The Genito-Urinary

System
Medical Surgical Nursing
Review

Outline of review
Recall the anatomy and physiology of
the Renal System
Renal Assessment
Renal Laboratory Procedure
Common Conditions:
UTI
Kidney Stones
ARF and CRF

Outline of review
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 Problems
EDEMA
associated with fluid
retention
Renal dysfunctions usually
produce ANASARCA

Urological Assessment
Key Signs and Symptoms of
Urological Problems
PAIN
Suprapubic pain= bladder
Colicky pain on the flank=
kidney

Urological Assessment
Key Signs and Symptoms of
Urological Problems
HEMATURIA
Painless hematuria may
indicate URINARY CANCER!
Early-stream hematuria=
urethral lesion
Late-stream hematuria=
bladder lesion

Urological Assessment
Key Signs and Symptoms of
Urological Problems
DYSURIA
Pain with urination= lower UTI

Urological Assessment
Key Signs and Symptoms of
Urological Problems
POLYURIA
More than 2 Liters urine per day

OLIGURIA
Less than 400 mL per day

ANURIA
Less than 50 mL per day

Urological Assessment
Key Signs and Symptoms of
Urological Problems
Urinary Urgency
Urinary retention
Urinary frequency

Urological Assessment
PHYSICAL EXAMINATION
Inspection
Auscultation
Percussion
Palpation

Urological Assessment
Laboratory examination
1. Urinalysis
2. BUN and Creatinine levels of
the serum
3. Serum electrolytes

Urological Assessment
Laboratory examination
Radiographic
IVP
KUB x-ray
KUB ultrasound
CT and MRI
Cystography

Implementation Steps for

selected problems
Provide PAIN relief
Assess the level of pain
Administer medications usually
narcotic ANALGESICS

Implementation Steps for

selected problems
Maintain Fluid and Electrolyte
Balance
Encourage to consume at least 2
liters of fluid per day
In cases of ARF, limit fluid as
directed
Weigh client daily to detect fluid
retention

Implementation Steps for

selected problems
Ensure Adequate urinary elimination
Encourage to void at least every 23 hours
Promote measures to relieve
urinary retention:
Alternating warm and cold compress
Bedpan
Open faucet
Provide privacy
Catheterization if indicated

Urinary Tract Infection (UTI)

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

Urinary Tract Infection (UTI)

Predisposing factors include
1. Poor hygiene
2. Irritation from bubble baths
3. Urinary reflux
4. Instrumentation
5. Residual urine, urinary stasis
6. Dehydration

Urinary Tract Infection (UTI)

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

Urinary Tract Infection (UTI)

Assessment findings
Low-grade fever
Abdominal pain
Enuresis
Pain/burning on urination
Urinary frequency
Hematuria

Urinary Tract Infection (UTI)

Assessment findings: Upper
UTI
Fever and CHIILS
Flank pain
Costovertebral angle
tenderness

Urinary Tract Infection (UTI)

Laboratory Examination
1. Urinalysis
2. Urine Culture

Urinary Tract Infection (UTI)

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).

Urinary Tract Infection (UTI)

Provide client teaching and
discharge planning concerning
a. Avoidance of tub baths
b. Avoidance of bubble baths
that might irritate urethra
c. Importance for girls to wipe
perineum from front to back
d. Increase in foods/fluids that
acidify urine.

Urinary Tract Infection (UTI)

Pharmacology
1. Sulfa drugs
Highly concentrated in the urine
Effective against E. coli!
Can cause CRYSTALLURIA

2. Quinolones
Not given to less than 18 because they
can cause cartilage degradation

3. Pyridium= urinary antiseptic

Can cause urine discoloration

Nephrolithiasis/Urolithia
sis
Presence of stones
anywhere in the urinary
tract
Calcium
oxalate
and uric acid

Nephrolithiasis/Urolithia
sis

Pathophysiology
Predisposing factors
a. Diet: large amounts of calcium
and oxalate
b. Increased uric acid levels
c. Sedentary life-style, immobility
d. Family history of gout or calculi
e. Hyperparathyroidism

Nephrolithiasis/Urolithia
sis
Pathophysiology
Supersaturation of crystals due to
stasis
Stone formation
May pass through the urinary tract
OBSTRUCTION, INFECTION and
HYDRONEPHROSIS

