Urinary System Ch 45-47

Urinary SystemCh 45-47

Zoya Minasyan RN MSN-Edu

Structures and Functions of Urinary System

Assessment of Urinary System

Assessment of Urinary System

Diagnostic Studies of Urinary System

Diagnostic Studies of Urinary System; Cystoscopic examination

Diagnostic Studies of Urinary System

Ch 45, table 45-8 Page 1114-1119

Diagnostic study

Bladder and its contents are free of bacteria in most healthy patients.

Escherichia coli most common pathogen Fungal and parasitic infections can cause

UTIs. Patients at risk

◦ Are immunosuppressed◦ Have diabetes◦ Have undergone multiple antibiotic courses◦ Have traveled to certain Third World countries

Urinary Tract Infection

Upper versus lower Upper tract

Renal parenchyma, pelvis, and ureters Typically causes fever, chills, flank pain Example

Pyelonephritis: inflammation of renal parenchyma and collecting system

Lower urinary tract Usually no systemic manifestations Example

Cystitis—Inflammation of bladder wall

Classification

Classification of UTI

Complicated versus uncomplicated◦ Uncomplicated

Occurs in otherwise normal urinary tract Usually involves only the bladder

◦ Complicated Those with coexisting presence of

Obstruction Stones Catheters Existing diabetes/neurologic disease Pregnancy-induced changes Recurrent infection

Classification

Bacterial persistence◦ Occurs when

Bacteria develop resistance to antibiotic agent. Foreign body in urinary system allows bacteria to survive

Unresolved bacteriuria◦ Occurs when

Bacteria are resistant to antibiotic Drug is discontinued before bacteriuria is completely

eradicated Antibiotic agent fails to achieve adequate

concentrations in bloodstream or urine to kill bacteria

Classification

Urinary tract above urethra normally sterile Defense mechanisms exist to maintain

sterility/prevent UTIs.◦ Complete emptying of bladder

Etiology and Pathophysiology

Defense mechanisms◦ Acidic pH◦ High urea concentration

Alteration in defense mechanisms increases risk of contracting UTI. Predisposing factors

◦ Factors increasing urinary stasis Examples: BPH, tumor, neurogenic bladder,stones

◦ Foreign bodies Examples: Catheters, instrumentation

◦ Anatomic factors Examples: Obesity, congenital defects, fistula

◦ Compromising immune response factors Examples: Age, HIV, diabetes

◦ Functional disorders Example: Constipation

◦ Other factors Examples: Pregnancy, multiple sex partners (women)


Organisms are introduced via the ascending route from the urethra.

Less common routes ◦ Bloodstream

Lymphatic system Hospital-acquired UTI accounts for 31% of

all nosocomial infections.◦ Causes

Often: E. coli Seldom: Pseudomonas

◦ Catheter-acquired UTIs Bacterial biofilms develop on inner surface of

catheter.


Symptoms related to bladder storage or bladder emptying◦ Bladder storage

Urinary frequency Abnormally frequent (> every 2 hours)

Urgency Sudden strong desire to void immediately

Incontinence Loss or leakage of urine Nocturia

Waking up ≥2 times at night to void Nocturnal enuresis

Complaint of loss of urine during sleep◦ Bladder emptying

Weak stream Hesitancy Difficulty starting the urine stream Intermittency

Interruption of urinary stream while voiding Postvoid dribbling

Urine loss after completion of voiding Urinary retention Inability to empty urine from bladder Dysuria

Difficulty voiding◦ Pain on urination

Flank pain, chills, and fever indicate infection of upper tract. Pyelonephritis

Clinical Manifestations

Older adults◦ Symptoms are often absent. ◦ Experience nonlocalized abdominal discomfort

rather than dysuria◦ May have cognitive impairment◦ Are less likely to have a fever

Patients over age 80 years may experience a slight decline in temperature.


History and physical examination Dipstick urinalysis

◦ Identify presence of nitrates, WBCs, and leukocyte esterase.

