2 Overview of Anatomy and Physiology Functions of the urinary systemExcretion of waste productsRegulation of water (ADH), electrolytes, and acid-base balance (pH of blood)Kidneys (two)Nephron: Functional unit of kidneysUrine composition and characteristics95% water; remainder is nitrogenous wastes and saltsUrine abnormalitiesAlbumin; glucose; erythrocytes; ketones; leukocytesAs the body takes in nutrients to meet the body’s requirements to sustain life, the breakdown of these elements results in waste products. The management of these waste products is handled by the urinary system.How is the body impacted by the different substances ingested by the body?
3 Coronal section through right kidney. Figure 10-2The kidneys are dark red, bean-shaped organs. They are located, one on each side, toward the back of the body, just below the diaphragm.Describe the parts of the kidney.(From Thibodeau, G.A., Patton, K.T. . Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)Coronal section through right kidney.
4 Figure 10-3 The nephron unit. (From Thibodeau, G.A., Patton, K.T. . Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)The nephron unit.
5 Urine Formation 3 Phases of Urine Formation Filtration Reabsorption Of water and blood products occurs in glomerulus of Bowman’s capsuleReabsorptionWater, glucose, and necessary ions back into blood (primarily done in proximal/distal convoluted tubules and Henle’s loop)SecretionCertain ions, nitrogenous waste and drugs (primarily distal convoluted tubule); this is the reverse of reabsorption; substances move from blood to filtrate
6 Hormonal InfluenceIncreased fluid loss (hemorrhage, vomiting, diarrhea, etc.=hypotensionDecreases amount of filtrate produced by kidneysPosterior pituitary releases ADHADH causes nephrons to increase rate of water reabsorptionThis causes water to return to bloodstream thus raising BP and urine to be concentrated
7 Overview of Anatomy and Physiology Ureters (two)Passageway for urine from the kidneys to the urinary bladderUrinary bladder (one)Temporary storage pouch for urineUrethra (one)Carries urine by peristalsis from the urinary bladder out to its external openingThe urinary system is comprised of two ureters, the bladder, and one urethra.What is the function of each of the parts listed?
8 The male urinary bladder, cut to show the interior. Figure 10-5(From Thibodeau, G.A., Patton, K.T. . Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)The male urinary bladder, cut to show the interior.
9 Laboratory and Diagnostic Examinations Urinalysis (most common urologic study)Blood urea nitrogen (BUN)Blood creatinineCreatinine clearanceProstate-specific antigen (PSA)OsmolalityKidney-ureter-bladder radiography (KUB)Intravenous pyelogram (IVP)Retrograde pyelographyVoiding cystourethrographyWhen attempting to diagnose a disorder of the urinary system, the first line of testing involves the urine. The urine provides clues into many disorders.Collection of the specimen will vary by test.What is each of the listed tests used to evaluate? What education should the nurse provide to the patient regarding each of the listed tests?
10 Laboratory and Diagnostic Examinations Endoscopic proceduresRenal angiographyRenal venogramComputed tomography (CT)Magnetic resonance imaging (MRI)Renal scanUltrasonographyTransrectal ultrasoundRenal biopsyUrodynamic studiesIn addition to analyzing the urine, detecting disorders of the urinary system can also include scanning or biopsy procedures.Review each of the tests listed and discuss the nursing implications for each.
11 Medication Considerations Diuretics to enhance urinary outputThiazide diureticsLoop (or high-ceiling) diureticsPotassium-sparing diureticsOsmotic diureticsCarbonic anhydrase inhibitor diureticsMedications for urinary tract infectionsQuinoloneNitrofurantoinMethenamineFluoroquinoloneDiuretics’ method of action is accomplished by increasing the kidney’s filtration of elements.In what disorders are the use of diuretics prescribed?There are different types of diuretics. What are examples of each type of diuretic? How do the types differ?In the event of an infection of the urinary system, antimicrobial medications can be prescribed. What nursing implications are indicated with each of the medications listed?