Nephrolithiasis/Urolithia
sis

Assessment findings
1. Abdominal or flank pain
2. Renal colic radiating to
the groin
3. Hematuria
4. Cool, moist skin
5. Nausea and vomiting

Nephrolithiasis/Urolithia
sis
Diagnostic tests
1. KUB Ultrasound and X-ray:
pinpoints location, number, and size
of stones
2. IVP: identifies site of obstruction
and presence of non-radiopaque
stones
3. Urinalysis: indicates presence of
bacteria, increased protein,
increased WBC and RBC (hematuria)

Nephrolithiasis/Urolithia
sis

Medical management
1. Surgery
a. Percutaneous nephrostomy:
tube is inserted through skin and
underlying tissues into renal
pelvis to remove calculi.
b. Percutaneous
nephrostolithotomy: delivers
ultrasound waves through a probe
placed on the calculus.

Nephrolithiasis/Urolithia
sis

Medical management
2. Extracorporeal shock-wave
lithotripsy: delivers shock
waves from outside the body to
the stone, causing pulverization
3. Pain management : Morphine or
Meperidine
4. Diet modification

Nephrolithiasis/Urolithia
sis
Nursing interventions
1. Strain all urine through
gauze to detect stones and
crush all clots.
2. Force fluids (30004000
cc/day).
3. Encourage ambulation to
prevent stasis.

Nephrolithiasis/Urolithia
sis
Nursing interventions
4. Relieve pain by
administration of analgesics as
ordered and application of
moist heat to flank area.
5. Monitor intake and output

Nephrolithiasis/Urolithia
sis
Nursing interventions
6. Provide modified diet,
depending upon stone
consistency: Calcium,
Oxalate and Uric acid
stones

Nephrolithiasis/Urolithia
sis
Nursing interventions
Calcium stones
limit milk/dairy products
provide acid-ash diet to
acidify urine (cranberry or
prune juice, meat, eggs,
poultry, fish, grapes, and
whole grains)

Nephrolithiasis/Urolithia
sis

Nursing interventions
Oxalate stones
avoid excess intake of foods/
fluids high in oxalate (tea,
chocolate, rhubarb, spinach)
maintain alkaline-ash diet to
alkalinize urine (milk;
vegetables; fruits except
prunes, cranberries, and plums)

Nephrolithiasis/Urolithia
sis
Nursing interventions
Uric acid stones
reduce foods high in purine
(liver, beans, kidneys,
venison, shellfish, meat
soups, gravies, legumes)
maintain alkaline urine

Nephrolithiasis/Urolithia
sis
Nursing interventions
7. Administer allopurinol
(Zyloprim) as ordered, to
decrease uric acid production
Allopurinol
Rashes
Nasal congestion

Nephrolithiasis/Urolithia
sis
Provide client teaching and
discharge planning concerning
Prevention of Urinary stasis by
maintaining increased fluid
intake especially in hot weather
and during illness; mobility;
voiding whenever the urge is
felt and at least twice during
the night
8.

Nephrolithiasis/Urolithia
sis
Provide client teaching and
discharge planning concerning:
Adherence to prescribed diet
Need for routine urinalysis (at
least every 34 months)
Need to recognize and report
signs/ symptoms of recurrence
(hematuria, flank pain).
8.

Acute renal failure

Sudden interruption of
kidney function to
regulate fluid and
electrolyte balance and
remove toxic products
from the body

Acute renal failure

Most important
manifestation:
OLIGURIA

Kidney function
The Nephron produces
urine to eliminate waste
Secretes Erythropoietin
to increase RBC
Metabolism of Vitamin D
Produces bicarbonate
and secretes acids
Excretes excess
POTASSIUM

Impaired urine production

and azotemia

ANEMIA
Calcium and Phosphate
imbalances
Metabolic ACIDOSIS
HYPERKALEMIA

Acute renal failure

PATHOPHYSIOLOGY
1. Pre-renal failure
2. Intra-renal failure
3. Post-renal failure

Acute renal failure

PATHOPHYSIOLOGY
Prerenal CAUSE:
Factors interfering with
perfusion and resulting in
diminished blood flow and
glomerular filtrate, ischemia,
and oliguria; include CHF,
cardiogenic shock, acute
vasoconstriction, hemorrhage,
burns, septicemia, hypotension,
anaphylaxis

