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renal system 1

Creatinine- normal 0.5-1.2 mg/dL
BUN- normal 10-20 mg/dL
BUN/Creatinine ratio both at the same rate
Urinalysis  Voided  Cean catch  Catheterized  Suprapubic aspiration
Urine collections typically for 24 hrs., usually refrigerated Test for: creatinine, urea nitrogen, sodium, chloride, calcium, protein, catecholamines,
Osmolality measures concentration of particles in blood or urine
Blood osmololity– N 285-295 mOsm/kg
Urine osmololity N 300-900 mOsm/kg
Radiographic/special procedures KUB Excretory urogram Intravenous pyelogram (IVP) CT scan Voiding cystourethrogram (VCUG) Renal ultrasound MAG3 study 99m MRI Renal scan Renal arteriogram
Renal Biopsy nformed consent- is an operative procedure Can be closed or open procedure Use U/S or fluoroscope Bleeding – major risk
Cystoscope & Cystourethroscope examine for trauma, identify causes of urinary tract obstruction from stones or tumors
Treatment remove bladder tumors or enlarged prostate gland
before treatment Bowel prep the day before General or local anesthesia with sedation May need indwelling catheter post-op, irrigate prn Informed consent – operative procedures
Retrograde Procedures Direct injection of radiopaque dye into the lower urinary tract
Ureters & pelves – pyelogram
Bladder – cystogram
Urethra – urethrogram
retrograde Procedure placement of cystoscope, catheter placed, dye instilled, catheter removed & x-rays taken
Purpose of retrograde procedures identify obstruction or structural abnormality (ex. fistulas, diverticula, tumors)
Urodynamic Studies To evaluate problems with urine flow
Cystometrogram (CMG) determines bladder capacity, bladder pressure & voiding reflexes
CMG determines bladder capacity, bladder pressure & voiding reflexes
Urethral Pressure Profile (UPP) information about nature of urinary incontinence or urinary retention
UPP procedure Urethral pressure catheter inserted into bladder Variations in pressure of muscle of urethra recorded as catheter withdrawn
Electromyogram (EMG) evaluate strength of muscles used in voiding
EMG procedure Electrodes placed in either rectum or urethra to measure muscle contraction & relaxation To identify methods of improving continence
Urine Stream Test evaluates pelvic muscle strength
urine stream test procedure Stops urine flow 3-5 seconds after starting Length of time to stop recorded
Inguinal hernia protrusion of abdominal contents through the inguinal canal into scrotum
Hydrocele fluid in the scrotum
Phimosis narrowing or stenosis of preputial opening of foreskin
Epispadias urethral opening on dorsal (upper) surface of penis
Hypospadias urethral opening on ventral (underside) surface of penis
Chordee ventral curvature of penis; usually seen with hypospadias
Cryptorchidism undescended testicles
Exstrophy of the bladder congenital absence of a portion of the abdominal & bladder wall; bladder appears to be turned “inside out”
Ambiguous genitalia may result in gender reassignment
Surgery in the pediatric client: Avoid genital surgery during the age of 3-6 years. (phallic-oedipal, preschool age). Surgery recommended at age 6-15 months.
Enuresis Passage of urine, without control, past the age when a child should be expected to attain bladder control (2-3 years of age for daytime, 4 years of age for nighttime). Children over 5 years of age need evaluation for organic cause.
Causes of enuresis may have a small bladder capacity. (Normal bladder capacity, in ounces, is the child’s age plus 2).
Rx of enuresis desmopressin (DDAVP)- is a synthetic ADH given transnasally OTC devices If enuresis is stress related, the child may develop another habit, such as thumb sucking or stuttering, if you remove this habit.
