Pharmacology of Urinary System

Sistem Urogenital

Terdiri dari:1. Sistem Uropoetika2. Sistem genitalis

Organ-organ sistem Uropoitika:3. Ren/ginjal/Kidney4. Ureter5. Vesika urinaria/Kandung kemih/ bladder4. Urethra

Fungsi ginjal dan saluran kemih• Ekskresi

– Pembuangan sisa metabolisme tubuh dan obat– Ekskresi dan reabsorbsi selektif bahan-bahan hasil metabolisme tubuh

• Regulasi– Pengaturan volume cairan tubuh dan komposisi ion– Peran utama homeostasis(pemeliharaan lingkungan internal tubuh)– Pengaturan keseimbangan asam basa

• Endokrin– Sintesis renin, eritopoitin dan prostaglandin

• Metabolisme– Metabolisme vitamin D dan protein-protein dengan berat molekul

kecil– Tempat utama katabolisme hormon insulin, paratiroid dan kalsitonin

• Recall the anatomy and physiology of the Renal System

• Renal Assessment • Renal Laboratory Procedure• Common Conditions:

– UTI– Kidney Stones– ARF and CRF– BPH– Prostatic cancer

Urological Assessment

• Nursing History– Reason for seeking care– Current illness– Previous illness– Family History– Social History– Sexual history

Urological Assessment

Key Signs and Symptoms of Urological ProblemsEDEMA

• associated with fluid retention• Renal dysfunctions usually produce ANASARCA

PAIN• Suprapubic pain= bladder• Colicky pain on the flank= kidney

HEMATURIA• Painless hematuria may indicate URINARY CANCER!• Early-stream hematuria= urethral lesion• Late-stream hematuria= bladder lesion

DYSURIA Pain with urination= lower UTI

POLYURIA• More than 2 Liters urine per day

OLIGURIA• Less than 400 mL per day

ANURIA• Less than 50 mL per day

Menghilangkan nyeri

Provide PAIN relief• Assess the level of pain• Administer medications analgesic usually narcotic ANALGESICS

Infeksi saluran kemih

• Keradangan bakterial saluran kemih dari pielum ginjal sampai urethra– Dengan /tanpa gejala– Lekosituria (=inflamasi)– Harus ditemukan kuman di dalam air kemih

(bakteriuri= infeksi)

Urinary Tract Infection (UTI)

• Bacterial invasion of the kidneys or bladder (CYSTITIS) usually caused by Escherichia coli

Predisposing factors include1. Poor hygiene2. Irritation from bubble baths3. Urinary reflux4. Instrumentation5. Residual urine, urinary stasis6. Dehydration

PATHOPHYSIOLOGY

• The invading organism ascends the urinary tract, irritating the mucosa and causing characteristic symptoms– Ureter= ureteritis– Bladder= cystitis– Urethra=Urethritis– Pelvis= Pyelonephritis

Assessment findings

• Low-grade fever• Abdominal pain• Enuresisn/ngompol• Pain/burning on urination• Urinary frequency• Hematuria

Assessment findings: Upper UTI• Fever and CHIILS• Flank pain• Costovertebral angle tendernessLaboratory Examination1. Urinalysis2. Urine Culture

Jaras infeksi ginjal

• Hematogenous infection– Common agents:

• E.Coli ( 80-90% ISK pada masyarakat)• Staphylococcus

• Ascending infection– E.coli– Proteus– Enterobacter

Diagnosis

• Anamnesis• Keluhan dan gejala ISK:

– Disuria, polakisuria, nokturia, urgensi, nyeri suprapubik (ISK bawah)

– Demam, mual, muntah, nyeri kostovertebral (ISK atas)

• Pemeriksaan fisik• Laboratorium

– Lekosituria – bakteriuria

Pengobatan

• Eradikasi kuman dari seluruh saluran kemih• Terapi efektif:

– Karakteristik penderita(jenis ISK)– Kuman penyebab diketahui– Antimikroba yang digunakan sesuai hasil test kepekaan.

• Terapi empiris:– Kesulitan menegakkan diagnosis– Kesulitan membedakan jenis ISK– Kultur/tes kepekaan belum ada

Prinsip pengobatan

– Sedikit/tidak mempengaruhi flora normal(saluran cerna/vagina)

– Harga murah– Kadar obat dalam urin tinggi– Batu, kateter, obstruksi dihilangkan dahulu, kecuali

keluhan berat– Berdasarkan biakan urin dan tes kepekaan – Hasil terapi dipastikan dengan kultur ulang– Kasus yang tidak mungkin teredikasi diterapi dg terapi

supresif– Minum banyak– Pengosongan buli-buli

Antibiotic Therapy

Cystitis

Acute Pyelonephritis

Short course Tx(3 days)

The longer course Tx (7 days)

Outpatient: good general condition & not pregnantTreat with oral fluoroquinolon, TMT-SMX or 3rd generation cephalosporin for 7-14 days (sometimes at least one dose of iv antibiotic, followed by oral Tx

Inpatient: initially treat with a 3rd generation cephalosporin or a fluoroquinilon for 10-14 days while the results of urine & blood cultures & antimicrobial susceptibility

TMT SMX 160/800 mgCyprofloxacin 2 x 250 – 500 mg/daysCypro. Extended release 500 mg/dayAnother Fluorquinolone

TERAPI UTI

ANTISEPTIK Metenamin, Asam nalidiksat, Nitrofurantoin, Fosfomisin Trometamin

Farmakologi obat infeksi sal. Kencing

Sulfonamid, kotrimoksazol dan antiseptik sal.kemih

• Sulfonamid resistensi bakt gram (-) Indikasi : sistitis akut & kronis

• Kotrimoksazol infeksi ringan sal kemih bag bawah, walaupun resisten terhadap sulfa.

