OVERVIEW OF ANATOMY AND PHYSIOLOGY

➢ The renal and urinary systems include the kidneys, ureters, bladders, and urethra.
➢ The primary purpose of the renal and urinary systems is to maintain the body’s state of homeostasis
by carefully regulating fluid and electrolytes, removing wastes, and providing other functions.

Kidneys
➢ a pair of bean-shaped, brownish-red structures located retroperitoneally (behind and outside the
peritoneal cavity) on the posterior wall of the abdomen—from the 12th thoracic vertebra to the 3rd
lumbar vertebra in the adult. The rounded outer convex surface of each kidney is called the hilum. Each
hilum is penetrated with blood vessels, nerves, and the ureter.
➢ The average adult kidney weighs approximately 113 to 170 g (about 4.5 oz) and is 10 to 12 cm long, 6
cm wide, and 2.5 cm thick.
➢ The right kidney is slightly lower than the left due to the location of the liver.

The Renal Parenchyma

➢ is divided into two parts: the cortex and the medulla.

MEDULLA
➢ approximately 5 cm wide
➢ is the inner portion of the kidney.
➢ It contains the loops of Henle, the vasa recta, and the collecting ducts of the juxtamedullary
nephrons.
➢ The collecting ducts from both the juxtamedullary and the cortical nephrons connect to the renal
pyramids, which are triangular and are situated with the base facing the concave surface of the kidney
and the point (papilla) facing the hilum, or pelvis.
➢ Each kidney contains approximately 8 to 18 pyramids.
➢ The pyramids drain into minor calyces, which drain into major calyces that open directly into the renal
pelvis. The tip of each pyramid is called a papilla and projects into the minor calyx. The renal pelvis is
the beginning of the collecting system and is composed of structures that are designed to collect and
transport urine.

CORTEX
➢ approximately 1 cm wide
➢ is located farthest from the center of the kidney and around the outermost edges. It contains the
nephrons (the structural and functional units of the kidney responsible for urine formation)

Blood Supply to the Kidneys

➢ The hilum is the concave portion of the kidney through which the renal artery enters and the ureters
and renal vein exit. The kidneys receive 20% to 25% of the total cardiac output, which means that all of
the body’s blood circulates through the kidneys approximately 12 times per hour.
➢ The renal artery (arising from the abdominal aorta) divides into smaller and smaller vessels, eventually
forming the afferent arterioles.
➢ Each afferent arteriole branches to form a glomerulus, which is the capillary bed responsible for
glomerular filtration [glomerulus - which is the tuft of capillaries forming part of the nephron through
which filtration occurs]
➢ Blood leaves the glomerulus through the efferent arteriole and flows back to the inferior vena cava
through a network of capillaries and veins.
Nephrons
➢ Each kidney has 1 million nephrons that are located within the renal parenchyma and are responsible
for the formation of filtrate that will become urine. The large number of nephrons allows for adequate
renal function even if the opposite kidney is damaged or becomes nonfunctional. If the total number of
functioning nephrons is less than 20% of normal, renal replacement therapy needs to be considered.

➢ There are two types of nephrons.

CORTICAL NEPHRONS
➢ Make up 80% to 85% of the total number and are located in the outermost part of the cortex, and the
JUXTAMEDULLARY NEPHRONS
➢ Make up the remaining 15% to 20% and are located deeper in the cortex
➢ distinguished by long loops of Henle and are surrounded by long capillary loops called vasa recta that
dip into the medulla of the kidney. The length of the tubular component of the nephron is directly
related to its ability to concentrate urine.

Nephrons are made up of two basic components:

GLOMERULUS
➢ is a unique network of capillaries suspended between the afferent and efferent blood vessels, which
are enclosed in an epithelial structure called the Bowman capsule.
➢ The glomerular membrane is composed of three filtering layers: the capillary endothelium, the
basement membrane, and the epithelium.
➢ This membrane normally allows filtration of fluid and small molecules yet limits passage of larger
molecules, such as blood cells and albumin. Pressure changes and the permeability of the glomerular
membrane of the Bowman capsule facilitate the passage of fluids and various substances from the
blood vessels, filling the space within the Bowman capsule with this filtered solution.
TUBULES
➢ The tubular component of the nephron begins in the Bowman capsule.
➢ The filtrate created in the Bowman capsule travels first into the proximal tubule, which is made up of
epithelial cells resting on the basement membrane, then the loop of Henle, the distal tubule, and either
the cortical or medullary collecting ducts.
➢ The structural arrangement of the tubule allows the distal tubule to lie in close proximity to where the
afferent and efferent arterioles, respectively, enter and leave the glomerulus. The distal tubular cells
located in this area, known as the macula densa, function with the adjacent afferent arteriole and
create what is known as the juxtaglomerular apparatus. This is the site of renin production.
➢ Renin is a hormone directly involved in the control of arterial blood pressure; it is essential for proper
functioning of the glomerulus.
➢ The tubular component consists of the Bowman capsule, the proximal tubule, the descending and
ascending limbs of the loop of Henle, and the cortical and medullary collecting ducts. This portion of
the nephron is responsible for making adjustments in the filtrate based on the body’s needs. Changes
are continually made as the filtrate travels through the tubules until it enters the collecting system and
is expelled from the body
Ureters, Bladder, and Urethra
The urine formed in the nephrons flows into the renal pelvis and then into the:

URETERS
➢ 24 to 30 cm long fibromuscular tubes that connect each kidney to the bladder
➢ The left ureter is slightly shorter than the right ureter
➢ The lining of the ureters is made up of transitional cell epithelium called urothelium. The urothelium
prevents reabsorption of urine
➢ The movement of urine from each renal pelvis through the ureter into the bladder is facilitated by
peristaltic contraction of the smooth muscles in the ureter wall
➢ There are three narrowed areas of each ureter: the ureteropelvic junction, the ureteral segment near
the sacroiliac junction, and the ureterovesical junction. These three areas of the ureters have a
propensity for obstruction by renal calculi (kidney stones) or stricture.
➢ Obstruction of the ureteropelvic junction is the most serious because of its close proximity to the
kidney and the risk of associated kidney dysfunction.

URINARY BLADDER
➢ is a distensible muscular sac located just behind the pubic bone
➢ The usual capacity of the adult bladder is 400 to 500 mL, but it can distend to hold a larger volume. The
bladder is characterized by its central, hollow area, called the vesicle, which has two inlets (the ureters)
and one outlet (the urethra). The area surrounding the bladder neck is called the urethrovesical
junction. The angling of the ureterovesical junction is the primary means of providing antegrade, or
downward, movement of urine, also referred to as efflux of urine. This angling prevents vesicoureteral
reflux (retrograde, or backward, movement of urine) from the bladder, up the ureter, toward the
kidney.
➢ The wall of the bladder contains four layers. The outermost layer is the adventitia, which is made up of
connective tissue. Immediately beneath the adventitia is a smooth muscle layer known as the detrusor.
Beneath the detrusor is a submucosal layer of loose connective tissue that serves as an interface
between the detrusor and the innermost layer, a mucosal lining. The inner layer contains specialized
transitional cell epithelium, a membrane that is impermeable to water and prevents reabsorption of
urine stored in the bladder. The bladder neck contains bundles of involuntary smooth muscle that form
a portion of the urethral sphincter known as the internal sphincter. An important portion of the
sphincter mechanism that helps maintain continence is the external urinary sphincter at the anterior
urethra, which is the segment most distal from the bladder (Grossman & Porth, 2014).

➢ During micturition (voiding or urination), increased intravesical pressure keeps the ureterovesical
junction closed and urine within the ureters. As soon as micturition is completed, intravesical pressure
returns to its normal low baseline value, allowing efflux of urine to resume. Therefore, the only time
that the bladder is completely empty is in the last seconds of micturition, before efflux of urine
resumes.

URETHRA
➢ The urethra arises from the base of the bladder:
➢ In the male, it passes through the penis; in the female, it opens just anterior to the vagina. In the male,
the prostate gland, which lies just below the bladder neck, surrounds the urethra posteriorly and
laterally.
➢ In the female, it opens just anterior to the vagina
FUNCTION OF THE RENAL AND URINARY TRACT
URINE FORMATION
➢ The healthy human body is composed of approximately 60% water.
➢ Water balance is regulated by the kidneys and results in the formation of urine. Urine is formed in the
nephrons through a complex three-step process: glomerular filtration, tubular reabsorption, and
tubular secretion. Each nephron functions independently from other nephrons because each has its own
blood supply.
➢ The various substances normally filtered by the glomerulus, reabsorbed by the tubules, and excreted in
the urine include sodium, chloride, bicarbonate, potassium, glucose, urea, creatinine, and uric acid.
Within the tubule, some of these substances are selectively reabsorbed into the blood. Others are
secreted from the blood into the filtrate as it travels down the tubule. Amino acids and glucose are
usually filtered at the level of the glomerulus and reabsorbed so that neither is excreted in the urine.
➢ Normally, glucose does not appear in the urine. However, renal glycosuria (excretion of glucose in the
urine) occurs if the amount of glucose in the blood and glomerular filtrate exceeds the amount that the
tubules are able to reabsorb. Renal glycosuria can occur on its own as a benign condition. It also occurs
in poorly controlled diabetes —the most common condition that causes the blood glucose level to
exceed the kidney’s reabsorption capacity.
➢ Protein molecules also are not usually found in the urine; however, low– molecular-weight proteins
(globulins and albumin) may periodically be excreted in small amounts. Protein in the urine is referred
to as proteinuria.

3 STEP PROCESS OF URINE FORMATION

1. GLOMERULAR FILTRATION
➢ The normal blood flow through the kidneys is between 1000 and 1300 mL/min.
➢ As blood flows into the glomerulus from an afferent arteriole, filtration occurs. The filtered fluid, also
known as filtrate or ultrafiltrate, then enters the renal tubules.
➢ Under normal conditions, about 20% of the blood passing through the glomeruli is filtered into the
nephron, amounting to about 180 L/day of filtrate.
➢ The filtrate normally consists of water, electrolytes, and other small molecules, because water and
small molecules are allowed to pass, whereas larger molecules stay in the bloodstream.
➢ As blood enters the glomerulus from the afferent arteriole, efficient filtration depends on adequate
blood flow that maintains a consistent pressure through the glomerulus called hydrostatic pressure.
➢ Many factors can alter this blood flow and pressure, including hypotension, decreased oncotic pressure
in the blood, and increased pressure in the renal tubules from an obstruction.

2. TUBULAR REABSORPTION AND

3. TUBULAR SECRETION
➢ The second and third steps of urine formation occur in the renal tubules.
➢ In tubular reabsorption, a substance moves from the filtrate back into the peritubular capillaries or
vasa recta.
➢ In tubular secretion, a substance moves from the peritubular capillaries or vasa recta into tubular
filtrate.
➢ Of the 180 L (45 gallons) of filtrate that the kidneys produce each day, 99% is reabsorbed into the
bloodstream, resulting in the formation of 1 to 2 L of urine each day. Although most reabsorption
occurs in the proximal tubule, reabsorption occurs along the entire tubule.
➢ Reabsorption and secretion in the tubule frequently involve passive and active transport and may
require the use of energy. Tubular secretion occurs when substances move from the peritubular
 capillary blood plasma (blood) into the tubular lumen (filtrate). Tubular secretion helps with the
elimination of potassium, hydrogen ions, ammonia, uric acid, some drugs, and other waste products.
➢ Filtrate becomes concentrated in the distal tubule and collecting ducts under hormonal influence and
becomes urine, which then enters the renal pelvis. In the absence of tubular reabsorption, volume
depletion would rapidly occur.

