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THE URINARY

SYSTEM
ANATOMY
THE URINARY SYTEM
The excretory (GUT)
system includes the
kidney, ureters,
urinary bladder,
urethra and the male
and female genitalia
Kidneys, Ureters, and
Bladder
Ma le Anatomy
Female Anatomy
The Kidney
• Two bean-shaped organs that lie in the
retroperitoneal space on either side of
the vertebral column at the level of T12
to L3
• Adrenal glands located on top of each
kidney surrounded by capsule and fats
• Right is lower than the left
• Each kidney is composed of:
- Renal parenchyma, Renal sinus and
pelvis and Nephrons
Kidney: Major Functions

C-ontrols electrolyte and fluid balance


R-egulates homeostasis of blood and
acid-base balance
R-egulates RBC production
E-liminates end products of
metabolism,
S-ecretes renin, parathyroid hormones
and Vitamin D
The Kidney:
Nephron
Functional unit of the kidney that
produces urine by filtration
The Kidney:
Blood Supply of the Kidney
• Renal artery- branch of the abdominal
aorta

• Renal vein- drains into the inferior


vena cava
Kidney Circulation
The Ureters
• 2 long slender tubes 25-35cms long that
extends from the renal pelvis to pelvic
cavity where they enter the bladder and
propels urine from the kidneys to the
urinary bladder
• Has smooth muscles and transitional
epithelium and a uterovesical valve that
prevents backflow of urine into ureters
• Has innervations from the sympathetic
and parasympathetic
The Urinary Bladder
• Hollow pyramid shaped organ located
in the pelvis behind the symphysis
pubis
• Composed of muscular, elastic tissue
that makes it distensible
• Serves as reservoir of urine (1 to 1.8L;
moderately full bladder=500ml)
• Lined with transitional epithelium
• Internal and external urethral
sphincters control the flow of urine
Fig. 18.17
The Urethra
• Tube extending from the urinary bladder
to the external urethral orifice
3-5cms (1-2 inches) in females
20 cms (8 inches) in males
3 Parts in Males
1. Prostatic urethra- most dilatable
2. Membranous urethra- least dilatable
and shortest
3. Penile urethra- longest
Ana of Male
Ana of Female
PHYSIOLOGY
Renal Physiology
Urine formation
1. Urinary blood flow
2. Glomerular filtration
3. Tubular reabsorption
4. Tubular secretion
Renal Physiology
Ur in e formatio n
Glomerular Filtration
• Ultrafiltration of blood by the glomerulus;
beginning of urine formation
• Requires hydrostatic pressure supplied
by the heart and assisted by vascular
resistance (glomerular hydrostatic
pressure) and sufficient circulating
volume
Renal Physiology
Ur in e formatio n
Glomerular Filtration
• Pressure in Bowman’s capsule opposes
hydrostatic pressure and filtration
• If glomerular pressure insufficient to
force substances out of the blood into
the tubules filtrate formation stops
Renal Physiology
Ur in e formatio n
Glomerular Filtration
• Glomerular Filtration Rate (GFR):
amount of blood filtered by the glomeruli
in a given time; normal is 125ml/min
• Filtrate formed has essentially same
composition as blood plasma without the
proteins; blood cells and proteins are
usually too large to pass the glomerular
membrane
Formation of Urine
Renal Physiology
Ur in e formatio n
Tubular Function
• The tubules and collecting ducts carry
out the functions of reabsorption,
secretion, and excretion
• Reabsorption of water and electrolytes is
controlled by antidiuretic hormone (ADH),
released by the pituitary, and
aldosterone, secreted by the adrenal
glands
Renal Physiology
Ur in e formatio n
Tubular Function
Proximal Convoluted Tubule
- reabsorption of certain constituents of
the glomerular filtrate: 80% electrolytes
and H2O, all glucose and amino acids,
and bicarbonate;
- secretes organic substances and
wastes
Renal Physiology
Ur in e formatio n
Tubular Function
Loop of Henle
- reabsorption of water in the
descending limb
- reabsorption of sodium and chloride
in the ascending limb > descending limb
- concentrates and then dilutes urine
Fig. 18.12
Fig. 18.13
Renal Physiology
Ur in e formatio n
Tubular Function
Distal Convoluted Tubule
- secretes potassium, hydrogen ions,
and ammonia
- reabsorbs H2O (regulated by ADH
and aldosterone) back into the tubule
- reabsorbs bicarbonate
- regulates calcium and phosphate
concentrations
Renal Physiology
Ur in e formatio n
Tubular Function
Collecting Ducts
- receives urine from distal convoluted
tubules
- reabsorbs water (regulated by ADH)
back in vessels
Fig. 18.14
Renal Physiology
Ur in e formatio n
• As fluid flows through the proximal
tubules, water and solutes reabsorption
starts
• Normal adult produces 1 to 1.5 liter/day
of urine
• The process of selective reabsorption
determines the amount of water and
solutes to be secreted
Renin-Angiotensin System
ASS ES SME NT
GU T Asse ssm ent