12 Maintaining Adequate Urinary Drainage Types of cathetersCoudé catheterFoley catheterMalecot, Pezzer, or mushroom cathetersRobinson catheterUreteral cathetersWhistle-tip catheterCystostomy, vesicostomy, or suprapubic catheterExternal (Texas or condom) catheterCatheters are indicated when a patient’s condition does not allow successful elimination of urine. In what cases is each of the catheter types indicated?
13 Different types of commonly used catheters. Figure 10-6Pictured are the types of catheters.Discuss the types and the times when their use is indicated.What are the nursing responsibilities associated with the care of a patient having an indwelling urinary catheter?(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. . Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.)Different types of commonly used catheters.
14 Disorders of the Urinary System Urinary retentionEtiology/pathophysiologyThe inability to void despite an urge to voidClinical manifestations/assessmentDistended bladderDiscomfort in pelvic regionVoiding frequent, small amountsWhen urinary retention results, what potential hazards exist?What nursing assessments are indicated to determine the presence of urinary retention?
15 Disorders of the Urinary System Urinary retention (continued)Medical management/nursing interventionsWarm shower or sitz bathNatural voiding position if possibleUrinary catheterSurgical removal of obstructionAnalgesicsNumerous interventions can be attempted to manage urinary retention. What are the goals of management?Ask students what interventions they have used or have observed being used in the clinical environment to manage urinary retention.
16 Disorders of the Urinary System Urinary incontinenceEtiology/pathophysiologyInvoluntary loss of urine from the bladderTotal incontinence; dribbling; stress incontinenceSecondaryInfection; loss of sphincter control; sudden change in pressure in the abdomenPermanent or temporaryUrinary incontinence is a common problem experienced by women.What subjective data should be assessed? What questions might assist the nurse in obtaining the needed information?What are potential causes of incontinence?Postmenopausal women have a greater risk for the development of urinary incontinence. What is the relationship between this stage in the lifespan of a woman and incontinence?
17 Disorders of the Urinary System Urinary incontinence (continued)Clinical manifestations/assessmentInvoluntary loss of urineLeaking with coughing, sneezing, or liftingMedical management/nursing interventionsTreat underlying causeSurgical repair of bladderTemporary or permanent catheterBladder trainingKegel exercisesThe goals of management are the treatment of the underlying causes of incontinence.Urinary incontinence is an embarrassing problem. What role does the nurse have in assisting the patient at this difficult time?
18 Disorders of the Urinary System Neurogenic bladderEtiology/pathophysiologyLoss of voluntary voiding controlResults in urinary retention or incontinenceLesion of the nervous system that interferes with normal nerve conduction to the urinary bladderTwo typesSpasticFlaccidA neurogenic bladder can be caused by a variety of factors. What are examples of potential causes?
19 Disorders of the Urinary System Neurogenic bladder (continued)Clinical manifestations/assessmentInfrequent voidingIncontinenceDiaphoresis, flushing, nausea prior to reflex incontinenceMedical management/nursing interventionsAntibiotics; urecholineIntermittent catheterizationBladder trainingWhen performing an assessment of a neurogenic bladder, the primary focus is locating the underlying cause and preventing complications.In addition to the observation of clinical manifestations, what diagnostic tests might be indicated?Medication therapies can be instituted in the management of a neurogenic bladder. What is the rationale for the use of these medications?
20 Disorders of the Urinary System Urinary tract infectionsEtiology/pathophysiologyType depends on locationPathogens enter the urinary tractNosocomial infectionBladder obstructionInsufficient bladder emptyingDecreased bactericidal secretions of the prostatePerineal soiling in femalesSexual intercourseUrinary tract infections result when pathogens enter the urinary tract. There are populations at risk for their development. Why are these people/groups at an increased risk?Compare and contrast urethritis, cystitis, interstitial cystitis, prostatitis, and pyelonephritis.
21 Disorders of the Urinary System Urinary tract infections (continued)Clinical manifestations/assessmentUrgency; frequency; burning on urinationNocturiaAbdominal discomfort; perineal or back painCloudy or blood-tinged urineMedical management/nursing interventionsPharmacological managementAntibiotics; urinary antiseptics/analgesicsEncourage fluidsPerineal careUrinary tract infections can lead to increasingly complicated medical problems. Prevention of urinary tract infections is possible in many cases. What interventions can be instituted to reduce their incidence?Complementary and alternative therapies can be used to manage/prevent urinary tract infections.
