Formation of Urine Excretion or Conservation of Water Electrolyte Balance Acid-base Balance Activation of Vitamin D Production of Erythropoietin Production of Renin
Glomerular filtration Glomerular filtration rate Tubular reabsorption
› Include water and electrolytes Tubular secretion Urine concentration
Renal Filtrate Kidneys form in 1 minute Averages 100-125 mL/minute
Renin-angiotensin-aldosterone system› Role in blood pressure and sodium
reabsorption Erythropoietin
› Role in RBC production Vitamin D and calcium regulation Acid-base balance
Ureters: carry urine from kidneys to bladder
Bladder: temporary storage of urine and its elimination
Urethra: carries urine from bladder to exterior
Amount: 1000-2000 mL/24 hours Color: straw or amber Clarity: clear Specific Gravity: 1.010-1.030
› Lower=Dilute; Higher=Concentrated pH: 4.6-8.0
Constituents› 95% water› Waste products: Urea, Creatinine, Uric Acid
Renal Mass Smaller Renal Flow Decreased 50% Decreased Tubular Function Bladder Muscles Weaken Bladder Capacity Decreases Voiding Reflex Delayed Nephrons lost with aging
› Reduces kidney mass and GFR Less urine concentration
› Risk for dehydration
Health History Pain/Burning with Voiding New Onset Edema, Shortness of
Breath, Weight Gain Fluid Intake Functional Ability
Color, clarity, amount of urine Difficulty initiating urination or changes
in stream Changes in urinary pattern Dysuria, nocturia, hematuria, pyuria
Vital Signs Lung Sounds Edema Daily Weights Intake and Output Skin Assessment
Urinalysis› Common test› Voided or Cath Specimen
24 hour Clean catch
› 10 mL of urine collected› Color, odor, clarity
Urine Culture› Identifies bacteria present› Urine collected before antibiotics› Sensitivity test determines antibiotic that
will destroy bacteria
Renal Function Tests› Serum Creatinine› Blood Urea Nitrogen› Uric Acid› Creatinine Clearance Test
Kidneys-Ureter-Bladder› Show tumors, swollen kidneys, kidney
stones
Intravenous Pyelogram› Dye injected› Dye outlines renal structures› Check allergies› Increase fluids afterward
Renal Angiography› Dye visualizes renal arteries› Check allergies
Cystoscopy and Pyelogram› Surgery: Cystoscope inserted in bladder
through urethra› Pyelogram: dye injected in kidney pelvis› X-rays taken
Noninvasive sound waves examine anatomy of urinary tract
Shows kidney enlargement, kidney stones, chronic infection, tumors
Percutaneous or Open Before - NPO, Mild Sedative
After› Vital signs› Observe for bleeding
Biopsy site, Urine
› Pressure dressing, sandbag› Bed rest for 24 hours
Types› Stress› Urge› Functional› Overflow› Reflex
total
Postvoid residual urine Ultrasonic bladder scan Cystometrography Uroflowmetry
Medications› Inhibit detrusor muscle contractions› Increase bladder capacity› Estrogen therapy
Surgery› Bladder neck suspension› Prostatectomy
Impaired Urinary Elimination Toileting Self-Care Deficit Social Isolation
Evaluating› Keep voiding diary› Identify wetting episodes› Assess willingness to participate in social
activities Teaching
› Home environment› Voiding diary› Therapies
Occurs when bladder cannot empty May be caused by obstructive or
functional problem› Benign prostatic hypertrophy› Surgery› Drugs› Neurologic diseases› Trauma
Acute› Anesthesia, medications, local trauma to
urinary structures Chronic
› Enlarged prostate, medications, strictures, tumors
Manifestations› Overflow voiding› Incontinence› Firm, distended bladder
May be displaced
Monitor› Urine output› Bladder distention› Bladder Scan
Residual volume of 150-200 cc urine Indicates need for treatment
Complications› Hydronephrosis› Acute renal failure› Urinary tract infection
Diagnostic tests› Portable bladder scan
Treatment depends on cause› Surgery› Medications› Stimulation techniques› Catheterization
Identify clients Take measures to promote urination
Indwelling Catheters› Justifiable reasons
Shock Urinary tract obstruction Neurogenic bladder
› Urinary incontinence is NOT justification Urinary catheters result in infection
Intermittent catheterization› Best› Reduces risk of infection› Patients may self-cath
Suprapubic Catheter› Indwelling catheter inserted through
incision in lower abdomen into bladder
Invasion of urinary tract by bacteria Women > Men Aging
› Older men due to enlarged prostate› Women due to declining estrogen› Nosocominal infections common
Stasis of urine Contamination in Perineal/Urethral area Instrumentation Reflux of urine Previous UTIs
Dysuria Urgency Frequency Cloudy, foul-smelling urine
Urethritis: inflammation of urethra Cystitis: inflammation/infection of
bladder wall Pyelonephritis: infection of the kidneys
Dysuria, flank pain, fever, chills, malaise
Urine examined for cloudiness, blood, foul odor