Acute renal failure

PATHOPHYSIOLOGY
Intrarenal CAUSE:
Conditions that cause damage to
the nephrons; include acute tubular
necrosis (ATN), endocarditis,
diabetes mellitus, malignant
hypertension, acute
glomerulonephritis, tumors, blood
transfusion reactions,
hypercalcemia, nephrotoxins
(certain antibiotics, x-ray dyes,
pesticides, anesthetics)

Acute renal failure

PATHOPHYSIOLOGY
Postrenal CAUSE:

Mechanical obstruction
anywhere from the tubules to
the urethra; includes calculi,
BPH, tumors, strictures,
blood clots, trauma, and
anatomic malformation

Acute renal failure

Three phases of acute renal
failure
1. Oliguric phase
2. Diuretic phase
3. Convalescence or recovery
phase

Acute renal failure

Four phases of acute renal
failure (Brunner and
Suddarth)
1. Initiation phase
2. Oliguric phase
3. Diuretic phase
4. Convalescence or recovery
phase

Acute renal failure

Assessment findings: The Three Phases of Acute
Renal Failure

1. Oliguric phase
Urine output less than 400 cc/24 hours
duration 12 weeks
Manifested by dilutional
hyponatremia, hyperkalemia,
hyperphosphatemia, hypocalcemia,
hypermagnesemia, and metabolic
acidosis
Diagnostic tests: BUN and creatinine
elevated

Acute renal failure

Assessment findings: The Three
Phases of Acute Renal Failure
2. Diuretic phase
Diuresis may occur (output 35
liters/day) due to partially
regenerated tubules inability to
concentrate urine
Duration: 23 weeks; manifested
by hyponatremia, hypokalemia,
and hypovolemia
Diagnostic tests: BUN and
creatinine slightly elevated

Acute renal failure

Assessment findings: The Three
Phases of Acute Renal Failure
3. Recovery or convalescent
phase:
Renal function stabilizes with
gradual improvement over next
312 months

Acute renal failure

Laboratory findings:
1. Urinalysis: Urine osmo and
sodium
2. BUN and creatinine levels
increased
3. Hyperkalemia
4. Anemia
5. ABG: metabolic acidosis

Acute renal failure

Nursing interventions
Monitor fluid and Electrolyte
Balance
Reduce metabolic rate
Promote pulmonary function
Prevent infection
Provide skin care
Provide emotional support

Acute renal failure

Nursing interventions
1. Monitor and maintain fluid and
electrolyte balance.
Measure l & O every hour. note
excessive losses in diuretic phase
Administer IV fluids and
electrolyte supplements as
ordered.
Weigh daily and report gains.
Monitor lab values; assess/treat
fluid and electrolyte and acid-base
imbalances as needed

Acute renal failure

Nursing interventions
2. Monitor alteration in fluid
volume.
Monitor vital signs, PAP,
PCWP, CVP as needed.
Weigh client daily.
Maintain strict I & O records.

Acute renal failure

Nursing interventions
2. Assess every hour for
hypervolemia
Maintain adequate
ventilation.
Restrict FLUID intake
Administer diuretics and
antihypertensives

Acute renal failure

Nursing interventions
3. Promote optimal nutritional
status.
Administer TPN as ordered.
With enteral feedings, check for
residual and notify physician if
residual volume increases.
Restrict protein intake to 1 g/kg/day
Restrict POTASSIUM intake
HIGH CARBOHYDRATE DIET, calcium
supplements

Acute renal failure

Nursing interventions
4. Prevent complications from
impaired mobility (pulmonary
embolism, skin breakdown,
and atelectasis)
5. Prevent fever/infection.
Assess for signs of infection.
Use strict aseptic technique for
wound and catheter care.

