Vocational NursingMission College

VN 55A2Medical Surgical Theory

Genitourinary

Lisa Chance, RN, BSN

Quiz Today

• Yes, there is a quiz today.• It is just a little one.• It is fill in.• It is on anatomy, physiology, and

medical terminology.• Not to worry. I will review items first.

• Nothing should be on your table top except the test, appropriate answer material, & your pencil.

• No calculators or electronic thesaurus are permitted.

• No cheating.• You may go to the bathroom during a test;

however, you will not be allowed to continue taking the test.

• Today is a fill in test.

• When there are color tests or exams, indicate what color, letter, or number of test you have on your test paper or Scan-Tron.

• You should not be sitting next to a person who has the same color quiz, test or exam.

• There are two finals in this class: one on GU & on of F&E.

Quizzes & Exams

• From current NCLEX test questions.

• From current nursing articles (last five years).– Continuing education articles

we will go over.

• Web sites questions we that will count as class participation points and will have the answers and rationales.

• Hints in lecture questions.

Urinary System•Upper

– Kidneys make urine

– Ureters convey urine

•Lower

– Bladder stores urine

– Urethra conveys urine

one on each side of the spine just below the liver and spleen.

The Kidneystwo organs located in the posterior part of the abdomen

The two kidneys are located in the lumbar region of the back behind the parietal peritoneum.

http://www.merckmedicus.com/pp/us/hcp/frame_emedtool_search.jsp?pg=/ppdocs/us/hcp/content/emed/Urinary/Urinary_JPEGs/index.htm

The Kidneys•Essential for survival!•Responsible for:

– regulating body fluid composition & water & chemicals in blood such as:

• sodium (Na+)• potassium (K+ primary

regulators !!)• phosphorus (P)• calcium (Ca)

filtering the blood – Remove drugs & toxins introduced

into the body.

– Releasing hormones into blood to help the body:

• regulate blood pressure

• red blood cell production

• Maintain body's calcium levels promote strong bones

The Kidneys

The kidneys are surrounded by fat, which protects them.

•Are attached to the abdominal wall at the level of the last thoracic & first three lumbar vertebra.

The kidneys:

•Hard to palpate unless:

– Enlarged with

Hydronephrosis

Cyst

neoplasm

– Patient slim.

– Often confused with spleen on palpation.

• Left is usually easier to find by palpation than right.

The Adrenal Glands

•Produce hormones that help control:

–heart rate

–blood pressure

– the way the body uses food (metabolism)

–& other vital functions

Adrenal Glands

•Cortex secretes:

– steroid (cortisone-related) hormones

– mineralocortoids that regulate the levels of minerals such as sodium and potassium in the blood

Open your workbooks!

• There is an error!

• Where is that line going?

●Note the location of the renal pelvis! It is used as a major landmark in this diagnostic test.

● Pt injected with radiopaque dye & X-rays are taken as the dye travels through the urinary tract.

The hard outer portion of the kidney is called the:

O CalyxO FasciaO PapillaO MedullaO Cortex

The hard outer portion of the kidney is called the:

Cortex

The 2 kidneys are only 0.4% of the body weight but receive about 25% of the blood flow (cardiac output).

The functional unit of the kidney is the

nephron.

•1 million nephrons in each kidney have the job of:

– filtering the blood to form urine

– excreting toxins and other wastes

– returning the filtered blood to the renal veins to put it back into the general circulation

GlomerulusBowman’scapsule

Distalconvolutedtubule

Afferent arterole

Efferentarteriole

LoopofHenle

Collectingduct

Interlobarartery

Interlobarartery

Glomerulus- tuft of capillaries where filtration occurs

Bowman's capsule- surrounds glomerulus, collects filtrate

• Bowman’s capsule, which surrounds the glomerulus, is the starting point of the tubule, where reabsorption and secretion take place. Filtrate passing into Bowman’s capsule is channeled into the tubule.

• The glomerulus is a group of tiny capillaries with very thin walls.

• As blood passes through, particles and waste products are filtered out into a liquid filtrate.

• Blood cells and proteins, too large to penetrate the glomerular walls, return to the general circulation.

Where filtration occurs.

