1

URIN ARY SYSTEM

KID NEYS:
− Located between 12th thoracic & 3rd lumbar vertebrae. Each kidney 4-5 inches
long. More than 1 million nephrons in each kidney. Urine flows from nephrons
in the parenchyma into the renal pelvis, which tunnels it into the ureter
− FU NCTIONS: (KIDNEYS)
o Filters blood to remove waste products
o Regulate fluid and electrolyte
o Regulates acid-base balance
o Urine formation
o Hormone production (growth hormone)
o Regulates calcium and phosphorous
o Erythropoietin (stimulates RBC production)
o Activates Vitamin D (promotes bone reabsorption of calcium &
phosphorus)
o Renin (assists with blood pressure regulation)
o Prostaglandin secretion
URETERS:
− Connects each kidney to the bladder. Urine is propelled from the kidney to the
urinary bladder via peristaltic contractions of the smooth muscle fibers in the
middle layer of the ureter.
URI NAR Y BLADDER:
− Muscular sac that serves as a reservoir for urine. Composed of an inner lining of
epithelial cells, a middle layer of three muscle types, and an outer lining.
− Holds 300 to 600 ml urine
− Bladder fullness sensation at 150 to 200 ml in adults
URET HRA:
− Provides passageway for urine to be eliminated, leads from urinary bladder to
the urethral meatus where urine exits the body: 6-8 inches in males, 1-2 inches
in females, this difference in length predisposes women to UTI’s
Urine Formation:
− 3 Step Process in Nephrons
o Glomerular Filtration- Fluid in the blood is filtered across the capillaries
of the glomerulus and into the urinary space of the Bowman’s capsule
o Tubular Reabsorption- Passage of fluid from Bowman’s capsule to the
proximal tubules where reabsorption takes place (body selectively keeps
the substances it needs while ridding itself of wastes)
 2

o Tubular Secretion- Passage of unwanted substances from capillaries

surrounding the nephron are added to the glomerular filtrate

Parts of N eph ron:

− Antidiuretic Hormone (ADH)
o Other name Vasopressin
o Hormone secreted by the posterior pituitary
o Decreases the production of urine by increasing reabsorption of water by
the renal tubules
− Atrial Natriuretic Factor (ANF) or Atrial Natriuretic Peptide (ANP)
o a hormone released to regulate renal and cardiovascular homeostasis
o Release in response to atrial dilation or increased intravascular volume
o Causes natriuresis, diuresis, renal vasodilation
o Reduces circulating concentrations of renin, aldosterone, and antidiuretic
hormone (ADH)
As se ssm ent:
− Health history
− Physical exam
− Age-related changes
− Health History
− Subjective Data
− Past health history
− Medications
− Nutritional status
− Activity-rest patterns
− Elimination patterns
− Sexuality and reproductive pattern
− Cognitive and perceptual pattern
− Self perception and self concept
− Role and relationship patterns
Physical E xam:
− Objective Data
− Inspection (external genitalia, edema)
− Palpation- costovertebral angle (CVA)
 3

− Percussion bladder (tympanic to dull)

− Auscultation (for bruits or thrills)
− Age-Related Changes of the Kidney
− Decrease in the size & weight
− Decrease in the blood flow
− Decrease in the number of functioning glomeruli
− Decreased glomerular filtration rate (GFR)
− Decrease ability to conserve Na, dilute or concentrate urine & excrete an acid
load
− Decrease renal reserve function

Diagnostic Studi es Use d to As ses s G enitou rinary Function:

− Urinalysis (needs at least 10 ml)
o Random specimens-collected at any time collected in a clean container,
cannot be used for urine C&S
− Clean-Catch Specimen (midstream urine)
o Women- separate labia and cleanse front to back with antiseptic
towelette, then void some into commode, then collect specimen in sterile
container.
o Men- Retract foreskin and cleanse in circular motion from meatus to glans
penis, void some in commode, then void in sterile container. This type
specimen is done if urine is to be cultured.
− Catheterized specimen- may be a catheterized specimen or may be withdrawn
from indwelling catheter (must be fresh urine), and almost always used for
specimens to be cultured.
− 24-Hour specimens (also referred to as “composite urine specimen”)- collected
in one large container. Some specimens need a chemical preservative in
container &/or refrigeration, so check with the lab.
o Container may be packed in container of ice or insulated ice packs. When
specimen collection begins, patient voids and this specimen is discarded.
All urine for next 24 hours is placed in container.
o 24 hours from time of first voiding, nurse instructs patient to void and
adds this to container and sends to lab. If any voiding is not added, must
restart test!!
− Renal Clearance
 4

o Kidneys ability to clear solutes from plasma

o Most popular test is creatinine clearance
− Creatinine clearance (urine) is most common 24 hour urine ordered.
o Male: 95-135 mL/min
o Female: 85-125 mL/min
o Calculated By
o Volume of urine(mL/min) X Urine creatinine (mL/dL) Serum creatinine
(mg/dL)
− Normal Findings in Routine Urinalysis
o Color- pale yellow to deep amber (some color changes because of
medications and certain foods or pathology)
o Opacity- clear (increases in opacity denote presence of bacteria, crystals,
or other foreign material)
o Specific Gravity- 1.003-1.030 (indicates concentration of urine, usually
the more concentrated the urine, the more fluid-depleted the person
o Osmolality 275-300 mOsm/L up to 900 mOsm/L(measures concentrating
ability of kidneys, urine osmolality ^ with hypernatremia, acidosis, &
shock, hypercalcemia, renal tubular acidosis and sometimes
hyperglycemia)
o pH- 4.5-8.0
o Ketones- negative (found if body’s fat stores are metabolized for energy;
diabetes, fasting, etc)
o Glucose- negative
o Protein- negative (if found, may indicate abnormal glomerular
permeability)
o Bilirubin- negative (indicates bilary tract obstruction or liver disease)
o RBC- none-3 (presence may indicate UTI or other pathology of urinary
tract, trauma and also seen in hemolytic transfusion reactions)
o WBC- none-4 (presence indicates infection in urinary tract)
o Bacteria- none (presence represents infection or contamination of
specimen)
o Casts- none (formed by agglutination of protein, presence usually
indicates tubular or glomerular disease)
o Crystals- none (presence may not indicate disease, but important
predisposing factor in calculus formation)
− Blood Studies
o BUN- 7-18 mg/dL
 5

 Blood urea nitrogen (any renal function impairment causes an

increase in the plasma urea level)
o BUN/Creatinine ratio= 10:1
o Serum Creatinine:
 Normal= 0.6-1.2 mg/dL (increased serum levels indicate decreased
renal function)
o Bacteremia- Presence of bacteria in blood. Identified by blood cultures
o GFR= 125mL/min to 200mL/min
− Radiological Studies
o KUB- X-ray of kidneys, ureters, bladder( determines size, location,
shape, malformation, stones and calcified areas)
o Ultasonography-sound waves that detect ab and of tissue)
o Computed Tomography (CT)-show cross sections of tissue
o Magnetic Resonance Imaging (MRI)- shows cross sections of tissue
 No metal objects, sedatives may be needed
o (Intravenous urography) IVP- intravenous pyelogram- IV contrast medium
is injected and X-rays taken at intervals to identify any pathophysiology
 *Make sure not allergic to shellfish
o Cystography - dye injected into bladder via a catheter and bladder is
filled, profiles size, shape, and any reflux from bladder into ureters.
o Cystogram-radiograph produced by cystography.
o Voiding cystourethrography –dye instilled into bladder by catheter. Then
person voids while x-raying. Used to assess reflux.
o Renal Angiography- dye injected via femoral artery to determine and
diagnose renal pathology. Observe for hemorrhaging after procedure,
pressure dressing, etc. and frequent checks of neurovascular status in
affected extremity.
− Diagnostic Study
o Cystoscopy : direct visualization of the urinary tract with insertion of a
cystoscope into the bladder via urethra
 Diagnostic: *inspect bladder to see tumors, calculi, ulcers,
irritation; *collect urine from renal pelvis; *retrograde pyelography;
*measuring bladder capacity
 Post-procedure: pink-tinged urine is common, but bright red
bleeding or clots should be reported. Back pain, bladder spasms,
fullness and dysuria may occur. Sitz baths, B&O supp. or
antispasmodics may be ordered. Observe for urinary retention.
 6