• Trimetoprim efektif untuk infeksi sal.kemih• Kotrimoksazol = sulfonamid : trimetoprim (800 mg : 160 mg)

PABA

Asam dihidrofolat

Asam tetrahidrofolat

Purin

DNA

Dihidropteroatsintetase Sulfonamid berkompetisi dg

PABA

TrimetoprimDihidrifolat reduktase

Mekanisme kerja kotrimoksazol

Efek samping :

-Gangguan sistem hematopoetik-Gangguan sal kemih : kristaluriuria-Reaksi alergi-Lain-lain : mual, muntah yg bersifat sentral

QUINOLON DAN FLUOROKUINOLON

ASAM NALIDIKSAT PROTOTIP GOL KUINOLON LAMA

1980 QUINOLON BARU

QUINOLON ASAM NALIDIKSATFLUOROKUINOLON SIPROFLOKSASIN, OFLOKSASIN, LEVOFLOKSASIN

Indikasi : Asam nalidiksat dan asam pipemidat : sisititis akut tanpa komplikasi pada wanita

Fluorokuinolon : Infeksi saluran kemih, infeksi sal cerna, infeksi sal nafas, infeksi tulang dan sendi, infeksi kulit dan jar lunak dan penyakit yang ditularkan melalui hub seksual

EFEK SAMPING KUINOLON

SALURAN CERNA MUAL, MUNTAH, RASA TIDAK ENAK

SSP SAKIT KEPALA DAN PUSING

HEPATOTOSIK JARANG

KARDIOTOKSISITAS : SPARFLOKSASIN, GREPAFLOKSASIN

DISGLIKEMIA KONTRAINDIKASI PD DIABETES MELITUS

FOTOTOKSISITAS

Nursing interventions• Administer antibiotics as ordered• Provide warm baths and allow client to void in water to alleviate painful

voiding.• Force fluids. Nurses may give 3 liters of fluid per day• Encourage measures to acidify urine (cranberry juice, acid-ash diet).

• intervensi keperawatan• Berikan antibiotik seperti yang diperintahkan• Menyediakan mandi air hangat dan memungkinkan klien untuk

membatalkan dalam air untuk mengurangi berkemih menyakitkan.• Cairan Force. Perawat dapat memberikan 3 liter cairan per hari• Mendorong langkah-langkah untuk mengasamkan urin (jus cranberry,

diet asam-abu).

• Provide client teaching and discharge planning concerninga. Avoidance of tub baths / hindari brendamb. Avoidance of bubble baths that might irritate urethra/ hindari sabunc. Importance for girls to wipe perineum from front to back/dari depan ke belakangd. Increase in foods/fluids that acidify urine./minum mkn asam

Diuretics1. Thiazides

hydrochlorothiazide chlorthalidone (Hygroton)

2. Loop diureticsfurosemide (Lasix); bumetadine (Burmex);ethacrynic acid (Edecrin)

3. K+ Sparingamiloride (Midamor); spironolactone (Aldactone);triamterene (Dyrenium)

4. Osmotic mannitol (Osmitrol); urea (Ureaphil)

5. Othertriamterene acetazolamide (Diamox)

Diuretics (cont)

2. Mechanism of Action

Urinary Na+ excretionUrinary water excretion

Extracellular Fluid and/or Plasma Volume

3. Effect on Cardiovascular System

Acute decrease in CO

Chronic decrease in TPR, normal COMechanism(s) unknown

1. Site of Action Renal Nephron

Diuretics (cont)4. Adverse Reactions

dizziness, electrolyte imbalance/depletion,hypokalemia, hyperlipidemia,hyperglycemia (Thiazides)gout

5. Contraindicationshypersensitivity, compromised kidney functioncardiac glycosides (K+ effects)hypovolemia,hyponatremia

Diuretics (cont)6. Therapeutic Considerations Thiazides (most common diuretics for HTN) Generally start with lower potency diuretics Generally used to treat mild to moderate HTN Use with lower dietary Na+ intake, and K+ supplement or high K+ food K+ Sparing (combination with other agent)

Loop diuretics (severe HTN, or with CHF) Osmotic (HTN emergencies)

Maximum antihypertensive effect reachedbefore maximum diuresis- 2nd agent indicated

URINARY ANTI SPASMODIC

• Relax the smooth muscle– in the wall of the ureter– bladder

• Promote normal bladder function

• atropine (Sal-Tropine)• bethanechol (Urecholine)• flavoxate (Urispas)antimuskarinik• L-hyoscyamine (Anaspaz, Cystospaz)• neostigmine (Prostigmin)• oxybutynin (Ditropan) antikolinergik

Combination Antibiotic, Analgesic, and Antispasmodic Drugs

• Contain various combinations of the following drugs:

• Urinary antibiotic drug– methenamine

• Urinary analgesic– phenazopyride– phenyl salicylate

• Sedative drug– butabarbitol

• Urinary antispasmodic drug– atropine– hyoscyamine

• Urinary antiseptic drug– methylene blue

spasminal

• Na metamizol 500 mg• Ekstrak belladonna 10 mg• Papaverin HCl 25 mg