The document provides an overview of the urinary system and disorders that can affect it. It discusses the anatomy and physiology of the kidneys and nephrons. Some key urinary disorders summarized include: 1. Urinary tract infections (UTIs), which are common in women and caused by bacteria entering the urinary tract. Symptoms can include painful urination. 2. Kidney stones, solid mineral deposits that can block the urinary tract. Treatment includes shockwave lithotripsy to break up stones. 3. Benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate common in aging men that causes urinary problems. Treatments include medications

1. URINARY SYSTEM DISORDERS

2. Objectives: After 12 hrs. varied teaching learning activities, the students should: Review the anatomy and physiology of the urinary system. Explain the role of the urinary system in maintaining homeotasis. Identify abnormal findings that may indicate impairment of the urinary system. Implement appropriate nursing management techniques for patients with urinary and kidney problem Use the nursing process as framework, for the care of patients undergoing surgery. Demonstrate compassion when caring for patients with Urinary system problem

3. Overview 4 components

5. Anatomy of the Kidney Cup-like that collects its urine

6. The Nephron Basic structural and functional unit of kidney

7. AMOUNT AND COMPOSITION OF BODY FLUIDS 60% of adult’s weight – fluids and electrolytes. FACTORS THAT INFLUENCE THE AMOUNT OF BODY FLUID Age Medications Surgery Stress Illness Diet Gender Body Fat Climate

8. 2 FLUID COMPARTMENTS Intracellular – 2/3 of body fluids in the skeletal muscle mass Extracellular Intravascular – contains plasma - 3L of the 6L of blood volume Interstitial – fluids that surrounds the cell = 11–12 L Transcellular– contains approximately 1L of fluid. Ex. CSF, pericardial, synovial, intraocular, pleural, sweat

9. FLUID INTAKE Fluid requirement/day- 2,500 mL Ave. adult drinks 1,500 mL/day Remaining 1,000 mL is preformed water. Thirst is triggered by: Intracellular dehydration Excess angiotensin II (potent vasoconstrictor) Hemorrhage

12. Formation of Urine THREE PROCESSES IN URINE FORMATION Glomerular Filtration Tubular reabsorption Tubular secretion Glomerular Filtration Rate- amount of fluid filtered from the blood into the capsule per minute. 120-125 ml/min held constant by instrinsic control Myogenic Reninangiotensin mechanism

14. CHARACTERISTICS OF NORMAL URINE Pale to deep yellow, clear Odor – Aromatic Specific Gravity – 1.001 – 1.030 pH- 4.5-8.0 Protein – Negative to trace Glucose – Negative WBC – 0-5 hpf RBC – 0-5/hpf Casts – Negative to occasional

15. Defects of Genitourinary Tract Inguinal Hernia Hydrocele- fluid in the scrotum Phimosis – narrowing or preputial opening of foreskin Hypospadias – urethral opening located behind the glans penis Epispadias Chordee – ventral curvature of penis

16. UTI a bacterial infection that affects any part of the urinary tract. The most common type of UTI: bladder infection (cystitis). kidney infection (pyelonephritis) Risk Factors Female: Short, straight urethra Proximity of urinary meatus to vagina and anus Sexual intercourse Use of spermicidal compound for birth control Male: Uncircumcized Prostatic hypertrophy Rectal intercourse Both: Aging Urinary tract obstruction Neurogenic bladder dysfunction Vesicoureteral reflux Genetic factors Catheterization

17. Symptoms & Signs For bladder infection Frequent urination along with the feeling of having to urinate even though there may be very little urine to pass. Nocturia Urethritis: Discomfort or pain at the urethral meatus or a burning sensation throughout the urethra with urination (dysuria). Pain in the midline suprapubic region. Pyuria Hematuria Pyrexia Cloudy and foul-smelling urine Some urinary tract infections are asymptomatic

18. For Kidney Infections Aforementioned symptoms. Emesis Back, side (flank) or groin pain. Abdominal pain or pressure. Shaking chills and high spiking fever. Night Sweats. Extreme Fatigue.