Acute renal failure

Nursing interventions
6. Support client/significant others
and reduce/ relieve anxiety.
Explain pathophysiology and
relationship to symptoms.
Explain all procedures and answer
all questions in easy-to-understand
terms
Refer to counseling services as
needed

7. Provide care for the client

receiving dialysis

Acute renal failure

Nursing interventions
8. Provide client teaching and discharge
planning concerning
Adherence to prescribed dietary
regimen
Signs and symptoms of recurrent renal
disease
Importance of planned rest periods
Use of prescribed drugs only
Signs and symptoms of UTI or
respiratory infection need to report to
physician immediately

Chronic Renal Failure

Gradual, Progressive
irreversible destruction
of the kidneys causing
severe renal
dysfunction.
The result is azotemia to
UREMIA

Chronic Renal Failure

Predisposing factors:
DM= worldwide leading
cause
Recurrent infections
Exacerbations of nephritis
urinary tract obstruction
hypertension

Chronic Renal Failure

PATHOPHYSIOLOGY
As renal functions
decline
Retention of endproducts of metabolism

Chronic Renal Failure

PATHOPHYSIOLOGY
STAGE 1= reduced renal reserve,
40-75% loss of nephron function
STAGE 2= renal insufficiency, 7590% loss of nephron function
STAGE 3= end-stage renal
disease, more than 90% loss.
DIALYSIS IS THE TREATMENT!

Chronic Renal Failure

Assessment findings
1. Nausea, vomiting; diarrhea or
constipation; decreased urinary
output
2. Dyspnea
3. Stomatitis
4. Hypertension (later),
lethargy, convulsions, memory
impairment, pericardial friction
rub

Chronic Renal Failure

Dermatologic

dry skin, pruritus, uremic

frost

CNS

seizures, altered LOC,

anorexia, fatigue

CVS

Acute MI, edema,

hypertension, pericarditis

Pulmo

Uremic lungs

Hema

Anemia

Musculoskeletal

loss of strength, foot

drop, osteodystrophy

Chronic Renal Failure

Diagnostic tests:
a. 24 hour creatinine
clearance urinalysis
b. Protein, sodium, BUN,
Crea and WBC elevated
c. Specific gravity, platelets,
and calcium decreased
D. CBC= anemia

Chronic Renal Failure

Medical management
1. Diet restrictions
2. Multivitamins
3. Hematinics and erythropoietin
4. Aluminum hydroxide gels
5. Anti-hypertensive
6. Anti-seizures

DIALYSIS

Chronic Renal Failure

Nursing interventions
1. Prevent neurological
complications.
Assess every hour for signs of
uremia (fatigue, loss of
appetite, decreased urine
output, apathy, confusion,
elevated blood pressure,
edema of face and feet, itchy
skin, restlessness, seizures).

Chronic Renal Failure

Nursing interventions
1. Prevent neurological
complications.
Assess for changes in mental
functioning.
Orient confused client to time,
place, date, and persons
Institute safety measures to
protect client from falling out
of bed.

Chronic Renal Failure

Nursing interventions
2. Promote optimal GI function.
Assess/provide care for
stomatitis
Monitor nausea, vomiting,
anorexia
Administer antiemetics as
ordered.
Assess for signs of Gl bleeding

Chronic Renal Failure

Nursing interventions
3. Monitor/prevent alteration in
fluid and electrolyte balance
4. Assess for
hyperphosphatemia
(paresthesias, muscle cramps,
seizures, abnormal reflexes),
and
administer aluminum
hydroxide gels (Amphojel) as
ordered

Chronic Renal Failure

Nursing interventions
5. Promote maintenance of skin
integrity.
Assess/provide care for
pruritus.
Assess for uremic frost (urea
crystallization on the skin) and
bathe in plain water

Chronic Renal Failure

Nursing interventions
6. Monitor for bleeding
complications, prevent injury
to client.
Monitor Hgb, hct, platelets,
RBC.
Hematest all secretions.
Administer hematinics as
ordered.
Avoid lM injections

Chronic Renal Failure

Nursing interventions
7. Promote/maintain maximal
cardiovascular function.
Monitor blood pressure and
report significant changes.
Auscultate for pericardial
friction rub.
Perform circulation checks
routinely.

Chronic Renal Failure

Nursing interventions
7. Promote/maintain maximal
cardiovascular function.
Administer diuretics as
ordered and monitor output.
Modify drug doses
8. Provide care for client
receiving dialysis.

