney disease, or recent strenuous exercise Albumin – normally trace amounts; albumin may indicate hypertension, kidney disease, or recent strenuous exercise

21 Typical Lab Values for Urine: Ammonia – 20 to 70 mEq/L; increases in liver disease and diabetes Ammonia – 20 to 70 mEq/L; increases in liver disease and diabetes Bile and bilirubin – normally absent; may be present if bile ducts are obstructed Bile and bilirubin – normally absent; may be present if bile ducts are obstructed Calcium – Less than 150 mg/day. Hyperparathyroidism causes increase. Hypoparathyroidism causes decrease. Calcium – Less than 150 mg/day. Hyperparathyroidism causes increase. Hypoparathyroidism causes decrease.

22 Typical Lab Values for Urine: Osmolarity – 500 to 800 mOsm / L; increases in dehydration and heart failure. Decreases in diabetes insipidus and aldosteronism Osmolarity – 500 to 800 mOsm / L; increases in dehydration and heart failure. Decreases in diabetes insipidus and aldosteronism pH – 4.6 to 8.0; increases in alkalosis and during urinary infections; decreases in acidosis, dehydration, and emphysema pH – 4.6 to 8.0; increases in alkalosis and during urinary infections; decreases in acidosis, dehydration, and emphysema

23 Typical Lab Values for Urine: Potassium (K) – 25 to 100 mEq / L; increases in dehydration and chronic renal failure. Decreases during diarrhea, vomiting, and adrenal insufficiency Potassium (K) – 25 to 100 mEq / L; increases in dehydration and chronic renal failure. Decreases during diarrhea, vomiting, and adrenal insufficiency Sodium (Na) – 75 to 200 mg / day. Increases in starvation and dehydration. Decreases in acute renal failure and in Cushing’s syndrome. Sodium (Na) – 75 to 200 mg / day. Increases in starvation and dehydration. Decreases in acute renal failure and in Cushing’s syndrome.

24 Typical Lab Values for Urine: Creatinine Clearance – 100 to 140 ml / min; increases in kidney disease Creatinine Clearance – 100 to 140 ml / min; increases in kidney disease Creatinine – 1-2 grams per day; increases during infection. Decreases in some kidney diseases and in some forms of anemia. Creatinine – 1-2 grams per day; increases during infection. Decreases in some kidney diseases and in some forms of anemia. Glucose – normally zero; increases in diabetes mellitus, hyperthyroidism, and hypersecretion of adrenal cortex. Glucose – normally zero; increases in diabetes mellitus, hyperthyroidism, and hypersecretion of adrenal cortex.

25 Typical Lab Values for Urine: Urea clearance -- >40 ml blood cleared per minute; increases in some kidney diseases Urea clearance -- >40 ml blood cleared per minute; increases in some kidney diseases Urea – 25 to 35 g / day; increases in some liver diseases and hemolytic anemia. Decreases during obstruction of bile ducts and severe diarrhea Urea – 25 to 35 g / day; increases in some liver diseases and hemolytic anemia. Decreases during obstruction of bile ducts and severe diarrhea

26 Typical Lab Values for Urine: Uric Acid – 0.5 to 1.0 grams per day; increases in gout. Decreases in some kidney diseases. Uric Acid – 0.5 to 1.0 grams per day; increases in gout. Decreases in some kidney diseases.

27 Microscopic Examination of Urine: Bacteria -- < 10,000 / ml; increases during urinary tract infections. Bacteria -- < 10,000 / ml; increases during urinary tract infections. Erythrocytes – trace; increases in pyelonephritis, damage from renal stones, infection, and cancer Erythrocytes – trace; increases in pyelonephritis, damage from renal stones, infection, and cancer Leukocytes – trace; increases during infection Leukocytes – trace; increases during infection

28 Microscopic Examination of Urine: Blood Cell Casts (RBC) – trace; increases in pyelonephritis Blood Cell Casts (RBC) – trace; increases in pyelonephritis Blood Cell Casts (WBC) – trace; increases during infection Blood Cell Casts (WBC) – trace; increases during infection Crystals – trace; increases during urinary retention. Very large crystals are renal calculi Crystals – trace; increases during urinary retention. Very large crystals are renal calculi

29 Microscopic Examination of Urine: Epithelial Casts – trace; increases in some kidney disorders and heavy metal toxicity Epithelial Casts – trace; increases in some kidney disorders and heavy metal toxicity Granular Casts – trace; increases in some kidney disorders Granular Casts – trace; increases in some kidney disorders Hyaline Casts – trace; increases in some kidney disorders and fever. Hyaline Casts – trace; increases in some kidney disorders and fever.

30 Ureters: Structure – long narrow tubes with expanded upper end (renal pelvis) located inside kidney and lined with mucous membrane. Structure – long narrow tubes with expanded upper end (renal pelvis) located inside kidney and lined with mucous membrane. Function – drain urine from renal pelvis to urinary bladder. Function – drain urine from renal pelvis to urinary bladder.