Proximalconvolutedtubule

Distalconvolutedtubule

Glomerulus

Loop of HenleTo bladder

Outgoingvenousblood

Incomingarterialblood

Collectingtubule

Bowman’scapsule

The actual filtration of the body's waste products takes place in the:

O Nephrons

O Bladder

O Urethra

O Renal pelvis

O Ureters

The actual filtration of the body's waste products takes place in the:

NephronsProximalconvolutedtubule

Distalconvolutedtubule

Glomerulus

Loop of HenleTo bladder

Outgoingvenousblood

Incomingarterialblood

Collectingtubule

Bowman’scapsule

Each nephron consists ofthe renal tubule & the renal corpuscle

called the:

O Nephron

O Efferent arteriole

O Afferent arteriole

O Glomerulus

O Bowman's capsule

Each nephron consists ofthe renal tubule & the renal corpuscle

called the:

Bowman's capsule

Another name for voiding is:

O Diuresis

O Cystitis

O Urgency

O Nephrosis

O Micturition

Another name for voiding is:

Micturition

Waste products are removed from the blood through the three stages called filtration, reabsorption, and:

O Enuresis

O Pubic symphysis

O Homeostasis

O Secretion

O Peristaltic waves

Waste products are removed from the blood through the three stages called filtration, reabsorption, and:

Secretion

One of the most vital functionsof the kidneys is to:

O Regulate blood pressure

O Produce aldosterone

O Regulate the body's electrolytes

O Supply blood to the renal artery

O Produce the hormone ADH

One of the most vital functionsof the kidneys is to:

Regulate blood pressure

The involuntary discharge of urine after the age by which bladder

control should have been established is called:

O Phimosis

O Enuresis

O Nocturia

O Dysuria

O Diuresis

The involuntary discharge of urine after the age by which bladder

control should have been established is called:

Enuresis

Practice for the NCLEX-PNby CramExam

a) 19:00

b) 12:00

c) 10:00

d) 07:00

The client with The client with enuresisenuresis is being taught is being taught regarding bladder retraining. The nurse regarding bladder retraining. The nurse should advise the client to refrain from should advise the client to refrain from drinking after:drinking after:

Practice for the NCLEX-PNby CramExam

The client with The client with enuresisenuresis is being taught is being taught regarding bladder retraining. The nurse regarding bladder retraining. The nurse should advise the client to refrain from should advise the client to refrain from drinking after:drinking after:

a) 19:00

Urea

• Nitrogenous waste product from the metabolism of amino acids.

• Over-consumption of protein for a prolonged period of time can also increase the formation of a highly toxic ammonia called urea.

• Since the urea in your body must be excreted, an overabundance of urea places a strain on your liver and kidneys and is oftentimes responsible for a form of arthritis known as gout.

anuria

• absence of urination

hematuria

• blood in the urine

dysuria

• painful urination

pyuria

• presence of pus in urine

oliguria• decreased urine output (<400 mL per 24 hours) • urine output less than 20 ml/hr may be found in

any patient due to disorders related to:– Cardiology– Nephrology– Urology– Endocrinology– Medical– surgical

uremia

• condition that occurs when waste products in the blood quickly accumulate to toxic levels

The combining form lith/o means:

O urine

O kidney

O renal pelvis

O bladder

O stone

The combining form lith/o means:

stone

•Little is stored in the body

•Instead it responses to what is circulating in the body, such as:

increased potassium levels

or decreased blood flow to the kidneys

• cells of adrenal cortex (the zona glomerulosa) secrete the mineralocorticoid aldosterone into the blood as part of the renin-angiotensin system

One of these mineralocorticoids

is aldosterone.

• Aldosterone regulates the body's concentration of electrolytes, primarily sodium and potassium, by acting on the distal convoluted tubule of kidney nephrons to:– increase potassium excretion – increase sodium reabsorption – increase water reabsorption through

osmosis

Endocrine Glandsrelease hormones (chemical messengers)

ADH

• a hormone

• Produced in a region of the brain called the hypothalamus

• Stored and released from the pituitary gland, a small gland at the base of the brain

antidiuretic hormone (ADH) blood level

• Alternative Names:– arginine vasopressin– antidiuretic hormone– AVP– Vasopressin

• Normal values: – 0 to 4.7 pg/mL

Note: pg/ml = picograms per milliliter

http://www.umm.edu/ency/article/003702res.htm

Diabetes Insipidus (DI)

• Uncommon condition• Occurs when the kidneys are unable to conserve

water as they perform their function of filtering blood.

