1. Medical Surgical Nursing Care
The Urinary System Assessment & Disorders
Dr Ibrahim Bashayreh, RN, PhD
03/05/2011

2. The kidneys, ureters, and bladder
The kidneys, ureters, and bladder. (Source: Dorling Kindersley Media Library)
03/05/2011

3. An illustration of the internal structures of the kidney.
03/05/2011

4. The structure of the nephron and the processes of urine formation
The structure of the nephron and the processes of urine formation. (Source: Pearson Education/PH College)
03/05/2011

5. Urine Formation Glomerular filtration Tubular reabsorption
Glomerular filtration rate
Tubular reabsorption
Include water and electrolytes
Tubular secretion
Urine concentration
03/05/2011

6. Endocrine Function Renin–angiotensin–aldosterone system Erythropoietin
Role in blood pressure and sodium reabsorption
Erythropoietin
Role in RBC production
Vitamin D and calcium regulation
Acid–base balance
03/05/2011

7. Age-Related Changes Nephrons lost with aging Less urine concentration
Reduces kidney mass and GFR
Less urine concentration
Risk for dehydration
03/05/2011

8. Assessment Color, clarity, amount of urine
Difficulty initiating urination or changes in stream
Changes in urinary pattern
Dysuria, nocturia, hematuria, pyuria
03/05/2011

9. Assessment History of urinary problems Urinary or abdominal surgeries
Smoking, alcohol use, number of sexual partners and type of sexual relationship
Chance of pregnancy
History of diabetes or other endocrine disorders
History of kidney stones
03/05/2011

10. Physical Assessment Obtain clean-catch urine specimen
Color, odor, clarity
Vital signs and skin assessment
03/05/2011

11. Diagnostic Tests Clean-catch urine 24-hour urine
Culture and sensitivity
BUN, creatinine and creatinine clearance
IVP
CT scan
Renal scan
03/05/2011

12. Diagnostic Tests Ultrasound Bladder scan Cystoscopy Uroflowmetry
03/05/2011

13. Renal Failure Acute and Chronic Renal Obstructive Disorder
Medical Surgical Nursing
Dr ibraheem Bashayreh, RN, PhD
03/05/2011

14. Acute Renal Failure
Sudden interruption of kidney function resulting from obstruction, reduced circulation, or disease of the renal tissue
Results in retention of toxins, fluids, and end products of metabolism
Usually reversible with medical treatment
May progress to end stage renal disease, uremic syndrome, and death without treatment
03/05/2011

15. Acute Renal Failure Persons at Risks Major surgery Major trauma
Receiving nephrotoxic medications
Elderly
03/05/2011

16. 03/05/2011

17. Acute Renal Failure Causes Prerenal Intrarenal Postrenal
Hypovolemia, shock, blood loss, embolism, pooling of fluid d/t ascites or burns, cardiovascular disorders, sepsis
Intrarenal
Nephrotoxic agents, infections, ischemia and blockages, polycystic kidney disease
Postrenal
Stones, blood clots, BPH, urethral edema from invasive procedures
Nephrotoxic agents – antibiotics, lead and mercury, chemicals,
03/05/2011

18. Acute Renal Failure Stages
Onset – 1-3 days with ^ BUN and creatinine and possible decreased UOP
Oliguric – UOP < 400/d, ^BUN,Creat, Phos, K, may last up to 14 d
Diuretic – UOP ^ to as much as 4000 mL/d but no waste products, at end of this stage may begin to see improvement
Recovery – things go back to normal or may remain insufficient and become chronic
03/05/2011

19. Acute Renal Failure Subjective symptoms Nausea Loss of appetite
Headache
Lethargy
Tingling in extremities
03/05/2011

20. Acute Renal Failure Objective symptoms Oliguric phase – vomiting
disorientation,
edema,
^K+
decrease Na
^ BUN and creatinine
Acidosis
uremic breath
CHF and pulmonary edema
hypertension caused by hypovolemia, anorexia
sudden drop in UOP
convulsions, coma
changes in bowels
03/05/2011

21. Acute Renal Failure Objective systoms Diuretic phase Increased UOP
Gradual decline in BUN and creatinine
Hypokalemia
Hyponaturmia
Tachycardia
Improved LOC
03/05/2011

