Medical Surgical Nursing Care

The Urinary System Assessment

& Disorders

Dr Ibrahim Bashayreh, RN, PhD

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The kidneys, ureters, and bladder. (Source: Dorling Kindersley Media Library)

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An illustration of the internal structures of the kidney.

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The structure of the nephron and the processes of urine formation. (Source: Pearson
Education/PH College)

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 Urine Formation
Glomerular filtration
Glomerular filtration rate
Tubular reabsorption
Include water and electrolytes
Tubular secretion
Urine concentration

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 Endocrine Function
Renin–angiotensin–aldosterone system
Role in blood pressure and sodium
reabsorption
Erythropoietin
Role in RBC production
Vitamin D and calcium regulation
Acid–base balance

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 Age-Related Changes
Nephrons lost with aging
Reduces kidney mass and GFR
Less urine concentration
Risk for dehydration

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 Assessment
Color, clarity, amount of urine
Difficulty initiating urination or changes
in stream
Changes in urinary pattern
Dysuria, nocturia, hematuria, pyuria

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 Assessment
History of urinary problems
Urinary or abdominal surgeries
Smoking, alcohol use, number of sexual
partners and type of sexual relationship
Chance of pregnancy
History of diabetes or other endocrine
disorders
History of kidney stones
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 Physical Assessment
Obtain clean-catch urine specimen
Color, odor, clarity
Vital signs and skin assessment

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 Diagnostic Tests
Clean-catch urine
24-hour urine
Culture and sensitivity
BUN, creatinine and creatinine
clearance
IVP
CT scan
Renal scan

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 Diagnostic Tests
Ultrasound
Bladder scan
Cystoscopy
Uroflowmetry

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 Renal Failure
Acute and Chronic
Renal Obstructive Disorder
Medical Surgical Nursing
Dr ibraheem Bashayreh, RN, PhD

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 Acute Renal Failure
Sudden interruption of kidney function
resulting from obstruction, reduced
circulation, or disease of the renal tissue
Results in retention of toxins, fluids, and end
products of metabolism
Usually reversible with medical treatment
May progress to end stage renal disease,
uremic syndrome, and death without
treatment

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 Acute Renal Failure
Persons at Risks
Major surgery
Major trauma
Receiving nephrotoxic medications
Elderly

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 Acute Renal Failure
Causes
Prerenal
Hypovolemia, shock, blood loss, embolism, pooling of
fluid d/t ascites or burns, cardiovascular disorders, sepsis
Intrarenal
Nephrotoxic agents, infections, ischemia and blockages,
polycystic kidney disease
Postrenal
Stones, blood clots, BPH, urethral edema from invasive
procedures

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 Acute Renal Failure
Stages
Onset – 1-3 days with ^ BUN and creatinine and
possible decreased UOP
Oliguric – UOP < 400/d, ^BUN,Creat, Phos, K,
may last up to 14 d
Diuretic – UOP ^ to as much as 4000 mL/d but no
waste products, at end of this stage may begin to
see improvement
Recovery – things go back to normal or may
remain insufficient and become chronic

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 Acute Renal Failure
Subjective symptoms
Nausea
Loss of appetite
Headache
Lethargy
Tingling in extremities

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 Acute Renal Failure
Objective symptoms
Oliguric phase –
vomiting CHF and pulmonary
disorientation, edema
edema, hypertension caused
^K+ by hypovolemia,
decrease Na anorexia
^ BUN and creatinine sudden drop in UOP
Acidosis convulsions, coma
uremic breath changes in bowels

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 Acute Renal Failure
Objective systoms
Diuretic phase
Increased UOP
Gradual decline in BUN and creatinine
Hypokalemia
Hyponaturmia
Tachycardia
Improved LOC

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 Acute Renal Failure
Diagnostic tests
H&P
BUN, creatinine, sodium, potassium. pH, bicarb.
Hgb and Hct
Urine studies
US of kidneys
KUB
ABD and renal CT/MRI
Retrograde pyloegram: is a urologic procedure
where the physician injects contrast into the
ureter in order to visualize the ureter and kidney.

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 Acute Renal Failure
Medical treatment
Fluid and dietary restrictions
Maintain E-lytes
D/C or change cause
May need dialysis to jump start renal
function
May need to stimulate production of urine
with IV fluids, Dopomine, diuretics, etc.

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 Acute Renal Failure
Medical treatment
Hemodialysis
Subclavian approach
Femoral approach
Peritoneal dialysis
Continous renal replacement therapy
(CRRT): The concept behind continuous renal
replacement techniques is to dialyse patients in a more
physiologic way, slowly, over 24 hours, just like the kidney
Can be done continuously
Does not require dialysate: the fluid and solutes in a
dialysis process that flow through the dialyzer, do not pass
through the membrane, and are discarded along with removed
toxic substances after leaving the dialyzer.

