Genital-Urinary System

Genital-Urinary System
Renal System Part 1

Behavioral Objectives:
Review the anatomy and physiology of the genito-urinary systems Describe the physical assessment of the GU systems Discuss the application of the nursing process as it relates to patients with disorders of the GU system Describe the purpose and methods for collecting sterile and “clean-catch” urine specimens. Discuss the importance of monitoring and maintaining intake and output and appropriate documentation Discuss common diagnostic tests, procedures and related nursing responsibilities for the patient with GU disorders. Explain the purpose of dialysis and differentiate between peritoneal and hemodialysis

Introduction Essential to life
4/13/2017 Introduction Essential to life Every head to toe assessment must include… Upper & lower urinary tract function Introduction It is essential to life that the urinary system function properly This module with present you with information you will need in order to properly care for patients who experience dysfunction of the kidneys and lower urinary tract. Every head to toe assessment must include assessment of the upper and lower urinary tract function

Anatomy: Kidney Kidneys Shape Bean Color Brown-red How many / # 2

Anatomy: Kidneys Kidneys Location Posterior wall of the abdomen
4/13/2017 Anatomy: Kidneys Kidneys Location Posterior wall of the abdomen Base of the rib cage Surrounded by renal capsule Right kidney is lower than the left Introduction It is essential to life that the urinary system function properly This module with present you with information you will need in order to properly care for patients who experience dysfunction of the kidneys and lower urinary tract. Every head to toe assessment must include assessment of the upper and lower urinary tract function Anatomy of the urinary systems Kidneys Location Two kidneys The kidneys are located behind and outside of the peritoneal cavity on the posterior wall of the abdomen They lie at the base of the rib cage and are well protected by the ribs, muscles fascia and fat They are surrounded by a renal capsule

Anatomy: kidney Do You Remember? What lies on top of each kidney?
Liver Pancreas Meat balls Adrenal gland

What hormones do the adrenal glands secrete?
4/13/2017 What hormones do the adrenal glands secrete? (Not a multiple choice question!) Hint Sugar, Sex & Salt Glucocorticoids Androgens Mineralcorticoids - aldosterone Aldosterone is going to play a big part in kidney function.

Anatomy: Kidney Two distinct regions: Renal parenchyma Renal pelvis
4/13/2017 Anatomy: Kidney Two distinct regions: Renal parenchyma Renal pelvis Divided into 2 parts Cortex Medulla Two distinct regions: Renal parenchyma and renal pelvis Renal parenchyma Consists of the Cortex and medulla Cortex Contains the nephrons (1 million/kidney) Glomerulus (surrounded by Bowman’s capsules Proximal convoluted tubule Loops of Henle Distal convoluted tubules Collecting tubules peritubular capillaries It is not necessary for you to know the different types of nephrons of the different filtering layer so the glomeruli Medulla Looks like pyramids (3-sided structures) These pyramids drain urine from the nephrons to the renal pelvis Urine drains by way of calices (calyx) – cup shaped structures

Renal parenchyma Medulla Inner portion Contain Loops of Henle
Vasa recta Collecting ducts

Renal parenchyma Medulla Collecting ducts connect to Renal pyramids
Shape: Triangle Point toward Hilum / pelvis Ea. Kidney contains 8-18 pyramids

Anatomy: Kidney Medulla Function
Drain urine from the Nephrons to the renal pelvis

Renal parenchyma Medulla Cortex Divided into 2 regions Contains
4/13/2017 Renal parenchyma Divided into 2 regions Medulla Cortex Contains Nephrons Functional unit of the kidneys

Anatomy: Kidney Renal pelvis Ureter Renal artery Renal Vein
4/13/2017 Anatomy: Kidney Renal pelvis Ureter Renal pyramids drain urine into the ureter Renal artery Renal Vein Renal pelvis The concave portion of the kidney through which urine passes to the ureter and then on toward the bladder Renal artery: blood is supplied to the kidney by way of the renal artery – which branches off the abdominal aorta The renal artery branches into smaller and smaller vessels until it finally branches into the afferent arteriole The afferent arteriole branches into the Glomerulus Glomerulus is the capillary bed responsible of glomerular filtration After the blood has been filtered by the Glomerulus, it leaves by way of the efferent arteriole The efferent arteriole branches down to the cellular level and the blood returns back to the heart by way of venules and veins.

Blood supply to the kidney
Aorta  Renal artery  Afferent arteriole  Glomerulus Capillary bed Efferent arteriole  Venules and veins Inferior Vena Cava

Can you do it? Place the following in order to best describe blood flow threw the kidney. Afferent arteriole Aorta Efferent arteriole Glomerulus Inferior Vena Cava Renal artery Vein Venules B-F-A-D-C-H-G-E

QUESTION???? Where in the flow of blood threw the kidney does filtration take place? Afferent arteriole Aorta Efferent arteriole Glomerulus Inferior Vena Cava Renal artery Vein Venules

Anatomy: Nephrons Functional unit* FYI
1 million Nephrons in ea. Kidney Adequate renal function with 1 kidney

Anatomy: Nephrons Nephron Glomerulus Bowman’s capsule
Proximal convoluted tubule Loops of Henle Distal convoluted tubule