◦ Table 45-8, page 1114

Diagnostic Studies

Urine for culture and sensitivity (if indicated)◦ Clean-catch sample preferred◦ Specimen by catheterization or suprapubic needle

aspiration more accurate Determine susceptibility of bacteria to antibiotics Imaging studies

◦ IVP(IV pyelogram)◦ Antegrade pyelogram◦ Retrograde pyelogram◦ Abdominal CT when obstruction suspected◦ Renal ultrasound for recurrent UTIs

Diagnostic Studies

◦ IVP(IV pyelogram) Visualizes urinary tract after IV injection of contrast media. Size, shape, position

of kidneys, ureters, bladder, tumor, cysts, lesions, obstructions Nursing

Check for iodine sensitivity Warmth, a flushed face and salty taste during injection of contrast media Force fluid after procedure to flush out contrast media.

◦ Antegrade pyelogram If pt has allergy to contrast media or decreased renal fx or no passage to

ureteral catheter -contrast media inserted into renal pelvis or via nephrostomy tube

◦ Retrograde pyelogram-X ray If pt has allergy to contrast, cyctoscope is inserted and ureteral catheter are

inserted through it into renal pelvis and contrast is inserted through catheter◦ Abdominal CT when obstruction suspected

Visualization of kidneys Masses, tumor Iv contrast to differentiate masses

◦ KUB- Kidneys, ureters, bladder Bowel prep if needed X-ray of abdomen for the size, shape and position of the kidneys Stones and foreign bodies can be seen

◦ Renal ultrasound for recurrent UTIs To detect mass

Diagnostic Studies

•Teach women •To wipe the periurethral area from front to back using a moistened, clean gauze sponge (no antiseptic is used, as it could contaminate the specimen and cause false-positives)

• tell them to collect the specimen 1 to 2 seconds after voiding starts.

•Instruct men to wipe the penis around the urethra. The specimen is collected 1 to 2 seconds after voiding begins.

•Refrigerate urine immediately on collection

Diagnostic Studies

◦ Trimethoprim/sulfamethoxazole (TMP/SMX) Used to treat uncomplicated or initial Inexpensive Taken twice a day

◦ E. coli resistance to TMP-SMX ◦ Nitrofurantoin (Macrodantin)

Given 3 or 4 times a day Long-term use

Pulmonary fibrosis Neuropathies

◦ Fluoroquinolones Treat complicated UTIs Example: Ciprofloxacin (Cipro)

◦ Pyridium Used in combination with antibiotics Provides soothing effect on urinary tract mucosa Stains urine reddish orange

Can be mistaken for blood and may stain underclothing OTC

Collaborative Care: Drug Therapy

Health history ◦ Previous UTIs, calculi, stasis, retention,

pregnancy, STDs, bladder cancer◦ Antibiotics, anticholinergics, antispasmodics◦ Urinary hygiene◦ N/V, anorexia, chills, nocturia, frequency, urgency◦ Suprapubic/lower back pain, bladder spasms,

dysuria, burning on urination

Nursing Management: Nursing Assessment

Objective data◦ Fever◦ Hematuria, foul-smelling urine, tender, enlarged

kidney◦ Leukocytosis, positive findings for bacteria, WBCs,

RBCs, pyuria, ultrasound, CT scan, IVP


Impaired urinary elimination Ineffective self-health management

Nursing ManagementNursing Diagnoses

Patient will have◦ Relief from lower urinary tract symptoms◦ Prevention of upper urinary tract involvement◦ Prevention of recurrence

Nursing ManagementPlanning

Health promotion ◦ Recognize individuals at risk.