19. Epidemiology Most common in sexually active women Diabetes anatomical malformations of the urinary tract. Allergies Use of urinary catheters as bladder wall is coated with various mannosylated proteins, such as Tamm-Horsfall proteins (THP), which interfere with the binding of bacteria to the uroepithelium

20. CYSTITIS PYELONEPHRITIS Is inflammation of the urinary bladder Types bacterial cystitis most often caused by coliform bacteria being transferred from the bowel through the urethra into the bladder interstitial cystitis (IC) is considered more of an injury to the bladder resulting in constant irritation and rarely involves the presence of infection radiation cystitis often occurs in patients undergoing radiation for the treatment of cancer. inflammation of the renal pelvis, and kidney tissues. Acute- bacterial “ascending infection” Chronic-non bacterial and inflammatory processes

21. Causes, incidence and risk factors sexually active women ages 20 to 50 but may also occur in those who are not sexually active or in young girls. escherichia coli ("E. coli“) Sexual intercourse insertion of instruments into the urinary tract obstruction of the bladder or urethra with resultant stagnation of urine

22. Diagnosis urine culture and sensitivity urinalysis. IVP Cystoscopy Manual prostate and pelvic exam Treatment oral antibiotics such as trimethoprim-sulfamethoxazole (TMP-SMZ), cephalosporins, nitrofurantoin, or a fluoroquinolone (e.g. ciprofloxacin, levofloxacin).

23. Nursing Management increased water-intake frequent voiding avoidance of sugars and sugary foods Avoid caffeinated drinks drinking unsweetened cranberry juice as well as taking vitamin C with the last meal of the day Prevention Cleaning the urethral meatus after intercourse urinating within 15 minutes of sexual intercourse to allow the flow of urine to expel the bacteria before specialized extensions anchor the bacteria to the walls of the urethra. Having adequate fluid intake, especially water. Not resisting the urge to urinate. Bathing in warm water without soap, bath foams, etc. Practicing good hygiene, including wiping from the front to the back to avoid contamination of the urinary tract by fecal pathogens.

24. URINARY RETENTION also known as ischuria is a lack of ability to urinate Signs and Symptoms poor urinary stream with intermittence straining, a sense of incomplete voiding and urgency

25. Causes: BPH Prostatic Cancer Damage to the bladder Obstruction in the urethra

26. Diagnostic tests Uroflowmetry may aid in establishing the type of micturition abnormality. A post-void residual scan may show the amount of urine retained. Serum prostate-specific antigen (PSA) may aid in diagnosing or ruling out prostate cancer. Urea and creatinine determinations may be necessary to rule out backflow kidney damage.

27. obstruction of the urinary tract may cause: Bladder stones Hydronephrosis Diverticula

28. Treatment ACUTE : urinary catheterization suprapubiccystostomy CHRONIC: transurethral resection of the prostate, TURP

29. Benign prostatic hyperplasia increase in size of the prostate in middle-aged and elderly men Symptoms: urinary hesitancy, frequent urination, increased risk of urinary tract infections and urinary retention. results in: stasis of bacteria in the bladder residue and an increased risk of urinary tract infections. Urinary bladder stones, Urinary retention

30. Diagnosis Rectal examination blood tests are performed to rule out prostatic malignancy: elevated prostate specific antigen (PSA) levels transrectalultrasonography Ultrasound examination of the testicles, prostate and kidneys

31. Treatment Lifestyle Patients should decrease fluid intake before bedtime, moderate the consumption of alcohol and caffeine-containing products, and follow timed voiding schedules. Medications Alpha blockers (α1-adrenergic receptorantagonists) provide symptomatic relief of BPH symptoms. Available drugs include doxazosin, terazosin, alfuzosin and tamsulosin. Alpha-blockers relax smooth muscle in the prostate and the bladder neck, and decrease the degree of blockage of urine flow. The 5α-reductase inhibitors (finasteride and dutasteride) are another treatment option. When used together with alpha blockers a reduction of BPH progression to acute urinary retention and surgery has been noted in patients with larger prostates.