Nursing History
Reason for seeking care
Current illness
Previous illness
Family History
Social History
Sexual history
GU T Asse ssm ent
Health History
• Presenting Problem: symptoms may
include
1. Pain in flank, groin; dysuria
2. Changes in urination patterns:
frequency, nocturia, hesitancy of
stream, urgency, dribbling,
incontinence, retention
GU T Asse ssm ent
Health History
• Presenting Problem: symptoms may
include
3. Changes in urinary output: polyuria,
oliguria, anuria
4. Changes in color/consistency of
urine: dilute, concentrated, malodorous;
hematuria, pyuria
GU T Asse ssm ent
Health History
Lifestyle:
- Occupation (type of employment,
exposure to chemicals such as carbon
tetrachloride, ethylene glycol)
- Level of activity
- Exercise
• Nutrition/Diet: water, calcium, dairy
product intake
GU T Asse ssm ent
Health History
Past Medical History
- Hypertension, diabetes mellitus, gout,
cystitis, kidney infections, connective
tissue diseases (SLE), infectious
diseases, drug use (prescribed/OTC);
previous catheterizations,
hospitalizations, or surgery for renal
problems
GU T Asse ssm ent
Health History
Family History
- Hypertension, diabetes mellitus, renal
disease, gout, connective tissue
disorders, urinary tract infections (UTIs),
renal calculi
GU T Asse ssm ent
Physical Examination
Inspect skin for color, turgor, and
mobility; purpuric lesions, integrity
Inspect mouth for color, moisture, odor,
ulcerations
Inspect abdomen, and palpate bladder
for distension; percuss bladder for
tympany or dullness (if full)
GU T Asse ssm ent
Physical Examination
Inspect face for edema, particularly
periorbital edema
Inspect extremities for edema
Determine rate, rhythm, and depth of
respirations
Inspect muscles for tremors, atrophy
GU T Asse ssm ent
Physical Examination
Palpate right and left kidneys for
tenderness, pain, enlargement; percuss
costovertebral angles for
tenderness/pain; first percuss kidneys
for tenderness/pain
Palpate flank area for pain
Auscultate aorta and renal arteries for
bruits
GUT Assessment

PHYSICAL EXAMINATION
Inspection
Auscultation
Percussion
Palpation
GUT Assessment
Key Signs and Symptoms of
Urological Problems
EDEMA
associated with fluid retention
renal dysfunctions usually
produce ANASARCA
check for weight daily ( weight
increase of 1 Kg = 1 Liter of fluid
retained)
GUT Assessment

Key Signs and Symptoms of


Urological Problems
PAIN
Suprapubic pain= bladder
Colicky pain on the flank= kidney
GUT 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
GUT Assessment

Key Signs and Symptoms of


Urological Problems
DYSURIA
Pain with urination= lower urinary
tract infection
GUT 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
GUT Assessment
Key Signs and Symptoms of
Urological Problems
Urinary Urgency

Urinary Retention

Urinary Frequency
GUT Assessment
Irritation
Dysuria
Frequency
Urgency
Nocturia
Strangury
GUT Assessment
Obstruction
Weak Stream
Hesitancy
Terminal Dribbling
Incomplete emptying
GUT Assessment
Pain
Flank or lumbar
Inguinal or iliac
Initiation of voiding
End of voiding
GUT Assessment
Uri ne Changes

