renal system 1
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| Creatinine- normal | 0.5-1.2 mg/dL
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| BUN- normal | 10-20 mg/dL
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| BUN/Creatinine ratio | both at the same rate
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| Urinalysis | Voided
Cean catch
Catheterized
Suprapubic aspiration
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| Urine collections | typically for 24 hrs., usually refrigerated
Test for: creatinine, urea nitrogen, sodium, chloride, calcium, protein, catecholamines,
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| Osmolality | measures concentration of particles in blood or urine
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| Blood osmololity– N | 285-295 mOsm/kg
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| Urine osmololity N | 300-900 mOsm/kg
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| Radiographic/special procedures | KUB
Excretory urogram
Intravenous pyelogram (IVP)
CT scan
Voiding cystourethrogram (VCUG)
Renal ultrasound
MAG3 study 99m
MRI
Renal scan
Renal arteriogram
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| Renal Biopsy | nformed consent- is an operative procedure
Can be closed or open procedure
Use U/S or fluoroscope
Bleeding – major risk
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| Cystoscope & Cystourethroscope | examine for trauma, identify causes of urinary tract obstruction from stones or tumors
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| Treatment | remove bladder tumors or enlarged prostate gland
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| 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
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| Retrograde Procedures | Direct injection of radiopaque dye into the lower urinary tract
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| Ureters & pelves | – pyelogram
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| Bladder | – cystogram
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| Urethra | – urethrogram
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| retrograde Procedure | placement of cystoscope, catheter placed, dye instilled, catheter removed &
x-rays taken
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| Purpose of retrograde procedures | identify obstruction or structural abnormality (ex. fistulas, diverticula, tumors)
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| Urodynamic Studies | To evaluate problems with urine flow
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| Cystometrogram (CMG) | determines bladder capacity, bladder pressure & voiding reflexes
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| CMG | determines bladder capacity, bladder pressure & voiding reflexes
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| Urethral Pressure Profile (UPP) | information about nature of urinary incontinence or urinary retention
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| UPP procedure | Urethral pressure catheter inserted into bladder
Variations in pressure of muscle of urethra recorded as catheter withdrawn
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| Electromyogram (EMG) | evaluate strength of muscles used in voiding
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| EMG procedure | Electrodes placed in either rectum or urethra to measure muscle contraction & relaxation
To identify methods of improving continence
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| Urine Stream Test | evaluates pelvic muscle strength
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| urine stream test procedure | Stops urine flow 3-5 seconds after starting
Length of time to stop recorded
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| Inguinal hernia | protrusion of abdominal contents through the inguinal canal into scrotum
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| Hydrocele | fluid in the scrotum
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| Phimosis | narrowing or stenosis of preputial opening of foreskin
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| Epispadias | urethral opening on dorsal (upper) surface of penis
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| Hypospadias | urethral opening on ventral (underside) surface of penis
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| Chordee | ventral curvature of penis; usually seen with hypospadias
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| Cryptorchidism | undescended testicles
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| Exstrophy of the bladder | congenital absence of a portion of the abdominal & bladder wall; bladder appears to be turned “inside out”
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| Ambiguous genitalia | may result in gender reassignment
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| 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.
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| 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.
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| Causes of enuresis | may have a small bladder capacity. (Normal bladder capacity, in ounces, is the child’s age plus 2).
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| 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.