22. Acute Renal Failure Diagnostic tests H&P
BUN, creatinine, sodium, potassium. pH, bicarb. Hgb and Hct
Urine studies
US of kidneys
KUB
ABD and renal CT/MRI
Retrograde pyloegram: is a urologic procedure where the physician injects contrast into the ureter in order to visualize the ureter and kidney.
03/05/2011

23. Acute Renal Failure Medical treatment Fluid and dietary restrictions
Maintain E-lytes
D/C or change cause
May need dialysis to jump start renal function
May need to stimulate production of urine with IV fluids, Dopomine, diuretics, etc.
If caused by meds, must stop meds
If caused by obstruction, must remove obstruction
If caused by blockage of artery, must open artery
Dietary restrictions may include : low K+, adequate carbs, also may give TPN
Fluids : calculate closley I/O
Hyperkalemia is life threatening
Lower K+ with Kayexalate, glucose, insulin, NaBicarb, caalcium carbonate
03/05/2011

24. Acute Renal Failure Medical treatment Hemodialysis Peritoneal dialysis
Subclavian approach
Femoral approach
Peritoneal dialysis
Continous renal replacement therapy (CRRT): The concept behind continuous renal replacement techniques is to dialyse patients in a more physiologic way, slowly, over 24 hours, just like the kidney
Can be done continuously
Does not require dialysate: the fluid and solutes in a dialysis process that flow through the dialyzer, do not pass through the membrane, and are discarded along with removed toxic substances after leaving the dialyzer.
03/05/2011

25. Acute Renal Failure Nursing Diagnosis- imbalanced fluid volume= excess
Altered electrolyte balance
Altered cardiac output
Impaired tissue perfusion: renal
Anxiety
Imbalanced nutrition
Risk for infection
Fatigue
Knowledge deficit
03/05/2011

26. Acute Renal Failure Plan- Promote recovery of optimal kidney function.
Maintain normal fluid and electrolyte balance.
Decrease anxiety.
Increase knowledge.
03/05/2011

27. Acute Renal Failure Nursing interventions
Monitor I/O, including all body fluids
Monitor lab results
Watch hyperkalemia symptoms: malaise, anorexia, or muscle weakness, EKG changes
watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions
Maintain nutrition
Safety measures
Mouth care
Daily weights
Assess for signs of heart failure
Skin integrity problems
03/05/2011

28. Kidney failure causes hypoglycemia in three separate ways
Kidney failure causes hypoglycemia in three separate ways. The kidneys help to generate new glucose from amino acids (called gluconeogenesis). Gluconeogenesis is impaired in kidney failure. Also, insulin circulates for a longer period of time and is cleared slowly when kidney function is poor. The third important reason is that kidney failure reduces the appetite and consequently, oral intake of food.
03/05/2011

29. Chronic Renal Failure
Results form gradual, progressive loss of renal function
Occasionally results from rapid progression of acute renal failure
Symptoms occur when 75% of function is lost but considered cohrnic if 90-95% loss of function
Dialysis is necessary D/T accumulation or uremic toxins, which produce changes in major organs
03/05/2011

30. Chronic Renal Failure Subjective symptoms are relatively same as acute
Objective symptoms
Renal
Hyponaturmia
Dry mouth
Poor skin turgor
Confusion, salt overload, accumulation of K with muscle weakness
Fluid overload and metabolic acidosis
Proteinuria, glycosuria
Urine = RBC’s, WBC’s, and casts
03/05/2011

31. Chronic Renal Failure Objective symptoms Neurological Cardiovascular
Hypertension
Arrythmias
Pericardial effusion
CHF
Peripheral edema
Neurological
Burning, pain, and itching, paresthesia
Motor nerve dysfunction
Muscle cramping
Shortened memory span
Apathy
Drowsy, confused, seizures, coma, EEG changes
03/05/2011

32. Chronic Renal Failure Objective symptoms Respiratory GI
^ chance of infection
Pulmonary edema
Pleural friction rub and effusion
Dyspnea
Kussmaul’s respirations
Objective symptoms GI
Stomatitis
Ulcers
Pancreatitis
Uremic fetor (Ammonia breath odour)
Vomiting
constipation
is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also renal failure.
03/05/2011