o Kidney Biopsy: Can be open or closed. Percutaneous renal biopsy is most

frequent (specially designed needle pierces the skin and enters the kidney
to obtain small sample of tissue)
 Pre-procedure:
• Consent
• H & H and coagulations studies prior
• Medicate so no coughing afterwards
• Pre-procedure teaching about 4 hours in bed without
movement afterwards
• Baseline VS
• Prone position
• May have to fast 6 to 8 hours before
• Baseline urine specimen collected
Post-procedure- *Hemorrhage is a major complication, observe for

hematuria, flank or abd. Pain, hypotension, heavy ecchymosis or
hematoma formation over kidney, observe site frequently, V/S,
bedrest X 4 hours (up to 24 hours if high risk for bleed)
 Avoid straining/coughing, force fluids, collect serial urines, keeping
samples of each voiding for comparison and analysis for presence
of blood and clearing of RBCs or increase.
− Normal Lab Value s:
o BUN (8- 25mg/dl
o Creatinine (0.6- 1.5mg/dl)
o Phosphorous (2.8- 4.5mg/dl)
o Calcium (9 – 11mg/dl)
o Sodium (135- 145mEq/L)
o Potassium (3.5- 5.5mEq/L)
o Hematocrit (38 – 47% female) (40- 54% male)
o Hemoglobin (12- 16g/dl female) (13.5 -18g/dl male)

Te rms :Page 1503

− Dysuria
− Enuresis
− Hematuria
− Nocturia
− Oliguria
 7

− Polyuria
− Anuria
− Residual urine
− Frequency
− Urgency
− Hesitancy
− Incontinence
− Proteinuria
− Pyuria
− Micturition

Re laps e:
− Bacterial Persistence
− Sterilization of the urine is short-lived
− Within weeks a relapse with the identical organism occurs
− Site of persistent infection within the urinary tract that could be a stone or
infected anatomic anomaly

Pr ev ention of Inf ections Fol ey Ca th ete rs:

− Maintain closed system
− *Aseptic technique if needs irrigation
− *Avoid backflow of urine, keep drainage bag below bladder level
− *Catheter care Q 8 hours
− Avoid unnecessary manipulation of catheter
− *Maintain patency of catheter
− *Encourage fluid intake
− *Provide urine acidification

UNIN ARY T RACT INFECTIO NS:

− LO WER URI NARY TRACT IN FECTIONS
o Cystitis- infection in bladder
o Urethritis- inflammation of the urethra
o Prostatitis -inflammation of the prostate
- CAUSES
- Bacteria (E.coli), ureterovesical (ureters connect to bladder), vesicoureteral
reflux(reflux of urine from urethra to bladder)
- ROUTES OF INFECTION
Transurethral route(ascending infection) most common
 8

- SIGNS & SYMPTOMS

- Dysuria (painful or difficult voiding)
- Burning on urination
- Frequency (voiding more than 3h)
- Urgency
- Nocturia
- Incontinence
- Suprapubic pain
- Hematuria & back pain may also be present
- Older adult – generalized fatigue, changes in cognitive functioning

DIAGNOSTIC FINDINGS
Urine cultures:
• Colony count of at least 100,000 of clean-catch or catheterized specimen
• Cellular studies – pyuria – greater than 4WBC
• Dipstick
• Acute urethritis caused by STD (chlamydia, trachomatis, nisseria, gonorrhea, herpes
simplex) or acute vaginitis infections may be responsible for symptoms similar to
UTI
• CT scan – detect pyelonephitis or abscesses
• Ultrasongraphy – detect obstruction, abscess, tumor, cysts
• Transrectal ultrasongraphy – prostate & bladder for men
• IV urogram – see ureters, detect strictures, stones, reflux nephropathy
MEDICAL MANAGEMENT
• Cephalosporin
• Ampicillin/ aminogycoside
• Trimethoprim-sulfamethoxazole (TMP-SMZ, Bactrium, Septra)
• Nitrofurantoin (Macrodantin, Furadantin) – should not be used in patients with renal
failure
• Ampicillin
• Amoxicillin
• Fluroquinolone ciprofloxacin (Cipro)
• Pyridium – turns urine rust color
• Prelief
• Cranberry juice
− UP PER URI NAR Y TRACT INFECTIONS
o Pyelonephritis- infection in renal pelvis
 9