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| Hemolytic-uremic syndrome (HUS) | Most frequent cause of acquired renal failure in children; ages 6 months - 5 years
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| Etiology of HUS | Etiology- thought to be associated with bacterial toxins, chemicals, and viruses; RBC’s hemolyze, causing renal failure
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| S/S of HUS | anemia, thrombocytopenia, renal dysfunction/failure
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| Rx of HUS | dialysis, FFP’s (fresh frozen plasma), PC’s (packed cells), plasmapheresis
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| Wilms tumor (Nephroblastoma) | Most common malignant abdominal tumor in children
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| S/S of Wilms | a firm, nontender, one sided, encapsulated mass (usually found by a parent), fatigue, fever, weight loss, hypertension
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| Dx of Wilms | U/S, CT, liver biopsy
Need a rapid diagnose & surgery within 24-48 hours of admission
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| 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
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| Urinary tract infections (UTIs) | Broad term used to describe any infection in the kidneys, ureters, bladder or urethra
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| 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
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| 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
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| 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
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| Cystitis (bladder) | Most common type of UTI
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| 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”
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| Asymptomatic bacteriuria | Common in the elderly & children
Usually considered benign
Rx- antibiotics
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| Bacterial cystitis | Most common cause of cystitis
S/S- polyuria, dysuria, urinary retention, suprapubic tenderness, hesitancy
Rx- antibiotics
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| 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
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| Pyelonephritis Rx | antibiotics
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| 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
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| Predisposing factors of UTIs | stagnation of urine, obstruction, sexual intercourse, high estrogen levels
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| 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
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| 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
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| 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
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| 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
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| Urethral strictures | narrowed areas of urethral
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| Etiology: | congenital, complication of STD, trauma (ex. catherization, urologic instrumentation,
or childbirth)
More common in men
Causes other problems - recurrent UTIs, urinary incontinence/retention
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| S/S of UTI | unable to urinate, overflow incontinence
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| Treatment- usually surgical | 1. Dilation of urethra (urethroplasty)
2. Removal or graft of affected area
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| 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
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| 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
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| 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
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| Stress Incontinence | involuntary loss of small amounts of urine with activities that increase abdominal and detrusor pressure (sneeze, cough, exercise)
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| 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
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| 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
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| 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
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| 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
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| 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
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| Reflex or overflow incontinence | detrusor muscle does not contract and the bladder becomes overdistended; urine leaks outs
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| S/S | bladder distended, often up to umbilicus, constant urine dribbling
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| Cause | urethra obstruction (cystocele, rectocele, prostate, etc.), diabetic neuropathy, medications, spinal cord injury, multiple sclerosis
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| Interventions: | bethanechol chloride (Urecholine)- increases bladder pressure
Surgery- if caused by obstruction
Bladder compression
Intermittent catherization
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| Bladder compression | to empty bladder; used for neurologic disorders
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| Crede method | external compression of bladder or sympathetic stimulation such as tugging at pubic hair or massaging the genital area
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| Valsalva maneuver | breathing exercises increase intrathoracic and abdominal pressure to cause bladder emptying
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| Double voiding | empties bladder and then within a few minutes, attempts a second bladder emptying
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| Splinting- if cystocele | female inserts fingers in vagina, pushes cystocele back into the vagina to urinate
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| 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
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| Functional incontinence | urine leakage caused by factors other than disease of the lower UT
Can be transient or permanent
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| 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
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| 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
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| Etiology | not entirely understood
May be metabolic disorders
Genetic link – family history
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| 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
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| 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)
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| 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
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| 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)
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| Cystine | 3%
Derived from urinary proteins; inherited defect in renal absorption of cystine
Rx: Dietary- same as uric acid Meds- Captopril (Capoten
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| Urinary Obstructions- Hydronephrosis, Hydroureter, Urethral stricture | Must fix the cause or can cause permanent renal damage.
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| cause: | kidney stones, tumors, trauma, structural defects, strictures, etc
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| Interventions | treat the cause of obstruction
Stent placement
May require urinary diversion system: temporary (nephrostomy tube, suprapubic catheter) or permanent
Dialysis for renal deterioration
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| 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
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| S/S | painless & intermittent hematuria (gross or microscopic), dysuria, polyuria
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| 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
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| Interventions: | Without treatment, tumor will invade surrounding tissues, metastasis (liver, lung, bone)
& lead to death
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| 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
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| 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
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| Ureterostomy | (single or bilateral)- bringing ureters to skin surface with a stoma; must wear pouch
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| Ileal conduit | transplanting ureters into a pocketed segment of the ileum & connected to a stoma; must wear a pouch
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| Ileal reservoir | ureters diverted into a pocketed segment of the ileum (a new “bladder”) & connected to a stoma; will be continent but catheterizations needed
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| Sigmoidostomy | ureters diverted into the large intestine; urine excreted with bowel movements.
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| 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
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