32. Surgery If medical treatment fails, transurethral resection of prostate (TURP) Transurethral electrovaporization of the prostate (TVP), laser TURP, visual laser ablation (VLAP), TransUrethral Microwave ThermoTherapy (TUMT), TransUrethral Needle Ablation (TUNA), ethanol injection

33. KIDNEY STONE ALSO CALLED RENAL CALCULI are solid concretions (crystal aggregations) of dissolved minerals in urine nephrolithiasis and urolithiasis at least 2-3 millimeters can cause obstruction of the ureter. severe episodic pain, most commonly felt in the flank, lower abdomen and groin a condition called renal colic Hematuria Staghorn calculus (struvite stone) Star shaped bladder urolith

34. Kidney Stones Calcium oxalate stones -consumption of low-calcium diets Other types of kidney stones are composed of struvite(magnesium, ammonium and phosphate) are always associated with urinary tract infections uric acid is associated with conditions that cause high blood uric acid levels, such as gout, leukemias; calcium phosphate is associated with conditions such as hyperparathyroidism and renal tubular acidosis. cystine.

35. Medical Management non-invasive Extracorporeal Shock Wave Lithotripsy or (ESWL) Ureteral (double-J) stents

36. HYDRONEPHROSIS is distention and dilation of the renal pelvis, usually caused by obstruction of the free flow of urine from the kidney. Ultrasound picture of hydronephrosis caused by a left ureteral stone.

37. Etiology The obstruction may be either partial or complete and can occur anywhere from the urethral meatus to the calyces of the renal pelvis. The obstruction may arise from either inside or outside the urinary tract or may come from the wall of the urinary tract itself. Intrinsic obstructions (those that occur within the tract) include blood clots, stones, sloughed papilla along with tumours of the kidney, ureter and bladder. Extrinsic obstructions (those that are caused by factors outside of the urinary tract) include pelvic or abdominal tumours or masses, retroperitoneal fibrosis or neurologicaldeficits. Strictures of the ureters (congenital or acquired), neuromuscular dysfunctions or schistosomiasis are other causes which originate from the wall of the urinary tract.

39. Comparing Categories of Acute Renal Failure

40. Pre-renal (causes in the blood supply): Hypovolemia, usually from shock or dehydration fluid loss or excessive diuretics use. hepatorenal syndrome in which renal perfusion is compromised in liver failure vascular problems, such as atheroembolic disease and renal vein thrombosis (which can occur as a complication of the nephrotic syndrome)

41. Renal (damage to the kidney itself): infection usually sepsis (systemic inflammation due to infection),rarely of the kidney itself, termed pyelonephritis toxins medication (e.g. some NSAIDs, aminoglycoside antibiotics, iodinated contrast, lithium) rhabdomyolysis (breakdown of muscle tissue) - the resultant release of myoglobin in the blood affects the kidney; it can be caused by injury (especially crush injury and extensive blunt trauma), statins, stimulants and some other drugs hemolysis - the hemoglobin damages the tubules; it may be caused by various conditions such as sickle-cell disease

42. Post-renal (obstructive causes in the urinary tract) due to: medication interfering with normal bladder emptying. benign prostatic hypertrophy or prostate cancer. kidney stones. due to abdominal malignancy (e.g. ovarian cancer, colorectal cancer). obstructed urinary catheter.