22 Obstructive Disorders of the Urinary System Urinary obstructionEtiology/pathophysiologyStrictures; kinksCysts; tumorsCalculiProstatic hypertrophyClinical manifestations/assessmentContinuous need to voidVoiding small amounts frequentlyPainNauseaAn obstruction at any location within the urinary tract can adversely affect functioning. The onset of the obstruction can be sudden or result over a long period of time. What are potential causes for each of the categories listed above?
23 Obstructive Disorders of the Urinary System Urinary obstruction (continued)Medical management/nursing interventionsEstablish urinary drainageIndwelling catheterSuprapubic cystostomyUreterostomyNephrostomyPharmacological managementPain reliefNarcoticsAnticholinergicsWhen an obstruction is suspected, diagnostic tests will be performed to detect the location and cause. What tests can be anticipated for this purpose?What factors will determine the prognosis for a patient experiencing a urinary obstruction?
24 Obstructive Disorders of the Urinary System HydronephrosisEtiology/pathophysiologyDilation of the renal pelvis and calycesUnilateral or bilateralObstruction of the urinary tractClinical manifestations/assessmentDull flank pain (slow onset)Severe stabbing pain (sudden onset)Nausea and vomitingFrequency, dribbling, burning, and difficulty starting urinationWhen urine cannot adequately pass through the renal pelvis, potential damage can result. This is the pathophysiology of hydronephrosis.Not all patients experiencing hydronephrosis experience visible symptoms.The onset of hydronephrosis can be rapid or result after a long-term assault on the urinary system.Differentiate between the signs and symptoms that present both rapidly and slowly.What objective data will be collected from the patient demonstrating the clinical manifestations associated with hydronephrosis?
25 Obstructive Disorders of the Urinary System Hydronephrosis (continued)Medical management/nursing interventionsPharmacological managementAntibioticsNarcotic analgesicsSurgery to relieve obstructionNephrectomySeverely damaged kidneyIn addition to the clinical picture presented, a series of diagnostic tests will be ordered to confirm the diagnosis and determine the degree of damage.What tests can be anticipated?Management options will vary, depending on the severity of the disease and the patient’s response to treatment.What are the responsibilities of the nurse when providing care to this patient?What complications can occur as a result of hydronephrosis?
26 Obstructive Disorders of the Urinary System UrolithiasisEtiology/pathophysiologyFormation of urinary calculi (stones)Develops from mineralsIdentified according to locationNephrolithiasis; ureterolithiasis; cystolithiasisClinical manifestations/assessmentFlank or pelvic painNausea and vomitingHematuriaKidney stones are a painful event. Although there is no exact cause for their occurrence, there are predisposed populations and risk factors associated with their development.What populations experience kidney stones most frequently?What lifestyle changes can be implemented to reduce the risk in identified populations?
27 Obstructive Disorders of the Urinary System Urolithiasis (continued)Medical management/nursing interventionsAntibioticsEncourage fluidsAmbulateSTRAIN ALL URINESurgical proceduresCystoscopy; ureterolithotomy; pyelolithotomy; nephrolithotomyLithotripsyWhen a patient presents with clinical manifestations associated with developing kidney stones, diagnostic tests will be performed to support the diagnosis.What tests can be anticipated? What findings will support the presence of kidney stones?
28 Figure 10-7(From Beare, P.G., Myers, J.L. . Adult health nursing. [3rd ed.]. St. Louis: Mosby.)Location and methods of removing renal calculi from upper urinary tract.
29 Renal Tumors Etiology/pathophysiology Adenocarcinomas that develop unilaterallyRenal cell carcinomas arise from cells of the proximal convoluted tubulesClinical manifestations/assessmentEarly: Intermittent painless hematuriaLateWeight lossDull flank painPalpable mass in flank areaGross hematuriaMen are affected more commonly by renal tumors than women.Unfortunately, finding a renal tumor occurs late, when the tumor is quite large.What risk factors support the development of renal tumors? Which of these risk factors are modifiable?