• Amount of water conserved is controlled by ADH• Two types of DI

– central diabetes insipidus– nephrogenic diabetes insipidus

central diabetes insipidus

• caused by damage to the hypothalamus or pituitary gland as a result of:

– surgery

– infection

– tumor– head injury

Nephrogenic Diabetes Insipidus

• involves a defect in the parts of the kidneys that reabsorb water back into the blood stream

• Even more uncommon than central DI

• may occur as an inherited disorder in which male children receive the abnormal gene that causes the disease on the X-chromosome from their mothers

• caused by– diseases of the kidney

• i. e. polycystic kidney disease

– effects of certain drugs• Lithium• amphotericin B• demeclocycline

Nephrogenic Diabetes Insipidus…continued

Does everyone have e-mail?

• Send me an e-mail telling me a little about yourself and why you want to become a nurse.

• Do not assume I have received your e-mail unless you get a reply from me via e-mail.

Does everyone have a home computer?

Picture from 1954 Popular Mechanics Magazine

Your e-mail addresses!!

• Send me an e-mail saying “Hi.”

• Put your name at the bottom. I do not know who Hotmamma27@yahoo.com is.

• I will send you the following articles:– Keeping kidney function flowing, Nursing

Made Incredibly Easy, Sept. 2004.– An ACE Up Your Sleeve…, Nursing Made

Incredibly Easy, Sept. 2003.

PowerPoint Slides

• http://salsa.missioncollege.org/chance/

What drugs should you know?

• Know drugs on page 334 of Williams & Hopper– Aldosterone antagonist spironolactone

(Aldactone) Blocks effects of aldosterone Positive effect on Na+ & K+ balance

– “loop diuretics” (meaning Loop of Henle) Furosemide (Lasix) Bumetanide (Bumex) Torsemide (Demadex)

Also:

• Drugs for heart & lungs that are renal protective

• Angiotensin-Converting Enzyme inhibitors (ACE-Is or ACE inhibitors) such as

• Angiotensin Receptor Blockers (ARBs)– Good choices for complex patients, such as

those with: hypertension heart failure diabetes or metabolic syndrome

Renin-angiotensin-aldosterone system (RAAS)

• Influences blood pressure• Normal response to decreased blood pressure or

vascular volume– Proteolytic enzyme renin is produced in the

kidneys– Renin circulates throughout the body via the

bloodstream & is converted to angiotensin I which is inactive.

RAAS…continued

– In the presence of angiotensin converting enzyme (ACE), angiotensin I is converted to angiotensin II, which is a powerful vasoconstrictor.

• Angiotensin II latches onto the angiotensin II receptors in:– vascular smooth muscle (blood vessels)– Kidneys– adrenal glands– Heart– Liver– brain

• Repercussions throughout the body, causing:

– an increase in sympathetic transmission,

which increases myocardial contractility

– This stimulates release of epinephrine and norepinephrine, resulting in blood vessel constriction.

– greater release of vasopressin, the antidiuretic hormone (ADH), which results in water retention

– increased release of aldosterone from the adrenal glands (which sit on top of the kidneys), leading to salt retention and further water retention

Non-steroidalanti-inflammatory drugs (NSAIDs)

• NSAIDs decrease the effectiveness of:– angiotensin-converting enzyme inhibitors

(ACE-Is)– angiotensin receptor blockers (ARBs)– exacerbate heart failure and hypertension

The kidneys and bones

• Convert vitamin D to it active form, a necessary step for bone maintenance and, research suggest, muscle maintenance, too.

Tufts University Health & Nutrition Letter, Mar2004, Vol. 22 Issue 1, Tufts University Health & Nutrition Letter, Mar2004, Vol. 22 Issue 1, p4-5, 2p, p4-5, 2p,

• Rate of filtration is approximately 125 ml/min or 45 gallons (180 liters) each day.

• Considering that you have 7 to 8 liters of blood in your body, this means that your entire blood volume gets filtered approximately 20 to 25 times each day!

Percussion of bladder

• Percussion of a distended bladder caused a dull sound.

• Percussion of a distended loop of bowel will be tympanitic.   