Hemolytic-uremic syndrome (HUS) Most frequent cause of acquired renal failure in children; ages 6 months - 5 years
Etiology of HUS Etiology- thought to be associated with bacterial toxins, chemicals, and viruses; RBC’s hemolyze, causing renal failure
S/S of HUS anemia, thrombocytopenia, renal dysfunction/failure
Rx of HUS dialysis, FFP’s (fresh frozen plasma), PC’s (packed cells), plasmapheresis
Wilms tumor (Nephroblastoma) Most common malignant abdominal tumor in children
S/S of Wilms a firm, nontender, one sided, encapsulated mass (usually found by a parent), fatigue, fever, weight loss, hypertension
Dx of Wilms U/S, CT, liver biopsy Need a rapid diagnose & surgery within 24-48 hours of admission
Rx of Wilms surgery to remove tumor, affected kidney & adrenal gland, followed by radiation & chemotherapy NOTE: Do NOT palpate the mass- could potentially cause a spread of cancer cells
Urinary tract infections (UTIs) Broad term used to describe any infection in the kidneys, ureters, bladder or urethra
At risk for UTIs: Those with indwelling catheters or immunocompromised Urinary obstruction- partial or total Vesicoureteral reflex Characteristics of urine- diabetic, concentrated or alkaline urine Females, older adults Sexual activity Recent use of antibiotics
Lower Urinary Tract Infections Urethritis (urethra) Males S/S- dysuria, urethral discharge Etiology- usually STD ex. gonorrhea, chlamydia, trichomonas Dx- U/A, urethral C & S Rx- antibiotics
Females usually postmenopausal S/S- similar to those with cystitis Etiology- tissue changes due to decreased estrogen Dx- U/A (normal) Rx- estrogen vaginal creme
Cystitis (bladder) Most common type of UTI
Interstitial cystitis -inflammatory Etiology unknown, chronic, rare 12:1 ratio women to men S/S- those of cystitis, have a small bladder, Hunner’s ulcers (bladder lesions) Dx- U/A normal, cystoscopy, potassium sensitivity test Rx- “Rescue cocktail”
Asymptomatic bacteriuria Common in the elderly & children Usually considered benign Rx- antibiotics
Bacterial cystitis Most common cause of cystitis S/S- polyuria, dysuria, urinary retention, suprapubic tenderness, hesitancy Rx- antibiotics
Upper Urinary Tract Infection: Pyelonephritis (kidney & renal pelvis) Can be acute or chronic Acute- active bacterial infection Chronic- repeated or continued infection;usually due to anomaly, obstruction or vesicourethral reflux (VUG) S/S- those of cystitis, flank pain (CVA tenderness), fever, chills, N & V, malaise
Pyelonephritis Rx antibiotics
Etiology of UTIs infection frm bacteria, viruses, fungi or parasites Most pathogens are org. from the GI ex. E.coli (90%),Klebsiella, Proteus, Pneumonas, S. aureus, Candida Infectious agents external urethra > bladder > ureter(s) spreads in blood and lymph fluid → sepsis
Predisposing factors of UTIs stagnation of urine, obstruction, sexual intercourse, high estrogen levels
Dx of UTIs S/S: urine may be cloudy, foul smelling or blood tinged U/A (CC or cath)- WBC’s, RBC’s, bacteria, nitrate C & S- determine causative organism Blood cult.– R/O sepsis Cystoscopy – if hx of recurrent UTIs (> 3-4 yrs.) IVP - R/O obstruction, malform
Rx: Dependent upon the cause If bacterial- antibiotics If fungal -antifungal agents Analgesics, antiemetics, antispasmodics Treat the cause prn ex. obstruction – kidney stone Force fluids Comfort measures- sitz baths
Prevention of UTIs Drink 2-3 L Adequate sleep, rest, nutrition pee before and after sex pee regularly, do not “hold” Complete antibiotics/ antifungals, U/A recheck in 10-14 day
Home remedies Female- wipe from front to back, wear cotton underwear, avoid bubble baths,scented toilet tissue, detergents Home remedies- to acidify urine 1. 50 ml cranberry juice daily 2. Apple cider vinegar- 2 T. in juice tid 3. Vitamin C- 500 mg daily
Urethral strictures narrowed areas of urethral
Etiology: congenital, complication of STD, trauma (ex. catherization, urologic instrumentation, or childbirth) More common in men Causes other problems - recurrent UTIs, urinary incontinence/retention
S/S of UTI unable to urinate, overflow incontinence
Treatment- usually surgical 1. Dilation of urethra (urethroplasty) 2. Removal or graft of affected area
Urinary Incontinence Involuntary loss of urine to cause social or hygienic problems Can be temporary or permanent – temporary usually involves no disorder of the UT
Etiology- have to consider the cause Surgery- urologic, prostate, gynecologic Trauma- back injuries (S2-S4) Procedures- radiation Cystocele or rectocele Inappropriate bladder contraction- disorders of brain, CNS, bladder Autonomic neuropathy ex. DM (diabetes mellitus), syphilis Elderly