30 Renal Tumors Medical management/nursing interventions Radical nephrectomyRadiationChemotherapyDiscuss the role of the nurse in the care of the patient diagnosed with renal tumors.What is the anticipated prognosis of the patient who has renal tumors?
31 Renal Cysts Etiology/pathophysiology Cysts form in the kidneysPolycystic kidney diseaseCysts cause pressure on the kidney structures and compromise functionClinical manifestations/assessmentAbdominal and flank painVoiding disturbancesRecurrent UTIsHematuriaHypertensionSingle cysts might never be detected because they might not hinder kidney functioning.Polycystic kidney disease is a genetic condition in which numerous cysts form in the kidney.What impact does the presence of cysts have on the kidney’s ability to function?
32 Renal Cysts Medical management/nursing interventions No specific treatmentPharmacological managementAnalgesicsAntibioticsAntihypertensivesRelieve painHeat (unless bleeding)DialysisRenal transplantWhen preparing to confirm a diagnosis of polycystic kidney disease, laboratory tests can be ordered. In addition, the physician could order screening tests to view the kidney. How will the kidney appear if the condition is present?
33 Tumors of the Urinary Bladder Etiology/pathophysiologyMost common site of cancer in the urinary tractRange from benign papillomas to invasive carcinomaClinical manifestations/assessmentPainless intermittent hematuriaChanges in voiding patternsMedical management/nursing interventionsLocalized—remove tissue by burningInvasive lesions—partial or total cystectomyTumors of the urinary system are more common in men than women. Other than gender, what are some other risk factors for the development of these tumors?Often, the diagnosis of tumors of the bladder does not take place until the disease is advanced and the tumors are quite large. To what can this delay in diagnosis be attributed?What diagnostic tests might be ordered when evaluating tumors of the urinary system?
34 Conditions Affecting the Prostate Gland Benign prostatic hypertrophyEtiology/pathophysiologyEnlargement of the prostate glandCommon in men 50 years old and olderCause is unknownThe man’s urethra is surrounded by the prostate gland. What is the function of the prostate gland?As men age, the gland might increase in size, causing problems. Although the cause is not known for certain, what theories could explain this occurrence?
36 Conditions Affecting the Prostate Gland Benign prostatic hypertrophy (continued)Medical management/nursing interventionsRelieve obstruction—Foley catheterProstatectomyPostoperativeTURPBladder irrigationsUrine will be pink to cherry redSuprapubic or abdominalAssess dressingsWhen a patient presents with complaints involving the prostate gland, what diagnostic tests can be anticipated?Review the technique needed to examine the prostate gland.What findings will support a prostate disorder?When an enlarged prostate is diagnosed, what will determine the course of treatment?
37 Conditions Affecting the Prostate Gland Cancer of the prostateEtiology/pathophysiologyMalignant tumor of the prostate glandClinical manifestations/assessmentInitiallyNo symptomsAdvanced stagesUrinary obstructionUnfortunately, when cancer of the prostate gland is present, metastasis can result. What body structures are most prone to becoming sites of metastasis?Why is this type of cancer at a high risk for spreading?
38 Conditions Affecting the Prostate Gland Cancer of the prostate (continued)Medical management/nursing interventionsLocalized: radiation and/or surgeryMen over 70 years old: Radiation and hormone therapyAdvancedEstrogen therapyOrchiectomyRadiation therapyChemotherapyWhat prognosis is associated with cancer of the prostate?
39 Urethral Strictures Etiology/pathophysiology Narrowing of the lumen of the urethra that interferes with urine flow; congenital or acquiredClinical manifestations/assessmentDysuria; nocturiaWeak urinary streamPain with bladder distentionMedical management/nursing interventionsCorrection of strictureAnalgesicsUrethral stricture can be a painful condition. Identify potential causes of acquired urethral strictures.Discuss the assessment of a patient presenting with suspected urethral strictures.What questions should be asked during the data collection phase and the physical examination?
