Genital-Urinary System

Renal System Part 1

Behavioral Objectives:• Review the anatomy and physiology of the genito-urinary systems• Describe the physical assessment of the GU systems• Discuss the application of the nursing process as it relates to patients with

disorders of the GU system• Describe the purpose and methods for collecting sterile and “clean-catch”

urine specimens.• Discuss the importance of monitoring and maintaining intake and output

and appropriate documentation• Discuss common diagnostic tests, procedures and related nursing

responsibilities for the patient with GU disorders.• Explain the purpose of dialysis and differentiate between peritoneal and

hemodialysis

Introduction

• Essential to life• Every head to toe

assessment must include…

– Upper & lower urinary tract function

Anatomy: Kidney

• Kidneys– Shape• Bean

– Color• Brown-red

– How many / #• 2

Anatomy: Kidneys

Kidneys• Location– Posterior wall of the

abdomen– Base of the rib cage– Surrounded by renal

capsule– Right kidney is lower

than the left

Anatomy: kidney

Do You Remember?• What lies on top of each kidney?

A. LiverB. PancreasC. Meat ballsD. Adrenal gland

• What hormones do the adrenal glands secrete?– (Not a multiple choice question!)– Hint• Sugar, Sex & Salt

– Glucocorticoids– Androgens– Mineralcorticoids - aldosterone

Anatomy: Kidney

• Two distinct regions:– Renal parenchyma– Renal pelvis

• Renal parenchyma– Divided into 2 parts

• Cortex• Medulla

Renal parenchyma

• Medulla– Inner portion– Contain

• Loops of Henle• Vasa recta• Collecting ducts

Renal parenchyma

• Medulla– Collecting ducts connect

to Renal pyramids• Shape:

– Triangle

• Point toward– Hilum / pelvis

• Ea. Kidney contains– 8-18 pyramids

Anatomy: Kidney

• Medulla– Function

• Drain urine from the Nephrons to the renal pelvis

Renal parenchyma

• Divided into 2 regions

–Medulla–Cortex• Contains –Nephrons »Functional unit of

the kidneys

Anatomy: Kidney

• Renal pelvis– Ureter• Renal pyramids

drain urine into the ureter

– Renal artery– Renal Vein

Blood supply to the kidney

• Aorta • Renal artery • Afferent arteriole • Glomerulus– Capillary bed

• Efferent arteriole • Venules and veins• Inferior Vena Cava

Can you do it?• Place the following in order to best describe blood

flow threw the kidney.A. Afferent arterioleB. AortaC. Efferent arterioleD. GlomerulusE. Inferior Vena CavaF. Renal arteryG. VeinH. Venules

• B-F-A-D-C-H-G-E

QUESTION????

• Where in the flow of blood threw the kidney does filtration take place?

A. Afferent arterioleB. AortaC. Efferent arterioleD. GlomerulusE. Inferior Vena CavaF. Renal arteryG. VeinH. Venules

Anatomy: Nephrons

• Functional unit*• FYI– 1 million Nephrons in

ea. Kidney– Adequate renal

function with 1 kidney

Anatomy: Nephrons

• Nephron – Glomerulus– Bowman’s capsule– Proximal convoluted

tubule• Loops of Henle• Distal convoluted

tubule

Anatomy: Ureters

• Urine:nephrons renal pyramids renal pelvis ureter,

• a long narrow muscular tube

• Extends from renal pelvis bladder

• Two• Upper urinary tract

Anatomy: Ureters

• 3 narrowed areas – promotes efflux– prevents reflux

• micturition

– Propensity for obstruction by renal calculi

Anatomy: Ureters

• lining urothelium– prevents

reabsorption of urine• The movement of

urine is facilitated by peristaltic waves

Anatomy: Bladder

BLADDER• Description– Muscular– hollow sac

• Location– Behind pubic bone

• Function– Reservoir for urine

Anatomy: Bladder

• Normal capacity – 300-500 ml of urine

• Capable of holding– 1500-2000 ml

• CNS stim. “need to void”– 150-200 ml urine

Anatomy: Bladder

• Neck of the bladder – Internal urinary

sphincter– Involuntary control

Anatomy: Urethra

• Carries urine from the bladder & expels it from the body

• External urinary sphincter– voluntary control

Physiology of the Urinary System

• Function of the kidneys

– Urine formation– Excretion of waste

products– Regulation of

• Electrolytes• Acid-base control• RBC production• Ca+ & Ph

– Control • water balance• blood pressure

– Renal clearance– Synthesis of Vit. D

Physiology of the Urinary System

• Urine formation– The nephrons form

urine through a complex 3-step process

1. Glomerular filtration2. Tubular

reabsorption3. Tubular secretion

1. Glomerular filtration

Step 1• Most of the elements of

blood, except– large molecules – blood cells

• forced out of the blood capillaries of the glomerulus Bowman’s capsule filtrate

• High capillary BP in the glomerulus.