Antidiuretic Hormone
➢ Antidiuretic hormone (ADH), also known as vasopressin, is a hormone that is secreted by the posterior
portion of the pituitary gland in response to changes in osmolality of the blood. With decreased water
intake, blood osmolality tends to increase, stimulating ADH release.
➢ ADH then acts on the kidney, increasing reabsorption of water and thereby returning the osmolality of
the blood to normal. With excess water intake, the secretion of ADH by the pituitary is suppressed;
therefore, less water is reabsorbed by the kidney tubule, leading to diuresis (increased urine volume).
➢ A dilute urine with a fixed specific gravity (about 1.010) or fixed osmolality (about 300 mOsm/L)
indicates an inability to concentrate and dilute the urine, which is a common early sign of kidney
disease.

Osmolarity and Osmolality

➢ Osmolarity refers to the ratio of solute to water.
➢ The regulation of salt and water is paramount for control of the extracellular volume and both serum
and urine osmolarity. Controlling either the amount of water or the amount of solute can change
osmolarity. Osmolarity and ionic composition are maintained by the body within very narrow limits. As
little as a 1% to 2% change in the serum osmolarity can cause a conscious desire to drink and
conservation of water by the kidneys.
➢ The degree of dilution or concentration of the urine is also measured in terms of osmolality (the
number of osmoles [the standard unit of osmotic pressure] dissolved per kilogram of solution). The
filtrate in the glomerular capillary normally has the same osmolality as the blood—280 to 300
mOsm/kg.

Regulation of Water Excretion

➢ Regulation of the amount of water excreted is an important function of the kidney. With high fluid
intake, a large volume of dilute urine is excreted. Conversely, with a low fluid intake, a small volume of
concentrated urine is excreted.
➢ A person normally ingests about 1300 mL of oral liquids and 1000 mL of water in food per day. Of the
fluid ingested, approximately 900 mL is lost through the skin and lungs (called insensible loss), 50 mL
through sweat, and 200 mL through feces. It is important to consider all fluid gained and lost when
evaluating total fluid status. Daily weight measurements are a reliable means of determining overall
fluid status. One pound (1 lb) equals approximately 500 mL, so a weight change of as little as 1 lb could
suggest an overall fluid gain or loss of 500 mL.

Regulation of Electrolyte Excretion

➢ When the kidneys are functioning normally, the volume of electrolytes excreted per day is equal to the
amount ingested. For example, the average American daily diet contains 6 to 8 g each of sodium
chloride (salt) and potassium chloride, and approximately the same amounts are excreted in the urine.
➢ The regulation of sodium volume excreted depends on aldosterone, a hormone synthesized and
released by the adrenal cortex.
 ➢ With increased aldosterone in the blood, less sodium is excreted in the urine, because aldosterone
fosters renal reabsorption of sodium. Release of aldosterone from the adrenal cortex is largely under
the control of angiotensin II.
➢ Angiotensin II levels are in turn controlled by renin, an enzyme that is released from specialized cells in
the kidneys. This complex system is activated when pressure in the renal arterioles falls below normal
levels, as occurs with shock, dehydration, or decreased sodium chloride delivery to the tubules.
➢ Activation of this system increases the retention of water and expansion of the intravascular fluid
volume, thereby maintaining enough pressure within the glomerulus to ensure adequate filtration.

Regulation of Acid–Base Balance

➢ The normal serum pH is about 7.35 to 7.45 and must be maintained within this narrow range for
optimal physiologic function.
➢ The kidney performs major functions to assist in this balance. One function is to reabsorb and return to
the body’s circulation any bicarbonate from the urinary filtrate;
➢ The second is to excrete acid in the urine [other functions are to excrete or reabsorb acid, synthesize
ammonia, and excrete ammonium chloride]
➢ Because bicarbonate is a small ion, it is freely filtered at the glomerulus. The renal tubules actively
reabsorb most of the bicarbonate in the urinary filtrate. To replace any lost bicarbonate, the renal
tubular cells generate new bicarbonate through a variety of chemical reactions. This newly generated
bicarbonate is then reabsorbed by the tubules and returned to the body.
➢ The body’s acid production is the result of catabolism, or breakdown, of proteins, which produces acid
compounds, particularly phosphoric and sulfuric acids. The normal daily diet also includes a certain
amount of acid materials. Unlike carbon dioxide (CO2), phosphoric and sulfuric acids cannot be
eliminated by the lungs. Because accumulation of these acids in the blood lowers pH (making the blood
more acidic) and inhibits cell function, they must be excreted in the urine. However, if the hydrogen
ions are low, they will be reabsorbed.
➢ A person with normal kidney function excretes about 70 mEq of acid each day. The kidney is able to
excrete some of this acid directly into the urine until the urine pH reaches 4.5, which is 1000 times
more acidic than blood
➢ However, more acid usually needs to be eliminated from the body than can be secreted directly as free
acid in the urine. These excess acids are bound to chemical buffers so that they can be excreted in the
urine. Two important chemical buffers are phosphate ions and ammonia (NH3). When buffered with
acid, ammonia becomes ammonium (NH4).
➢ Phosphate is present in the glomerular filtrate, and ammonia is produced by the cells of the renal
tubules and secreted into the tubular fluid. Through the buffering process, the kidney is able to excrete
large quantities of acid in a bound form without further lowering the pH of the urine.

Autoregulation of Blood Pressure

➢ Regulation of blood pressure is an important function of the kidney. Specialized vessels of the kidney,
called the vasa recta, constantly monitor blood pressure as blood begins its passage into the kidney.
➢ When the vasa recta detect a decrease in blood pressure, specialized juxtaglomerular cells near the
afferent arteriole, distal tubule, and efferent arteriole, secrete the hormone renin.
➢ Renin converts angiotensinogen to angiotensin I, which is then converted to angiotensin II—the most
powerful vasoconstrictor known; angiotensin II causes the blood pressure to increase. The adrenal
cortex secretes aldosterone in response to stimulation by the pituitary gland, which occurs in response
to poor perfusion or increasing serum osmolality.
 ➢ The result is an increase in blood pressure. When the vasa recta recognize the increase in blood
pressure, renin secretion stops. Failure of this feedback mechanism is one of the primary causes of
hypertension

Bladder Emptying
➢ Micturition (voiding) normally occurs approximately eight times in a 24-hour period. It is activated via
the micturition reflex arc within the sympathetic and parasympathetic nervous systems, which causes
a coordinated sequence of events. Initiation of voiding occurs when the efferent pelvic nerve, which
originates in the S1 to S4 area, stimulates the bladder to contract, resulting in complete relaxation of
the striated urethral sphincter. This is followed by a decrease in urethral pressure, contraction of the
detrusor muscle, opening of the vesicle neck and proximal urethra, and flow of urine.
➢ This coordinated effort by the parasympathetic system is mediated by muscarinic and, to a lesser
extent, cholinergic receptors within the detrusor muscle. The pressure generated in the bladder during
micturition is about 20 to 40 cm H2O in females. It is somewhat higher and more variable in males 45
years and older due to the normal hyperplasia of the cells of the middle lobes of the prostate gland,
which surround the proximal urethra. Any obstruction of the bladder outlet, such as in advanced benign
prostatic hyperplasia (BPH), results in a high voiding pressure. High voiding pressures make it more
difficult to start urine flow and maintain it.
➢ If the spinal pathways from the brain to the urinary system are destroyed (e.g., after a spinal cord
injury), reflex contraction of the bladder is maintained, but voluntary control over the process is lost. In
both situations, the detrusor muscle can contract and expel urine, but the contractions are generally
insufficient to empty the bladder completely, so residual urine (urine left in the bladder after voiding)
remains.
➢ Normally, residual urine amounts to no more than 50 mL in the middle-aged adult and less than 50 to
100 mL in the older adult.

Health History
➢ Obtaining a urologic health history requires excellent communication skills, because many patients are
embarrassed or uncomfortable discussing genitourinary function or symptoms (Weber & Kelley, 2014).
➢ It is important to use language the patient can understand and to avoid medical jargon.

When obtaining the health history, the nurse should inquire about the following:
➢ The patient’s chief concern or reason for seeking health care, the onset of the problem, and its effect
on the patient’s quality of life
➢ The location, character, and duration of pain, if present, and its relationship to voiding; factors that
precipitate pain, and those that relieve it
➢ History of urinary tract infections, including past treatment or hospitalization for urinary tract infection
➢ Fever or chills
➢ Previous renal or urinary diagnostic tests, surgeries or procedures; or the use of indwelling urinary
catheters
➢ Dysuria (painful or difficult urination), as well as during voiding (i.e., at initiation or at termination of
voiding) this occurs
➢ Hesitancy, straining, or pain during or after urination
➢ Urinary incontinence (stress incontinence, urge incontinence, overflow incontinence, or functional
incontinence)
➢ Hematuria (RBCs in the urine) or change in color or volume of urine Nocturia and its date of onset
➢ Renal calculi (kidney stones), passage of stones or gravel in urine
 o In female patients, the number and type (vaginal or cesarean) of deliveries; the use of forceps;
vaginal infection, discharge, or irritation; contraceptive practices
➢ History of anuria (decreased urine production of less than 50 mL in 24 hours) or other kidney problem
➢ Presence or history of genital lesions or sexually transmitted infections
➢ The use of tobacco, alcohol, or recreational drugs
➢ Any prescription and over-the-counter medications (including those prescribed for renal or urinary
problems)

COMMON SYMPTOMS
Pain
➢ Genitourinary pain is usually caused by distention of some portion of the urinary tract as a result of
obstructed urine flow or inflammation and swelling of tissues. Severity of pain is related to the sudden
onset, rather than the extent of distention.
➢ lists the various types of genitourinary pain, characteristics of the pain, associated signs and symptoms,
and possible causes. However, kidney disease does not always involve pain. It tends to be diagnosed
because of other symptoms that cause a patient to seek health care, such as pedal edema, shortness of
breath, and changes in urine elimination

Changes in Voiding
➢ Micturition is normally a painless function that occurs approximately eight times in a 24-hour period.
The average person voids 1 to 2 L of urine in 24 hours, although this amount varies depending on fluid
intake, sweating, environmental temperature, vomiting, or diarrhea.
➢ Common problems associated with voiding include frequency (voiding more frequently than every 3
hours), urgency, dysuria, hesitancy, incontinence, enuresis, polyuria, oliguria, and hematuria. Increased
urinary urgency and frequency, coupled with decreasing urine volumes strongly suggest urine retention.
Depending on the acuity of the onset of these symptoms, immediate bladder emptying via
catheterization and evaluation may be necessary to prevent kidney dysfunction.