Predisposing factors Urinalysis and culture results
Urinalysis Urine culture & sensitivity CBC with differential IP Voiding cystourethrography Cystoscopy
Acute pain Impaired urinary elimination Risk for injury Knowledge deficit
Monitor symptoms Monitor intake and output Pain control Teaching
› Medications: take all antibiotics – 3-7 days› Prevention
Obstruction of urine flow is always significant
Backup of urine destroys kidney
Urethral Strictures› Urethra lumen narrowing due to scar tissue
Renal Calculi› Hard, generally small stones› Kidney stones
Nephrolithiasis
Urolithiasis most common cause of obstructed urine flow
Calculi› Masses of crystals formed from materials
normally excreted in urine› Most made from calcium
Etiology› Heredity› Chronic dehydration› Infection› Immobility› Men > Women
Kidney/Pelvis› May be asymptomatic› Dull, aching flank pain
Ureter› Acute severe flank pain, may radiate› Nausea/vomiting› Pallor› Hematuria
Bladder› May be asymptomatic› Dull suprapubic pain› Hematuria
Diagnosis› Kidney-ureter-bladder x-ray› Intravenous Pyelogram (IVP)› Renal ultrasound› Urinalysis
Small stones passed IV fluids Pain control Thiazide diuretics Allopurinol Lithotripsy
Medications Dietary management Surgery
› Lithotripsy› ESWL› Cystoscopy› Nephrolithotomy› Nephrectomy
Prevention› Foods› Hydration› Exercise
Complications› UTIs› Hydronephrosis
Nursing Diagnosis› Acute pain› Risk for infection› Deficient knowledge
Monitor symptoms Strain all urine Intake and output Pain control Hydration Teaching
Abnormal dilation of renal pelvis and calyces
Results from urinary tract obstructions or backflow of urine
Manifestations depend on how rapidly it develops
Diagnosis› Ultrasound› CT scan› Cystoscopy
Treatment› Stents
Signs and symptoms› Frequency› Urgency› Dysuria› Flank and back pain› Renal failure
Treat cause Urinary catheter Stents Nephrostomy tube
› Intake and output› No clamping
Focuses on prevention and ensuring urinary drainage
Most common urinary tract cancer Men > Women Ages 50-70 years Etiology
› Smoking› Industrial pollution
Signs and symptoms› Early
Painless Hematuria
Signs and symptoms (cont’d)› Late
Pelvic pain Lower back pain Dysuria Inability to void
Diagnosis› Urinalysis
Telomerase
› Urine for Cytology, Culture› Cystoscopy and Transurethral Biopsy› IVP
Therapeutic Interventions› Chemotherapy› Bacille Calmette-Guérin Vaccine› Photodynamic Therapy
Therapeutic Interventions› Surgery
Cystoscopy & Pyelogram with Fulguration Laser Robotic Laparoscopic Radical Cystectomy Urinary diversion
Therapeutic Interventions› Incontinent urinary diversion
Ileal conduit
› Continent urinary diversion Kock pouch
› Othotopic bladder substitution Studer pouch Hemi-Kock pouch Ileal W-Neobladder
Nursing Care› WOC Nurse› Monitor urine output› Education› Preop and postop care
Uncommon Renal cell carcinoma most common
primary tumor Risk factors
› Smoking› Obesity› Renal calculi› Hypertension› Long term kidney dialysis› Radiation exposure› Asbestos› Industrial pollution
Most arise from tubular epithelium Can occur anywhere Often metastasize Often silent
Later signs and symptoms› Hematuria› Dull pain in flank area› Mass
IVP Cystoscopy and Pyelogram Ultrasound CT scan MRI Renal biopsy
Therapeutic Interventions› Radical Nephrectomy› Nephron-sparing surgery› Radiation therapy› Immunotherapy› Chemotherapy
Nursing Management› Monitor urine output› Education› Preop and postop care
Pain Ineffective breathing pattern Risk for impaired urinary elimination Anticipatory grieving
Flank pain Hematuria Treat injury
Nursing Care› I & O› Vital signs› IV fluids› Pain control
Multiple cysts in the kidney Signs and symptoms
› Dull heaviness in flank/back› Hematuria› Hypertension› UTI
Progressive No treatment
Long-term complication of diabetes Most common cause of renal failure Atherosclerotic changes decrease blood
to kidney Smaller doses of insulin as progresses Chronic renal failure develops
Inflammatory condition of glomerulus Acute or chronic Primary kidney disorder or secondary
to systemic disease
Affects structure and function of glomerulus
Damages capillary membrane› Blood cells and proteins escape into filtrate› Hematuria, Proteinuria, Azotemia
Usually follows infection of group A beta-hemolytic Streptococcus
Manifestations develop abruptly Hematuria, proteinuria, edema,
hypertension, fatigue Anorexia, nausea, vomiting, headache Elevated BUN and serum creatinine
Older adults may show less characteristic manifestations
Symptoms may subside spontaneously Some may develop chronic
glomerulonephritis
Usually end-stage kidney damage Slow, progressive destruction of
glomeruli Gradual loss of nephrons Kidneys decrease in size Symptoms develop slowly
ASO titer ESR BUN Serum creatinine