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 Acute Renal Failure
Nursing Diagnosis-
imbalanced fluid volume= excess
Altered electrolyte balance
Altered cardiac output
Impaired tissue perfusion: renal
Anxiety
Imbalanced nutrition
Risk for infection
Fatigue
Knowledge deficit

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 Acute Renal Failure

Plan-
Promote recovery of optimal kidney
function.
Maintain normal fluid and electrolyte
balance.
Decrease anxiety.
Increase knowledge.

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 Acute Renal Failure
Nursing interventions
Monitor I/O, including all Maintain nutrition
body fluids
Safety measures
Monitor lab results
Mouth care
Watch hyperkalemia
symptoms: malaise, Daily weights
anorexia, or muscle Assess for signs of heart
weakness, EKG changes failure
watch for hyperglycemia Skin integrity problems
or hypoglycemia if
receiving TPN or insulin
infusions

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 Kidney failure causes hypoglycemia in three separate
ways. The kidneys help to generate new glucose
from amino acids (called gluconeogenesis).
Gluconeogenesis is impaired in kidney failure. Also,
insulin circulates for a longer period of time and is
cleared slowly when kidney function is poor. The
third important reason is that kidney failure reduces
the appetite and consequently, oral intake of food.

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 Chronic Renal Failure
Results form gradual, progressive loss of
renal function
Occasionally results from rapid progression of
acute renal failure
Symptoms occur when 75% of function is lost
but considered cohrnic if 90-95% loss of
function
Dialysis is necessary D/T accumulation or
uremic toxins, which produce changes in
major organs

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 Chronic Renal Failure
Subjective symptoms are relatively same as
acute
Objective symptoms
Renal
Hyponaturmia
Dry mouth
Poor skin turgor
Confusion, salt overload, accumulation of K with muscle
weakness
Fluid overload and metabolic acidosis
Proteinuria, glycosuria
Urine = RBC’s, WBC’s, and casts

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 Chronic Renal Failure

Objective symptoms
Cardiovascular Neurological
Hypertension Burning, pain, and
itching, paresthesia
Arrythmias
Motor nerve dysfunction
Pericardial effusion Muscle cramping
CHF Shortened memory span
Peripheral edema Apathy
Drowsy, confused,
seizures, coma, EEG
changes

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 Chronic Renal Failure
Objective symptoms Respiratory
GI ^ chance of infection
Stomatitis Pulmonary edema
Ulcers Pleural friction rub
Pancreatitis and effusion
Uremic fetor Dyspnea
(Ammonia breath Kussmaul’s
odour) respirations
Vomiting is a deep and labored breathing pattern often
constipation associated with severe metabolic acidosis,
particularly diabetic ketoacidosis (DKA) but
also renal failure.

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 Chronic Renal Failure
Objective symptoms
Endocrine Hemopoietic
Stunted growth in Anemia
children Decrease in RBC
Amenorrhea survival time
Male impotence Blood loss from dialysis
and GI bleed
^ aldosterone secretion
Platelet deficits
Impaired glucose levels
R/T impaired CHO Bleeding and clotting
metabolism disorders – purpura and
hemorrhage from body
Thyroid and parathyroid
orifices , ecchymoses
abnormalities

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 Chronic Renal Failure
Objective symptoms Skin
Skeletal Yellow-bronze skin
Muscle and bone pain with pallor
Bone demineralization Puritus
Pathological fractures Purpura
Blood vessel Uremic frost
calcifications in Thin, brittle nails
myocardium, joints, Dry, brittle hair, and
eyes, and brain may have color
changes and alopecia
Uremic frost: A clinical finding in severe chronic renal failure, in which the
concentration of urea is markedly increased in sweat, causing precipitation of
crystallised urea in the skin

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 Chronic Renal Failure
Lab findings
BUN – indicator of glomerular filtration rate and is
affected by the breakdown of protein. Normal is
10-20mg/dL. When reaches 70 = dialysis
Serum creatinine – waste product of skeletal
muscle breakdown and is a better indicator of
kidney function. Normal is 0.5-1.5 mg/dL. When
reaches 10 x normal, it is time for dialysis
Creatinine clearance is best determent of kidney
function (GFR). Must be a 12-24 hour urine
collection. Normal is > 100 ml/min

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 Chronic Renal Failure
K+ -
The kidneys are means which K+ is excreted.
Normal is 3.5-5.0 ,mEq/L. maintains muscle
contraction and is essential for cardiac function.
Both elevated and decreased can cause problems
with cardiac rhythm
Hyperkalemia is treated with IV glucose and Na
Bicarb which pushes K+ back into the cell
Kayexalate (Sodium polystyrene sulfonate ) is also
used to promote the exchange of sodium and
potassium in the body.