4/13/2017 Anatomy: Ureters Urine:nephrons  renal pyramids  renal pelvis  ureter, a long narrow muscular tube Extends from renal pelvis  bladder Two Upper urinary tract Ureters Urine, which is formed within the nephrons, flow into the ureter, a long narrow muscular tube which starts at the lower portion of the renal pelvis and extends down to the bladder Two ureters (right and left) Upper urinary tract Each ureter has 3 narrowed areas along its length. These junctions cause an angling of the ureter that promotes efflux of urine (downward flow) and prevents reflux (backwards movement)t of urine up toward the kidney When a person voids (micturition) – the process of expelling urine from the urinary bladder these narrowed areas close off so that no more urine will enter the bladder. After the person finishes voiding, the junction will re-open and urine can again grain from the ureters into the bladder The lining of the ureters (as well at the bladder) is made up of urothelium, and epithelial tissue that prevents reabsorption of urine The movement of urine within the ureters is facilitated by peristaltic waves within the musculature of the tubes

Anatomy: Ureters 3 narrowed areas promotes efflux prevents reflux
micturition Propensity for obstruction by renal calculi

Anatomy: Ureters lining urothelium
prevents reabsorption of urine The movement of urine is facilitated by peristaltic waves

Anatomy: Bladder BLADDER Description Location Function Muscular
4/13/2017 Anatomy: Bladder BLADDER Description Muscular hollow sac Location Behind pubic bone Function Reservoir for urine Bladder The urinary bladder is a muscular, hollow sac located just behind the symphysis pubis. Normal bladder capacity if ml of urine But an overdistended bladder can hold in excess of 1500ml of urine When you insert a Foley, it is important for you to take note of the amount of urine that is drained as the distended bladder is emptied. When a patient loses too much fluid too rapidly, his/her hemodynamics can’t tolerate the rapid change (release of pressure on abdominal vessels) and he/she may develop hypovolemic shock This can be prevented by temporarily clamping the Foley drainage tubing after 750 ml of urine has entered the drainage bag. You are not responsible for knowing the names of the 4 layers of the bladder wall. Just remember that the bladder is surrounded by a spherically shaped muscle called the detrusor muscle In the neck of the bladder is an area of smooth muscle that makes up the internal urinary sphincter which is under involuntary control

Anatomy: Bladder Normal capacity Capable of holding
ml of urine Capable of holding ml CNS stim. “need to void” ml urine

Anatomy: Bladder Neck of the bladder Internal urinary sphincter
Involuntary control

4/13/2017 Anatomy: Urethra Carries urine from the bladder & expels it from the body External urinary sphincter voluntary control Urethra The urethra carries the urine from the bladder and expels it from the body Within the urethra is the external urinary sphincter, which is the only structure within the urinary system that is under voluntary control. Everything else is operated by the autonomic nervous system

Physiology of the Urinary System
4/13/2017 Physiology of the Urinary System Function of the kidneys Urine formation Excretion of waste products Regulation of Electrolytes Acid-base control RBC production Ca+ & Ph Control water balance blood pressure Renal clearance Synthesis of Vit. D Physiology of the urinary systems The urinary system is responsible for several essential bodily functions. They include: Urine formation Excretion of waste products Regulation of excretion of electrolytes, acid and water Auto-regulation of blood pressure

Physiology of the Urinary System
4/13/2017 Physiology of the Urinary System Urine formation The nephrons form urine through a complex 3-step process Glomerular filtration Tubular reabsorption Tubular secretion Urine formation The nephrons form urine through a complex 3-step process Glomerular filtration Tubular reabsorption Tubular secretion

1. Glomerular filtration
4/13/2017 1. Glomerular filtration Step 1 Most of the elements of blood, except large molecules blood cells forced out of the blood  capillaries of the glomerulus  Bowman’s capsule  filtrate High capillary BP in the glomerulus. Glomerular filtration Most of the contents of the blood, except for large molecules and blood cells, are forced out of the blood from the capillaries of the glomerulus and into the Bowman’s capsule. This occurs because of the high capillary blood pressure within gthe glomerulus. The glomerular basement membrane assists with the process of filtration.

Filtration at Glomerulus Water Na+ Cl- Bicarbonate K+ Glucose Urea Creatinine Uric Acid

Factors that can alter process: Blood flow Blood pressure

2. Tubular reabsorption Step 2 Filtrate  Proximal convoluted tubule 
4/13/2017 2. Tubular reabsorption Step 2 Filtrate  Proximal convoluted tubule  Reabsorption (back into blood) Most Water Na+ Cl- Bicarb K+ Uric Acid All of the glucose None of the Creatinine Tubular reabsorption As the filtrate passes though the first parts of the tubular structure, carious substances such as necessary amounts of electrolytes, glucose, and water are reabsorbed back into the capillaries

3. Tubular Secretion Elements secreted from blood into tubule for excretion in urine Some Water Na+ Cl- Bicarbonate K+ Uric acid Most Urea

Filtrate  Tubules  Collecting duct  Renal pelvis Ureter 
Bladder  Urethra

4/13/2017 Glucose Normally all the glucose filtered through the glomeruli will be reabsorbed back into blood No glucose in the urine Glycosuria Diabetes mellitus h serum glucose levels overwhelm the nephron’s ability to reabsorb glucose Sweet pea! Normally all the glucose filtered through the glomeruli will be reabsorbed from the tubule back into the blood stream. Therefore under normal conditions, no glucose can be detected in the urine Glucose will be present in the urine of a person with diabetes mellitus when the concentration of glucose in the blood is so high (>200mg/dl), it overwhelms the nephron’s ability to adequately perform tubular reabsorption. When this occurs, some of the glucose fails to be reabsorbed and is therefore passed through the urine