31 Urinary Bladder: Structure: Structure: 1.Elastic muscular organ, capable of great expansion 2.Lined with mucous membrane arranged in rugae, just like stomach lining  Function: 1.Storage of urine before micturation 2.Micturation

32 Urethra: Structure: Structure: 1.Narrow tube from urinary bladder to exterior of body 2.Lined with mucous membranes Function: Function: 1.Passage of urine from bladder to exterior of body 2.Passage of semen from prostate gland to exterior of body when mating.

33 Micturation: Micturation is the passage of urine from the body. Micturation is the passage of urine from the body. Also called voiding or urination. Also called voiding or urination.

34 Regulatory Sphincters: Internal Urethral Sphincter – involuntary Internal Urethral Sphincter – involuntary External Urethral Sphincter – voluntary External Urethral Sphincter – voluntary

35 Bladder Wall: Expands as urine collects Expands as urine collects Permits storage of urine with little increase in pressure Permits storage of urine with little increase in pressure A full bladder triggers the stretch reflex A full bladder triggers the stretch reflex

36 Emptying Reflex: Initiated by stretch reflex in bladder wall. Initiated by stretch reflex in bladder wall. Bladder wall contracts Bladder wall contracts Internal sphincter relaxes Internal sphincter relaxes External sphincter relaxes and urination occurs. External sphincter relaxes and urination occurs.

37 Urinary Retention: Kidneys produce urine Kidneys produce urine Urine collects in the bladder Urine collects in the bladder Urine is not voided due to obstruction or failure of the voiding reflex Urine is not voided due to obstruction or failure of the voiding reflex

38 Urinary Suppression: Bladder is normal but no urine is produced by kidneys. Bladder is normal but no urine is produced by kidneys.

39 Incontinence: Urine is voided involuntarily Urine is voided involuntarily May be caused by spinal injury or stroke May be caused by spinal injury or stroke Retention of urine may cause cystitis (inflammation of the bladder) Retention of urine may cause cystitis (inflammation of the bladder)

40 Renal and Urinary Disorders: Obstructive Disorders Obstructive Disorders Urinary Tract Infections Urinary Tract Infections Glomerular Disorders Glomerular Disorders Renal Failure Renal Failure

41 Obstructive Disorders: 1.Interfere with normal urine flow 2.Urine may back up and cause hydronephrosis or other kidney damage 3.Renal Calculi (kidney stones) may block ureters, causing intense pain called renal colic 4.Neurogenic bladder – paralysis or abnormal function of bladder, preventing normal flow of urine out of the blody 5.Tumors – renal cell carcinoma and bladder cancer are often characterized by hematuria

42 Urinary Tract Infections: Are often caused by gram-negative bacteria Are often caused by gram-negative bacteria Urethritis – inflammation of the urethra Urethritis – inflammation of the urethra Cystitis – inflammation of the bladder Cystitis – inflammation of the bladder Pyelonephritis – inflammation of the renal pelvis and connective tissue; may be Pyelonephritis – inflammation of the renal pelvis and connective tissue; may be 1.Acute (infectious) 2.Chronic (autoimmune)

43 Urinary Catheterization: Involves insertion of a urinary catheter through the urethra and into the bladder for the withdrawal of urine Involves insertion of a urinary catheter through the urethra and into the bladder for the withdrawal of urine Urine is collected in a bag strapped to the leg or attached to the bed rail Urine is collected in a bag strapped to the leg or attached to the bed rail Commonly performed as a diagnostic procedure and as a treatment for urinary retention. Commonly performed as a diagnostic procedure and as a treatment for urinary retention.

44 Urinary Catheterization: Requires aseptic technique Requires aseptic technique UTI is a common complication of catheterization UTI is a common complication of catheterization Approximately 8% of patients who are catheterized develop a UTI Approximately 8% of patients who are catheterized develop a UTI Infection can ultimately kill a significant number of patients Infection can ultimately kill a significant number of patients

45 Glomerular Disorders: Nephrotic Syndrome Nephrotic Syndrome Acute Glomerulonephritis Acute Glomerulonephritis Chronic Glomerulonephritis Chronic Glomerulonephritis

46 Nephrotic Syndrome: Nephrotic syndrome accompanies many glomerular disorders Nephrotic syndrome accompanies many glomerular disorders Characterized by: Characterized by: 1.Protein in the urine 2.Low plasma protein – caused by loss of proteins to urine 3.Edema – tissue swelling caused by loss of water from plasma due to hypoalbuminemia

47 Acute Glomerulonephritis: Is usually caused by a delayed immune response to a streptococcal infection Is usually caused by a delayed immune response to a streptococcal infection May lead to renal failure May lead to renal failure Similar to rheumatic heart disease – autoimmune response causes end- organ damage Similar to rheumatic heart disease – autoimmune response causes end- organ damage

48 Chronic Glomerulonephritis: Typically presents as a slow, progressive inflammatory condition Typically presents as a slow, progressive inflammatory condition Believed to be an autoimmune disorder Believed to be an autoimmune disorder Often leads to renal failure Often leads to renal failure

49 Renal Failure: Acute Renal Failure – an abrupt reduction in kidney function that is usually reversible. Acute Renal Failure – an abrupt reduction in kidney function that is usually reversible. Chronic Renal Failure – slow, progressive loss of nephrons caused by a variety of underlying diseases. Chronic Renal Failure – slow, progressive loss of nephrons caused by a variety of underlying diseases.