• Causes of distended bladder:  – Outlet obstruction: urethral valves (child)– Prostatic hypertrophy– carcinoma urethral stricture

• Decreased bladder tone:– neurogenic bladder (spinal cord injury)– myogenic (overstretched bladder) – Senility or bed rest: Some patients are unable

to void in the supine position 

• DIFFERENTIAL DIAGNOSIS:  – Uterus: pregnancy or tumor– Ovary: cyst or tumor – Colon: tumor or fecal impaction   

Percussion of bladder

Urinalysis (UA)

• Red cells and casts may indicate glomerular disease. Casts only originate in the kidneys and because of gelation within the tubules. Casts can trap other materials when they are formed.

• Type of cast seen gives clue to where in the kidney they were made; for example:– Glomerular– Tubulointerstitial– vascular

UA …continued

• White blood cells can be seen in interstitial nephropathies

• Pyuria

• Protein, if present, is an important marker of renal disease

• Persistent proteinuria is usually the first indicator of kidney damage.

GFR and EGFR

Glomerular Filtration Rate &Estimated Glomerular Filtration Rate

Why get tested?To assess kidney function

When to get tested?As a screening test to look for evidence of kidney damage (EGFR) or for changes in kidney function if you already have kidney disease (GFR)

Sample required?EGFR is calculated from your age, weight, gender, and serum creatinine (requires a blood sample from a vein in your arm); in some formulas, race is also used in the calculation.

GFR is calculated from serum and urine creatinine; it requires both a blood sample from a vein in your arm and a 24-hour collection of urine.

GFR and EGFR

• In a healthy person GFR fluctuates somewhat in response to– hydration status– Pregnancy– drug use– Age– Sex– body size

•GFR is considered the most accurate way to detect changes in kidney status.

•While measurement of serum BUN (urea nitrogen) and creatinine are easier to do, they cannot pick up early damage to the kidneys.

•If kidney damage is detected early, it may be possible to prevent worsening damage to the kidneys with treatment of high blood pressure, diabetes, or other diseases that can damage the kidney.

• Normal: 0.6 to 1.5 mg/dL

• > 1.5 mg/dL means kidney dysfunction

• Creatinine levels may be 10%-30% higher in people who eat a diet that is very high in meat.

• ratio of BUN to creatinine is usually between 10:1 and 20:1

Creatinine

Creatinine• What is being tested?

– test measures the amount of creatinine in blood and/or urine

– Creatinine is a waste product produced in muscles from the breakdown of a compound called creatine.

– Creatine is part of the cycle that produces energy needed to contract muscles and it as well as creatinine are produced at a relatively constant rate.

– Almost all creatinine is excreted by the kidneys, so blood levels are a good measure of how well the kidneys are working.

– The quantity produced depends on the size of the person and their muscle mass. For this reason, creatinine concentrations will be slightly higher in men than in women and children.

Creatinine…continued

Creatinine…continued

• Blood and urine levels of creatinine stay relatively constant.

• The body's ability to keep these levels constant depends in part on the glomerular filtration rate (GFR).

• The GFR, or rate at which the kidneys filter blood, is normally 120 ml/min in adults, but can not be measured directly.

• So when the kidneys are not functioning properly, the rate of filtration decreases, and you will see– rise in the serum creatinine level– a drop in urine creatinine

• This test measures the amount of urea nitrogen in the blood.

• Nitrogen, in the form of ammonia, is produced in the liver when protein is broken into its component parts (amino acids) and metabolized.

• The nitrogen combines with other molecules in the liver to form the waste product urea.

• The urea is then released into the bloodstream and carried to the kidneys, where it is filtered out of the blood and excreted in the urine.

BUN: Blood Urea Nitrogen

What is being tested?What is being tested?

BUN

• Since this is an ongoing process, there is usually a small but stable amount of urea nitrogen in the blood.

• Most diseases or conditions that affect the kidneys or liver have the potential to affect the amount of urea present in the blood.

• If increased amounts of urea are produced by the liver or decreased amounts are excreted by the kidneys, then urea concentrations will rise.

• If significant liver damage or disease inhibits the production of urea, then BUN concentrations may fall.