Pneumaturia
Proteinuria
Ketonuria
Glycosuria
Hematuria
GUT Assessment
Incontinence

Stress
Urge
Overflow
Total
Mixed
Enuresis
LAB OR ATO RY
DIA GNO STI CS
GUT: LABORATORY
DIAGNOSTICS
Urine Studies:
• Urinalysis: examination to assess the
nature of the urine produced
- evaluates color, pH and specific gravity
- determines presence of glucose
(glycosuria), protein (proteinuria), blood
(hematuria), ketones (ketonuria)
- analyzes sediment for cells (presence of
WBC called pyuria), casts, bacteria, crystals
Urine Specimen
GUT: LABORATORY
DIAGNOSTICS
Urine Studies:
1. Urinalysis: Interventions
- Wash perineal area & use a clean container
- Obtain 10 to 15 mL of the first morning
sample
- Specimen should be examined within 1 hour
of voiding. Note that refrigerated samples may
alter the specific gravity
- If the client is menstruating, indicate this on
Urine Specimen
Collection of Urine
Specimen
Clean catch (midstream) urine specimen
A. Cleanse perineal area
1. Females: spread labia and cleanse
meatus front to back using antiseptic sponges
2. Males: retract foreskin (if uncircumcised)
and cleanse glans with antiseptic sponges
B. Have client initiate urine stream then stop
C. Collect specimen in a sterile container
D. Have client complete urination but not in
specimen container
Collection of Urine
Specimen
24-hour urine specimen
- Preferred method for creatinine clearance test
INTERVENTIONS:
- Have client void and discard specimen; note
time
- Collect all subsequent urine specimens for 24
hours
- If specimen is accidentally discarded, the test
must be restarted
- Record exact start and finish collection; include
date and times
Collection of Urine
Specimen