Gastrointestinal Symptoms
➢ Gastrointestinal signs and symptoms are often associated with urologic conditions because of shared
autonomic and sensory innervation and renointestinal reflexes.
➢ The proximity of the right kidney to the colon, duodenum, head of the pancreas, common bile duct,
liver, and gallbladder may cause gastrointestinal disturbances.
➢ The proximity of the left kidney to the colon (splenic flexure), stomach, pancreas, and spleen may also
result in intestinal symptoms.
 ➢ The most common signs and symptoms are nausea, vomiting, diarrhea, abdominal discomfort, and
abdominal distention. Urologic symptoms can mimic such disorders as appendicitis, peptic ulcer
disease, and cholecystitis; this can make diagnosis difficult, especially in the elderly, who have
decreased neurologic innervation to this area

Unexplained Anemia
➢ Gradual kidney dysfunction can be insidious in its presentation, although fatigue is a common
symptom. Fatigue, shortness of breath, and exercise intolerance all result from the condition known as
“anemia of chronic disease.”

Past Health, Family, and Social History

➢ Data collection about previous health problems or diseases provides the health care team with useful
information for evaluating the patient’s current urinary status.
➢ People with diabetes who have hypertension are at risk for renal dysfunction. Older men are at risk for
prostatic enlargement, which causes urethral obstruction and can result in urinary tract infections and
kidney disease.
➢ People with a family history of urinary tract problems are at increased risk for renal disorders. Genetics
may also influence renal conditions
➢ It is also important to assess the patient’s psychosocial status, level of anxiety, perceived threats to
body image, available support systems, and sociocultural patterns.

Physical Assessment
➢ Several body systems can affect upper and lower urinary tract dysfunction, and conversely that
dysfunction can affect several end organs; therefore, a head-to-toe assessment is indicated.
➢ Areas of emphasis include the abdomen, suprapubic region, genitalia, lower back, and lower
extremities.
➢ The kidneys are not usually palpable. However, palpation of the kidneys may detect an enlargement
that could prove to be very important
DIAGNOSTIC TESTS AND NURSING IMPLICATIONS

Non-invasive Tests

Diagnostic Imaging
Kidney, Ureter, and Bladder Studies
➢ An x-ray study of the abdomen or kidneys, ureters, and bladder (KUB) may be performed to delineate
the size, shape, and position of the kidneys and to reveal urinary system abnormalities

General Ultrasonography
➢ Ultrasonography is a noninvasive procedure that uses sound waves passed into the body through a
transducer to detect abnormalities of internal tissues and organs.
➢ Abnormalities such as fluid accumulation, masses, congenital malformations, changes in organ size,
and obstructions can be identified.
➢ During the test, the lower abdomen and genitalia may need to be exposed. Ultrasonography requires a
full bladder; therefore fluid intake should be encouraged before the procedure

Bladder Ultrasonography
➢ Bladder ultrasonography is a noninvasive method of measuring urine volume in the bladder
➢ It may be indicated for urinary frequency, inability to void after removal of an indwelling urinary
catheter, measurement of postvoiding residual urine volume, inability to void postoperatively, or
assessment of the need for catheterization during the initial stages of an intermittent catheterization
training program

Computed Tomography and Magnetic Resonance Imaging

➢ Computed tomography (CT) scans and magnetic resonance imaging (MRI) are noninvasive techniques
that provide excellent cross-sectional views of the anatomy of the kidney and urinary tract
➢ They are used to evaluate genitourinary masses, nephrolithiasis, chronic renal infections, renal or
urinary tract trauma, metastatic diseases, and soft tissue abnormalities.
➢ Both MRIs and CT scans can view internal body structures. However, a CT scan is faster and can provide
pictures of tissues, organs, and skeletal structure
➢ An MRI is highly adept at capturing images that help doctors determine if there are abnormal tissues
within the body. MRIs are more detailed in their images

Computed Tomography Scan

➢ Computed tomography (CT) scan, also known as computerized axial tomography (CAT), or CT scanning
computerized tomography is a painless, noninvasive diagnostic imaging procedure that produces cross-
sectional images of several types of tissue not clearly seen on a traditional X-ray
➢ CT scans may be performed with or without contrast medium. A contrast may either be an iodine-
based or barium-sulfate compound that is taken orally, rectally, or intravenously which can enhance
the visibility of specific tissues, organs, or blood vessels.

RENAL - A Renal scan examines the structural and functional abnormalities of the kidney. It is indicated to
detect tumors, destructions, and lesions.
Indication
➢ Identify and diagnose renal abnormalities, such as calculi, obstruction, tumor, polycystic disease,
congenital abnormalities, and abnormal fluid accumulation
➢ Evaluate retroperitoneal pathologies

Abnormal Results
➢ Abscesses
➢ Calculi
➢ Congenital anomalies
➢ Hematomas
➢ Kidney infection or damage
➢ Lymphoceles
➢ Obstructions
➢ Polycystic kidney disease
➢ Renal cell carcinoma
➢ Renal cysts or masses
➢ Vascular or adrenal tumors

Procedure
1. The patient is positioned on an adjustable table inside an encircling body scanner (gantry); straps and
pillows may be used to help in maintaining the correct position.
2. The patient may be instructed to hold his breath during the scanning.
3. A series of transverse radiographs are taken and recorded.
4. The information is reconstructed by a computer and selected images are photographed.
5. Once the images are reviewed, an I.V. contrast enhancement may be ordered and additional images
are obtained.
6. The patient is assessed carefully for adverse effects to the contrast medium

Nursing Responsibilities
The following are the nursing interventions BEFORE computed tomography:
• Informed Consent. Obtain an informed consent properly signed.
• Look for allergies. Assess for any history of allergies to iodinated dye or shellfish if contrast media is
to be used.
• Get health history. Ask the patient about any recent illnesses or other medical conditions and
current medications being taken. The specific type of CT scan determines the need for an oral or I.V.
contrast medium
• Check for NPO status. Instruct the patient to not to eat or drink for a period amount of time
especially if a contrast material will be used.
• Get dressed up. Instruct the patient to wear comfortable, loose-fitting clothing during the exam.
• Provide information about the contrast medium. Tell the patient that a mild transient pain from
the needle puncture and a flushed sensation from an I.V. contrast medium will be experienced.
• Instruct the patient to remain still. During the examination, tell the patient to remain still and to
immediately report symptoms of itching, difficulty breathing or swallowing, nausea, vomiting,
dizziness, and headache.
• Inform about the duration of the procedure. Inform the patient that the procedure takes from five
(5) minutes to one (1) hour depending on the type of CT scan and his ability to relax and remain still.
The following are the nursing interventions AFTER computed tomography:
• The nurse should be aware of these post-procedure nursing interventions after computed
tomography (CT) scan:
• Diet as usual. Instruct the patient to resume the usual diet and activities unless otherwise ordered.
• Encourage the patient to increase fluid intake (if a contrast is given). This is so to promote
excretion of the dye.

Magnetic Resonance Imaging

➢ It is an imaging test that uses powerful magnets and radio waves to create images or pictures of your
body in detail. It has become the preferred procedure for diagnosing a large number of potential
problems in many different parts of the body. It does not use radiation (c-rays). It is also called Nuclear
magnetic resonance (NMR) imaging.

PROCEDURE
➢ You may be asked to wear a hospital gown or clothing without zippers or snaps (such as sweatpants
and a t-shirt). Certain types of metal can cause blurring images.
➢ You will lie on a narrow table, which slides into a large tunnel-shaped scanner.
➢ Some exams require a special dye (contrast). Most of the time, the dye is given during the test through
a vein (IV) in your hand or forearm. The dye helps the radiologist see certain areas more clearly.
➢ During the MRI, the person who operates the machine will watch you from another room. The test
lasts about 30 to 60 minutes, but it may take longer.

Nursing Responsibilities
a. Before the procedure
1. Patient may be asked not to eat or drink anything for 4 – 6 hours before the scan.
2. Asked patient if they are afraid of close spaces or claustrophobia and inform the doctor. Patient may
be given a medicine to help them feel sleepy and less anxious, or the doctor may suggest an “open”
MRI, in which the machine is not as close to the body.
3. Before the test, asked the patient if they have the following: pacemakers, hearing aids, aneurysm clips
and etc.
4. Asked patients to remove the following:
• Items such as jewelry, watches, credit cards, and hearing aids – may be damaged.
• Pens, pocketknives, and eyeglasses – may fly across the room.
• Pins, hairpins, metal zippers, and similar metallic items – can distort the images.
• Removable dental work should be taken our just before the scan.
• Because the MRI contains strong magnets, metal objects are not allowed into the room with
the MRI scanner.
• It is important to inform the health care provider of any pregnancy or suspected pregnancy
prior to the procedure

b. During the procedure

• Patient will be asked to remain perfectly still during the time the imaging takes place, but between
sequences some minor movement may be allowed. The MRI Technologist will advise accordingly.
• When MRI procedure begins, patient may breathe normally, however, for certain examinations it may
be necessary for you to hold your breath for a short period of time.
• Monitoring is indicated to patients who are great potential for change in physiologic status (respiratory
rate, oxygen saturation, temperature, heart rate, and blood pressure) during the procedure or
 whenever a patient requires observations of vital physiologic parameters due to an underlying health
problem.
• Monitoring is imperative to patients who are using sedative or anesthesia to ensure patient safety

c. After the procedure

• Prior to allowing the patient to leave the MRI facility, the patient should be alert, oriented, and have
stable vital signs. A responsible adult should accompany the patient home. Written instructions that
include an emergency telephone number should be provided to the patient.

Invasive Procedures

Intravenous Pyelogram
➢ An intravenous pyelogram, also called an excretory urogram, is an X-ray exam of your urinary tract.An
intravenous pyelogram lets your doctor view your kidneys, your bladder and the tubes that carry urine
from your kidneys to your bladder (ureters).
➢ An intravenous pyelogram may be used to diagnose disorders that affect the urinary tract, such as
kidney stones, bladder stones, enlarged prostate, kidney cysts or urinary tract tumors.
➢ During an intravenous pyelogram, you'll have an X-ray dye (iodine contrast solution) injected into a
vein in your arm. The dye flows into your kidneys, ureters and bladder, outlining each of these
structures. X-ray pictures are taken at specific times during the exam, so your doctor can clearly see
your urinary tract and assess how well it's working.

PROCEDURE
1. A cannula is inserted in the vein usually in the arm where in a contrast media is injected.
2. Using the X-ray, the contrast media is seen and termed as “renal blush”.
3. X ray shots are taken in intervals to capture the way it travels inside the urinary system.
4. After three (3) minutes of X-ray shots, the calices and renal pelvis can now be seen.
5. After 9 to 13 minutes it goes to the bladder.
6. The contrast is excreted or removed from the bloodstream via the kidneys.
7. A post micturition X-ray is then taken in order to compare the images for more evidence of pathology.