40 Urinary Tract Trauma Urinary tract trauma Etiology and pathophysiology Injury to the urinary tract may result from accidents, surgical intervention, and fracturesClinical manifestationsHematuriaAbdominal pain and tendernessMedical management/nursing interventionsUrinary tract trauma may result from lacerations and contusions to urinary tract structures.What diagnostic tests may be ordered to assess for the presence of urinary tract trauma?
41 Immunological Disorders of the Kidney Nephrotic syndromeEtiology/pathophysiologyPhysiologic changes of the glomeruli interfere with selective permeabilityClinical manifestations/assessmentProteinuria; hypoalbuminemiaGeneralized edemaAnorexiaFatigueOliguriaNephrotic syndrome is a grouping of interrelated clinical manifestations in which the permeability of the glomerulus is altered, resulting in changes in the composition of both blood and urine.Provide a detailed discussion of the resulting changes in the blood and urine.How might the urine of the patient experiencing nephrotic syndrome appear?
42 Immunological Disorders of the Kidney Nephrotic syndrome (continued)Medical management/nursing interventionsPharmacological managementCorticosteroidsDiureticsDietLow sodiumHigh proteinThe goal of treatment is geared at locating and treating the underlying causes. What are potential causes of nephrotic syndrome?What is the prognosis for the patient diagnosed with nephrotic syndrome? What impact does this condition have on the body’s immune response?
43 Immunological Disorders of the Kidney Nephritis (acute glomerulonephritis)Etiology/pathophysiologyPrevious infection with β-hemolytic streptococcus (2-3 weeks prior)Preexisting multisystem diseasesNephritis results from an inflammation of the kidney. Multiple disorders belong to this classification.Acute glomerulonephritis results after an immune response is triggered by an illness in the body. Explain the pathophysiological mechanism of the condition.
44 Immunological Disorders of the Kidney Nephritis (acute glomerulonephritis) (continued)Clinical manifestations/assessmentEdema of the facePallorMalaiseAnorexiaDyspnea with exertionHematuriaChanges in voiding patternsOliguria; dysuriaDiscuss the objective and subjective data that should be collected for the patient suspected of having acute glomerulonephritis.
45 Immunological Disorders of the Kidney Nephritis (acute glomerulonephritis) (continued)Medical management/nursing interventionsPharmacological managementAntibioticsDiureticsAntihypertensivesSupportive managementDietProtein and sodium restrictionsIncrease caloriesThe physician will order a series of tests to confirm a diagnosis. These tests will include BUN, serum creatinine, potassium levels, erythrocyte sedimentation rate, antistreptolysin-O titer, and urinalysis. What test findings will support the diagnosis?The treatment is aimed at caring for the presenting symptoms. What are the nursing responsibilities relating to patient education?
46 Immunological Disorders of the Kidney Nephritis (chronic glomerulonephritis)Etiology/pathophysiologySlow, progressive destruction of glomeruliCommonly caused by other chronic illnessesDiabetes mellitusSystemic lupus erythematosusGlomerulonephritis may be acute or chronic. How do the two types differ?Does the patient diagnosed with acute glomerulonephritis have the risk of developing chronic glomerulonephritis? If so, how?
47 Immunological Disorders of the Kidney Nephritis (chronic glomerulonephritis) (continued)Clinical manifestations/assessmentMalaise; morning headachesDyspnea with exertionVisual and digestive disturbancesGeneralized edemaWeight lossFatigueHypertensionAnemiaProteinuriaPatients suffering from chronic glomerulonephritis could exhibit alterations in mental functioning/abilities. What is the underlying cause of these changes on cognition? What questions/assessment tools can be used in the assessment process?
48 Immunological Disorders of the Kidney Nephritis (chronic glomerulonephritis) (continued)Medical management/nursing interventionsSame as acute glomerulonephritisRenal dialysisKidney transplantManagement of chronic glomerulonephritis involves treating the side effects of the disorder. Dialysis could be indicated. What will dialysis accomplish?What is the role of the nurse in providing care of this patient?Identify the prognosis for the patient with chronic glomerulonephritis.