Random urine sample


Urine straining
Double catch
Catheter
Diversionary Method
Collection of Urine
Specimen
It involves overall characteristics of urine:
Appearance
normal urine is clear
cloudy = due to pus, blood, bacteria and lymph
fluid
Odor
normal is faint aromatic odor
offensive odor = bacterial action
Collection of Urine
Specimen
Color
normal is clear yellow or amber
straw colored = diluted
highly colored = concentrated urine due to
insufficient fluid intake
cloudy or smoky = infection, spermatozoa
red or red brown = hematuria, bleeding or
drugs and food
yellow-brown or green-brown = obstructive
jaundice or lesion from bile duct
dark-brown or black = malignant melanoma
or leukemia
Collection of Urine
Specimen
pH
maintain normal hydrogen ion
concentration in plasma and ECF
must be measured in fresh urine because
the breakdown of urine to ammonia causes
urine to become alkali
normal pH is around 6 (acid) or 4.6-7.5
Check: ketones, glucose and
albumin
Collection of Urine
Specimen
Specific Gravity Determination
Reflects ability of the kidneys to
concentrate or dilute urine, normal range is
from 1.005-1.025 (1.003- 1.030)
INTERVENTIONS:
Specific gravity can be measured by
multiple dipstick (most common method),
refractometer (an instrument used in the
laboratory setting) or urinometer (least
accurate method)
Collection of Urine
Specimen
Specific Gravity Determination
INTERVENTIONS:
Factors that interfere with an accurate
reading include radiopaque contrast
agents, glucose, and proteins
An increase in specific gravity occurs with
insufficient fluid intake, decreased renal
perfusion, or the presence of SIADH
Collection of Urine
Specimen
Specific Gravity Determination
INTERVENTIONS:
A decrease in specific gravity occurs with
increased fluid intake, renal failure (diuretic
phase) and diabetes insipidus
Cold specimens may produce a false high
reading
Collection of Urine
Specimen
Osmolality
more precise test than specific gravity
1-2 ml urine are required
normal range is from 300-1090 mOsm/kg
(number of particles per unit volume of
water)
GUT: LABORATORY
DIAGNOSTICS
Urine Studies:
• Urine Culture and Sensitivity-
examination for bacterial infections of urinary
tract that identifies the presence of
microorganisms and determines the specific
antibiotics that will treat the existing
microorganism appropriately
INTERVENTIONS:
- Clean perineal area and urinary meatus
with bacteriostatic solution
GUT: LABORATORY
DIAGNOSTICS
Urine Studies:
1. Urine Culture and Sensitivity-
INTERVENTIONS:
- Collect midstream sample in a sterile
container
- Send the collected specimen to the
laboratory immediately
- Note that urine from the client who forced
fluids may be too diluted to provide a positive
GUT: LABORATORY
DIAGNOSTICS
Urine Studies:
1. Urine Culture and Sensitivity-
INTERVENTIONS:
- Identify any sources of peritoneal
contaminants during the collection of the
specimen, such as the hands, skin, clothing,
hair, or vaginal or rectal secretions
GUT: LABORATORY
DIAGNOSTICS
Urine Studies:
• Residual Urine- amount of urine left in
bladder after voiding measured via catheter
(permanent or temporary) in bladder
GUT: LABORATORY
DIAGNOSTICS
Urine Studies:
• Creatinine Clearance- determine
amount of creatinine (waste product of protein
breakdown) in the urine over 24 hours,
measures overall renal function
INTERVENTIONS:
- Encourage adequate fluids before and
during the test
- Instruct the client, as prescribed, to
avoid tea, coffee, and medications during
GUT: LABORATORY
DIAGNOSTICS
Urine Studies:
1. Creatinine Clearance-
INTERVENTIONS:
- If the client is taking corticosteroids or
thyroid medication, check with the physician
regarding the administration of these
medications during testing
- Maintain the urine specimen on ice or
refrigerate and check with the laboratory
regarding the addition of a preservative to the
GUT: LABORATORY
DIAGNOSTICS
Blood Studies:
• BUN: measures renal ability to excrete
urea nitrogen
• Serum creatinine: specific test for renal
disorders; reflects ability of kidneys to
excrete creatinine
• Bicarbonate
• Calcium
GUT: LABORATORY
DIAGNOSTICS
Blood Studies:
1. Phosphorus
2. Potassium
3. Sodium
GUT: LABORATORY
DIAGNOSTICS
Blood Urea Nitrogen (BUN)
• primary end product of protein metabolism
and is excreted by the kidneys
• an elevation of BUN may indicate chronic
renal disease
• not specific for the kidney function
• normal value= 20-30 mg/dl
• assess concentration of urea in the blood
• can be reabsorbed by the kidney tubules
GUT: LABORATORY
DIAGNOSTICS
Serum Creatinine
• is more specific for renal function test