Debilitated persons Older adults Underlying diseases (HIV, diabetes)

◦ Taking immunosuppressive drug or corticosteroids◦ Emptying bladder regularly and completely◦ Evacuating bowel regularly◦ Wiping perineal area front to back◦ Drinking adequate fluids

Nursing ManagementNursing Implementation

Health promotion (cont’d) ◦ Cranberry juice or cranberry essence may help

decrease risk.◦ Avoid unnecessary catheterization and early

removal of indwelling catheters.◦ Aseptic technique must be followed during

instrumentation procedures.◦ Wash hands before and after contact.◦ Wear gloves for care of urinary system.◦ Routine and thorough perineal care for all

hospitalized patients◦ Avoid incontinent episodes by answering call light

and offering bedpan at frequent intervals


o Adequate fluid intake Patient may think will worsen condition because of discomfort. Dilutes urine, making bladder less irritable Flushes out bacteria before they can colonize

◦ Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods. Potential bladder irritants

◦ Emphasize taking full course of prescribed drugs despite disappearance of symptoms. Second or reduced drug may be ordered after initial course in

susceptible patients. Instruct patient about drug therapy and side effects. Instruct

patient to watch urine for changes in color and consistency and decrease in cessation of symptoms.

◦ Application of local heat to suprapubic or lower back may relieve discomfort.

◦ Counsel on persistence of lower tract symptoms beyond treatment; onset of flank pain or fever should be reported immediately

Nursing Management: Nursing Implementation

Ambulatory and home care◦ Emphasize compliance with drug regimen.

Take as ordered.◦ Maintain adequate fluids.◦ Regular voiding (every 3 to 4 hours)◦ Void after intercourse.◦ Instruct on follow-up care.◦ Recurrent symptoms typically occur

1 to 2 weeks after therapy.


Use of nonanalgesic relief measures Appropriate use of analgesics Passage of urine without urgency Urine free of blood Adequate intake of fluids

Nursing ManagementEvaluation

Inflammation of renal parenchyma(consisting of the nephrones) and collecting system

Caused most commonly by bacteria, Fungi, protozoa, or viruses.

Acute Pyelonephritis

Acute Pyelonephritis

Fig. 46-2. Acute pyelonephritis. Cortical surface shows grayish white areas of inflammation and abscessformation (arrow).

Urosepsis◦ Systemic infection from urologic source

Can lead to septic shock and death

Septic shock: Outcome of unresolved bacteremia involving gram-negative organism

Usually begins with colonization and infection of lower tract via ascending urethral route

Frequent causes ◦ Escherichia coli◦ Proteus◦ Klebsiella◦ Enterobacter


Hospitalization for patients with severe infections and complications ◦ Such as nausea and vomiting with dehydration

•Signs/symptoms typically improve within 48 to 72 hours after therapy is started.

•The patient with mild symptoms may be treated as an outpatient with antibiotics for 14 to 21 days.

•When initial treatment resolves acute symptoms and the patient is able to tolerate oral fluids and drugs, the person may be discharged on a regimen of oral antibiotics for an additional 14 to 21 days.

Collaborative Care

Health history ◦ Nausea, vomiting, anorexia, chills, nocturia,

frequency, urgency Suprapubic or lower back pain, bladder

spasms, dysuria, burning on urination Objective data

◦ Fever◦ Hematuria, foul-smelling urine, tender, enlarged

kidney◦ Leukocytosis, positive findings for bacteria, WBCs,

RBCs,ultrasound, CT scan, IVP


Nursing Diagnoses Acute pain Impaired urinary elimination Planning

◦ Patient will have Relief of pain Normal body temperature No complications Normal renal function No recurrence of symptoms

Nursing Management

Health promotion◦ Early treatment for cystitis to prevent ascending

infection Patient with structural abnormalities is at high risk

Stress the need for regular medical care. Ambulatory and home care

◦ Need to continue drugs as prescribed◦ Need for follow-up urine culture◦ Identification of risk for recurrence◦ Encourage adequate fluids. ◦ Rest to increase comfort◦ Low-dose, long-term antibiotics to prevent re infections


Appropriate use of analgesics Passage of urine without urgency Urine free of blood Adequate intake of fluids

Nursing ManagementEvaluation

The nurse identifies the patient with the greatest risk for a urinary tract infection as a:

1. 37-year-old man with kidney stones.2. 26-year-old pregnant woman who has a history

of urinary tract infection.3. 69-year-old man who has urinary retention

caused by benign prostatic hyperplasia.4. 72-year-old woman hospitalized with a stroke

who has a urinary catheter because of urinary incontinence.