33. Chronic Renal Failure Objective symptoms Hemopoietic Endocrine Anemia
Decrease in RBC survival time
Blood loss from dialysis and GI bleed
Platelet deficits
Bleeding and clotting disorders – purpura and hemorrhage from body orifices , ecchymoses
Objective symptoms
Endocrine
Stunted growth in children
Amenorrhea
Male impotence
^ aldosterone secretion
Impaired glucose levels R/T impaired CHO metabolism
Thyroid and parathyroid abnormalities
03/05/2011

34. Chronic Renal Failure Objective symptoms Skin Skeletal
Yellow-bronze skin with pallor
Puritus
Purpura
Uremic frost
Thin, brittle nails
Dry, brittle hair, and may have color changes and alopecia
Objective symptoms
Skeletal
Muscle and bone pain
Bone demineralization
Pathological fractures
Blood vessel calcifications in myocardium, joints, eyes, and brain
Uremic frost: A clinical finding in severe chronic renal failure, in which the concentration of urea is markedly increased in sweat, causing precipitation of crystallised urea in the skin
03/05/2011

35. Chronic Renal Failure Lab findings
BUN – indicator of glomerular filtration rate and is affected by the breakdown of protein. Normal is 10-20mg/dL. When reaches 70 = dialysis
Serum creatinine – waste product of skeletal muscle breakdown and is a better indicator of kidney function. Normal is mg/dL. When reaches 10 x normal, it is time for dialysis
Creatinine clearance is best determent of kidney function (GFR). Must be a hour urine collection. Normal is > 100 ml/min
Diagnosis is made by all the test previously discussed
03/05/2011

36. Chronic Renal Failure K+ -
The kidneys are means which K+ is excreted. Normal is ,mEq/L. maintains muscle contraction and is essential for cardiac function.
Both elevated and decreased can cause problems with cardiac rhythm
Hyperkalemia is treated with IV glucose and Na Bicarb which pushes K+ back into the cell
Kayexalate (Sodium polystyrene sulfonate ) is also used to promote the exchange of sodium and potassium in the body.
03/05/2011

37. Chronic Renal Failure Ca
With disease in the kidney, the enzyme for utilization of Vit D is absent
Ca absorption depends upon Vit D
Body moves Ca out of the bone to compensate and with that Ca comes phosphate bound to it.
Normal Ca level is mEq/L
Hypocalcemia = tetany
Treat with calcium with Vit D and phosphate
Avoid antacids with magnesium
Magnesium = MOM, mag carbonate, mag oxide,
03/05/2011

38. Chronic Renal Failure Other abnormal findings Metabolic acidosis
Fluid imbalance
Insulin resistance
Anemia
Immunoligical problems
Kidneys cannot excrete wastes or change bicarb levels if needed
Retain Na and water which can elevate which can elevate B/P
Insulin resistance cells cause rise in glucose which produces more lipids in the liver
Anemia = kidneys produce erythropioetin which is needed to make RBC’s
Patients have less resistance to illness
03/05/2011

39. Chronic Renal Failure Nursing diagnosis Excess fluid volume
Imbalanced nutrition
Ineffective coping
Risk for infection
Risk for injury
03/05/2011

40. Chronic Renal Failure Nursing care Frequent monitoring
Hydration and output
Cardiovascular function
Respiratory status
E-lytes
Nutrition
Mental status
Emotional well being
Ensure proper medication regimen
Skin care
Bleeding problems
Care of the shunt
Education to client and family
03/05/2011

41. Chronic Renal Failure Treatment
03/05/2011

42. Chronic Renal Failure Medical treatment IV glucose and insulin
Na bicarb, Ca, Vit D, phosphate binders
Fluid restriction, diuretics
Iron supplements, blood, erythropoietin
High carbs, low protein
Dialysis - After all other methods have failed
03/05/2011

43. Dialysis ½ of patients with CRF eventually require dialysis
Diffuse harmful waste out of body
Control BP
Keep safe level of chemicals in body
2 types
Hemodialysis
Peritoneal dialysis
03/05/2011

44. Dialysis Peritoneal dialysis Automated peritoneal dialysis CAPD
Semipermeable membrane
Catheter inserted through abdominal wall into peritoneal cavity
Cost less
Fewer restrictions
Can be done at home
Risk of peritonitis
3 phases – inflow, dwell and outflow
Automated peritoneal dialysis
Done at home at night
Maybe 6-7 times /week
CAPD
Continous ambulatory peritoneal dialysis
Done as outpatient
Usually 4 X/d
03/05/2011