Diagnose UTI History/diary keeping Physical exam Urinalysis Radiographic Urogram Voiding cystourethrogram (VCUG) Urodynamic studies General treatment of all types: Use of absorbent pads& undergarments Tests to determine the cause
Stress Incontinence involuntary loss of small amounts of urine with activities that increase abdominal and detrusor pressure (sneeze, cough, exercise)
Causes unable to tighten the urethra enough to overcome the increased detrusor pressure 1. Weakness of bladder neck supports 2. Damage to urethral sphincter from urethral surgery, trauma, radiation, childbirth 3. Low estrogen levels
Interventions Kegels,Diet- weight loss, stop smoking,avoid alcohol & caffeine, artificial sweeteners, citrus Urethral inserts Vag ring, vag cones Drug therapy- not FDA 1. estrogen 2. anticholinergics/ antispasm. 3. antidepressants- Tofranil C
Surgery- recommended if frequent UTIs or kidney stones 1. Anterior vaginal repair (colporrhaphy) 2. Retropubic suspension (Marshall-Marchetti- Krantz or Burch) 3. Transvaginal needle suspension 4. Pubovaginal or midurethral “sling” 5. Artificial sphincters 6. Collagen injections
Urge incontinence “overactive bladder”, involuntary loss of large amounts of urine associated with strong desire to urinate Cause unknown or related to abnormal detrusor contractions
Interventions- surgery not recommended Drugs- primarily anticholinergics/antispasmatics Diet- avoid bladder irritants, space fluid intake at regular intervals in the day, limit fluids after dinner Behavioral mod: bladder training habit training exercise therapy electrical stimu
Reflex or overflow incontinence detrusor muscle does not contract and the bladder becomes overdistended; urine leaks outs
S/S bladder distended, often up to umbilicus, constant urine dribbling
Cause urethra obstruction (cystocele, rectocele, prostate, etc.), diabetic neuropathy, medications, spinal cord injury, multiple sclerosis
Interventions: bethanechol chloride (Urecholine)- increases bladder pressure Surgery- if caused by obstruction Bladder compression Intermittent catherization
Bladder compression to empty bladder; used for neurologic disorders
Crede method external compression of bladder or sympathetic stimulation such as tugging at pubic hair or massaging the genital area
Valsalva maneuver breathing exercises increase intrathoracic and abdominal pressure to cause bladder emptying
Double voiding empties bladder and then within a few minutes, attempts a second bladder emptying
Splinting- if cystocele female inserts fingers in vagina, pushes cystocele back into the vagina to urinate
Intermittent self-catherization: Caregivers and pt. taught procedure using clean (not sterile) technique Regular schedule established to prevent bladder overdistention (usually 300 ml or less) On prophylactic antibiotics, 2-3 weeks when started U/A q 2-4 weeks
Functional incontinence urine leakage caused by factors other than disease of the lower UT Can be transient or permanent
functional incontinence If transient, treat the cause ex. urinary fistula If permanent: 1. Habit training 2. Applied devices females- intravag. pessaries males- penile clamps, artificial sphincters, or condom catheters 3. Urinary catherization- indwelling cathe
Urolithiasis kidney stone;asymptomatic until passes into the lower urinary tract Calculi can form in kidney (nephrolithiasis) or ureter reterolithliasis)When calculi occludes ureter and blocks urine, ureter and kidney dilates; hydroureter & hydronephrosis develop
Etiology not entirely understood May be metabolic disorders Genetic link – family history
Ca+ Cause of Stone Formation: 75% (may be calcium oxalate); Not influenced by Ca intake Usual age, 30-50 yrs, 3x more frequent in males High urine alkality, if oxalate will have increased oxalic acid in the urine
RX of stones Low salt diet Thiazide diuretics ex. Hctz (Hydrochlorathiazide- promotes Ca+ reabsorption from renal tubules back into the body)If stone calcium oxalate- dietary rest. of foods high in oxalate (tea, cocoa, beer, green leafy veg., fruits, nuts, wht germ)
Struvite (15%) stones formed are usually staghorn calculi that grow & fill renal pelvis; made of mg, ammonium, & phosphate Etiology- UTI Usually “staghorn” stones requiring surgical removal Urine alkaline Dietary- limit high phosphate foods (dairy products
Uric acid 8%- may occur with gout High urine acidity- urine pH 6-6.5 Rx: Dietary- decrease intake of purine sources (organ meats, poultry, fish, gravies, red wines) Meds- allopurinal (Zyloprim)