Nursing Responsibilities
Before the procedure
1. Assess the history of allergy, medications currently taken and risk of pregnancy for women
2. Check if consent is properly signed
3. Emphasize to the patient that nothing should be taken or ingested 12 hours before the procedure

After the procedure

1. Monitor the intake and output strictly especially the next 24 hours
2. Assess for adverse reactions
3. Assess the puncture site for active bleeding
4. Document the findings properly
Renal Angiogram
➢ A renal angiogram, or renal arteriogram, provides an image of the renal arteries
➢ The femoral (or axillary) artery is pierced with a needle, and a catheter is threaded up through the
femoral and iliac arteries into the aorta or renal artery
➢ A contrast agent is injected to opacify the renal arterial supply. Angiography is sued to evaluate renal
blood flow in suspected renal trauma, to differentiate renal cysts from tumors, and to evaluate
hypertension. It is used preoperatively for renal transplantation.
➢ Before the procedure, a laxative may be prescribed to evacuate the colon so that unobstructed x-rays
can be obtained. Injection sites (groin for femoral approach or axilla for axillary approach) may be
shaved. The peripheral pulse sites (Radial, femoral, and dorsalis pedis) are marked for easy access
during postprocedural assessment
➢ The patient is informed that there may be a brief sensation of warmth along the course of the vessel
when the contrast agent is injected

Renal Scan
➢ A renal scan involves the use of radioactive material to examine your kidneys and assess their function.
A renal scan is also known as a renal scintigraphy, renal imaging, or a renogram
➢ During this procedure, a technician injects a radioactive material called a radioisotope into your vein.
The radioisotope releases gamma rays. A gamma camera or scanner can detect gamma rays from
outside your body.
➢ The gamma camera scans the kidney area. It tracks the radioisotope and measures how the kidneys
process it. The camera also works with a computer to create images. These images detail the structure
and functioning of the kidneys based on how they interact with the radioisotope.
➢ Images from a renal scan can show both structural and functional abnormalities. This helps doctors
diagnose a kidney problem in its earlier stages without invasive techniques or surgery.
➢ A renal scan can explore more than one type of problem during the same procedure. A renal scan
measures kidney function by monitoring the flow of the radioisotope and how efficiently your kidneys
absorb and pass it. It also shows abnormalities in the structure, size, or shape of your kidneys.

Cystometogram
It helps to diagnose problems related to urine control. These can be incontinence, difficulty emptying the
bladder, overactive bladder, obstructions or frequent infections.
➢ Before the test, you will be asked to empty your bladder as much as you can. A small soft tube (called a
catheter) is inserted into the urethra until it reaches your bladder. The catheter allows the bladder to
be emptied completely. It is also used to measure the amount of urine remaining in the bladder after
you go. Plus, it measures the strength of your bladder by recording pressure.
➢ Another small catheter, about the size of a soft spaghetti noodle, is placed into the rectum. This
catheter is used to measure pressure on the outside of the bladder in the abdomen.
➢ The bladder is then slowly filled with liquid (usually sterile water, sterile saline, or a sterile fluid). This
liquid includes a dye that can be seen on x-ray. You will be asked to describe what you feel in your
bladder. Does it feel cool? Do you feel full? Does it hurt? You may be asked to cough or bear down to
see if there are leaks.
➢ When you feel a full bladder and you need to urinate, you will do so in a special toilet. You will go while
the special catheters and sensors are in place. This allows your health care provider to measure
pressure as you urinate. This part of the test is called a Voiding Pressure Study (pressure flow study).
➢ For about one day after the study, some people feel a sense of burning or pain when they urinate or
may see blood. This will go away. If you continue to see blood in your urine or have a fever, please tell
your doctor.
Cystoscopy and Biopsy
➢ Known as cystoureterohraphy or prostatography, is an invasive diagnostic procedure that allows direct
visualization of the urethra, urinary bladder, and ureteral orifices through the transurethral insertion of
a cystoscope into the bladder
➢ There are two types of cystoscopy: rigid and flexible. A rigid cystoscopy uses a thin, lighted tube that
consists of an obturator and a telescope with a lens and light system; It is usually performed to take
tissue samples and carry out complicated surgeries. It is done under general or spinal anesthesia.
While flexible cystoscopy uses a flexible fiber-optic telescope to provide diagnosis of urinary
abnormalities and to evaluate the effectiveness of a treatment. It is performed under local anesthesia.
➢ If a prostatic tumor is found, a biopsy specimen may be obtained by means of a cytology brush or
biopsy forceps inserted through the scope. If the tumor is small and localized, it can be excised and
fulgurated. This procedure is termed transurethral resection of the bladder.
o Polyps can also be identified and excised.
o Ulcers or bleeding sites can be fulgurated using electrocautery.
o Renal calculi can be crushed and removed from the ureters and bladder.
o Ureteral catheters can be inserted via the scope to obtain urine samples from each kidney for
comparative analysis and radiographic studies.
o Ureteral and urethral strictures can also be dilated during this procedure.

Nursing Responsibilities
Before cystoscopy
The following are the nursing interventions prior to cystography:
• Assess patient’s understanding of the procedure and answer any queries. The procedure is usually
performed in a urology clinic and it takes about 30-45 minutes. Inform the patient who will perform
the test, where it will take place, and other health team members involved in the care.
• Obtain informed consent. A written and informed consent is signed prior to the procedure and
before administration of medications.
• Withhold blood thinning medications. Some examples are aspirin, warfarin (Coumadin),
enoxaparin (Lovenox), heparin, clopidogrel (Plavix), and dabigatran (Pradaxa).
• Provide instruction for fasting and non-fasting preparation. Unless a general anesthetic has been
ordered, inform the patient that he doesn’t need to restrict food and fluids. If a general anesthetic
will be administered, instruct the patient to fast for at least 6 to 8 hours prior to the test.
• Establish an IV line. To allow infusion of fluids, anesthetics, sedatives or emergency medications.
• Prepare the patient. Instruct patient to empty the bladder prior to the procedure and to change
into the hospital gown provided.
• Administer sedation and other medications as ordered. Preoperative medications are given 1 hour
before the test. Sedative decreases the spasm of the bladder sphincter, reducing the patient’s
discomfort.

After cystoscopy
The nurse should note of the following nursing care after cystoscopy:
• Monitor and record vital signs. An increase in pulse (tachycardia) and a decrease in blood
pressure (hypotension) may indicate a sign of hemorrhage.
• Assess the patient’s ability to void at least 24 hours after the procedure. Urinary retention may be
secondary to edema as a result from instrumentation.
• Observe the color of urine. Pink-tnged urine and burning or mild discomfort when urinating may be
experienced for a few voidings after the procedure. This usually resolves within two or three days.
 • Encourage increased fluid intake as indicated. Fluids will help flush the bladder to decrease the
amount of bleeding and to reduce risk of infection.
• Encourage deep breathing exercises. These exercises may relieve the patient from bladder spasms.
• Provide warm sitz baths and administer mild analgesics as ordered. These may relieve urinary
discomfort and promote muscle relaxation.
• Watch out for signs of serious complications (sepsis, bladder perforation, hematuria). Persistent,
severe flank pain, elevated temperature over 101° F, chills, bright red blood or clots in the urine,
painful urination, or urinary retention must be reported immediately to the HCP.

Renal Biopsy
Renal and Ureteral Brush Biopsy
➢ Brush biopsy techniques provide specific information when abnormal x-ray findings of the ureter or
renal pelvis raise questions about whether a defect is a tumor, a stone, a blood clot, or an artifact.
➢ First, a cystoscopic examination is conducted. Then, a ureteral catheter is introduced, followed by a
biopsy brush that is passed through the catheter. The suspected lesion is brushed back and forth to
obtain cells and surface tissue fragments for histologic analysis.
➢ After the procedure, IV fluids may be administered to help clear the kidneys and prevent clot
formation. Urine may contain blood (usually clearing in 24 to 48 hours) from oozing at the brush site.
Postoperative renal colic occasionally occurs and responds to analgesic agents

Kidney Biopsy
➢ Biopsy of the kidney is used to help diagnose and evaluate the extent of kidney disease.
➢ Indications for biopsy include unexplained acute kidney injury, persistent proteinuria or hematuria,
transplant rejection, and glomerulopathies.
➢ A small section of renal cortex is obtained either percutaneously (needle biopsy) or by open biopsy
through a small flank incision.
➢ Before the biopsy is carried out, coagulation studies are conducted to identify any risk of post biopsy
bleeding. Contraindications to kidney biopsy include bleeding tendencies, uncontrolled hypertension,
sepsis, a solitary kidney, large polycystic kidneys, kidney neoplasm, urinary tract infection, and morbid
obesity
LABORATORY TESTS

Urinalysis and Urine Culture

➢ The urinalysis provides important clinical information about kidney function and helps diagnose other
diseases, such as diabetes.
➢ The urine culture determines whether bacteria are present in the urine, as well as their strains and
concentration. Urine culture and sensitivity also identify the antimicrobial therapy that is best suited
for the particular strains identified, taking into consideration the antibiotic agents that have the best
rate of resolution in that particular geographic region. Appropriate evaluation of any abnormality can
assist in detecting serious underlying diseases.

Components
Urine examination includes the following:
• Urine color
• Urine clarity and odor
• Urine pH and specific gravity
• Tests to detect protein, glucose, and ketone bodies in the urine (proteinuria, renal glycosuria, and
ketonuria, respectively) M
• icroscopic examination of the urine sediment after centrifugation to detect RBCs (hematuria), white
blood cells (pyuria), casts (cylindruria), crystals (crystalluria), and bacteria (bacteriuria)

Significance of Findings
• Several abnormalities, such as hematuria and proteinuria, produce no symptoms but may be detected
during a routine urinalysis using a dipstick.
• Normally, about 1 million RBCs pass into the urine daily, which is equivalent to one to three RBCs per
high-power field. Hematuria (more than three RBCs per high-power field) can develop from an
abnormality anywhere along the genitourinary tract and is more common in women than in men.
• Common causes include acute infection (cystitis, urethritis, or prostatitis), renal calculi, and neoplasm.
Other causes include systemic disorders, such as bleeding disorders; malignant lesions; and
medications, such as warfarin (Coumadin) and heparin (Heparin Sodium). Although hematuria may
initially be detected using a dipstick test, further evaluation is necessary with a 24-hour collection
• Proteinuria may be a benign finding, or it may signify serious disease. Occasional loss of up to 150
mg/day of protein in the urine, primarily albumin and Tamm–Horsfall protein (also known as
uromodulin), is considered normal and usually does not require further evaluation.
• A dipstick examination, which can detect from 30 to 1000 mg/dL of protein, should be used as a
screening test only, because urine concentration, pH, hematuria, and radiocontrast materials all affect
the results. Because dipstick analysis does not detect protein concentrations of less than 30 mg/dL, the
test cannot be used for early detection of diabetic nephropathy. Microalbuminuria (excretion of 20 to
200 mg/dL of protein in the urine) is an early sign of diabetic nephropathy. Common benign causes of
transient proteinuria are fever, strenuous exercise, and prolonged standing.
• Causes of persistent proteinuria include glomerular diseases, malignancies, collagen diseases, diabetes,
preeclampsia, hypothyroidism, heart failure, exposure to heavy metals, and the use of medications,
such as nonsteroidal anti-inflammatory drugs and angiotensin-converting enzyme (ACE) inhibitors
BUN and Creatinine
Urea is a waste product formed in the liver when protein is metabolized into its component parts (amino
acids). This process produces ammonia, which is then converted into the less toxic waste product urea. This
test measures the blood urea nitrogen (BUN) level in the blood. Sometimes, a BUN to creatinine ratio is
calculated to help determine the cause of elevated levels.