45. Peritoneal Dialysis Abdominal lining filters blood 3 types
Continuous ambulatory
Continuous cyclical
Intermittent
03/05/2011

46. Hemodialysis 3-4 times a week Takes 2-4 hours Machine filters
blood and
returns it to
body
03/05/2011

47. Chronic Renal Failure Hemodialysis Vascular access Can be done rapidly
Temporary – subclavian or femoral
Permanent – shunt, in arm
Care post insertion
Can be done rapidly
Takes about 4 hours
Done 3 x a week
03/05/2011

48. Types of Access Temporary site: subclavian or femoral
Permanent: shunt, in arm
AV fistula
Surgeon constructs by combining an artery and a vein
3 to 6 months to mature
AV graft
Man-made tube inserted by a surgeon to connect artery and vein
2 to 6 weeks to mature
03/05/2011

49. Temporary Catheter
03/05/2011

50. AV Fistula & Graft
03/05/2011

51. What This Means For You No BP on same arm as fistula
Protect arm from injury
Control obvious hemorrhage
Bleeding will be arterial
Maintain direct pressure
No IV on same arm as fistula
A thrill will be felt – this is normal
03/05/2011

52. Access Problems AV graft thrombosis AV fistula or graft bleeding
AV graft infection
Steal Phenomenon: also called subclavian steal syndrome (SSS), or subclavian steal steno-occlusive disease, is a constellation of signs and symptoms that arise from retrograde (reversed) flow of blood in the vertebral artery or the internal thoracic artery, due to a proximal stenosis (narrowing) and/or occlusion of the subclavian artery.
Early post-op
Ischemic distally
Apply small amount of pressure to reverse symptoms
03/05/2011

53. Nursing Considerations
Make sure the dressing remains intact
Do not push or pull on the catheter
Do not disconnect any of the catheters
Always transport the patient and bags/catheters as one piece
Never inject anything into catheter
03/05/2011

54. Dialysis Related Problems
Lightheaded –give fluids
Hypotension
Dysrhythmias
Disequilibration Syndrome
At end of early sessions
Confusion, tremor, seizure
Due to decrease concentration of blood versus brain leading to cerebral edema
03/05/2011

55. Chronic Renal Failure Transplant Must find donor Waiting period long
Good survival rate – 1 year 95-97%
Must take immunosuppressant’s for life
Rejection
Watch for fever, elevated B/P, and pain over site of new kidney
03/05/2011

56. End-Stage Renal Disease
Slow, insidious process
Final stage is end-stage renal disease
Increasing in incidence
Diabetic nephropathy and hypertension are leading causes in U.S.
03/05/2011

57. End-Stage Renal Disease
Nephrons destroyed by disease process
Remaining nephrons hypertrophy and have increased workload
Can compensate for a while
Renal insufficiency develops
Further insult leads to ESRD
Uremia develops
03/05/2011

58. End-Stage Renal Disease - Manifestations
Often not identified until uremia develops
Nausea
Apathy
Weakness
Fatigue
Confusion
03/05/2011

59. 03/05/2011

60. Chronic Renal Failure Post op care ICU I/O B/P Weight changes
Electrolytes
May have fluid volume deficit
High risk for infection
03/05/2011

61. Transplant Meds Patients have decreased resistance to infection
Corticosteroids – anti-inflammarory
Deltosone
Medrol
Solu-Medrol
Cytotoxic – inhibit T and B lymphocytes
Imuran
Cytoxan
Cellcept
T-cell depressors - Cyclosporin
03/05/2011

62. Obstructive Renal Disorders
03/05/2011

63. Hydronephrosis, Hydroureter, and Urethral Stricture
Outflow obstruction
Urethral stricture
Causes bladder distention and progresses to the ureters and the kidneys
Hydronephrosis –
Kidney enlarges as urine collects in the pelvis and kidney tissue due to obstruction in the outflow tract
Over a few hours this enlargement can damage the blood vessels and the tubules
Hydroureter
Effects are similar, but occurs lower in the ureter
03/05/2011

64. Causes of Obstruction Tumor Stones Congenital structural defects
Fibrosis
Treatment with radiation in pelvis
03/05/2011