Question

Involves progressive, irreversible loss of kidney function

Disease staging based on decrease in GFR ◦ Normal GFR 125 mL/min, which is reflected by

urine creatinine clearance◦ Last stage of kidney failure

End-stage renal disease (ESRD) occurs when GFR <15 mL/min

Chronic Kidney Disease (CKD)

Defined as presence of ◦ Kidney damage

Pathologic abnormalities Markers of damage

Blood, urine, imaging tests ◦ Glomerular filtration rate (GFR)

<60 mL/min for 3 months or longer

Chronic Kidney Disease

Leading causes of ESRD◦ Diabetes◦ Hypertension

Chronic Kidney Disease

Polyuria◦ Results from inability of kidneys to concentrate

urine ◦ Occurs most often at night

Oliguria ◦ Occurs as CKD worsens◦ 300-500 ml/day

Anuria ◦ Urine output <40 mL per 24 hours

Clinical ManifestationsUrinary System

Waste product accumulation◦ As GFR ↓, BUN ↑ and serum creatinine levels ↑

BUN ↑ Not only by kidney failure but by protein intake, fever,

corticosteroids, and catabolism N/V, lethargy, fatigue, impaired thought processes, and

headache may occur. Altered carbohydrate metabolism

◦ Caused by impaired glucose use From cellular insensitivity to the normal action of insulin

Defective carbohydrate metabolism◦ Patients with diabetes who become uremic may require

less insulin than before onset of CKD. Insulin dependent on kidneys for excretion

Clinical ManifestationsMetabolic Disturbances

Elevated triglycerides◦ Hyperinsulinemia stimulates hepatic production of

triglycerides.◦ Altered lipid metabolism

↓ levels of enzyme lipoprotein lipase Important in breakdown of lipoproteins

Clinical Manifestations Metabolic Disturbances

Potassium◦ Hyperkalemia

Most serious electrolyte disorder in kidney disease Fatal dysrhythmias

Sodium◦ May be normal or low◦ Because of impaired excretion, sodium is retained.

Water is retained. Edema Hypertension CHF

Calcium and phosphate alterations Magnesium alterations

Clinical ManifestationsElectrolyte/Acid-Base Imbalances

Metabolic acidosis◦ Results from

Inability of kidneys to excrete acid load (primary ammonia)

•Defective reabsorption/regeneration of bicarbonate• The average adult produces 80 to 90 mEq of acid

per day. This acid is normally buffered by bicarbonate.

• In kidney failure, plasma bicarbonate, which is an indirect measure of acidosis, usually falls to a new steady state at around 16 to 20 mEq/L (16 to 20 mmol/L).

Clinical Manifestations Electrolyte/Acid-Base Imbalances

Hematologic System Anemia

◦ Due to ↓ production of erythropoietin From ↓ in functioning renal tubular cells

Bleeding tendencies Defect in platelet function Infection

◦ Changes in leukocyte function◦ Altered immune response and function◦ Diminished inflammatory response


Cardiovascular System Hypertension Heart failure Left ventricular hypertrophy Peripheral edema Dysrhythmias Uremic pericarditis


Respiratory System Kussmaul respiration Dyspnea Pulmonary edema Pleural effusion Predisposition to respiratory infection


Gastrointestinal System Every part of GI is affected.

◦ Due to excessive urea Mucosal ulcerations Stomatitis

with exudates and ulcerations, a metallic taste in the mouth, and uremic fetor (a urinous odor of the breath)

Uremic fetor (urinous odor of breath) GI bleeding

• Anorexia, nausea, vomiting• may develop if CKD progresses to ESRD and is not

treated with dialysis.