4/13/2017 Protein Filtered by glomeruli & returned to the blood by tubular reabsorption. Slight proteinuria OK globulin, albumin Persistent proteinuria Glomerular damage In a manner similar to that of glucose, protein is usually filtered by the glomeruli and returned to the blood stream by way of tubular reabsorption. However, some protein molecules (globulin, albumin) may occasionally avoid reabsorption and be present in the urine. This is not of clinical concern when proteinuria is slight (<150 mg/dL) and occurs only transiently. When a patient exhibits persistent proteinuria, it is usually an indication of significant glomerular damage

Anti-diuretic hormone (ADH)
4/13/2017 Anti-diuretic hormone (ADH) AKA Vasopressin Secreted by Posterior Pituitary Secreted in response to changes in blood osmolality Antidiuretic hormone ADH (Vasopressin), which is secreted by the posterior pituitary gland, regulates water excretion and urine concentration. It does this by varying the amount of water that is absorbed. ADH is released whenever the Osmolality of the blood rises (as when there is a decreased in the amount of fluid s that are taken it. In response to the presence of ADH, the kidneys increase the reabsorption of water. This returns the Osmolality of the blood to normal When there is an increase of fluid intake, the pituitary is suppressed from secreting ADH. Without the presence of ADH, less water is reabsorbed through the renal tubules and urine volume is increased (diuresis).

Normally Water intake i  Blood osmolality  h Stim. pituitary to ADH ADH receptor site  Kidney Action h reabsorption of H2O i urine volume/output  returns blood osmolality to normal

Normally Water intake h  Blood osmolality  i Stim. pituitary to ADH ADH receptor site Kidney Action i reabsorption of H2O h urine volume (diuresis)  returns blood osmolality to normal

Osmolarity & Osmolality
# of particles dissolved in solution Osmolality Thickness of solution Urine Serum / blood

Regulation of water excretion
4/13/2017 Regulation of water excretion The amt. of urine formed is r/t the amt. of fluid intake h fluid intake  volume urine h Characteristic Dilute i fluid intake  volume of urine i Concentrated Normally: kidneys rid the body of about 75% of fluids taken in Regulation of water excretion The kidney also perform the important function of regulation of the amount of water that is excreted. The amount of urine formed is related to the amount of fluid taken in High fluid intake results in the excretion of a large volume of dilute urine Low fluid intake results in the excretion of a small volume of concentrated urine Normally, the kidneys rid the body of about 75% of all the fluids taken in. The remained of the fluids taken in are excreted through the skin, (sweat), lungs, (breathing) and in feces.

Regulation of Electrolytes Excretion
4/13/2017 Regulation of Electrolytes Excretion Sodium Normally serum Na+: mmol/L Na+ filtered from the blood & reabsorbed from the tubule back into the blood Na+ excretion is controlled by Aldosterone h Aldosterone  h Na retention  __?__ Serum Sodium level h serum sodium level Na+ most abundant electrolyte found outside the cells (extracellular) Regulation of electrolytes excretion On a daily bases, the kidneys will normally excrete all the electrolytes (Na & K) that have been ingested Sodium As you can see on figure43-3 nearly all of the Na filtered from the blood (glomerular filtration) is reabsorbed from the tubule back into the blood stream The amount of Na excreted is controlled by Aldosterone which is a hormone manufactured by the adrenal cortex The more Aldosterone in the blood, the more Na will be retained (the less Na will be excreted) Aldosterone fosters renal reabsorption of Na Na is the most abundant electrolyte found outside the cells (extracellular) Potassium K is the most abundant elecrolyte found inside the cells (intracellular). K and Na remain balanced within their environment through the influence of Aldosterone. As you will recall, the more Aldosterone in the blood, the more Na will be reabsorbed. The opposite is true of K, the more Aldosterone in the blood, the more K will be excreted.Regardless of the amount of aldosteron, when the kidney’s nephrons are not functioning normally, sodium and potassium cannot be adequately filtered from the blood The most life-threatening effect of renal failure is retention of K. Hyperkalemia can result in potentially fatal cardiac dysrhythmias.

4/13/2017 Regulation of Electrolytes Excretion Potassium K+ is the most abundant electrolyte found inside the cells (intracellular). h Aldosterone  h K excretion  __?__ serum K+ level i serum K+ level Regulation of electrolytes excretion On a daily bases, the kidneys will normally excrete all the electrolytes (Na & K) that have been ingested Sodium As you can see on figure43-3 nearly all of the Na filtered from the blood (glomerular filtration) is reabsorbed from the tubule back into the blood stream The amount of Na excreted is controlled by Aldosterone which is a hormone manufactured by the adrenal cortex The more Aldosterone in the blood, the more Na will be retained (the less Na will be excreted) Aldosterone fosters renal reabsorption of Na Na is the most abundant electrolyte found outside the cells (extracellular) Potassium K is the most abundant elecrolyte found inside the cells (intracellular). K and Na remain balanced within their environment through the influence of Aldosterone. As you will recall, the more Aldosterone in the blood, the more Na will be reabsorbed. The opposite is true of K, the more Aldosterone in the blood, the more K will be excreted.Regardless of the amount of aldosteron, when the kidney’s nephrons are not functioning normally, sodium and potassium cannot be adequately filtered from the blood The most life-threatening effect of renal failure is retention of K. Hyperkalemia can result in potentially fatal cardiac dysrhythmias.