1. Glomerular filtration

• Filtration at Glomerulus– Water– Na+

– Cl-

– Bicarbonate– K+

– Glucose– Urea– Creatinine– Uric Acid

1. Glomerular filtration

• Glomerular filtration– Factors that can alter

process:• Blood flow• Blood pressure

2. Tubular reabsorption

Step 2• Filtrate Proximal convoluted

tubule • Reabsorption (back into blood)

– Most• Water• Na+• Cl-• Bicarb• K+• Uric Acid

– All of the glucose– None of the Creatinine

3. Tubular Secretion

• Elements secreted from blood into tubule for excretion in urine– Some

• Water• Na+• Cl-• Bicarbonate• K+• Uric acid

– Most Urea

• Filtrate – Tubules – Collecting duct – Renal pelvis – Ureter – Bladder – Urethra

Glucose• Normally all the glucose

filtered through the glomeruli will be reabsorbed back into blood – No glucose in the urine

• Glycosuria – Diabetes mellitus– serum glucose levels overwhelm

the nephron’s ability to reabsorb glucose

Sweet pea!

Protein

• Filtered by glomeruli & returned to the blood by tubular reabsorption.

• Slight proteinuria– OK– globulin, albumin

• Persistent proteinuria– Glomerular damage

Anti-diuretic hormone (ADH)

• AKA– Vasopressin

• Secreted by– Posterior Pituitary

• Secreted in response to– changes in blood

osmolality

Anti-diuretic hormone (ADH)Normally• Water intake • Blood osmolality

– • Stim. pituitary to

– ADH•

• ADH receptor site – Kidney

• Action– reabsorption of H2O – urine volume/output– returns blood osmolality to normal

Anti-diuretic hormone (ADH)Normally• Water intake • Blood osmolality

– • Stim. pituitary to

– ADH•

• ADH receptor site Kidney• Action

– reabsorption of H2O – urine volume (diuresis)– returns blood osmolality to normal

Osmolarity & Osmolality

• Osmolarity – # of particles

dissolved in solution• Osmolality– Thickness of solution

• Urine• Serum / blood

Regulation of water excretion

• The amt. of urine formed is r/t the amt. of fluid intake– fluid intake – volume urine

• • Characteristic

– Dilute

– fluid intake – volume of urine

• • Characteristic

– Concentrated

• Normally: kidneys rid the body of about 75% of fluids taken in

Regulation of Electrolytes Excretion

• Sodium– Normally serum Na+:

• 135 - 145 mmol/L

– Na+ filtered from the blood & reabsorbed from the tubule back into the blood

– Na+ excretion is controlled by Aldosterone– Aldosterone Na retention

• __?__ Serum Sodium level• serum sodium level

– Na+ most abundant electrolyte found outside the cells (extracellular)

Regulation of Electrolytes Excretion

• Potassium– K+ is the most abundant electrolyte found

inside the cells (intracellular). – Aldosterone K excretion • __?__ serum K+ level• serum K+ level

Regulation of Electrolytes Excretion

• Kidney’s not functioning normally– Na+ & K+ will not be adequately filtered from the blood

• Retention of K+ is the most life-threatening effect of renal failure

• Renal failure – Retention of K+ – Hyperkalemia – Cardiac dysrhythmias – Death

Regulation of acid excretion

• Proteins are broken down into acids– phosphoric acid – sulfuric acid.

• Acids in the blood – pH

• Normally kidneys– Filter acids from the

blood • Tubular filtration• Chemical buffer

mechanism

Regulation of acid excretion

• Tubular filtration– Acid is excreted into

the urine through tubular secretion

– Used until the bladder acidity • pH 4.5

– Any excess acid must be neutralized

Regulation of acid excretion

Neutralize acids – binding them to

chemical buffers – Be excreted without

altering the pH• Important buffers– Phosphate ions– Ammonia• NH3

Regulation of Red Blood Cell Production

• Kidneys measure O2 tension of the blood (PaO2)– PaO2 – (Hormone) erythropoietin – (Receptor site) bone marrow – (Action) production of RBC – Hgb – PaO2