43. D. Pathogenesis 1. Loss of renal autoregulation (altered renal blood flow) 2. Initially renal blood flow decrease, but then GFR decreases out of proportion to renal flow 3. Tubular obstruction may cause tubular reabsorption and (tubular obstruction) 4. Decreased GFR because of hydrostatic pressure (back leak theory) E. Clinical picture 1. Severe decrease GFR 2. Oliguria or anuria (30-50% no oliguria) 3. Increased BUN & creatinine

45. h. Anemiabecausesuppressederythropoietin i. Progressiveazotemia 3. Recovery (begins >24 hrs post onset) a.Diuresis; gradual increase in output asmuchas 6L/day b. Tubular function still altered because large amounts of Na+ and K+ still lost in urine c. Dehydration, hypokalemia d. Increased RBC production e. Continues over 6-12 months; 30% never fully recover renal function

47. treating infections

48. nutrition

49. drugs and metabolites aren't excretedII. Chronic renal failure= slowly progressive loss of nephrons and damage to glomeruli characterized by irreversible reduction in the GFR. Affects all functions normally carried out by the kidneys. A. Causes: 1. Glomerulopathies 2. Tubulo-interstitial renal diseases 3. Hereditary diseases 4. Vascular diseases: 5. Obstructive nephropathy

50. B. Problems created by CRF 1. Fluid imbalance Unable to concentrate urine early so excess H20 loss Until 25% loss of function maintains solute, then once past threshold osmotic diuresis with dehydration As progresses, inability to dilute urine so isosthenuria (urine and plasma have same, fixed specific gravity 1.010) 2. Na+ imbalance a. Intact nephrons receive more Na+ so... b. Osmotic diuresis, so... c. Reduction in blood volume and GFR

51. 3. K+ imbalance a. If water balance is maintained and acidosis controlled, not a problem b. Hyperkalemia if increased acidosis or hyponatremia or catabolism c. Hypokalemia if diuretic therapy, vomiting, renal tubular disease that prevents reabsorption. 4. Acid-base imbalance a. Metabolic acidosis because kidneys can't excrete enough H+ b. Renal tubule dysfunction leads to progressive inability toe excrete H+ c. H+ excretion is proportional to GFR d. Acids are continuously formed, but glomerulus cannot filer as effectively, production of ammonia decreases, and tubular damage

52. 5. Anemia - Hct. proportionate to azotemia a. Short life span of RBCs because of altered plasma b. Increased loss of RBCs because of GI ulceration, dialysis, and lab draws c. Reduced erythropoietin because of decreased renal formation and inhibition from uremia d. Folate deficiency if dialysis e. Iron deficiency f. Elevated parathyroid which stimulates fibrous replacement of bone marrow 6. Bleeding disorders a.Thrombocytopenia or platelet dysfunction b.Nitrogenous wastes increase risk of hemorrhage

53. 7. Urea and creatinine alterations (renal function studies) a.BUN increases (also increases with shock, protein intake, infection, gout) b.Creatinine - excretion=production c.BUN up with nonrenal; hepatorenal then BUN low F. Uremic syndrome= symptomatic renal failure associated with metabolic events and multi-organ complications 1. Cardiovascular a. Fluid and Na+ retention b. Accelerated atherosclerosis c. Pericarditis increased without dialysis d. Heart Failure

55. From decreased erythropoietin

56. Uremia = decrease RBC life span

57. Uremia = inability of cells to pump out Na+ so swelling and hemolysis

58. Immunosuppression from reduction of lymphocytes

60. Dehydration and atrophy of the sweat glands

61. Uremic itching = (?) skin deposits, peripheral neuropathy

62. Uremic frost = urea deposits from sweat

64. 7. Neurologic Encephalopathy - fatigue, decreased concentration, irritability, depression, drowsiness, insomnia, personality changes, seizures, and death Peripheral neuropathy - burning, numbness, delayed sensory and motor responses Diagnosis Creatinine or blood urea nitrogen tests Urinalysis Blood test Medical ultrasonography of the tract ( is essential to rule out obstruction of the urinary tract)

65. Treatment There are several modalities of renal replacement therapy (RRT) for patients with acute renal failure: Intermittent hemodialysis Continuous hemodialysis (used in critically ill patients)