Kidney’s not functioning normally Na+ & K+ will not be adequately filtered from the blood Retention of K+ is the most life-threatening effect of renal failure Renal failure Retention of K+  Hyperkalemia  Cardiac dysrhythmias  Death

Regulation of acid excretion
4/13/2017 Regulation of acid excretion Proteins are broken down into acids phosphoric acid sulfuric acid. Acids in the blood  i pH Normally kidneys Filter acids from the blood Tubular filtration Chemical buffer mechanism Regulation of acid excretion Proteins are broken down (catabolized) into acids, particularly, phosphoric acid and sulfuric acid. The presence of these acids in the blood would lower the pH of the blood if they were allowed to remain in the blood. Normally kidneys effectively filter these acids from the blood by two different mechanisms. Tubular filtration Much of the acid is excreted directly into the urine through tubular filtration. The body uses this mechanism until the acidity of the bladder reaches pH 4.5 Any excess acid must be neutralized so that the pH of the urine does not become too acidic. Chemical buffer mechanism This second mechanism neutralizes acids by binding them to chemical buffers so that they can be excreted in the urine without altering the pH. Important buffers Phosphate ions Phosphate is present in the glomerular filtrate where it can buffer the acids Ammonia NH3 Buffers with acid to form ammonium (NH4)

4/13/2017 Regulation of acid excretion Tubular filtration Acid is excreted into the urine through tubular secretion Used until the bladder acidity pH 4.5 Any excess acid must be neutralized Tubular filtration Much of the acid is excreted directly into the urine through tubular filtration. The body uses this mechanism until the acidity of the bladder reaches pH 4.5 Any excess acid must be neutralized so that the pH of the urine does not become too acidic.

4/13/2017 Regulation of acid excretion Neutralize acids binding them to chemical buffers Be excreted without altering the pH Important buffers Phosphate ions Ammonia NH3 Chemical buffer mechanism This second mechanism neutralizes acids by binding them to chemical buffers so that they can be excreted in the urine without altering the pH. Important buffers Phosphate ions Phosphate is present in the glomerular filtrate where it can buffer the acids Ammonia NH3 Buffers with acid to form ammonium (NH4)

Regulation of Red Blood Cell Production
4/13/2017 Regulation of Red Blood Cell Production Kidneys measure O2 tension of the blood (PaO2) i PaO2  (Hormone) h erythropoietin  (Receptor site) bone marrow  (Action) h production of RBC  h Hgb  h PaO2 Regulation of Red Blood Cell Production The kidneys are able to sense the oxygen tension of the blood entering the kidney. When a low oxygen tension is detected, the kidneys release a hormone called erythropoietin. This hormone stimulates the bone marrow to produce more BRC’s With more RBC’s circulating, there is more Hgb to carry oxygen Normal RBC level =

Normal RBC-Erythrocytes
Male: million/mm3 Female: million/mm3 Normal Hemoglobin Male g/dL Female g/dL

Vitamin D Synthesis Kidneys activate ingested Vitamin D 
4/13/2017 Vitamin D Synthesis Kidneys activate ingested Vitamin D  Aid absorption of calcium Vitamin D Synthesis The kidneys are also able to activate ingested Vitamin D so that it can aid in the absorption of calcium

Excretion of waste products
4/13/2017 Excretion of waste products Urea, (waste product of protein metabolism) Blood Urea Nitrogen h BUN = renal dysfunction Other waster products of metabolism are Creatinine Phosphates Sulphates Ketone Along with BUN the serum Creatinine level is usually ordered whenever the MD suspects renal disease Excretion of waste products With kidneys, people would not be able to excrete metabolic wastes from the body Urea, a waste product from protein metabolism, is the major constituent of wastes normally eliminated from the body by way of the kidneys. A high BUN is an indication of renal dysfunction Inability of the kidneys to adequately filter urea from the blood Other waster products of metabolism are Creatinine phosphates sulphates Ketone Along with BUN the serum Creatinine level is usually ordered whenever the MD suspects renal disease Uric acid is another waste product excreted by the kidneys. It is formed as an end-product of purine metabolism Hyperuricemia which results in gout, could be due to either renal dysfunction, or overproduction of uric acid from diet or an inherited enzyme deficiency The kidneys also are the primary means of ridding the body of drug metabolism

Excretion of waste products
4/13/2017 Excretion of waste products Uric acid (purine metabolism) Hyperuricemia gout, Kidneys also are the primary means of ridding the body of Drug metabolism Uric acid is another waste product excreted by the kidneys. It is formed as an end-product of purine metabolism Hyperuricemia which results in gout, could be due to either renal dysfunction, or overproduction of uric acid from diet or an inherited enzyme deficiency The kidneys also are the primary means of ridding the body of drug metabolism

Auto-regulation of Blood Pressure
4/13/2017 Auto-regulation of Blood Pressure Vasa recta constantly monitor the blood pressure i blood pressure  h Renin h angiotensin 2 h vasoconstriction  h blood pressure. h B/P i Renin Vasa recta failure to recognize h BP & stop/halt Renin secretion  primary causes of hypertension. Auto-regulation of Blood Pressure Specialized vessels of the kidney called the vasa resta constantly monitor the blood pressure as blood begins its passage into the kidneys When a decrease in blood pressure is detected the hormone Renin is secreted by specialized cells in the kidney Renin causes a conversion of chemicals that results in angiotensin 1. Angiotensin 1 then converts to angiotensin 2, which is the most powerful vasoconstrictor known. The vasoconstriction causes an increase in blood pressure. When the vasa resta recognize the increase in B/P, Renin secretion stops. Failure of the ability of the vasa recta to recognize the increased pressure and cause a halt to Renin secretion is one of the primary causes of hypertension.