• Normal RBC-Erythrocytes– Male: 4.7 - 6.1

million/mm3– Female: 4.2 - 5.4

million/mm3• Normal Hemoglobin– Male 14 - 18 g/dL– Female 12 - 16 g/dL

Vitamin D Synthesis

• Kidneys activate ingested Vitamin D

• Aid absorption of calcium

Excretion of waste products• Urea, (waste product of protein metabolism)– Blood Urea Nitrogen– BUN = renal dysfunction

• Other waster products of metabolism are – Creatinine– Phosphates– Sulphates– Ketone

• Along with BUN the serum Creatinine level is usually ordered whenever the MD suspects renal disease

Excretion of waste products

• Uric acid (purine metabolism)– Hyperuricemia

• gout,

• Kidneys also are the primary means of ridding the body of Drug metabolism

Auto-regulation of Blood Pressure

• Vasa recta constantly monitor the blood pressure

• blood pressure – Renin– angiotensin 2– vasoconstriction – blood pressure.

• B/P– Renin

• Vasa recta failure to recognize BP & stop/halt Renin secretion primary causes of hypertension.

Gerontological Considerations

– Function of the urinary tract declines. – GFR declines– Prone to develop hypernatremia & fluid volume

deficit – At risk for adverse drug effects

Assessment

Risk Factors • age• Instrumentation of urinary

tract• Immobility• Diabetes mellitus• HTN• Gout, hyperparathyroidism,

Crohn’s disease • Benign prostatic

hypertrophy• Obstetric injury

Assessment: Health history

• Chief complaint• Pain• Hx of UTI’s• Fever or Chills• instrumentation • Dysuria • Hesitancy, straining• Urinary incontinence• Hematuria

• Nocturia • Hx of kidney stones• Hx of STD’s• Tobacco, alcohol, drugs• Meds• Females

– # & types of deliveries– Hx vaginal infections

Physical Exam

• Abdomen, supropubic region, genitalia and lower back, the lower extremities

• Palpate kidney– Feel the rounded

lower border of the kidney • Right kidney

Physical Exam

• Palpation of bladder– Performed after voiding

if suspect urinary retention

Terms - matching1. Urgency2. Pyuria3. Proteinuria4. Polyuria5. Oliguria6. Nocturia7. Incontinence8. Hesitancy9. Hematuria10. Frequency11. Euresis12. Dysuria13. Anuria

A. Frequent voiding – more than every 3 hours

B. Strong desire to voidC. Painful or difficult voidingD. Delay, difficulty in initiating voidingE. Excessive urination at nightF. Involuntary loss of urineG. Involuntary voiding during sleepH. Increased volume of urine voidedI. Urine output less than 400 ml/dayJ. Urine output less than 50 ml/dayK. Red blood cells in the urineL. Abnormal amounts of protein in the urineM. Pus in the urine

• The presence of peritoneal fluid build up is described as which one of the following?A. “I’m so nervous I have to void” phenomenonB. BruitsC. Generalized edemaD. Peritoneal dialysisE. Ascites

Diagnostic Evaluation:Urinalysis

– Color; clarity; odor; urine pH and specific gravity• Colorless to pale yellow

» dilute (diuretics, alcohol, diabetes Insipidus, excess fluid intake)• Yellow to milky white

» Pyuria, infection• Bright yellow

» Multiple vitamin• Pink to red

» RBC, menses, Bladder or prostate surgery, beets, meds• Blue, blue green

» dyes, meds• Orange to amber

» Dehydration, bile, excess bilirubin or carotene, meds• Brown to black

» Old red blood cells, dehydration,

Diagnostic Evaluation: Urine Culture and Sensitivity

• ID microorganism(s) • Sensitivity report• Time– 2-3 days (48-72 hours)

Specific Gravity• The weight of urine • The specific gravity of distilled water

– 1.000• Normal urine specific gravity

– 1.003 – 1.030• Urine specific gravity is related to the level of

hydration. – fluid intake H20 excretion specific gravity – fluid intake H20 excretion specific gravity

Diagnostic Evaluation:Sterile urine specimens

• Safety– Standard precautions – Biohazard bag for transport

• Collection– Indwelling Foley Catheter

• Not from the drainage bag• Aspiration port

– Catheter – straight cath– A small amount of urine is allowed to run out of the catheter into

a basin, then the urine is allowed to run into a sterile specimen bottle.