Creatinine is a chemical waste product in the blood that passes through the kidneys to be filtered and
eliminated in urine. The chemical waste is a by-product of normal muscle function. The more muscle a person
has, the more creatinine they produce.

A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your
kidneys and liver are working. A BUN test measures the amount of urea nitrogen that's in your blood.

➢ BUN and creatinine levels that are within the ranges established suggest that your kidneys are
functioning as they should.
➢ Increased BUN and creatinine levels may mean that your kidneys are not working as they should. Your
healthcare practitioner will consider other factors, such as your medical history and physical exam, to
determine what condition, if any, may be affecting your kidneys
➢ Some examples of conditions that can increase BUN levels include:
o Kidney disease, kidney damage, or kidney failure
o Decreased blood flow to the kidneys, caused by conditions such as congestive heart failure,
shock, stress, recent heart attack, or severe burns
o Conditions that can block the flow of urine, such as kidney stones
o Dehydration
o Increased protein breakdown or significantly increased protein in the diet

Creatinine Clearance Test

➢ Measures the rate at which the kidneys clear creatinine from the blood
➢ Creatinine is a chemical waste product in the blood that passes through the kidneys to be filtered and
eliminated in urine. The chemical waste is a by-product of normal muscle function. The more muscle a
person has, the more creatinine they produce.
➢ Because all the creatinine filtered by the kidneys in a given time interval is excreted into the urine.
Creatinine levels are equivalent to the glomerular filtration rate (GFR); the rate at which the kidneys
process blood through the glomerular system
➢ A creatinine clearance test compares the serum creatinine with the amount of creatinine excreted in a
volume of urine for a specified time. A 24-hour time frame is most common.
➢ At the beginning of the test, the patient empties his bladder and the urine is discarded. Then, all urine
voided during the specific time period is collected. Sometime during the test period a blood sample is
drawn to determine the serum creatinine, so that the amount excreted in the urine and the amount
remaining in the blood can be compared. The nurse has an important role in instructing the patient
about the purpose of the test and the procedures that will be used.

Expected creatinine clearance values (expressed as number of milliliters per minute per 1.72 meters squared
of body surface)
➢ Adult males: 97 - 137 ml/min
➢ Adult females: 88 - 128 ml/min
➢ Pregnancy: may be as high as 150 - 200 ml/min
 ➢ Elderly: values diminish with age even if no renal disease exists, as the GRF declines about 10% per
decade after age 50

Uric Acid Test

➢ This test measures the amount of uric acid in your blood or urine.
➢ Uric acid is a normal waste product that’s made when the body breaks down chemicals called purines.
➢ Foods with high levels of purines include liver, anchovies, sardines, dried beans, and beer.
➢ Most uric acid dissolves in your blood, then goes to the kidneys. From there, it leaves the body through
your urine. If your body makes too much uric acid or doesn’t release enough into your urine, it can
make crystals that form in your joints. This condition is known as gout, which is a form of arthritis that
causes painful inflammation in and around the joints. High uric acid levels can also cause other
disorders, including kidney stones and kidney failure.

A uric acid test is most often used to:

• Help diagnose gout
• Help find the cause of frequent kidney stones
• Monitor the uric acid level of people undergoing certain treatments. Chemotherapy and radiation
therapy can cause high levels of uric acid to go into the blood.

➢ A uric acid test can be done as a blood test or a urine test.

➢ During a blood test, a health care professional will take a blood sample from a vein in your arm, using
a small needle. After the needle is inserted, a small amount of blood will be collected into a test tube
or vial. You may feel a little sting when the needle goes in or out. This usually takes less than five
minutes.
➢ For a uric acid urine test, you'll need to collect all urine passed in a 24-hour period. This is called a 24-
hour urine sample test. Your health care provider or a laboratory professional will give you a container
to collect your urine and instructions on how to collect and store your samples. A 24-hour urine sample
test generally includes the following steps:
o Empty your bladder in the morning and flush that urine away. Record the time.
o For the next 24 hours, save all your urine passed in the container provided.
o Store your urine container in the refrigerator or a cooler with ice.
o Return the sample container to your health provider's office or the laboratory as instructed.
MANAGEMENT OF URINARY ELIMINATION DISORDERS
The different treatment modalities of urinary elimination disorders

DIALYSIS
➢ To remove fluid and uremic waste products from the body
➢ Indicated for hepatic coma, uremia, edema, hypertension, hyperkalemia, and hypercalcemia
➢ Could be for acute case such as removing toxins, poison, and to correct electrolyte imbalance
➢ Chronic dialysis is for ESRD [End-stage renal disease] patients, patients with uremia and fluid overload
not responsive to diuretics
➢ 2 kinds of dialysis: (same principles, route and method varies)
1. HEMODIALYSIS
2. PERITONEAL DIALYSIS

HEMODIALYSIS
➢ Process of removing toxins and excess fluid from the blood and tissues by continually circulating blood
through a filter known as a Dialyzer
o It serves as an artificial kidney and is used as an artificial kidney machine
o Has two compartments separated by a membrane that is semipermeable and only particles of a
certain size can pass through it
o A solution called dialysate circulates on one site of the membrane and blood flows through the
other site
o It is made up of water, dextrose and chemicals which make it similar to normal body fluids
without toxins
➢ The dialysis is accomplished through different principles:
o DIFFUSION
▪ A passage of particles from an area of higher concentration to an area of lower
concentration
▪ Toxins move to dialysate wherein there is lesser concentration of lower concentration of
solute
▪ Membrane impedes passage of larger molecules such as the RBC and proteins

o OSMOSIS
▪ The diffusion of water through a semipermeable membrane from a solution of low
solute concentration or high-water potential to solution with high solute concentration
or low water potential, a solute concentration gradient
▪ It is a physical process in which a solvent moves without input of energy across a
semipermeable membrane or a permeable to the solvent but not to the solute
separating two solutions of different concentrations

o ULTRAFILTRATION
▪ Similar to osmosis just that it uses pressure to draw out water or to suction water
towards the dialysate

➢ The dialyzer contains tube with dialysate similar with blood except for the presence of urea and waste
products
➢ The dialyzer is capable of filtering blood up to 200-800 mL/minute
➢ Dialyzer nowadays have already developed and we have different characteristics that will be very
beneficial for our clients:
 1. BIOCOMPATIBILITY wherein the dialyzer will prevent any hypersensitivity reaction towards
the patient
2. HIGH-FLUX DIALYSIS. This will allow the dialyzer to filter more blood in a lesser time. It will
allow higher volume of blood filtered in time shortening the duration and the use of
heparin.

➢ We have different vascular accesses for hemodialysis.

1. Subclavian, internal, jugular, and femoral catheter
- This is a tube or catheter that is used temporarily if there is no time to get a permanent
access.
- The catheter is usually placed in a vein in the neck, chest, or groin
- Because it can clog and become infected, this type of catheter or route is not routinely
used for permanent access but if there is a need to start hemodialysis right away, a
catheter may be used while the permanent access develops
- RISK FACTORS: hematoma, pneumothorax, infection, and thrombosis
- 2 kinds of catheters: double lumen and triple lumen
o DOUBLE LUMEN – 2 ports, one is for input while the other one is for output
o TRIPLE LUMEN – another port that is for the purpose of blood transfusion,
medication administration, or IV therapy

2. Arteriovenous Fistula (AV Fistula)

- A fistula is created by connecting one of the arteries to one of the veins in the lower arm
- A fistula allows repeated access for each dialysis session
- It may take about 6-12 weeks for the fistula to form
- A fistula may not clot as easily as other dialysis access methods
- A fistula is the most effective dialysis access and the most durable
- COMPLICATIONS: infection at the site of access and clot formation or thrombosis

3. Graft (Polytetrafluorethylene)
- The most common arteriovenous graft used is the PTFE
- It uses a vascular access with a synthetic tube implanted under the skin in the arm
maybe used if there are or the patient has very small veins. The tube becomes an
artificial vein that can be used repeatedly for needle placement and blood access during
hemodialysis
- A graft does not need to develop as a fistula does
- A graft can sometimes be used as soon as one week after placement. Compared with
fistulas, grafts tend to have more problems with clotting or infection and need to be
replaced sooner
- Aside from PTFE, we also have gore-tex, another kind of graft that is commonly used for
hemodialysis

➢ The start of hemodialysis treatment, a dialysis nurse or technician places two needles into the arm. A
numbing cream or spray can be used if placing the needles bothers the patient. Each needle is attached
to the soft tube connected to the dialysis machine. Coming from the arterial blood vessel, the dialysis
machine pumps blood through the filter and returns the blood to the body through the veins. During
the process, the dialysis machine checks the blood pressure and controls how quickly blood flows
through the filter and how quick fluid is removed from the body.
➢ Blood enters at one end of the filter and is forced into many, very thin, hollow fibers. The blood passes
through the hollow fibers with a dialysate or the dialysis solution which passes in the opposite
 direction on the outside of the fibers. Waste products from your blood move into the dialysis solution.
The filtered blood will then pass through a machine which is responsible for detecting air to prevent air
emboli flowing to the blood vessels of the patient. Filtered blood remains in the hollow fibers and
returns to the veins.
➢ COMPLICATIONS:
o Atherosclerotic Cardiovascular Disease
▪ One of the most common complications due to disturbing metabolism brought about by
hemodialysis
o Anemia & Fatigue
▪ Due to decreased RBC
▪ We need to administer erythropoietin part of the hemodialysis care to increase
hematocrit
o Dialyzer clotting
▪ Blood clot or thrombus formation in tbe venous access catheter is one of the most
common complication that is why heparin administration or anticoagulant
administration is important
o Gastric ulcer
o Hypotension
▪ Disturbed calcium metabolism which could lead to fracture
o Muscle cramping
▪ If cramp occurs, the usually happen in the last half of the dialysis session
o Dysrhythmia
▪ This is brought about by electrolyte changes within the body
o Exsanguination
▪ Or dislodged lines which will lead to bleeding
o Dialysis disequilibrium
▪ Disequilibrium syndrome is a rapid change in the composition of the extracellular fluid
(ECF) that occurs. Solutes are removed from the blood faster than from the CSF and
brain thus fluid is pulled into the brain causing cerebral edema.
▪ Manifestations: nausea, vomiting, headache, hypertension, restlessness, agitation,
confusion, and seizure

NURSING CONSIDERATIONS
➢ Monitor vital signs
➢ Monitor laboratory values before and after dialysis
➢ Assess the client for fluid overload prior to the procedure
➢ Assess patency of the blood access devised
➢ Weigh the client before and after the procedure to determine fluid loss

1. Timing of medications, especially antihypertensive medications.

➢ Take note of the timing or adjust the timing of the medications taken during dialysis day. Ideally,
antihypertensives and other medications that can affect blood pressure prior to the procedure is put
on hold as prescribed. Also, medications that could be dialyzed off such as water-soluble vitamins and
certain antibiotics are also put on hold. With regards to this since there is a high chance of
hypovolemia or hypotension, then we monitor the client for shock and hypovolemia during the
procedure.
2. Dietary modifications (Alkaline-ash diet)
➢ We also provide adequate nutrition by doing some dietary modifications. Take note that clients for
hemodialysis suffer from acidosis so we encourage the clients to take or to have an alkaline-ash diet.
➢ Alkaline-ash diet would increase or has the capability to increase the pH of the blood. This would
include vegetables, fruits, salmon, and meat.
➢ We need to have some dietary restrictions especially to protein intake. The ideal protein intake for
clients undergoing hemodialysis would be 1 gram/kg/day. Protein = 1g/kg/day
➢ Sodium restriction should be within 2-3 grams/day. Na+ = 2-3g/day
➢ Fluid would be based on the 24hour urine output plus 500 mL/day. Fluid = UO + 500mL/day
➢ Potassium is equal to 1.5-2.5 grams/day. K- = 1.5-2.5g/day
➢ It is also important that we maintain interdialytic weight gain of 1.5 kg. This is the weight gain
allowance of the client in between periods of dialysis sessions.