Gerontological Considerations
4/13/2017 Gerontological Considerations Function of the urinary tract declines. GFR declines Prone to develop hypernatremia & fluid volume deficit At risk for adverse drug effects As people get older, the function of the urinary tract begins to decline. The rate at which the glomeruli filter the blood (GFR) begins to decline when people reach their late 30’s. The GFR declines by about 1 ml/min every year thereafter. Normal GFR 120 ml/min Ave 80 y/o GFR = 80 ml/min Although this reduction of GFR doesn’t usually affect adequate renal functioning, it does put the older person at risk during times of drastic and sudden physiologic changes. During these times, the kidneys may not be able to respond effectively. The older person who must take multiple medication sis also at risk for adverse drug effects. This is because the kidneys are responsibly for ridding the body of most medication metabolites. When GFT is decreased, the kidneys cannot effectively filter out all of their metabolites, which allow them to remain in the circulation blood.

Assessment Risk Factors h age Instrumentation of urinary tract
4/13/2017 Assessment Risk Factors h age Instrumentation of urinary tract Immobility Diabetes mellitus HTN Gout, hyperparathyroidism, Crohn’s disease Benign prostatic hypertrophy Obstetric injury General The first step when obtaining a health history is to assess for any risk fatos your patient may have tha may increase his/her risk of developing urinary tract dysfunction Risk Factors (see chark 43-2 p. 1257) Advanced age Instrumentation of urinary tract Immobility Diabetes mellitus Hypertension Gout, hyperparathyroidism, Crohn’s disease (leased to kidney stone formations) Benign prostatic hypertrophy Obstetric injury

Assessment: Health history
4/13/2017 Assessment: Health history Chief complaint Pain Hx of UTI’s Fever or Chills instrumentation Dysuria Hesitancy, straining Urinary incontinence Hematuria Nocturia Hx of kidney stones Hx of STD’s Tobacco, alcohol, drugs Meds Females # & types of deliveries Hx vaginal infections hen talking with the patient during the health history-collecting meeting, be aware that discussion of urinary problems may present an embarrassing situation for some patients. It is important therefore, to use a straightforward approach avoiding the use of medication terminology. This way, you can empathetically pose question is such a way that the patient will not feel ill at ease. Information you want to obtain during the health history meeting: The chief complaint: and how it is effecting the patient quality of life. Pain: location, character, duration, its relationship to voiding, precipitation factors, methods of relief. History of UTI’s: What treatment was received? Any hospitalization for UTI? Fever or Chills Any previous instrumentation of the urinary tract: (Diagnostic procedures, catheterizations) Dysuria (difficulty urination – or painful urination) Hesitancy, straining, or pain during or after urination urinary incontinence Hematuria of change in color and volume of the urine Nocturia (the need to get up our of bed at night to void) History of kidney stones Females: Number of types of deliveries, forceps used? History of vaginal infections History of STD’s Use of tobacco, alcohol or recreational drugs List of all meds being used (Rx and OTC)

4/13/2017 Physical Exam Abdomen, supropubic region, genitalia and lower back, the lower extremities Palpate kidney Feel the rounded lower border of the kidney Right kidney When performing a head to toe physical assessment of a patient, urological problems may be detected by concentration of the abdomen, supropubic region, genitalia and lower back, as well as the lower extremitiesl You can detect the size and mobility of the kidney by directly palpating it as shown in fig 43-5 (p.1261) This way you may be able to feel the rounded lower border of the kidney between your two hands. TI is easirer to feel the right kidney because it sits lower in the body. If palpation elistics tenderness in the costovetebral angle (the area where the 12th rib joins with the spline) that may be an indication of renal dysfunction.

Physical Exam Palpation of bladder
4/13/2017 Physical Exam Palpation of bladder Performed after voiding if suspect urinary retention Percussion of he bladder should be performed after voiding in patients with suspected urinary retention. Percussion will enable you to determine whether or not the bladder was emptied at the time of voiding. Begin at the midline just above the umbilicus and percuss downward in a straight line. Initially, tympany (drum-like) will be heard, as you progress downward, tympany will change to dullness if there is still urine in the bladder. (bong- bong- bong – thud-thud- thud) When urinary retention is extreme the patient will require Foley catheterization so that large amounts of urine will not remain in the bladder and possible retrograde up the ureters and cause kidney dysfunction

Terms - matching Urgency Pyuria Proteinuria Polyuria Oliguria Nocturia
Incontinence Hesitancy Hematuria Frequency Euresis Dysuria Anuria Frequent voiding – more than every 3 hours Strong desire to void Painful or difficult voiding Delay, difficulty in initiating voiding Excessive urination at night Involuntary loss of urine Involuntary voiding during sleep Increased volume of urine voided Urine output less than 400 ml/day Urine output less than 50 ml/day Red blood cells in the urine Abnormal amounts of protein in the urine Pus in the urine