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 Chronic Renal Failure
Ca
With disease in the kidney, the enzyme for
utilization of Vit D is absent
Ca absorption depends upon Vit D
Body moves Ca out of the bone to compensate
and with that Ca comes phosphate bound to it.
Normal Ca level is 4.5-5.5 mEq/L
Hypocalcemia = tetany
Treat with calcium with Vit D and phosphate
Avoid antacids with magnesium

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 Chronic Renal Failure

Other abnormal findings

Metabolic acidosis
Fluid imbalance
Insulin resistance
Anemia
Immunoligical problems

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 Chronic Renal Failure
Nursing diagnosis
Excess fluid volume
Imbalanced nutrition
Ineffective coping
Risk for infection
Risk for injury

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 Chronic Renal Failure

Nursing care
Frequent monitoring Ensure proper
Hydration and output medication regimen
Cardiovascular Skin care
function
Bleeding problems
Respiratory status
Care of the shunt
E-lytes
Nutrition Education to client
and family
Mental status
Emotional well being

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 Chronic Renal Failure Treatment

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 Chronic Renal Failure
Medical treatment
IV glucose and insulin
Na bicarb, Ca, Vit D, phosphate binders
Fluid restriction, diuretics
Iron supplements, blood, erythropoietin
High carbs, low protein
Dialysis - After all other methods have
failed

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 Dialysis
½ of patients with CRF eventually
require dialysis
Diffuse harmful waste out of body
Control BP
Keep safe level of chemicals in body
2 types
Hemodialysis
Peritoneal dialysis

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 Dialysis
Peritoneal dialysis Automated peritoneal
Semipermeable dialysis
membrane
Done at home at night
Catheter inserted
through abdominal wall Maybe 6-7 times /week
into peritoneal cavity CAPD
Cost less Continous ambulatory
Fewer restrictions peritoneal dialysis
Can be done at home Done as outpatient
Risk of peritonitis
Usually 4 X/d
3 phases – inflow, dwell
and outflow

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 Peritoneal Dialysis

Abdominal lining filters blood

3 types
Continuous ambulatory
Continuous cyclical
Intermittent

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 Hemodialysis

3-4 times a week

Takes 2-4 hours
Machine filters
blood and
returns it to
body

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 Chronic Renal Failure
Hemodialysis
Vascular access
Temporary – subclavian or femoral
Permanent – shunt, in arm
Care post insertion
Can be done rapidly
Takes about 4 hours
Done 3 x a week

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 Types of Access
Temporary site: subclavian or femoral
Permanent: shunt, in arm
AV fistula
Surgeon constructs by combining an artery and a
vein
3 to 6 months to mature
AV graft
Man-made tube inserted by a surgeon to connect
artery and vein
2 to 6 weeks to mature

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 Temporary Catheter

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 AV Fistula & Graft

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 What This Means For You
No BP on same arm as fistula
Protect arm from injury
Control obvious hemorrhage
Bleeding will be arterial
Maintain direct pressure
No IV on same arm as fistula
A thrill will be felt – this is normal

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 Access Problems
AV graft thrombosis
AV fistula or graft bleeding
AV graft infection
Steal Phenomenon: also called subclavian steal
syndrome (SSS), or subclavian steal steno-occlusive disease, is
a constellation of signs and symptoms that arise from retrograde
(reversed) flow of blood in the vertebral artery or the internal thoracic
artery, due to a proximal stenosis (narrowing) and/or occlusion of the
subclavian artery.
Early post-op
Ischemic distally
Apply small amount of pressure to reverse
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symptoms 52
 Nursing Considerations
Make sure the dressing remains intact
Do not push or pull on the catheter
Do not disconnect any of the catheters
Always transport the patient and
bags/catheters as one piece
Never inject anything into catheter

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 Dialysis Related Problems
Lightheaded –give fluids
Hypotension
Dysrhythmias
Disequilibration Syndrome
At end of early sessions
Confusion, tremor, seizure
Due to decrease concentration of blood
versus brain leading to cerebral edema

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 Chronic Renal Failure

Transplant
Must find donor
Waiting period long
Good survival rate – 1 year 95-97%
Must take immunosuppressant’s for life
Rejection
Watch for fever, elevated B/P, and pain over
site of new kidney

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 End-Stage Renal Disease

Slow, insidious process

Final stage is end-stage renal disease
Increasing in incidence
Diabetic nephropathy and hypertension
are leading causes in U.S.