67. It is used to remove fluid and uremic waste products from the body when the kidneys are unable to do so.

68. It may be indicated to treat patients with edema that do not respond to treatment.

70. PERITONEAL DIALYSIS TYPES: Intermittent peritoneal dialysis = acute or chronic renal failure Continuous ambulatory peritoneal dialysis = chronic renal failure Continuous cycling peritoneal dialysis = prolonged dwelling time

71. PERITONEAL DIALYSIS Indwelling catheter is implanted into the peritoneum. A connecting tube is attached to the external end of peritoneal catheter T –tube. Plastic bag of dialysate solution is inserted to the end of T-tube; the other end is recap. Dialysate bag is raised to shoulder level and infused by gravity in the peritoneal cavity Infusion time = 10 minutes/2 liters; dwelling time is 4-6 hours depending on doctor’s order. At the end of dwelling time, dialysis fluid is drained from the peritoneal cavity by gravity Draining time is 10-20 minutes/2 liters Then repeat the procedure when necessary

72. Peritoneal Dialysis Usually for patients with absolutely no other options of dialysis Or as a temporary measure until options of dialysis sorted out

73. Pre and post operative care for Tenckhoff catheter insertion Pre operative care Fast for 8 hours Allow essential medications Bowel preparation not necessary Removal of body hair limited to that necessary to facilitate performance of procedure Empty bladder Single dose of prophylactic antibiotic Operating room or well equipped procedure room

74. Pre and post operative care for Tenckhoff catheter insertion Post operative care Catheter irrigation with 1 L of heparinized saline performed as an in-and-out flush within 72 hours following surgery and weekly thereafter until PD initiated Delay PD for a min of 2 weeks to allow wound healing Change dressings weekly for 2 weeks Then patient should begin a routine of daily exit-site cleansing with antibacterial soap Showering only permitted after 1 month if wound healing uncomplicated Avoid catheter movement at the exit site Use sterile gauze dressing over exit site No tub bathing and swimming

75. PERITONEAL DIALYSIS

76. PERITONEAL DIALYSIS

77. PERITONEAL DIALYSIS NURSING CONSIDERATIONS: Dialysate must be room-warmed before use ( for better absorption) Drugs (heparin, potassium and antibiotics) must be added in advance. Allow the solution to remain in the peritoneal cavity for the prescribed time. Check outflow for cloudiness, blood and fibrin (early peritonitis). NEVER PUSH THE CATHETER IN. Monitor the VS regularly. Keep a record of patient’s fluid balance (daily weighing) Monitor blood chemistry Turn the patient side to side if drainage stop Observe for abdominal pain (cold solution), dialysate leakage (prevent infection) Intake must be equal to output.

79. Waste products in the blood move to the dialysis solution passing through the membrane by means of diffusion

80. Excess water is also removed from the blood by way of ultrafiltration

82. HEMODIALYSIS Patient Access Vascular catheter A-V fistula Synthetic vascular graft

83. HEMODIALYSIS

84. HEMODIALYSIS NURSING CONSIDERATIONS: Blood can be heparinized unless it is contraindicated to prevent blood clot. Dialysis solution has some electrolytes and acetate and HCO3 added to achieve proper pH balance. Methods of circulatory access: AV fistula; AV graft or U-tube Assess the access site for bruit, signs of infections and ischemia of the hand. Absence of thrill may indicate occlusion No BP taking on the access site. Cover the access site with adhesive bandage Dietary adjustments of CHON, Na and fluid intake. Monitor VS regularly Check blood chemistry Constant monitoring of hemodynamic status, electrolytes and acid-base balance.

86. T and B lymphocytes are involved in the rejection response

87. To reduce the rejection process, immunosuppressive drugs are given

89. end

91. Imbalanced Nutrition: less than body requirements

93. Fluid excesses can be detected by the clinical findings of dyspnea, tachycardia, and distended neck veins. Nursing Management: Monitoring fluid and electrolyte Reducing metabolic rate Promoting pulmonary function

95. Preventing infection