o Interstitial nephritis- inflammation of the kidney

o Renal abscesses
o Urosepsis- sepsis (widespread infection in bloodstream) resulting from
UTI
o Pyelonephritis
 Upper Urinary tract infection involving the renal pelvis, tubules,
and interstitial tissue of the kidney
- CAUSES
Bacteria that has spread to kidneys
Incompetent ureterovesical valve
Obstruction
Bladder tumors
Strictures
Benign prostatic hyperplasia
Stones
Systemic infections (TB)
Acute pyelonephritis causes – enlarged kidneys, abscesses or renal
capsule & corticomedullary junction
Chronic pyelonephitis causes – cause of chronic kidney disease
AC UTE PYEL ONEP HRITIS
- Acute: caused by infections and abscesses
 Clinical Manifestations Pyelonephritis
• Acute
o Fever
o Chills
o Leukocytosis
o Bacteriuria
o Pyuria
o Low back pain
o Flank pain
o N/V
o HA
o Malaise
o Dysuria
o Frequency

DIAGNOSTIC
- Ultrasound
 10

- CT scan
- C & S urinalysis

MEDICAL MANAGEMENT
- TMP-SMZ – sulfa drug, Bactrim, cause kidney stones, keep hydrated
- Ciprofloxacin (Cipro)
- Gentamicin (toxicity)
- Cephalosporin
- Ampicillin
- Follow-up U/A
- Hydration
CHR ONIC PYELO NEP HRITIS
Chronic - caused by chronic kidney disease
CAUSE – repeat of acute pyelonephritis
SIGNS & SYMPTOMS
• Usually no symptoms
• Fatigue
• H/A
• Poor appetite
• Polyuria
• Excessive thirst
• Weight loss
DIAGNOSTIC
• IV urogram
• Creatinine
• BUN
• Ultrasound
COMPLICATIONS: end-stage renal disease (ESRD)
 Treatment Chronic Pyelonephritis
o Long term antibiotic use
o Monitor renal function studies
 Nursing Management Pyelonephritis
o Collection of U/A
o Monitor intake and output
o Encourage 3 to 4 Liters fluid/day(unless
contraindicated)
o Monitor temp (q4h)
o Teach preventive measures
 11

o Administer antipyretics & antibiotics

− Factors That Increase The Incidence of UTIs

o Obstruction-
o Stricture
o Congenital abnormality
o Prostatic hypertrophy
o Renal stone
o Renal cyst
o Factors That Increase The Incidence of UTIs
o Urinary Instrumentation-
o Cystoscopy
o Prostatectomy
o Renal biopsy
o Prostatic biopsy
o Foreign Body-
o Indwelling catheter
o Ureteric stent
o Nephrostomy tube
o Metabolic disease or illness-
o Diabetes
o Postrenal transplantation
o Urinary diversion-
o Ileal conduit
o Functional abnormality-
o Neurogenic bladder
o Vesicoureteral reflux
− Prevention of UTIs
o Wiping from urinary meatus back
o *Taking showers instead of baths, or taking baths w/less water in tub
o *Avoiding bubble baths
o *Wearing cotton underpants
o *Cleansing perineum prior and voiding prior to and after intercourse
o Not wearing wet bathing suits all day
o *Drinking adequate fluids, esp. cranberry
o *Voiding at regular intervals
o *Unprotected anal intercourse
 12