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 End-Stage Renal Disease

Nephrons destroyed by disease process

Remaining nephrons hypertrophy and
have increased workload
Can compensate for a while
Renal insufficiency develops
Further insult leads to ESRD
Uremia develops

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 End-Stage Renal Disease -
Manifestations
Often not identified until uremia
develops
Nausea
Apathy
Weakness
Fatigue
Confusion

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 Chronic Renal Failure
Post op care
ICU
I/O
B/P
Weight changes
Electrolytes
May have fluid volume deficit
High risk for infection

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 Transplant Meds
Patients have decreased resistance to
infection
Corticosteroids – anti-inflammarory
Deltosone
Medrol
Solu-Medrol
Cytotoxic – inhibit T and B lymphocytes
Imuran
Cytoxan
Cellcept
T-cell depressors - Cyclosporin

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 Obstructive Renal Disorders

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 Hydronephrosis, Hydroureter,
and Urethral Stricture
Outflow obstruction
Urethral stricture
Causes bladder distention and progresses to the ureters
and the kidneys
Hydronephrosis –
Kidney enlarges as urine collects in the pelvis and kidney
tissue due to obstruction in the outflow tract
Over a few hours this enlargement can damage the
blood vessels and the tubules
Hydroureter
Effects are similar, but occurs lower in the ureter

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 Causes of Obstruction

Tumor
Stones
Congenital structural defects
Fibrosis
Treatment with radiation in pelvis

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 Complication of Obstruction

If untreated, permanent damage can

occur within 48 hours
Renal failure
Retention of
Nitrogenous wastes (urea, creatinine, uric acid)
Electrolytes (K, Na, Cl, and Phosphorus)
Acid base balance impaired

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 Renal Calculi
Called nephrolithiasis or urolithiasis
Most commonly develop in the renal pelvis
but can be anywhere in the urinary tract
Vary in size –from very large to tiny
Can be 1 stone or many stones
May stay in kidney or travel into the ureter
Can damage the urinary tract
May cause hydronephrosis
More common in white males 30-50 years of
age

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 Renal Calculi
Predisposing factors
Dehydration
Prolonged immobilization
Infection
Obstruction
Anything which causes the urine to be alkaline
Metabolic factors
Excessive intake of calcium, calcium based antacids or
Vit D
Hyperthyroidism
Elevated uric acid

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 Renal Calculi

Subjective symptoms
Sever pain in the flank area, suprapubic
area, pelvis or external genitalia
If in ureter, may have spasms called “renal
colic”
Urgency, frequency of urination
N/V
Chills

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 Renal Calculi

Objective symptoms
Increased temperature
Pallor
Hematuria
Abdominal distention
Pyuria
Anuria
May have UTI on urinalysis

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 Renal Calculi- Manifestations

Kidney/Pelvis
May be asymptomatic
Dull, aching flank pain
Ureter
Acute severe flank pain, may radiate
Nausea/vomiting
Pallor
Hematuria
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 Renal Calculi- Manifestations

Bladder
May be asymptomatic
Dull suprapubic pain
Hematuria

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 Renal Calculi

Diagnostic procedures
Urinalysis with C and S
24 hour urine
KUB
IVP
Renal CT
Kidney ultrasound
Cystoscopy with retrograde pyleogram

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 Renal Calculi
Treatment
Most are passed without intervention
May need cysto with basket retrieval
Lithotripsy : Extracorporeal shock wave lithotripsy
(ESWL) is the non-invasive treatment of kidney stones
(urinary calculosis) and biliary calculi (stones in the
gallbladder or in the liver) using an acoustic pulse.
Lasertripsy :
Lithotomy: is a surgical method for removal of calculi, stones
formed inside certain hollow organs, such as the bladder and
kidneys (urinary calculus) and gallbladder (gallstones), that cannot
exit naturally through the urethra, ureter or biliary duct

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 Renal Calculi
Assessment
History and physical exam
Location, severity, and nature of pain
I/O
Vital signs, looking for fever
Palpation of flank area, and abdomen
? N/V

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 Renal Calculi
Nursing interventions
Primary is to treat pain – usually with
opioids
Ambulate
Force fluids, may have IV
Watch for fluid overload
Strain urine – send stone to lab if passed
Accurate I/O
Medicate N/V

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 Renal Calculi
Surgical removal
Routine pre and post op care
May return with catheter, drains, nephrostomy
tube and ureteral stent – must maintain patency
and may need to irrigate as ordered
Measure drainage from all tubes – need at least
30 cc/hr
Watch site for bleeding
May need frequent dressing changes due to fluid
leakage, or may have collection bag

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 Renal Calculi

Discharge and prevention

Continue to force fluids post discharge
May need special diet
Stones are analyzed for calcium or other
minerals
May need to watch products with calcium

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