Cystine 3% Derived from urinary proteins; inherited defect in renal absorption of cystine Rx: Dietary- same as uric acid Meds- Captopril (Capoten
S/S: stones Renal colic- severe pain (usually flank) with radiation to groin; pain when stone is moving or if obstructed Pallor, N & V, diaphoresis Hematuria, oliguria, anuria V/S- BP, pulse and RR
Dx Studies: CT scan KUB- most stones are radiopaque IVP U/S (ultrasound)- stone dense and may not see; can see hydronephrosis U/A- hematuria 24 hour urine to measure calcium, uric acid, creatinine, sodium, pH, & total volume Stone analysis
Interventions: rate pain before & after analgesics Analgesics:Opioids Lortab, Percocet IV or PCA- Duragesic (fentanyl), morphine sulfate, Demerol (meperidine) NSAIDs- Toradol (ketorolac) IV or PO Spasmolytic agents- Ditropan (oxybutynin Relax thrpy, acupun., posit
Interventions: STRAIN ALL URINE- (urine strainer) Fluid intake; 2-3 liters per day Stent placement- small tube placed in ureter during ureteroscopy Purpose: dilate ureter to allow passage of stone or stone fragments Indwell cath may be placed to allow passage > ureth
Procedures – if unable to pass Extracorporeal Shock Wave Lithotripsy (ESWL) – commonly called lithotripsy May have IVP done prior to ESWL May have stent placement by endoscopy before procedure Adverse effect: flank bruising Lithotripsy can also be performed through a ureteroscope
Procedures – if unable to pass Retrograde uretherscopy(endoscopy)stone remved w/grasping baskets, forceps or loops Percutaneous ureterolithotomy/nephrolithotomy removal of stone in ureter or kidney through skin Fluoroscopy used to identify entrance site, needle pssed Stone broken & re
Open procedures- only when other attempts have failed Ureterolithotomy- remove stone in ureter Nephrolithotomy- remove stone from kidney Pyelolithotomy- remove stone from kidney pelvis.Used for a large, impacted stone Flank incision for kidney, low abdominal incision for ureters.Nephrostomy tube, ureteral
Postop care - prevent urosepsis TCDB, ambulation Incision & drain care I & O Strain urine Fluid intake; 2-3 l/day Monitor labs- renal function, CBC Meds- Antibiotics Analgesics Antiemetics
Urinary Obstructions- Hydronephrosis, Hydroureter, Urethral stricture Must fix the cause or can cause permanent renal damage.
cause: kidney stones, tumors, trauma, structural defects, strictures, etc
Interventions treat the cause of obstruction Stent placement May require urinary diversion system: temporary (nephrostomy tube, suprapubic catheter) or permanent Dialysis for renal deterioration
Urothelial Cancer- malignant tumors of the urothelium (lining of cells in the UT organs) Primarily of the bladder Once spread beyond these cells, usually highly invasive and metastatic (liver, lung, bone) Risk factors: tobacco use, exposure to environmental toxins, o
S/S painless & intermittent hematuria (gross or microscopic), dysuria, polyuria
Diagnose: Urinalysis- microscopic or gross hematuria Bladder-wash specimens Bladder biopsy by cystoscopy Surgical removal of tumors for diagnose & staging Lymph node biopsy & tests to R/O metastasis CT scan- tumor invasion MRI- shows deep, invasive tumors
Interventions: Without treatment, tumor will invade surrounding tissues, metastasis (liver, lung, bone) & lead to death
Nonsurgical: Prophylactic immunotherapy- bladder installation of bacille Calmetti-Guerin Multiagent systemic chemotherapy & radiation therapy - rarely a cure; used to prolong life for those with metastasis Chemotherapy and/or radiation therapy used in addition to su
Surgical treatment: Confirmed to bladder mucosa- simple excision TURBT or partial cystectomy for small, early superficial tumors If tumor beyond mucosa but not into muscle layer- incision surgery followed by intravesical chemotherapy or immunotherapy Spread deeper into bl
Ureterostomy (single or bilateral)- bringing ureters to skin surface with a stoma; must wear pouch
Ileal conduit transplanting ureters into a pocketed segment of the ileum & connected to a stoma; must wear a pouch
Ileal reservoir ureters diverted into a pocketed segment of the ileum (a new “bladder”) & connected to a stoma; will be continent but catheterizations needed
Sigmoidostomy ureters diverted into the large intestine; urine excreted with bowel movements.
Postoperative: (“routine” post-operative care) Wound, skin & drainage site care Address self-esteem, body image, sexual function Education: External pouch system or catherizations, skin care
Created by: minimouse74