49 Renal Failure Acute renal failure Etiology/pathophysiology Kidney function alteredInterference with ability to filter bloodDecrease in blood flow to the kidneyThree phasesOliguric phaseDiuretic phaseRecovery phaseRenal failure is a serious medical problem. The onset could be the result of chronic urinary dysfunction or an unexpected rapidly progressing disease process.There are predisposing factors associated with the onset of renal failure. Identify some of the more common factors.What role can be played by nurses in preventing the onset of renal failure?
50 Renal Failure Acute renal failure (continued) Clinical manifestations/assessmentAnorexiaNauseaVomitingEdemaDry mucous membranesPoor skin turgorUrine output less than 400 mL/24 hours (oliguric phase)The progression of renal failure is typically described in phases. During each phase, there are a series of characteristic events. What occurs during each phase?Discuss the role of the nurse regarding the assessment and education in each phase.
51 Renal Failure Acute renal failure (continued) Medical management/nursing interventionsPharmacological managementDiureticsAntibioticsKayexalateAdminister fluidsAssess for and treat electrolyte imbalancesDialysisDiet: High in carbohydrates; low in protein, potassium, and sodiumThe clinical findings associated with renal failure will be combined with laboratory testing to confirm a diagnosis. What tests can be anticipated? What results will confirm the onset of renal failure?What are the goals of medical management for acute renal failure?Recovery from acute renal failure can occur. What factors will affect the body’s ability to regain renal function?
52 Renal Failure Chronic renal failure Etiology/pathophysiology End-stage renal failureKidneys are unable to regain normal functionDevelops slowly over an extended period of timeResult of kidney disease or other disease process that compromises renal blood flowIn some cases, it might be impossible for the body’s kidneys to resume functioning. This total loss of function results in end-stage renal failure.What populations are at highest risk for this to happen?
53 Renal Failure Chronic renal failure (continued) Clinical manifestations/assessmentHeadacheLethargy; decreased strengthAnorexiaPruritusAnuriaMuscle cramps or twitchingDusky yellow-tan or gray skin colorDisorientation and mental lapsesAnemiaThe presenting symptoms of chronic renal failure are very individualized. The patient’s overall health status will have a large impact on the clinical presentation.
54 Renal Failure Chronic renal failure (continued) Medical management/nursing interventionsDialysisRenal transplantMedications to treat symptomsDiet: High in calories; restricted protein, potassium, and sodiumRestricted fluids300 to 600 mL above urine outputThe goals of medical management are to safeguard renal function as long as possible.Dialysis, dietary modification, and drug therapy could be instituted.The patient in renal failure will face numerous challenges concerning the prescribed diet. What elements are restricted in the diet? What is the underlying rationale for the dietary restrictions?Review the actual foods limited in the care of a patient in chronic renal failure.
55 Care of the Patient Requiring Dialysis A medical procedure for the removal of certain elements from the blood through a semi-permeable membrane (external or peritoneum)Mimics kidney functionTwo typesHemodialysisPeritoneal dialysisWhen the kidneys fail to adequately remove toxins from the body, dialysis is instituted.The physician could order either peritoneal dialysis or hemodialysis. How do these procedures differ? Which patients are most suited for each type?What emotional stressors are associated with dialysis?
56 Surgical Procedures for Urinary Disorders NephrectomyNephrostomyKidney transplantationUrinary diversionIleal conduitContinent ileal urinary reservoir or Kock pouchSurgical intervention might be needed if less invasive measures of treatment are not successful in managing urinary disorders.Review the procedure of each of the listed surgeries. When is each of them performed?What is the role of the nurse in the preoperative and postoperative phases of care for the patient undergoing surgical management of a urinary disorder?
57 Figure 10-12 Renal transplantation. (From Belcher, A.E. . Cancer nursing. St. Louis: Mosby.)Renal transplantation.
58 Ileal conduit or ileal loop. Figure 10-13Ileal conduit or ileal loop.
59 Figure 10-14(From Thibodeau, G.A., Patton, K.T. . Structure and function of the body. (13th ed.). St. Louis: Mosby.)Kock pouch.