Important Drugs
Aluminum hydroxide
(Amphogel)

Binds with
PHOSPHATE to
decrease phosphorus

Kayexalate

Binds with
POTASSIUM to
manage hyperkalemia

Diuretics

To decrease edema

Erythropoietin
(Epogen)

To increase RBC

Anti-Hypertensives

To manage
Hypertension

DIALYSIS
a procedure that is used to
remove fluid and uremic
wastes from the body when
the kidneys cannot function

DIALYSIS
Two methods
1. Hemodialysis
2. Peritoneal dialysis

DIALYSIS
Diffusion
Osmosis
Ultrafiltration

DIALYSIS
Nursing management
1. Meet the patient's
psychosocial needs
2. Remember to avoid any
procedure on the arm with the
fistula (HEMO)
Monitor WEIGHT, blood pressure
and fistula site for bleeding

DIALYSIS
Nursing management
3. Monitor symptoms of uremia
4. Detect complications like
infection, bleeding (Hepatitis B/C
and HIV infection in
Hemodialysis) Peritonitis in
peritoneal dialysis
5. Warm the solution to increase
diffusion of waste products
(PERITONEAL)
6. Manage discomfort and pain

DIALYSIS
Nursing management
7. To determine effectiveness,
check serum creatinine,
BUN and electrolytes

Male reproductive
disorders
BPH
Prostatic cancer

Male reproductive
disorders
DIGITAL RECTAL EXAMINATIONDRE
Recommended for men annually
with age over 40 years
Screening test for cancer
Ask patient to BEAR DOWN

Male reproductive
disorders
TESTICULAR EXAMINATION
Palpation of scrotum for nodules
and masses or inflammation
BEGINS DURING ADOLESCENCE

Male reproductive
disorders
Prostate specific antigen (PSA)
Elevated in prostate cancer
Normal is 0.2 to 4 nanograms/mL
Cancer= over 4

Male reproductive
disorders
BENIGN PROSTATIC HYPERPLASIA
Enlargement of the prostate that
causes outflow obstruction
Common in men older than 50
years old

Male reproductive
disorders
BENIGN PROSTATIC HYPERPLASIA
Assessment findings
1. DRE: enlarged prostate gland that
is rubbery, large and NON-tender
2. Increased frequency, urgency and
hesitancy
3. Nocturia, DECREASE IN THE
VOLUME AND FORCE OF URINE
STREAM

Male reproductive
disorders
BENIGN PROSTATIC HYPERPLASIA
Medical management
1. Immediate catheterization
2. Prostatectomy
3. TRANSURETHRAL RESECTION of the
PROSTATE (TURP)
4. Pharmacology: alpha-blockers,
alpha-reductase inhibitors. SAW
palmetto

BPH
NURSING INTERVENTION
1. Encourage fluids up to 2 liters per day
2. Insert catheter for urinary drainage
3. Administer medications alpha
adrenergic blockers and finasteride
4. Avoid anticholinergics
5. Prepare for surgery or TURP
6. Teach the patient perineal muscle
exercises. Avoid valsalva until healing

BPH
NURSING INTERVENTION: TURP
Maintain the three way bladder
irrigation to prevent
hemorrhage
Only initially the drainage is
pink-tinged and never reddish
Administer anti-spasmodic to
prevent bladder spasms

Prostate Cancer
a slow growing malignancy of
the prostate gland
Usually an adenocarcinoma
This usualy spread via blood
stream to the vertebrae

Prostate Cancer
Predisposing factor
Age

Prostate Cancer

1.
2.
3.
4.

Assessment Findings
DRE: hard, pea-sized nodules
on the anterior rectum
Hematuria
Urinary obstruction
Pain on the perineum radiating
to the leg

Prostate Cancer

Diagnostic tests
1. Prostatic specific antigen (PSA)
2. Elevated SERUM ACID
PHOSPHATASE indicates
SPREAD or Metastasis

Prostate Cancer
Medical and surgical management
1. Prostatectomy
2. TURP
3. Chemotherapy: hormonal
therapy to slow the rate of
tumor growth
4. Radiation therapy

Prostate Cancer
Nursing Interventions
1. Prepare patient for
chemotherapy
2. Prepare for surgery

Prostate Cancer
Nursing Interventions: Postprostatectomy
1. Maintain continuous bladder
irrigation. Note that drainage is
pink tinged w/in 24 hours
2. Monitor urine for the presence
of blood clots and hemorrhage
3. Ambulate the patient as soon
as urine begins to clear in color