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