Neurologic System Expected as renal failure progresses

◦ Attributed to ↑ nitrogenous waste products Electrolyte imbalance Metabolic acidosis Axonal atrophy

◦ Demyelination of nerve fibers ◦ Restless leg syndrome◦ Muscle twitching◦ Irritability◦ Decreased ability to concentrate◦ Peripheral neuropathy ◦ Altered mental ability◦ Seizures◦ Coma◦ Dialysis encephalopathy


Musculoskeletal System CKD mineral and bone disorder

◦ Systemic disorder of mineral and bone metabolism◦ Results in skeletal complications and extra-skeletal (vascular)

calcifications

• As kidney function deteriorates, less vitamin D is converted to its active form, resulting in decreased serum levels.

• To absorb calcium from the GI tract, activated vitamin D is necessary.

• Thus decreased active vitamin D levels result in less calcium absorption from the intestine, and therefore decreased serum calcium levels.


Integumentary System Pruritus

• includes dry skin, calcium-phosphate deposition in the skin, and sensory neuropathy.

• The itching may be so intense that it can lead to bleeding or infection secondary to scratching.


Reproductive System Infertility

◦ Experienced by both sexes Decreased libido Low sperm counts Sexual dysfunction

Female-decreased levels of estrogen, progesterone, and luteinizing hormone, causing an ovulation and menstrual changes

Men experience loss of testicular consistency, decreased testosterone levels, and low sperm counts

Sexual function may improve with maintenance dialysis and may become normal with successful transplantation.


Psychologic Changes Personality and behavioral changes Emotional ability WithdrawalDepression

• Changes in body image caused by edema, integumentary disturbances, and access devices (e.g., fistulae, catheters) may contribute to the development of anxiety and depression.


History and physical examination Dipstick evaluation(detects protein-

albumin) Albumin-creatinine ratio (first morning void) GFR Renal ultrasound Renal scan CT scan Renal biopsy

Diagnostic Studies

Nutritional Therapy Protein restriction

◦ Benefits are being studied. Water restriction Intake depends on daily urine output. Sodium restriction

◦ Diets vary from 2 to 4 g, depending on degree of edema and hypertension.

◦ Sodium and salt should not be equated. Salt substitutes should not be used because they contain

potassium chloride. Potassium restriction

◦ 2 to 3 g◦ High-potassium foods should be avoided.

Collaborative Care

Acute kidney failure Onset- sudden Cause-tubultar necrosis Dx-acute reduction in UO and/or elevation

of serum creatinin Mortality rate-high-60% Primary cause of death-infection TABLE-1,2 and3, ch 47, page 1165

Acute kidney Injury(AKI)

Movement of fluid and molecules across a semi permeable membrane from one compartment to another.

Two dialysis are available◦ Peritoneal ◦ Hemodialysis◦ Table 47-13, page 1182

Dialysis

UI is an uncontrolled leakage of urine◦ Cause: infection, urinary retention, restricted

mobility, fecal impaction, drugs, prostate inlargment

UR is the inability to empty the bladder◦ Cause: bladder outlet obstruction and /or

decreased the contraction strength of bladder muscle

Urinary incontinence and retention

Stress incontinence; coughing laughing, sneezing, lifting, exercising (Increase in intra abdominal pressure)

Urge incontinence :involuntary urination, periodic leakage but also frequent and in large amount

Overflow incontinence: distended bladder, small frequent urination

Reflex incontinence :Fequent, moderate and equally during the day and night

Incontinence after trauma or surgery: alteration in control of proximal and distal sphincter of urethra

Functional incontinence: loss of urine resulting from cognitive, functional or environmental factors

Urinary incontinence

Lifestyle modifications: weight reduction, smoking cessation, decrease caffeine intake, fluid modification, etc

Scheduling voiding regimens Pelvic floor muscle exercises or training:

Kegels Anti- incontinence devices: surgical

treatment Drugs

Urinary incontinence: Interventions

Minimize the risk:◦ avoid intake of large volumes of fluid over short

period of time, ◦ avoid alcohol, coffee intake and hot tea(it

increase the urgency of urination, distention of the bladder.

◦ Take warm shower or bath and attempt to urinate while in the bathtub or shower.

◦ Indwelling or intermittent catheterization- straight cath i/o.

Urinary retention

Documents

Urinary System Ch 45-47