65. Complication of Obstruction
If untreated, permanent damage can occur within 48 hours
Renal failure
Retention of
Nitrogenous wastes (urea, creatinine, uric acid)
Electrolytes (K, Na, Cl, and Phosphorus)
Acid base balance impaired
03/05/2011

66. Renal Calculi Called nephrolithiasis or urolithiasis
Most commonly develop in the renal pelvis but can be anywhere in the urinary tract
Vary in size –from very large to tiny
Can be 1 stone or many stones
May stay in kidney or travel into the ureter
Can damage the urinary tract
May cause hydronephrosis
More common in white males years of age
03/05/2011

67. Renal Calculi Predisposing factors Dehydration
Prolonged immobilization
Infection
Obstruction
Anything which causes the urine to be alkaline
Metabolic factors
Excessive intake of calcium, calcium based antacids or Vit D
Hyperthyroidism
Elevated uric acid
Dehydration and immobilization causes urinary concentration and pooling of calculus forming substances
Urine should be acidic –
Alkaline urine- bacteria (proteus, klebsiella, and pseudmonas
03/05/2011

68. Renal Calculi Subjective symptoms
Sever pain in the flank area, suprapubic area, pelvis or external genitalia
If in ureter, may have spasms called “renal colic”
Urgency, frequency of urination
N/V
Chills
03/05/2011

69. Renal Calculi Objective symptoms Increased temperature Pallor
Hematuria
Abdominal distention
Pyuria
Anuria
May have UTI on urinalysis
03/05/2011

70. Renal Calculi- Manifestations
Kidney/Pelvis
May be asymptomatic
Dull, aching flank pain
Ureter
Acute severe flank pain, may radiate
Nausea/vomiting
Pallor
Hematuria
03/05/2011

71. Renal Calculi- Manifestations
Bladder
May be asymptomatic
Dull suprapubic pain
Hematuria
03/05/2011

72. Renal Calculi Diagnostic procedures Urinalysis with C and S
24 hour urine
KUB
IVP
Renal CT
Kidney ultrasound
Cystoscopy with retrograde pyleogram
03/05/2011

73. Renal Calculi Treatment Most are passed without intervention
May need cysto with basket retrieval
Lithotripsy : Extracorporeal shock wave lithotripsy (ESWL) is the non-invasive treatment of kidney stones (urinary calculosis) and biliary calculi (stones in the gallbladder or in the liver) using an acoustic pulse.
Lasertripsy :
Lithotomy: is a surgical method for removal of calculi, stones formed inside certain hollow organs, such as the bladder and kidneys (urinary calculus) and gallbladder (gallstones), that cannot exit naturally through the urethra, ureter or biliary duct
Litotrispy – patient placed in bath of water and stone located by ultrasound and a series of shock waves disintegrates the stone
usually given anesthesia due to pain from shock waves
stone is passed through the urine (may take 1-4 weeks)
may need stents inserted prior to procedure to allow for passage of stones
urine will be bright red then back to normal
usually antibiotics will be given for prevention
Lasortripsy – under general anesthesia, a scope is passed into the location of stone and is destroyed by the laser
Lithotomy – surgical removal of stone
pylelolithotomy – removal from renal pelvis
urolithotomy – removal from the ureter
nephrolithotomy – removal from kidney
03/05/2011

74. Renal Calculi Assessment History and physical exam
Location, severity, and nature of pain
I/O
Vital signs, looking for fever
Palpation of flank area, and abdomen
? N/V
03/05/2011

75. Renal Calculi Nursing interventions
Primary is to treat pain – usually with opioids
Ambulate
Force fluids, may have IV
Watch for fluid overload
Strain urine – send stone to lab if passed
Accurate I/O
Medicate N/V
03/05/2011

76. Renal Calculi Surgical removal Routine pre and post op care
May return with catheter, drains, nephrostomy tube and ureteral stent – must maintain patency and may need to irrigate as ordered
Measure drainage from all tubes – need at least 30 cc/hr
Watch site for bleeding
May need frequent dressing changes due to fluid leakage, or may have collection bag
03/05/2011

77. Renal Calculi Discharge and prevention
Continue to force fluids post discharge
May need special diet
Stones are analyzed for calcium or other minerals
May need to watch products with calcium
03/05/2011