Serum electrolytes Urinalysis KUB x-ray Kidney scan or
biopsy
Signs and symptoms› Oliguria› Hypertension› Electrolyte imbalances› Edema› Flank pain
Focus is on identifying and treating underlying disease process and preserving kidney function
Medications Plasma exchange therapy Dietary management Renal failure treatment
Vital signs Symptom support Rest Fluid, sodium, protein restrictions Renal failure care Education
Preventing acute renal failure is goal of care
Diagnostic tests› Serum creatinine, BUN› Creatinine clearance› Serum electrolytes, ABGs, CBC› Urinalysis› Kidney biopsy
Kidneys unable to remove waste products from blood
Acute or chronic Azotemia
› Waste products accumulate Fluid, electrolyte, acid-base imbalances
› Oliguric
Rapid decline in function Abrupt onset Often reversible with treatment Risk factors
› Major trauma, surgery, infection, hemorrhage, severe heart failure, lower urinary tract obstruction
› Older adults at risk
Prerenal Failure› Decreased blood supply to kidneys
Intrarenal Failure› Damage to nephrons
Postrenal Failure› Obstruction
Nephrotoxins› Diagnostic Contrast Media (Dyes)› Medications
IV Aminoglycosides, Tobramycin (Tobrex), Amikacin (Amikin), Cisplatin (Platinol)
› Chemicals
Prevention› Check serum BUN and creatinine prior to
dyes or meds› Hydrate before/after contrast media› Monitor peak/trough levels of nephrotoxic
drugs per institutional policy
Phases› Oliguric› Diuretic› Recovery
Therapeutic Interventions› Treat cause› Supportive treatment› Dialysis› Continuous renal replacement therapy
Removes fluid continuously along with Hemodialysis
Remove fluid/solutes in controlled, continuous manner in unstable patients
Blood flows through Hemofilter, excess fluids/solutes move into collection bag
Gradual decrease in kidney function Irreversible Slow, insidious process Final stage is end-stage renal disease Increasing in incidence Diabetic nephropathy and hypertension
leading causes in U.S.
Etiology› Diabetic Nephropathy› Nephrosclerosis› Glomerulonephritis› Autoimmune diseases
Nephrons destroyed by disease process Remaining nephrons hypertrophy and
have increased workload› Can compensate for a while
Renal insufficiency develops – 75% of nephrons lost
Further insult leads to ESRD› Uremia develops
End-stage: 90% of nephrons lost Uremia: urea in the blood Affects all body systems
Often not identified until uremia develops› Nausea› Apathy› Weakness› Fatigue› Confusion
Fluid accumulation Electrolyte imbalance Waste products retained Acid-base imbalance Anemia
Diet› High calorie› Low protein (unless dialysis)› Low sodium, potassium, phosphorus› Increased calcium› Vitamins
Fluid restrictions
Medications› Diuretics› Antihypertensives› Phosphate binders› Calcium/Vitamin D supplements› Kayexalate prn
Dialysis› Symptoms of fluid overload› High potassium› Neurological signs› Uremia
Hemodialysis› Artificial kidney removes waste products
and excess water from blood
Vascular Access› Temporary› LifeSite Hemodialysis Access System› A-V Graft› A-V Fistula
Vascular Access Care› Thrill, Bruit› Protect› Postop
NV checks, pain Elevate extremity
Continuous dialysis done by patient Peritoneal membrane is
semipermeable membrane, across which excess wastes/fluids move from blood
Peritoneal catheter Exchange process: fill, dwell time, drain
Excess fluid volume Imbalanced nutrition: less than body
requirements Risk for infection Disturbed body image Activity intolerance Impaired skin integrity Risk for injury
Excess fluid volume› Monitor weight› I & O› Fluid restriction› Monitor for fluid retention
Electrolyte imbalance› Monitor levels› Dietary restriction› Monitor dysrhythmias
Waste products› Oral care, skin care› Lotion› Protect from injury
Impaired hematological function› Protect from injury/infection
BPH tends to occur in men over 40 years of age
Intervention is required when symptoms of obstruction occur
The most common treatment is transuretheral resection (TURP)
PSA› False high levels can be present for up to
12 days after a rectal examination or instrumentation around the prostate gland especially after a cystoscopy
Signs and symptoms› Increased frequency with a decrease in
amount of each voiding› Nocturia› Hesitancy› Terminal dribbling› Decrease in size and force of stream› Acute urinary retention› Bladder distention
TURP› Preop teaching› Monitor urinary drainage system› Provide pain relief› Monitor urinary drainage system for clots› Irrigate bladder as prescribed› Monitor H &H› Monitor v/s
Hematuria generally is present for at least 23 hours following a TURP
Monitor color & content of urinary output
Care post catheter removal› Monitor # of voids and amount› Have client collect urine in specimen cups
Force fluids