3. Encourage verbalization of feelings

➢ Dealing with patients undergoing dialysis, they may suffer from financial problems, difficulty holding a
job, no interest in sexual desire and impotence, depression and fear of dying. Their lifestyle is also
altered due to imposed frequent dialysis visits and food restrictions. We give the patient and family
chances to express their feelings.
➢ We promote good communication and the five E’s:
o Encouragement. Impose positive attitude
o Education. Teach clients new strategies to successfully adapt to dialysis
o Exercise
o Employment
o Evaluation of outcomes

4. Periodically assess for presence of bruit and thrill

➢ This will give an idea if the access or the arteriovenous access is patent

5. Continuously monitor for complications (Steal Syndrome)

➢ Steal syndrome – a syndrome caused by ischemia (not enough blood flow) resulting from a vascular
access device (such as an arteriovenous fistula or synthetic vascular graft–AV fistula) that was installed
to provide access for the inflow and outflow of blood during hemodialysis.
o S/S: pain, numbness or tingling sensation in the certain part of the extremity and decreased
CRT.

6. Precautionary measures on affected arm

➢ To keep access sites patent and safe
• Keep the access site clean at all times to prevent infection.
• Avoid injections, intravenous (IV) needles or fluids, or taking blood samples in the access site
arm.
• Needle insertions for hemodialysis treatments should be rotated so that one spot is not
repeatedly stuck and weakened.
• Do not take blood pressure or put pressure on the access arm.
• Advise patients to avoid wearing jewelry or tight clothing, sleeping on, or lifting heavy objects
with the access arm.
• Check the temperature and color of the fingers and the pulse of the access arm for adequate
circulation.
• Check for signs of infection at the access site.
 7. Accurate I/O
➢ Due to the high fluid or massive amount of fluid loss brought about by hemodialysis

8. Blood transfusion
➢ Is ideally done during trans hemodialysis because hemodialysis could lesson or could excrete4 out the
potassium brought about by blood transfusion

9. Manage uremic frost

➢ By keeping the nails of the client short
➢ Instruct the client not to scratch and also to apply calamine lotion to soothe the skin of the client

PERITONEAL DIALYSIS
➢ This uses peritoneum as a semipermeable membrane
➢ There would be high chances of excreting urea than creatinine in this method
➢ Ultrafiltration is done by adding glucose into the dialysate
➢ Provides a steady state of blood chemistries.

➢ Patients can dialyze alone in any location without the need for machinery, can readily be taught to
process.
➢ Patient has a fewer dietary restriction because of loss of protein in dialysate. Patient is usually placed
on high protein diet
➢ Patient has more control over daily life
➢ This can be used for patients that are hemodynamically unstable
➢ In doing the PD, it is important to obtain consent from the patient first. Then, if we are still about to
apply or install the catheter, usually we use the Tenckhoff Catheter.
➢ It is important that the patient should empty the bladder and his bowel.

➢ We administer broad spectrum antibiotic

➢ For the dialysate, we administer medications especially antibiotic to prevent infection within the
peritoneum
➢ Dry heating the dialysate is important to dilate the blood vessels in the abdomen and decrease
cramping
➢ During the insertion of the catheter we use local anesthesia
➢ The catheter is inserted 3.5 cm below the umbilicus and it has cuffs to prevent dislodgement of the
catheter and to keep it still on that certain location

➢ During the exchange, for the exact procedure, we need to focus on the proper timing of exchange.
o Exchange is a combination of infusion or the infusion of dialysate into the peritoneum
o Dwelling is the time we allow the dialysate to stay inside the peritoneum for quite some time
to collect waste, fluid, and chemicals from the peritoneal blood vessels
o Drain is to remove the dialysate with all the toxins that has been removed from the blood.
➢ In doing this, a permanent indwelling catheter is implanted into the peritoneum. The internal cuff of
the catheter becomes imbedded which stabilizes it and minimizes leakage

➢ A connecting tube is attached to the external end of the peritoneal catheter and the distal end of the
tube is inserted into a sterile plastic bag of dialysate solution
 ➢ The dialysate bag is raised to shoulder level and infused by gravity into the peritoneal fluid
approximately ten minutes for a 2L volume. The typical dwelling time is 4-6 hours but it may matter
depending on the physician’s order. At the end of the dwelling time, the dialysate fluid is drained from
the peritoneal cavity by gravity. Drainage of 2L + ultrafiltration takes about 10-20 minutes if the
catheter is functioning optimally. After the dialysate is drained, a fresh bag of dialysate solution is
infused using the aseptic technique and the procedure is repeated.
➢ The patient performs 4-5 exchanges daily, 7 days a week with an overnight dwell time allowing
uninterrupted sleep. Most patients become unaware of fluid in the peritoneal cavity

3 common types of peritoneal dialysis

1. Acute Intermittent Peritoneal Dialysis
o Indicated for uremic patients, patients with fluid overload, or poisoning
o Hemodynamically unstable patients also tend to have these
o Also indicated for children
o Patient does not follow a regular schedule of peritoneal dialysis. Thus, it is only done as needed

2. Continuous Ambulatory Peritoneal Dialysis

o 1.5-3L of dialysate is instilled into the abdomen and lasts in place for a prescribed period of
time. The empty dialysate bag is folded up and carried in a pouch or pocket until it is time to
drain the dialysate. The bag is then unfolded and placed lower than the insertion site so that
the fluid drains by gravity flow. When full, the bag is changed and new dialysate is instilled into
the abdomen as the process continues.
o It usually uses four dialysis cycles every 24 hours including an 8-hour dwell overnight

3. Continuous Cyclic Peritoneal Dialysis

o This necessitate use a peritoneal cycling machine. It can be performed as continuous cyclic,
intermittent, or nightly intermittent peritoneal dialysis. There are usually three cycles at night
and one cycle with an 8-hour dwell time in the morning
o The advantage is that the peritoneal dialysis is open only for on and off procedures which
reduces the risk of infection
o The client does not require exchanges at work or school
o This is performed for 8-12 hours each night with no day-time dwells

➢ Look out for COMPLICATIONS:

1. Peritonitis
o Most common and serious complication of peritoneal dialysis
o S/S: cloudy dialysate drainage, diffuse abdominal pain, rebound tenderness
o Mgmt: submitting the drainage fluid to the laboratory for analysis, administration of antibiotic
agent could be done intraperitoneally; if 4 days after and there is no resolution for the
infection, it is indicated to remove catheter and resume hemodialysis instead for 1 month
before inserting a new catheter
2. Leakage
o Common esp. on newly inserted catheters
o Important to allow time for the catheter to heal
o Nsg con: limit straining or any undue abdominal muscle activity, dialysate should start in small
volume and gradually increase up
3. Bleeding
o This may indicate internal bleeding, however, bloody affluents would be normal for women
who are menstruating and for patients who just have enema
NURSING CONSIDERATIONS
1. Periodically monitor abdominal girth
➢ Through this, we will be able to determine if there is retention of dialysate. In case that retention
occurs, it is important to facilitate drainage by gravity by moving the patient from side to side

2. Strict aseptic technique

➢ To prevent any infection especially peritonitis

3. Educate client on how to independently perform PD

➢ Since this is usually done independently in the comfort of the home or workplace of the client

4. Facilitate drainage by gravity

➢ It’s better that during drainage or time to drain the dialysate, it is important to put the drainage bag
below the level of the catheter site and the patient should be in an upright position
➢ In case there is retention, reposition the client from side to side to allow drainage

5. Secure catheter and keep drainage dry

➢ This is to prevent any infection especially around the catheter site

6. Diet modifications
➢ Would include high fiber and high protein diet because constipation can alter drainage and also, PD will
remove protein excessively compared to hemodialysis. We need to replenish protein loss in PD.
However, since weight gain is common in PD, thus, we need to decrease carbohydrate intake of the
client.

URINARY DIVERSION
➢ Involve removal of the urinary bladder and adjacent tissues and organs and rerouting of the urinary
stream
➢ It establishes an uninterrupted flow of urine most often via stoma where urine is collected in an
appliance attached to the skin’s surface
➢ The flow of urine may be diverted at any level of the urinary system
➢ Urinary diversion procedures are done for patients with cancer of the bladder, congenital defects of
the urinary tract, neurogenic bladder, chronic progressive pyelonephritis and irreparable trauma to the
urinary tract
➢ Under general anesthesia, an incision is made in the abdomen, the ureters – tubes that carry urine
away from the kidneys are caught and tied, the bladder and the surrounding tissues are caught free
and removed. The ureters are then attached to a portion of the intestine
➢ We have the most common types of urinary diversions. These are categorized into two:
1. Cutaneous Urinary Diversion
2. Continent urinary diversion
Cutaneous Urinary Diversion
1. Ileal Conduit
o Ureters are attached to a portion of the small intestine usually the ileum, one end of which is
brought trough the abdominal wall as a conduit for the urine, creating a stoma. The ureters are
excised from the bladder and transplanted into a segment of the colon, usually the ascending,
the transverse, or the descending, and it’s brought out of the skin through the stoma
o An ileostomy bag is applied on the skin of the patient to drain or catch the urine expelled from
the stoma.
2. Cutaneous Ureterostomy
o In this method, the detached ureters from the bladder will be directed from the kidney directly
to the skin wherein there will be an opening for the urine to flow outside of the body.
o Instead of having the kidney connected to the bladder through the ureter, the ureters are now
brought towards the skin to create a stoma
3. Vesicostomy
o Suturing the bladder to the abdominal wall and create an opening. The bladder is stitched
towards the skin with an opening wherein we can collect the urine out from the stoma
4. Nephrostomy
o A temporary or permanent urinary diversion. A single tube or self-retaining new loop is
attached to a closed drainage. This is indicated to bypass an obstruction in the ureter or lower
urinary tract.
o A permanent nephrostomy is due to change every month.
o Directly from the kidney, there will be a tube draining the urine out to a catheter bag wherein
the patient will be bringing all throughout his life, instead of using ureters, because this method
is indicated in case the ureters are blocked.