• is not affected by dietary intake or hydration
status
• normal value 0.5-1.5 mg/dl
• can not be reabsorbed by the kidney tubules
• assess GFR
• can be elevated in cases of glomerulonephritis
Pyelonephritis, acute tubular necrosis
nephrotoxicity, renal insufficiency and renal
failure.
GUT: LABORATORY
DIAGNOSTICS
KUB Radiograph
 Initial procedure for KUB disorders
 An X-ray film of the urinary system and
adjacent structures that is used to detect
urinary calculuses
INTERVENTIONS:
 No specific preparation is necessary
GUT: LABORATORY
DIAGNOSTICS
KUB Ultrasound
 Non-invasive method
 NPO for 6 to 8 hours
 Is a noninvasive method of determining
renal damage, stones in the urinary tract
and measuring the volume of urine in the
bladder
 May be performed for evaluating urinary
frequency or inability to urinate
GUT: LABORATORY
DIAGNOSTICS
Computed Tomography
 Imaging methods that provide cross-
sectional views of the kidney and urinary
tract
INTERVENTIONS (CT Scan):
 Obtain an informed consent if a dye is used
 Assess for allergies to iodine, contrast dyes,
or shellfish if a dye is used
Contrast Media
GUT: LABORATORY
DIAGNOSTICS
Computed Tomography
INTERVENTIONS (CT Scan):
 Instruct the client in the need to lie still and
flat during the test
 Instruct the client to hold his or her breath
when requested
 Initiate an IV line if prescribed
GUT: LABORATORY
DIAGNOSTICS
Computed Tomography
INTERVENTIONS (CT Scan):
 Assess for claustrophobia
 Inform the client of possible mechanical
noises as the scanning occurs
 Inform the client that there may be a hot,
flushed sensation and a metallic taste in
the mouth when the dye is injected
GUT: LABORATORY
DIAGNOSTICS
Computed Tomography
INTERVENTIONS (CT Scan):
 Note some clients may be given the dye
even if they report an allergy and are
treated with an antihistamine and
corticosteroids before the injection to
reduce the severity of a reaction
GUT: LABORATORY
DIAGNOSTICS
Computed Tomography
INTERVENTIONS (CT Scan): Post-
Procedure
 Provide replacement fluids because diuresis
from the dye is expected
 Monitor for an allergic reaction to the dye
 Assess dye injection site for bleeding or
hematoma, and monitor extremity for color,
warmth, and the presence of distal pulses
GUT: LABORATORY
DIAGNOSTICS
Magnetic Resonance Imaging
 Non-invasive imaging methods that provide
more detailed cross-sectional views of the
kidney and urinary tract that identifies types
of tissues, tumors, and vascular
abnormalities
INTERVENTIONS (MRI): Pre-Procedure
 Remove all metal objects from the client
 Remove IV fluid pumps during the test
GUT: LABORATORY
DIAGNOSTICS
Magnetic Resonance Imaging
INTERVENTIONS (MRI): Pre-Procedure
 Determine whether the client has a
pacemaker, implanted defibrillator, or metal
implants such as a hip prosthesis or vascular
clips because these clients cannot have this
test performed
 Provide precautions for the client who is
attached to pulse oximeter because it can
cause a burn during testing if coiled around
the body or a body part
GUT: LABORATORY
DIAGNOSTICS
Magnetic Resonance Imaging
INTERVENTIONS (MRI): Pre-Procedure
 Provide an assessment of the client with
claustrophobia
 Administer medication as prescribed for the
client with claustrophobia
 Determine whether a contrast agent is to be
used, and follow the prescription related to
the administration of food, fluids, and
medications
GUT: LABORATORY
DIAGNOSTICS
Magnetic Resonance Imaging
INTERVENTIONS (MRI): Pre-Procedure
 Instruct the client that he or she will need to
remain still during the procedure
INTERVENTIONS: Post-Procedure
 Client may resume normal activities
 Expect diuresis if a contrast agent was used
GUT: LABORATORY
DIAGNOSTICS
Intravenous Pyelogram
 A radiopaque dye is injected that outlines the
renal system to identify abnormalities
INTERVENTIONS: Pre-Procedure
 Obtain an informed consent
 Assess the client for allergies to iodine,
seafood, and radiopaque dyes
 Withhold food and fluids after midnight on the
night before the test
IVP
GUT: LABORATORY
DIAGNOSTICS
Intravenous Pyelogram
INTERVENTIONS: Pre-Procedure
 Administer laxatives as prescribed
 Inform the client about possible throat
irritation, flushing of the face, warmth, or a
salty taste during the test
INTERVENTIONS: Post-Procedure
 Monitor vital signs
 Assess the venipuncture site for bleeding
GUT: LABORATORY
DIAGNOSTICS
Intravenous Pyelogram
INTERVENTIONS: Post-Procedure
 Monitor urinary output
 Instruct the client to drink at least 1 L of fluid
unless contraindicated
 Monitor for signs of a possible allergic
reaction to the dye used during the test