o *Infrequent changing of baby’s diapers

− Other Risk Factors For UTIs
o Tampons & tight clothing
o *Diaphragm & spermicides
o *Lack of circumcision
o Women at higher risk because urethra is shorter & men have zinc in
prostatic fluid which acts as antibacterial agent
− Clinical Manifestations of UTIs
o Burning upon urination
o *Frequency
o *Urgency
o *Inability to void
o *Voiding in small amounts
o *Hematuria
o *Abdominal/flank pain
o *Malaise, fever, chills
− Treatment of UTIs
o * Increase fluids
o *Antibacterial agents for prescribed length of time:
o Bactrim common antiinfective
 (sulfa family causes crystalluria = force fluids to 8 glasses a day.
Avoid excessive sunlight = burns)
o Pyridium- urinary anesthetic agent, turns urine red-orange = decreased
pain & burning.
URET HRAL SYNDRO ME:
− Primarily affects women, unknown cause
− Irritated bladder
− Frequency
- Urgency
− Hesitancy
− Burning
− Low back pain
- Suprapubic pain
− Urethral Syndrome

DIAGNOSTIC
• Cytoscopy
 13

• X rays
TREATMENT
• Antibiotics
• Nursing care

INTERSTITIAL CYSTITIS
No cause, inflammation, autoimmune. Scars bladder (ulcers), mostly in women. No test
for it. Medication – UT analgesics – Pyridium (rust colored urine) & Preleif. S/S –
dysuria (huts to void). Do not give acidic food or drinks – because they cause ulcers.

AC UTE GLO MER ULO NEPHRITIS

− Acute Glomerulonephritis
o Acute poststreptococcal glomerulonephritis is the result of antigen-
antibody reaction where insoluble immune complexes develop and become
entrapped in glomerular tissue, producing swelling and death of capillary
cells.
o Also occurs after Impetigo, Acute viral infections
o Renal function is impaired by scarring and obstruction of circulating blood
flow through the glomerulus
o Most common in children and young adults

COMPLICATIONS – HTN w/ encephalopathy, HF, pulmonary edema

Clinical Manifestations
o Early:
 Hematuria with smoky or rusty appearance
 Proteinuria
 Azotemia
 Increased urine specific gravity
 ^ESR (erythrocyte sedimentation rate)
 Oliguria

o Late:
 Circulatory congestion = CHF & pulmonary edema (in Elderly)
 Hypertension
 Edema
 Kidney failure
 Possible abd or flank pain
 H/A
 14

 Malaise
 Treatment/Nursing Care
MEDICATIONS
Antibiotics-penicillin if strep present
Steroids to reduce inflammation
Immunosuppressants
Loop diuretics
Angiotensin II receptor blocking agents
Maybe Kayexalate to treat ^ K+
o Treatment/Nursing Care
 Sodium, water, protein restrictions
 Bed rest till B/P normal and edema abates.
 I&O
 Daily weights
 Monitor edema and lung sounds frequently along with VS
 Patient education
 Protein restricted
DIAGNOSTIC
Kidneys become large
Edematous & congested
Kidney biopsy
Creatnine
Sediments rate
BUN
CHR ONIC GLO MERU LO NEPHRITIS
o Results from acute glomerulonephritis, hypertensive nephrosclerosis,
hyperlipidemia, chronic tubulointerstitial injury, glomerular sclerosis,
goodpasture syndrome (caused by antibodies to glomerulal basement
membrane)
o It’s characterized by progressive destruction of glomeruli and gradual loss
of renal function.
o The glomeruli become sclerosed and the kidney size decreases.
o Signs/Symptoms of CGN
 Proteinuria  Edema (l)
 Hematuria  Nocturia (early)
 Dyspnea on  Weight loss (e)
exertion  H/A (early)
 Blurred vision  Dizziness (early)
 Weakness/fatigue
 15

 Digestive  Yellow-gray
disturbances (e) pigment to skin (l)
 Irritability (e)  Symptoms of heart
failure (l)

o Treatment/Nursing Care
 Symptomatic
 Similar to that of AGN when hematuria, hypertension, and edema
present.
 Treatment of kidney failure begins when the illness progresses to
end-stage renal disease
 Nursing care as AGN

DIAGNOSTIC
Specific gravity fixed at 1.010
Creatnine to test renal function
GFR below 50