NURSING CONSIDERATIONS
1. Monitoring strict I/O (Goal: >30mL/hr)
o Having lesser than this amount will be a sign of dehydration or obstruction of the conduit
2. Catheterization in case of urinary stasis
o In case there is low urine output coming out from the stoma, then we can do catheterization.
We need to ensure strict effective aseptic technique to avoid infection
3. Irrigation of stents
o Stents are used to keep the ureter patent. However, irrigation of stents needs to have the
doctor’s order. In doing irrigation, we administer or instill 5-10mL of sterile normal saline but
we also need to make sure that we don’t apply too much tension to prevent dislodging the
stents
4. Urine testing (always keep urine acidic)
o The urine should have pH of less than 6.5 because alkaline urine can cause encrustation of the
stoma. To do this, we need to check the leakage such as wet bed linens, clothing or other urine
around the patient; these are signs that urine is leaking out from the stoma.
o When we drain or obtain urine sample, it should be direct from the stoma and not to obtain it
from the appliance
5. EOF
o To minimize mucous forming from the stoma
6. Promote independence of patient
o The patient should be taught on how to manage the stoma, how to perform stoma care, how to
apply or change the appliance – the ostomy bag, to prevent any complications and to promote
ADLs towards the patient
 7. Control odor
o We instruct the patient not to eat foods that may cause foul or strong odor to the urine such as
asparagus, cheese, eggs. Ascorbic acid is important in helping acidify the urine and lessen urine
odor
8. Stoma care
o It is important to keep the appliance properly fitted to prevent exposure of peristomal skin
(surrounding skin around the stoma) to the urine
o Make sure to keep the stoma pinkish or reddish beefy-like. This would indicate that the stoma
is good and healthy and is well perfused with blood
o In cases that there will be necrosis, purplish or dark discoloration of the stoma, it would
indicate that there is poor circulation or blood flow towards the stoma and needs to be
surgically managed.
o If the urine or alkaline urine leaks out from the stoma, it can cause encrustation of the skin
around the stoma which needs to be managed like how we manage infection

Flange on skin barrier – important to prevent irritation on the

peristomal skin

It is important for us to:

– assess for latex allergy because some appliances are made of
latex.
– change appliance before leakage occurs.
– use skin barrier and avoid moisturizing soaps because it
adheres with tapes

In customizing the appliance, we need to customize that part

depending on the size of the soma. Estimate or measure the
widest diameter/part of the stoma with the stroma and allow
1.6 mL or 1/8-inch allowance.

VIDEO: Ostomy Bag Pouch Change | Ostomy Care Nursing | Colostomy, Ileostomy Bag Change

SUPPLIES:
➢ A pouching system
➢ May need a barrier ring which will go around the stoma for extra protection in case the patient's
having a lot of skin breakdown
➢ Clips (if patient needs one), which is not needed if the pouch is using Velcro
➢ Measuring card, to measure the stoma
➢ Pen
➢ Ostomy scissors
➢ Gloves
➢ Wash cloth, to clean and dry the stoma
➢ Towel to prevent any leakage onto the patient

PROCEDURE:
1. Perform hand hygiene and wear gloves
2. Get a towel and place that on your patient to protect their gown and their skin from any stool while
you are changing the system
3. Keep in mind while doing this you'll want to change the system about every three to five days and you
will empty the pouch whenever it becomes one-third to half way full
4. While you're doing this you want to allow the patient to help you as much as possible because they
need to become independent in doing this because they’ll be doing it whenever they go home
5. If you are a nurse who has a very sensitive nose and you're bothered by odorous smells then you need
to be prepared for this because whenever you're changing an ostomy bag there are some pungent
odors and to help with this you can maybe wear a mask or put vapor rub around the nose before they
go in to change the pouch to prevent the smell and so you can have a menthol smell. Prepare
beforehand
6. We are going to remove the system and you want to do this when the gut is the least active because
you don't want to be changing it and all the stool is just coming out on you because you're going to be
making a huge mess
7. Usually in the morning before breakfast before the patient eats is the best time or ask the patient
because they'll know
8. You're just gently going to remove the adhesive because this is the one piece system and it has it's
sticking to the skin and if you have difficulty removing it, you can use some adhesive remover and then
discard this appropriately
9. Take your washcloth with warm water and try not to use any soap that have lotion, powders, creams,
or any alcohol containing products around or on the stoma because it can cause some problems and
before you do it you want to make sure you're looking around the stoma and looking for any skin
breakdown like extreme redness
10. In the video’s example, there is redness around the stoma. This is not good and what is happening is
that stool is leaking probably under that skin barrier and getting on to the skin, so, whenever you're
replacing the bear at the pouching system, you may want to use a barrier ring and make sure that
you're cutting the skin barrier should fit the stoma appropriately so it's not leaking onto the skin.
11. You'll start around the skin and just gently clean the skin making sure to get any residue off and then
you will clean your stoma. The stoma is not painful to the patient, remember it's just the inside of the
intestines flipped inside out so it's not painful for you to clean the stoma. Make sure you have it all
clean
12. Then you will Pat the area dry. You want this to be very dry because if it's not dry your skin barrier is
not going to stick to the skin
13. If you have a patient who has a lot of hair on the abdomen because you know hair grows back, you
may want to trim the hair, because number one it will stick better and when you remove next pouch
change it's not going to wax or hair off which can be very painful
14. Discard your gloves and perform hand hygiene and put on a new pair of gloves
15. Now we're going to measure our stoma using our measuring card and the reason we want to do this is
because we're going to be cutting a hole on our skin barrier and this is going to be going on the skin
and we don't want to cut it too big or stool will leak to the skin or cut it too small where it will constrict
the stoma.
16. You'll take your measuring card you'll put it flush up against the skin and you want about a 1/8 inch an
area around the stoma so this right here one and that one looks like it's perfect
17. Look and see what it reads and in the video, it says 45 millimeters so we're going to match that up on
our bag and trace it. Now some skin barriers are already labeled and they have outline of where your
measurement is but sometimes skin barriers don't have that so what you would have to do is put your
measuring card over it and trace where you had your measurement. Create a circle on the barrier and
then cut it out using the ostomy scissors. Make sure everything's nice and round and there's no jagged
edges because you don't want this to wear on the stoma or on the patient's skin.
 18. Now let's put the new pouching system on. Using the Velcro or clips, the bag and make sure it's closed
before putting it on just in case something leaks out.
19. Take the backing off of your skin barrier and if you're going to place a barrier ring, now would be the
time to do that so you place the barrier ring on around the stoma and then you would place your skin
barrier, your wafer flange on over the stoma
20. Make sure that it fits really good and that you smooth it around the sign so it's sticking to the skin
appropriately
21. Keep in mind if this is a new ostomy for the patient, you want to explain to them that they need to be
checking their bags ever so often because it can inflate with gas and they will need to do what's called
burping their bag. To burp this particular bag you would take off this clip or Velcro and just let the air
out. Some bags do have a filter that allows the gas to escape and prevents an odorous smell from
coming out so you just have to look to see what you have and just warn the patient that when they do
relieve the gas from their bag, they may want to make sure that no one's around if someone's visiting
them or something like that because it can produce an odorous smell
22. As a nurse, check this as well because our patients tend to wear those big bulky gowns and they can't
include you being able to see the bags so you'll have to pull the gown back and actually look at the bag.

Continent Urinary Diversion

➢ Has an internal reservoir made from intestine that holds urine
➢ This diversion has valves as the reservoir feels preventing urine leakage
➢ The client enters a catheter into the valve? several time each day to empty the urine. Between
catheterization, the client wears a small dressing over the stoma to protect the clothing from mucous
drainage.

1. Continent Ileal Urinary Reservoir (Indiana Pouch)

o This consists of portions of large intestine and ileum. A segment of the ileum and cecum forms
the reservoir. A catheter is inserted into the pouch through a stoma drained at regular intervals.
o This is indicated for patients wherein the bladder was removed or for patients with neurogenic
bladder
2. Continent Ileal Urinary Diversion (Koch Pouch)
o This is formed from loops of small intestine. With this, ureters are transplanted to an isolated
segment of the small bowel, ascending colon or ileocolonic segment.
o Urine is drained by inserting a catheter into the stoma.
o Some modifications can be done for male clients. The pouch can be modified by attaching one
end of the pouch to the urethra of the male client to facilitate normal voiding position. The
valves will prevent leaking of the urine. A catheter is inserted to drain off the urine in regular
intervals.
3. Ureterosigmoidostomy
o The ureters are attached to a portion of the large intestines specifically the sigmoid colon,
which allows the urine to flow through the large intestine and out through the rectum. With
this, both the urine and feces will be expelled through the rectum.
o Drainage needs to be facilitated every two hours with watery diarrhea inconsistency.
NURSING CONSIDERATIONS
1. Post-op: Liquid diet
o Upon post-op, the client should have a liquid diet. This is to reduce residue in colon since most
of the GI tract is used as diversion
2. Anal sphincter control
o Determined by the patient’s ability to retain enema, which will serve as a practice for the client.
The time after rectal catheter is removed, the client should practice or learn how to control his
anal sphincter by trying to retain enema.
3. Voiding pattern – q2-3 hours
o The client should never wait longer than 2-3 hours before emptying urine. This keeps rectal
pressure low and minimizes absorption of urinary constituents from the colon.
4. Diet modifications
o Would include gas forming food such as bubble gum, decreasing sodium and increasing
potassium to treat acidosis
5. Monitor for complications
o Such as pyelonephritis, or the reflux of bacteria from the colon to the kidneys causing
inflammation
o Peritonitis, wherein the urine leaks at the anastomosis
o Stomal ischemia or necrosis. Normally, a stoma would be red or pink, if it turns to purple,
brown, or black, it means that blood supply is compromised. Also, the stoma normally is
insensitive to pain because it has no nerve endings. It is also vascular and may bleed when
cleaned. Presence of mucus is normal if using the GI tract

URINARY CATHETERIZATION
➢ The introduction of a catheter through the urethra into the urinary bladder
➢ Usually performed only when absolutely necessary because the danger exists of introducing
microorganisms in the bladder
➢ Catheterization can be indwelling or intermittent
o Indwelling – catheter will be inserted and will dwell into the urethra with a drainage bag
o Intermittent – one-time catheterization, done to simply drain off urine in a certain time

VIDEO: How to perform catheterization on a male client

SUPPLIES:
➢ Plastic apron
➢ Catheterization kit
➢ Sterile catheter
➢ Syringe
➢ Sterile water
➢ Valve
➢ Hand disinfection
➢ Sodium chloride irrigation solution
➢ Anesthetic catheter gel
➢ Anesthetic catheter gel syringe
➢ Urinary bag
PROCEDURE:
1. Start by opening the catheterization kit.
2. First, you will find the sterile gloves but you can put them aside for now.
3. Pour some sodium chloride irrigation solution into the tray.
4. Remove the catheter from its packaging, while carefully keeping its sterility and place it on the sterile
field.
5. Fill a syringe with sterile water that you will use to fill the catheter balloon with at a later stage.
6. Only now, put on the sterile gloves.
7. Remove the EVA bag and place the catheter into the tray.
8. Prepare the anesthetic catheter gel syringe.
9. It is important to follow the manufacturer’s instructions.
10. The BIP Foley Catheter should be pre-wetted to activate the hydrophilic coating. You can use sterile
water or some of the sodium chloride for this as long as you use cotton pads that don’t release any
fibers into the liquid.
11. Catheterization of a man. Gently pull back the foreskin so you can easily access to clean around the
urethral opening. Remember that this hand is not sterile anymore after touching the patient.
12. Carefully clean the area to avoid any hairs, textile fibers or other particles to enter with the new
catheter.
13. Anesthetize the urethra by completely filling it with anesthetic catheter gel. Use 1-gram gel per cm
urethra. Meaning that for a man, you need approximately 20-30 grams.
14. After filling approximately half of the gel, wait for one minute so the external sphincter muscle is
relaxed.
15. Then fill the remaining amount of gel and let it work a little while before inserting the catheter. (full
effect within 5 minutes)
16. Using your sterile hand, insert the catheter gently. It shouldn’t hurt.
17. When you feel some resistance, the catheter has likely reached the external sphincter muscle. Be extra
careful at this point.
18. Insert the catheter all the way until the final junction.
19. Get some urine in exchange before you fill the catheter balloon with the fluid and precise amount that
the catheter manufacturer recommends.
20. Remember to constantly observe the patient – also this step should not hurt.
21. After you have completed this procedure, make sure that the catheter is positioned correctly and can
move freely.
22. Finally, attach a urinary bag or a valve.

EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL)

➢ Uses shockwaves to break a kidney stone into small pieces that can more easily travel into the urinary
tract and pass from the body
➢ Through this, a client with less than 2 cm of stones could relieve the obstruction in the urinary tract
➢ CONTRAINDICATED: pregnant clients because it uses x-rays and shock waves, clients with bleeding
disorders, infections, and those who are obese
➢ Involves high energy amplitude of pressure abruptly release from transmuted shock waves through
water and soft tissues
➢ As the stones turn into small pieces, it can easily pass through the urine.
➢ Client entails to have 1000-3000 shock to have a successful procedure
 The shock wave comes from underneath the client. The shock
travels from a waterfilled cushion wherein the client is lying down
and will pass through the tissues and directed into the kidney or
part of the renal tract that the calculi is lying and the x-ray receiver
will receive the shock.

After the procedure, the doctor or the technician will take in an

imaging of how the stone change after the shock. It’s around 1000-
3000 shock that the patient receives per therapy. Patient could be
sedated or locally anesthetized depending on the status of the client
to bear the shock.

NURSING CONSIDERATIONS
1. Strain all urine
o After the therapy, assist the client and educate him/her to strain all urine post-op. It is expected
that the stone may have been fragment and may have passed through already through ureter
or urethra of the client. Strain all the urine by placing a gauze on a strainer and all the
sediments that are collected within the gauze should be sent to the laboratory for analysis.
2. Post-op health teachings
o Pain and minimal bleeding is normal within the first few days post-op. it is important to tell
them what are the normal findings and what they should look out for such as fever or
prolonged abdominal discomfort or pain which could indicate that there was no therapeutic
effect done from the therapy

RENAL TRANSPLANT
➢ The goals of kidney transplant:
o Avoid dialysis
o Improve sense of well-being
➢ Transplanting a kidney from a living donor or a human cadaver to a recipient who has ESRD
➢ This is done by:
1. Diseased kidney removed (nephrectomy). Adrenal gland remains intact. Renal artery and vein tied
off.
2. Transplanted donor kidney cradled in the iliac fossa anterior to the iliac crest.
3. Renal artery sutured to iliac artery. Renal vein sutured to iliac vein.
4. Ureter sutured to ladder or anastomosed to the recipient’s ureter.

NURSING CONSIDERATIONS
a. Preoperative
1. Free from infection
▪ Make sure that the client is free from infection considering that post-operatively, the
client will undergo immunosuppression.
 2. Test for compatibility
▪ Facilitate testing for compatibility which covers tissue typing, blood typing, and antibody
screening
3. Psychiatric assessment
▪ Also facilitate psychiatric assessment because steroids, which is given during the
immunosuppression therapy could aggravate some psychiatric disorders
b. Post-operative
1. Immunosuppressive therapy
▪ Facilitate immunosuppressive therapy which is the administration of high-dose
immunosuppressants. This is thought that survival of a transplanted kidney depends on
the ability to block the body’s immune response to the transplanted kidney.
▪ Medications such as Azathioprine (Imuran), Corticosteroid (Prednisone), Cyclosporine,
OKT-3, are given in high doses and gradually decreased over a period of several weeks
depending on the patient’s immunologic response
2. Monitor for complications
3. Maintain vascular access for hemodialysis functional
▪ Considering that clotting may improve after having a new kidney but the client may still
need to have HD until the new kidney is fully functional
4. Strict I/O
▪ Needed since the kidney from a living donor may produce great amount of urine
immediately post-op compared to a kidney of a cadaver

COMMON COMPLICATIONS:
1. Renal Graft Rejection
o May happen within 24 hours, that is considered hyperacute graft rejection
o If it happens within 3-14 days, that is acute rejection
o Within years, it is chronic rejection
o Diagnosed through:
▪ Ultrasound – will be able to detect enlargement of the kidney
▪ Percutaneous Renal Biopsy – most reliable
o S/S: oliguria, edema, fever, hypertension, weight gain, increased creatinine
2. Infection
o Secondary to immunosuppressant therapy
o Patient is vulnerable to opportunistic infections such as candidiasis, cytomegalovirus,
pneumocystis carinii pneumonia
o Maintain the client in a reverse isolation precaution
o Perform aseptic technique in handling the client especially invasive procedures. Careful hand
hygiene is imperative.
o As much as possible, let the client wear protective mask and avoid crowded places
o Encourage the client to have effective coping especially in the sudden changes in lifestyle all
throughout the immunosuppression therapy and gradually developing or having a normal life
after renal transplant.
URINARY TRACT DISORDERS

URINARY TRACT INFECTIONS

• UTI, are acute infections of the urinary tract that can be subdivided into two general anatomic
categories:
➢ Cystitis - Inflammation of the bladder
➢ Urethritis - Inflammation of the urethra

ETIOLOGY SIGNS & SYMPTOMS DIAGNOSIS MANAGEMENT

➢ Bacteria ➢ Frequency and urgency ➢ MSCC – high ➢ Urine c/s
➢ Neurogenic bladder ➢ Dysuria bacteria count ➢ EOF
➢ Calculus ➢ Strangury ➢ Altered ➢ Acidify urine
➢ Hormonal ➢ Retention mentation – ➢ Antibiotic treatment
➢ Catheters ➢ Lower abdominal & back elderly ➢ Aseptic
➢ Invasive procedures discomfort catheterization
➢ Sexual intercourse ➢ Cloudy, dark, foul-smelling ➢ Perineal Care
(honeymoon cystitis) urine
➢ Hematuria
➢ Bladder spasms
➢ Malaise, chills, fever
➢ Nausea & vomiting

PYELONEPHRITIS
➢ Acute infective tubulointerstitial nephritis
➢ A sudden inflammation caused by bacteria that primarily affect the interstitial area and the renal pelvis
or less often the renal tubules

ETIOLOGY SIGNS & SYMPTOMS DIAGNOSIS MANAGEMENT

➢ E. coli ➢ Urgency ➢ Urinalysis ➢ Pharmacologic:
➢ Proteus ➢ Frequency ➢ Urine C/S antibiotic therapy,
➢ Pseudomonas ➢ Dysuria antipyretics, urinary
➢ S. aureus ➢ Nocturia analgesics
➢ E. faecalis ➢ Hematuria [phenazopyridine
➢ High fever, chills (Pyridium)]
RISK FOR: ➢ (+) kidney punch ➢ Force fluids
➢ Sexually active ➢ Anorexia ➢ Rest
➢ Pregnant ➢ Enlarged kidneys ➢ Monitor for renal
➢ Diabetic failure
➢ Lower UTI
➢ Instrumentation
URINARY CALCULI
➢ One of the obstructive disorders
➢ Commonly called kidney stones, may form anywhere in the urinary tract but usually develop in the
renal pelvis or the calyces of the kidneys.
➢ Calculi formation follows precipitation of substances normally dissolved in the urine such as:
o Calcium oxalate or calcium phosphate – commonly derived from cereal and can cause
decreased pH
o Urate / uric acid – from purine
o Cystine
o Struvite
o Xanthine

RISK FACTORS SIGNS A SYMPTOMS DIAGNOSIS MANAGEMENT

➢ Dehydration ➢ Pain (key symptom) ➢ Ultrasound ➢ EOF
➢ Infection ➢ Fever and chills ➢ IV pyelogram ➢ Pharmacologic:
➢ Obstruction ➢ Hematuria ➢ Stone analysis Analgesics, Antibiotic
➢ Metabolic factors ➢ Dysuria ➢ 24-hr urine therapy,
➢ Gout ➢ Abdominal distention collection Antispasmodics
➢ immobilization ➢ Pyuria ➢ ESWL
➢ Anuria ➢ Surgery:
Ureterolithotomy,
Nephrolithotomy
➢ Ambulation
➢ Diet modifications

URINARY TRACT TUMOR

RISK FACTORS SIGNS A SYMPTOMS DIAGNOSIS MANAGEMENT
➢ Men ➢ Painless and gross ➢ Biopsy ➢ Surgery -
➢ 40-70 y.o. hematuria ➢ Cystoscopy nephroureterectomy
➢ Misuse of certain pain ➢ dysuria ➢ Ultrasonography ➢ Chemotherapy
medications ➢ obstruction of urine flow ➢ Bimanual ➢ Radiation therapy
➢ Industrial chemicals ➢ development of fistula examination ➢ Oncologic care
➢ Smoking ➢ Urinary diversion
URINARY RETENTION
ETIOLOGY SIGNS A SYMPTOMS DIAGNOSIS MANAGEMENT
➢ Detrusor failure ➢ Bladder fullness ➢ Post-void ➢ Environmental
➢ Enlarged prostate ➢ Sensation of incomplete residual (PVR) modifications
➢ Failure of bladder to voiding ➢ Urodynamic ➢ Regularly offer
contract tests commode
➢ Assume natural
position in voiding
➢ Warm compress
➢ Bladder training

NEUROGENIC BLADDER

Neural lesion TYPE ETIOLOGY

- lack of voluntary control in infancy
Uninhibited
- multiple sclerosis
Upper Motor
- spinal cold tumors
Reflex or automatic
- multiple sclerosis
- sacral cord injury
- tumor
Autonomous
- herniated disk
- abdominal surgery
Lower Motor - lesions at S2, S3, S4
Motor Paralysis - Poliomyelitis
- Tumors
- DM, Tabes dorsalis
Sensory Paralysis
- Posterior lumbar nerve roots

Management:
➢ Timing fluid intake
➢ Avoid diuretics after 4PM
➢ Avoid bladder irritants
➢ Void regularly – first thing in AM, before each meal, before going to bed, during the night as needed
➢ Kegel exercises
➢ Stop smoking