50 Acute Renal Failure: An abrupt reduction in kidney function characterized by oliguria and a sharp rise of nitrogenous compounds in the blood. An abrupt reduction in kidney function characterized by oliguria and a sharp rise of nitrogenous compounds in the blood. Often assessed by the blood urea nitrogen (BUN) test; a high BUN indicates failure of the kidneys to remove urea from the blood Often assessed by the blood urea nitrogen (BUN) test; a high BUN indicates failure of the kidneys to remove urea from the blood May be caused by trauma, hemorrhage. severe burns; acute glomerulonephritis, pyelonephritis, or obstruction of the urinary tract. May be caused by trauma, hemorrhage. severe burns; acute glomerulonephritis, pyelonephritis, or obstruction of the urinary tract. If the underlying cause can be treated successfully, recovery is usually rapid and complete. If the underlying cause can be treated successfully, recovery is usually rapid and complete.

51 Chronic Renal Failure: Presents as a slow, progressive condition resulting from the gradual loss of nephrons. Presents as a slow, progressive condition resulting from the gradual loss of nephrons. Caused by many disease processes including infection, glomerulonephritis, tumors, auto-immune disorders, and obstruction of the urinary tract. Caused by many disease processes including infection, glomerulonephritis, tumors, auto-immune disorders, and obstruction of the urinary tract.

52 Stages of Chronic Renal Failure: 1. Stage One – some nephrons are lost but the remaining nephrons compensate and maintain urine output. 2. Stage Two – renal insufficiency. The progressive loss of nephrons becomes critical and the remaining nephrons can no longer compensate.

53 Stages of Chronic Renal Failure – Continued: 3.Stage Three – End Stage Renal Disease (ESRD) Urine is no longer being formed Urine is no longer being formed Toxins, waste, and fluid build up in the body. Toxins, waste, and fluid build up in the body. Renal Dialysis or kidney transplant becomes necessary – otherwise death occurs. Renal Dialysis or kidney transplant becomes necessary – otherwise death occurs.

54 Renal Dialysis: Renal Dialysis is a mechanical process that removes metabolic waste from the blood and helps regulate the fluid and electrolyte balance during renal failure. Renal Dialysis is a mechanical process that removes metabolic waste from the blood and helps regulate the fluid and electrolyte balance during renal failure.

55 Renal Dialysis: Two basic methods of renal dialysis are commonly used: Two basic methods of renal dialysis are commonly used: 1.Hemodialysis 2.Peritoneal Dialysis

56 Hemodialysis: Requires arterial and venous vascular access in the patient: Requires arterial and venous vascular access in the patient: –A fistula is created surgically to join an artery and vein in the forearm –A graft made of surgical tubing or a leg vein is used to join an artery and vein –Permanent indwelling catheters are placed in a large artery and vein.

57 Hemodialysis: Arterial blood flows from the patient into a dialysis machine. Arterial blood flows from the patient into a dialysis machine. The blood flows through a mechanical filter that removes waste products, toxins, and minerals. The blood flows through a mechanical filter that removes waste products, toxins, and minerals. The blood is warmed, anti-coagulants are added, and returned to the body into a vein. The blood is warmed, anti-coagulants are added, and returned to the body into a vein.

58 Hemodialysis: Patients typically require three or more four-hour dialysis runs per week Patients typically require three or more four-hour dialysis runs per week Iatrogenic complications may include dehydration, infection, hypoglycemia, hyponatremia, and hypocalcemia. Iatrogenic complications may include dehydration, infection, hypoglycemia, hyponatremia, and hypocalcemia. Some dialysis patients may eventually receive a kidney transplant. Some dialysis patients may eventually receive a kidney transplant.

59 Peritoneal Dialysis: 1 to 3 liters of saline is introduced into the peritoneal cavity 1 to 3 liters of saline is introduced into the peritoneal cavity Peritoneal membranes transfer waste products from the blood into the dialysis fluid Peritoneal membranes transfer waste products from the blood into the dialysis fluid Dialysis fluid is drained from the peritoneal cavity after appx. 2 hours Dialysis fluid is drained from the peritoneal cavity after appx. 2 hours

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61 Peritoneal Dialysis: Less expensive than hemodialysis Less expensive than hemodialysis Does not require expensive or complex equipment Does not require expensive or complex equipment Can be done at home Can be done at home

62 Peritoneal Dialysis: Not all patients are candidates for peritoneal dialysis Not all patients are candidates for peritoneal dialysis Infection can result in peritonitis – a potentially fatal complication Infection can result in peritonitis – a potentially fatal complication


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