GUT: LABORATORY
DIAGNOSTICS
Renal Angiography
 The injection of a radiopaque dye through a
catheter for examination of the renal arterial
supply
INTERVENTIONS: Pre-Procedure
 Obtain an informed consent
 Assess the client for allergies to iodine,
seafood, and radiopaque dyes
 Inform the client about the possible burning
feeling along the vessel when the dye is used
GUT: LABORATORY
DIAGNOSTICS
Renal Angiography
INTERVENTIONS: Pre-Procedure
 Withhold food and fluids after midnight on the
night before the test
 Instruct the client to void immediately before
the procedure
 Administer enemas as prescribed
 Shave injection sites as prescribed
 Assess and mark the peripheral pulses
GUT: LABORATORY
DIAGNOSTICS
Renal Angiography
INTERVENTIONS: Post-Procedure
 Assess vital signs and peripheral pulses
 Provide bed rest and use of a sandbag at the
insertion site for 4 to 8 hours
 Assess the color and temperature of the
involved extremity
 Inspect the catheter insertion site for bleeding
or swelling
GUT: LABORATORY
DIAGNOSTICS
Renal Angiography
INTERVENTIONS: Post-Procedure
 Encourage increased fluids unless
contraindicated
 Monitor urinary output
GUT: LABORATORY
DIAGNOSTICS
Renal Scan
 An IV injection of a radioisotope for visual
imaging of renal blood flow
INTERVENTIONS: Pre-Procedure
 Obtain an informed consent form
 Assess for allergies
 Assist with administering radioisotope as
necessary
 Instruct the client that he or she will be
required to remain motionless during the test
GUT: LABORATORY
DIAGNOSTICS
Renal Scan
INTERVENTIONS: Pre-Procedure
 Instruct the client that imaging may be
repeated at various intervals before the test is
complete
INTERVENTIONS: Post-Procedure
 Encourage fluid intake unless contraindicated
 Assess the client for signs of delayed allergic
reaction such as itching and hives
GUT: LABORATORY
DIAGNOSTICS
Renal Scan
INTERVENTIONS: Post-Procedure
 Note that the radioactivity is eliminated in 24
hours
 Follow standard precautions when caring for
incontinent clients and double-bag client
linens per agency policy
GUT: LABORATORY
DIAGNOSTICS
Cystometrogram
 A graphic recording of the pressures exerted
at varying phases of the bladder
INTERVENTIONS: Pre-Procedure
 Inform the client of the voiding requirements
during the procedure
INTERVENTIONS: Post-Procedure
 Monitor the client’s voiding after the
procedure
Cystometrogram
GUT: LABORATORY
DIAGNOSTICS
Cystoscopy and Biopsy
 The bladder mucosa, ureteral orifice and
urethra is examined for inflammation,
calculuses, or tumors by means of
cystoscope; a biopsy may be obtained
INTERVENTIONS: Pre-Procedure
 Obtain an informed consent
 If biopsy is planned, withhold food and fluids
after midnight on the night before the test
Cystoscopic Examination
GUT: LABORATORY
DIAGNOSTICS
Cystoscopy and Biopsy
INTERVENTIONS: Pre-Procedure
 If a cystoscopy alone is planned, no special
preparation is necessary
 And the procedure may be performed in the
physician’s office
 Post-procedure includes increasing fluid
intake
GUT: LABORATORY
DIAGNOSTICS
Cystoscopy and Biopsy
INTERVENTIONS: Post-Procedure
 Monitor vital signs
 Increase fluid intake and output
 Encourage deep-breathing exercises to
relieve bladder spasms
 Administer analgesics as prescribed
 Administer sitz baths for back and abdominal
pain
GUT: LABORATORY
DIAGNOSTICS
Renal Biopsy
 Ultrasound guided insertion of needle into the
kidney to obtain a sample of tissue for
examination
INTERVENTIONS: Pre-Procedure
 Assess vital signs
 Assess baseline clotting studies (Bleeding time)
 Obtain an informed consent
 Withhold food and fluids after midnight on the
night before the test
GUT: LABORATORY
DIAGNOSTICS
Renal Biopsy
INTERVENTIONS: During the Procedure
 Position the client prone with a pillow under the
abdomen and shoulders
 Hold breath when the kidney is about to
puncture
INTERVENTIONS: Post-Procedure
 Monitor vital signs
 Place the client in the supine position and on
bed rest for 8 hours as prescribed
Renal Biopsy
GUT: LABORATORY
DIAGNOSTICS
Renal Biopsy
INTERVENTIONS: Post-Procedure
 Monitor hemoglobin and hematocrit
 Avoid palpation and manipulation on the area
 Monitor complications:
Colicky pain = clot in the ureter/s
Flank pain = bleeding in the muscle
Evaluate hematuria = collect serial
urine specimen
GUT: LABORATORY
DIAGNOSTICS
Renal Biopsy
INTERVENTIONS: Post-Procedure
 Provide pressure to the biopsy site for 30
minutes
 Check the biopsy site for bleeding
 Encourage fluid intake of 1500 to 2000 mL as
prescribed
 Instruct the client to avoid heavy lifting and
strenuous activity for 2 weeks