BUNBlood Urea Nitrogen

Why get tested?To evaluate kidney function and monitor the effectiveness of dialysis and other treatments related to kidney disease or damage

When to get tested?As part of a routine comprehensive or basic metabolic panel (sometimes called a “Chem7” or “Panel7” and when a patient is acutely or chronically ill with a condition that may cause or be exacerbated by kidney dysfunction.

Sample required?A blood sample drawn from a vein in the arm.

HbA1c

• A hemoglobin A1c (HbA1c) assay– measures a type of glycosylated hemoglobin– indicates one’s level of glucose control– Generally between about 4% and 6% for

people without diabetes– recommend under 7% for those with diabetes

Frequently used drugsthat may effect urine color

Generic & brand names

Drug classification

Urine color

Cascara sagrada Stimulant laxative

Red in alkaline urine; yellow-brown in acid urine

Chloropuine (Aralen)

AntimalVerdana, Arial, Helvetica, san-serif

Rusty yellow or brown

Chlorzoxazone (Paraflex)

Skeletal muscle relaxant

Orange or purple-red

Docusate calcium (Doxidan, Surfak)

Laxative Pink to red to red-brown

Furazolidone (Furoxone)

Antiinfective, antiprotozoal

Brown

Iron preparations (Ferotran, Imferon)

Hematinic Dark brown or black on standing

Frequently used drugsthat may effect urine color

Generic & brand names

Drug classification

Urine color

Levodopa Antiparkinsonian Dark brown on standing

Methylene blue (Urolene Blue)

Antimethemoglobinemic

Blue-green

Methyldopa (Aldomet)

Antihypertensive Darkening

Metronidazole (Flagyl)

Antiinfective Darkening, reddish brown

Nitrofurantoin (Macrodantin,

Nitrodan)

Antibacterial Brown-yellow

Phenazopyridine (Pyridium)

Urinary tract anagestic

Orange to red

Phenolphthalein(Ex-Lax)

Contact laxative Red or purplish pink in alkaline urine

Frequently used drugsthat may effect urine color

Generic & brand names

Drug classification

Urine color

Phenothiazine (e.g., prochlorperazine

[Compazine])

Antipsychotic, neuroleptic, antiemetric

Red-brown

Phenytoin (Dilantin)

Anticonvulsant Pink, red, red-brown

Riboflavin (vitamin B)

Vitamin Intense yellow

Rifampin Antibiotic Red-orange

Sulfasalizine (Azulfidine)

Antibacterial Orange-yellow in alkaline urine

Triamterene (Dyrenium)

Diuretic Pale blue fluorescence

Off The Mark, by Mark Parisi

April 22, 2004

1. acute renal failure2. alkaline ash diet & acid-ash diet3. benign prostatic hypertrophy or hyperplasia

(BPH)4. chronic renal failure5. continuous ambulatory peritoneal dialysis6. cystoscopy7. cystitis/urinary tract infections8. epididymitis9. supra pubic cath care10. genitourinary tuberculosis

Patient Teaching Projects

11. glomerulonephritis12. hemodialysis13. hydronephrosis14. hypercalcemia & hypocalcemia 15. hyperkalemia & hypokalemia16. hypermagnesemia & hypomagnesemia17. hyperphosphatemia & hypophosphatemia18. hyponatremia & hypernatremia19. incontinence, management of20. IVP

Patient Teaching Projects

20. kidney biopsy21. kidney stones22. kidney transplantation23. kidney tumors24. nephrotic syndrome25. peritoneal dialysis26. peritoneal dialysis-dietary guidelines27. pheochromocytoma28. polycystic kidney disease

Patient Teaching Projects

29. pre & post op care of TURP30. prostatitis31. renal angiogram32. renal ultrasound33. uremic syndrome34. ureteritis and pyelonephritis35. Lasix36. Aldactone37. HydroDIURIL38. BUN39. creatinine tests40. Pyelogram41. Clean intermittent self-catheterization (home)

Patient Teaching Projects

Assessing a Web Site

• .org

• .gov

• .edu

Nursing Center

http://www.nursingcenter.com

www.rnweb.com

National Library of MedicineNational Institutes of Health (NIH)

www.nlm.nih.gov

http://kidney.niddk.nih.gov/

• Imagine you are at a party…you have been drinking…and then you have to visit this bathroom?

• Now remember, the floor is just a painted floor!

Kind of Kind of takes takes your your breath breath away… away… doesn’t doesn’t it?!it?!