The presence of peritoneal fluid build up is described as which one of the following?
“I’m so nervous I have to void” phenomenon Bruits Generalized edema Peritoneal dialysis Ascites

Diagnostic Evaluation: Urinalysis
4/13/2017 Diagnostic Evaluation: Urinalysis Color; clarity; odor; urine pH and specific gravity Colorless to pale yellow dilute (diuretics, alcohol, diabetes Insipidus, excess fluid intake) Yellow to milky white Pyuria, infection Bright yellow Multiple vitamin Pink to red RBC, menses, Bladder or prostate surgery, beets, meds Blue, blue green dyes, meds Orange to amber Dehydration, bile, excess bilirubin or carotene, meds Brown to black Old red blood cells, dehydration, Diagnostic Evaluation Urinalysis The urinalysis is a valuable diagnostic tool. It provides important clinical information on the kidney function and is also used to help diagnose other diseases (diabetes). The UA provides information on the following characteristics of urine specimen: Color; clarity; odor; urine pH and specific gravity Colorless to pale yellow dilute urine due to diuretics, alcohol, diabetes Insipidus excess fluid intake, renal disease Yellow to milky white Pyuria, infection Bright yellow Multiple vitamin preparations Pink to red Hemoglobin breakdown, RBC, menses, Bladder or prostate surgery, beets, meds Blue, blue green dyes, meds Orange to amber Dehydration (concentrated) fever, bile, excess bilirubin or carotene, meds Brown to black Old red blood cells, dehydration, Presence of any protein, glucose or ketones RBC’s and WBC’s Casts (tiny structures formed from deposits on the walls of the renal tubules) Crystals (presence indicates patient is in imminent danger of kidney stone formation) Pus and bacteria

Diagnostic Evaluation: Urine Culture and Sensitivity
4/13/2017 Diagnostic Evaluation: Urine Culture and Sensitivity ID microorganism(s) Sensitivity report Time 2-3 days (48-72 hours) Is used to facilitate appropriate antibiotic therapy. Laboratory examination will identify the microorganism (s) present in a urine specimen. Ti also lists the antimicrobial drugs to which the microorganism is sensitive.

Specific Gravity The weight of urine
4/13/2017 Specific Gravity The weight of urine The specific gravity of distilled water 1.000 Normal urine specific gravity 1.003 – 1.030 Urine specific gravity is related to the level of hydration. h fluid intake  h H20 excretion  i specific gravity i fluid intake  i H20 excretion  h specific gravity Specific Gravity Testing the specific gravity of a urine sample will give the nurse and indication of the kidneys ability to concentrate urine. It is a measurement compating the weight of urine (weight of particle to the weight of distilled water. The specific gravity of distilled water is 1.000 Normal urine specific gravity is – 1.025 Urine specific gravity is related to the level of hydration. As a person takes in more fluid, the specific gravity decreased. However, as the volume of fluid intake decreases, the specific gravity increases. A person with Glomerulonephritis or severe renal damage will present with urine that is low in specific gravity, because the kidney is unable to filter out particles from the blood

Diagnostic Evaluation: Sterile urine specimens
4/13/2017 Diagnostic Evaluation: Sterile urine specimens Safety Standard precautions Biohazard bag for transport Collection Indwelling Foley Catheter Not from the drainage bag Aspiration port Catheter – straight cath A small amount of urine is allowed to run out of the catheter into a basin, then the urine is allowed to run into a sterile specimen bottle. Collection of sterile and “clean-catch” urine specimens Safety All urine collected requires the use of standard precautions to prevent the transmission of microorganism among nurses, clients and other health care providers. All specimen containers should be sealed in a biohazard bag prior to transport to the lab Sterile specimen A sterile specimen can be collected from a client with an indwelling Foley Catheter and closed drainage system A sterile specimen is used for urine culture The urine specimen should not be obtained from the drainage bag, because the analytes in the urine drainage bag change, leading to inaccurate results, and bacteria grows quickly in the drainage bag The catheter’s closed drainage tubing has an aspiration port that is used for sterile specimen collections Sometimes a sterile urine specimen is required when the client does not have an indwelling catheter and cloclosed drainage system In such cases, the client is catheterized A small amount of urine is allowed to run out of the catheter into a basin, then the urine is allowed to run into a sterile specimen bottle. Clean-catch or Clean-voided specimen Clean-voided (clean catch or midstream) specimen collection is done to secure a specimen uncontaminated by skin flora. Different aseptic techniques are used fro women and men Female clients are instructed to cleanse from the front to back and then void into the specimen bottle The male client is instructed to cleanse from the tip of the penis downward and then void into the specimen bottle Collect a "clean-catch" (midstream) urine sample. To obtain a clean-catch sample, men or boys should wipe clean the head of the penis. Women or girls need to wash the area between the lips of the vagina with soapy water and rinse well. As you start to urinate, allow a small amount to fall into the toilet bowl (this clears the urethra of contaminants). Then, in a clean container, catch about 1 to 2 ounces of urine and remove the container from the urine stream.