Diagnostic Evaluation: Clean-catch or Clean-voided specimen

• Clean-voided – uncontaminated by skin flora.– Female

• Cleanse: front to back

– Male• Cleanse: tip of the penis downward

• Collect a "clean-catch" – Start to void– Midstream catch– Collect 1 to 2 oz of urine

Renal Clearance

• Purpose– Assess the Kidney’s ability to

clear solutes from the plasma • Procedure

– 24 hr urine collection – 12 hr serum Creatinine level

• Creatinine– waste product of skeletal muscle

contraction

Renal Clearance

• One function of the kidney is to excrete Creatinine. If the Creatinine clearance level (the amount of Creatinine excreted by the kidney) decreases, what does that tell you about the function of the kidney?

Renal Clearance

• renal function – Creatinine clearance

• Creatinine clearance evaluates – glomerular filtration rate

(GFR)• Detects and evaluates

progression of renal disease

Can you Critical Think????

• Mrs. Notafeela Sowell had a renal clearance test done 3 times this week. Is her renal disease getting better or worse?– Monday: Renal clearance = 70 ml/min– Wednesday: Renal clearance = 80 ml/min– Friday: Renal clearance = 90 ml/min

Diagnostic Evaluation: Intake and Output

• I&O– All fluids taken orally – Form

• Time • Amount

• Output– Urine– drainage from nasogastic tube– drainage tubes – Chest tubes– Wound tubes

Apply it!• Mr. Noah Awl is recovering from Prostatectomy due to benign

hypertrophy of the Prostate. Mr. Awl is on strict intake and Output. He requests a cup of ice chips because his throat hurts (due to intubation). You give him a 200cc cup of ice chips and he eats them all. How much to you make on the Intake?

A. 100ccB. 150 ccC. 200ccD. 300 ccE. 400 cc

Dialysis: Overview

• Purpose– Remove fluids and waste products from the

body • Definition– Mechanical means of removing waste from the

blood • Types:– Hemodialysis– Peritoneal dialysis

Dialysis: Process

• Process– Diffusion and osmosis across a semi permeable

membrane into a dialysate solution• prescribed specific to the individual clients needs

Dialysis: process

• Diffusion– Toxins & wastes

are removed by diffusion–Move from an

area of higher concentration to an area of lower concentration

• This photo shows the diffusion of fluids. I added a few drops of blue food coloring in a vase of water, and took a picture after a few seconds. Diffusion is the process of a substance moving from high concentration to low concentration. The cause of diffusion is random molecular motion of the fluids, in other words, molecules of both the food coloring and the water move at random causing them to mix. In this case, the diffusion of the food coloring goes from high concentration to low concentration.

• Osmosis– Excess water is removed

by osmosis– Water move from an area

of higher solute concentration (blood) to an area of lower solute concentration (dialysate)

Hemodialysis

• A machine with an artificial semi-permeable membrane used for the filtration of the blood.

Hemodialysis

– A graft or fistula is surgically prepared to access the clients circulatory system

Hemodialysis

– With each hemodialysis treatment, the catheter is inserted into the graft of fistula

Hemodialysis

– The clients blood is circulated past the semi permeable membrane

– Excess fluids are removed by osmosis

Hemodialysis

• Waste products are removed from the blood by diffusion

Hemodialysis

• Nursing interventions– Weighted before and

after – Strict asepsis

technique

HemodialysisNursing interventions:

• Assess fistula or graft– A thrill

• felt– A bruit

• heard– Pulse peripheral

• Protect Grafts – Not an IV port!– No BP in graft arm

The nurse is preparing to teach a client about his new shunt for hemodialysis. What should be included in this teaching?

A. Avoid overusing the arm with the shunt to protect from accidental harm.

B. Always use this arm for blood pressure readingsC. If you feel any vibrations over the skin of the shunt, call the

doctor.D. There’s nothing special to the care of the shunt. Pretend it

isn’t there.

HemodialysisNursing interventions:

• Meds are given after• Usually performed 3

time a week• Usually take 3-6 hours

Peritoneal Dialysis

• Uses the peritoneal lining of the abdominal cavity

Peritoneal Dialysis

– A catheter is placed by the MD into peritoneal space

Peritoneal Dialysis

• The dialysate, – In sterile container similar – Instilled aseptically into the abdominal

cavity.• The container remains connected to the

catheter– rolled up – dialysate remains in the abdominal

cavity for a specified length of time.• The container is then unrolled and

lowered– below the abdominal cavity – Dialysate drains back into the container

Peritoneal Dialysis

• Usually 2 liters of dialysate

• Less expensive, easier to perform and less stressful

• Complication– INFECTION

• Usually 4 x day – 7day/wk