Diagnostic Evaluation: Clean-catch or Clean-voided specimen
4/13/2017 Diagnostic Evaluation: Clean-catch or Clean-voided specimen Clean-voided uncontaminated by skin flora. Female Cleanse: front to back Male Cleanse: tip of the penis downward Collect a "clean-catch" Start to void Midstream catch Collect 1 to 2 oz of urine Clean-catch or Clean-voided specimen Clean-voided (clean catch or midstream) specimen collection is done to secure a specimen uncontaminated by skin flora. Different aseptic techniques are used fro women and men Female clients are instructed to cleanse from the front to back and then void into the specimen bottle The male client is instructed to cleanse from the tip of the penis downward and then void into the specimen bottle Collect a "clean-catch" (midstream) urine sample. To obtain a clean-catch sample, men or boys should wipe clean the head of the penis. Women or girls need to wash the area between the lips of the vagina with soapy water and rinse well. As you start to urinate, allow a small amount to fall into the toilet bowl (this clears the urethra of contaminants). Then, in a clean container, catch about 1 to 2 ounces of urine and remove the container from the urine stream.

Renal Clearance Purpose Procedure Creatinine
4/13/2017 Renal Clearance Purpose Assess the Kidney’s ability to clear solutes from the plasma Procedure 24 hr urine collection 12 hr serum Creatinine level Creatinine waste product of skeletal muscle contraction Renal Clearance Renal clearance refers to the kidney’s ability to clear solutes from the plasma (filter particles from the blood). This is usually measured by the way of a 24 hour urine collection to evaluate how well the kidneys are excreting varying substances via glomerular filtration. The measurement of Creatinine clearance is an effective method of evaluating the glomerular filtration rate (GFR). Creatinine, one of the substances cleared by the kidneys, is a waste product of skeletal muscle contraction. TI is filtered across the Glomerulus and passed through the tubules without any chemical change. That makes is easily detected and that’s why we monitor the urine for its presence when we want to evaluate GFR. 12 hours after a 24 hour urine collection is begun, a blood sample is taken to assess the serum Creatinine level. At the end of the 24 hour urine collection, the urine is measured for volume and the urine Creatinine level. With this data, a formule is used to calculate Creatinine clearance. (volume of urine (ml/min) X urine Creatinine (mg/dL)) Serum Creatinine (mg/dL) Normal GFR is ml/min. As renal function declines, Creatinine clearance decreases. Detects and evaluated progression of renal disease

Renal Clearance One function of the kidney is to excrete Creatinine. If the Creatinine clearance level (the amount of Creatinine excreted by the kidney) decreases, what does that tell you about the function of the kidney?

Renal Clearance i renal function  Creatinine clearance evaluates
4/13/2017 Renal Clearance i renal function  i Creatinine clearance Creatinine clearance evaluates glomerular filtration rate (GFR) Detects and evaluates progression of renal disease Renal Clearance Renal clearance refers to the kidney’s ability to clear solutes from the plasma (filter particles from the blood). This is usually measured by the way of a 24 hour urine collection to evaluate how well the kidneys are excreting varying substances via glomerular filtration. The measurement of Creatinine clearance is an effective method of evaluating the glomerular filtration rate (GFR). Creatinine, one of the substances cleared by the kidneys, is a waste product of skeletal muscle contraction. TI is filtered across the Glomerulus and passed through the tubules without any chemical change. That makes is easily detected and that’s why we monitor the urine for its presence when we want to evaluate GFR. 12 hours after a 24 hour urine collection is begun, a blood sample is taken to assess the serum Creatinine level. At the end of the 24 hour urine collection, the urine is measured for volume and the urine Creatinine level. With this data, a formule is used to calculate Creatinine clearance. (volume of urine (ml/min) X urine Creatinine (mg/dL)) Serum Creatinine (mg/dL) Normal GFR is ml/min. As renal function declines, Creatinine clearance decreases. Detects and evaluated progression of renal disease

Can you Critical Think???? Mrs. Notafeela Sowell had a renal clearance test done 3 times this week. Is her renal disease getting better or worse? Monday: Renal clearance = 70 ml/min Wednesday: Renal clearance = 80 ml/min Friday: Renal clearance = 90 ml/min

Diagnostic Evaluation: Intake and Output
4/13/2017 Diagnostic Evaluation: Intake and Output I&O All fluids taken orally Form Time Amount Output Urine drainage from nasogastic tube drainage tubes Chest tubes Wound tubes Intake and Output Procedure Wash hands Explainthe purpose of keeping I&O all fluids taken orally must be recorded Form for recording must to used Client must void into bedpan, urinal or “hat” in toilet for collecting urine – not into the toilet Toilet tissue should be disposed of in plastic lined container not in bedpan Measure all oral fluids in accord with agency policy ( Record time and amount of all fluid intake in the designated space on bedside form Output Urine drainage from nasogastic tube drainage tubes Chest tubes Wound tubes

Apply it! Mr. Noah Awl is recovering from Prostatectomy due to benign hypertrophy of the Prostate. Mr. Awl is on strict intake and Output. He requests a cup of ice chips because his throat hurts (due to intubation). You give him a 200cc cup of ice chips and he eats them all. How much to you make on the Intake? 100cc 150 cc 200cc 300 cc 400 cc

Dialysis: Overview Purpose Definition Types:
4/13/2017 Dialysis: Overview Purpose Remove fluids and waste products from the body Definition Mechanical means of removing waste from the blood Types: Hemodialysis Peritoneal dialysis Dialysis Definition As the kidneys continue to deteriorate, nitrogenous waste products accumulate in the circulatory system These waste products then need to be removed artificially with dialysis Dialysis is a mechanical means of removing nitrogenous waste from the blood by imitating the function of the nephrones. In valves filtration and diffusion of waste, drugs, and excess electrolytes and or osmosis of water across a semi permeable membrane into a dialysate solution The dialysate, a solution designed to approximate the normal electrolyte structure of plasma and extra cellular fluid, is prescribed specific to the individual clients needs There are two types of dialysis: hemodialysis peritoneal dialysis

Dialysis: Process Process
Diffusion and osmosis across a semi permeable membrane into a dialysate solution prescribed specific to the individual clients needs

Dialysis: process Diffusion Toxins & wastes are removed by diffusion
Move from an area of higher concentration to an area of lower concentration

This photo shows the diffusion of fluids
This photo shows the diffusion of fluids. I added a few drops of blue food coloring in a vase of water, and took a picture after a few seconds. Diffusion is the process of a substance moving from high concentration to low concentration. The cause of diffusion is random molecular motion of the fluids, in other words, molecules of both the food coloring and the water move at random causing them to mix. In this case, the diffusion of the food coloring goes from high concentration to low concentration.

Osmosis Excess water is removed by osmosis
Water move from an area of higher solute concentration (blood) to an area of lower solute concentration (dialysate)

4/13/2017 Hemodialysis A machine with an artificial semi-permeable membrane used for the filtration of the blood. Hemodialysis Hemodialysis is performed by a machine with an artificial semi permeable membrane used for the filtration of the blood. Artificial kidney (machine is referred to as) A graft or fistula is surgically prepared to access the clients circulatory system With each hemodialysis treatment, the catheter is inserted into the graft of fistula The clients blood is circulated through the semi permeable membrane Excess fluids are removed by osmosis By-products of protein metabolism especially urea, uric acid, creatine, drugs and excess electrolytes are removed from the blood by diffusion or filtration. Nursing interventions The patient should be weighted before and after each dialysis Strict asepsis technique Assess fistula or graft A thrill should be felt A bruit should be heard Pulse peripheral to graft site should be assessed Blood pressure and blood draws should never be done on the extremity where the graft or fistula is placed. Not and IV port! (Fistula) Since meds are removed in the dialysis they are usually not given until after the session Usually performed 3 time a week Usually take 3-6 hours

Hemodialysis A graft or fistula is surgically prepared to access the clients circulatory system

Hemodialysis With each hemodialysis treatment, the catheter is inserted into the graft of fistula

Hemodialysis The clients blood is circulated past the semi permeable membrane Excess fluids are removed by osmosis

Hemodialysis Waste products are removed from the blood by diffusion

Hemodialysis Nursing interventions Weighted before and after
4/13/2017 Hemodialysis Nursing interventions Weighted before and after Strict asepsis technique Hemodialysis Hemodialysis is performed by a machine with an artificial semi permeable membrane used for the filtration of the blood. Artificial kidney (machine is referred to as) A graft or fistula is surgically prepared to access the clients circulatory system With each hemodialysis treatment, the catheter is inserted into the graft of fistula The clients blood is circulated through the semi permeable membrane Excess fluids are removed by osmosis By-products of protein metabolism especially urea, uric acid, creatine, drugs and excess electrolytes are removed from the blood by diffusion or filtration. Nursing interventions The patient should be weighted before and after each dialysis Strict asepsis technique Assess fistula or graft A thrill should be felt A bruit should be heard Pulse peripheral to graft site should be assessed Blood pressure and blood draws should never be done on the extremity where the graft or fistula is placed. Not and IV port! (Fistula) Since meds are removed in the dialysis they are usually not given until after the session Usually performed 3 time a week Usually take 3-6 hours

Hemodialysis Nursing interventions:
Assess fistula or graft A thrill felt A bruit heard Pulse peripheral Protect Grafts Not an IV port! No BP in graft arm

The nurse is preparing to teach a client about his new shunt for hemodialysis. What should be included in this teaching? Avoid overusing the arm with the shunt to protect from accidental harm. Always use this arm for blood pressure readings If you feel any vibrations over the skin of the shunt, call the doctor. There’s nothing special to the care of the shunt. Pretend it isn’t there.

Hemodialysis Nursing interventions:
Meds are given after Usually performed 3 time a week Usually take 3-6 hours

Peritoneal Dialysis Uses the peritoneal lining of the abdominal cavity

Peritoneal Dialysis A catheter is placed by the MD into peritoneal space

Peritoneal Dialysis The dialysate,
4/13/2017 Peritoneal Dialysis The dialysate, In sterile container similar Instilled aseptically into the abdominal cavity. The container remains connected to the catheter rolled up dialysate remains in the abdominal cavity for a specified length of time. The container is then unrolled and lowered below the abdominal cavity Dialysate drains back into the container The dialysate, held in a sterile soft container similar to an IV bag, is instilled aseptically through the catheter into the abdominal cavity. The container still connected to the catheter is then rolled up and the dialysate remains in the abdominal cavity for a specified length of time. The container is then unrolled and lowered below the abdominal cavity to allow the dialysate to drain, by gravity back into the container. Usually exchange about 2 liters of dialysate each time

Peritoneal Dialysis Usually 2 liters of dialysate
4/13/2017 Peritoneal Dialysis Usually 2 liters of dialysate Less expensive, easier to perform and less stressful Complication INFECTION Usually 4 x day – 7day/wk Peritoneal is less expensive, easier to perform and less stressful for he client and almost as effective. Complication = INFECTION

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