The Urinary System

• “Bones can break, muscles can atrophy,

glands can loaf, even the brain can go to
sleep without immediate danger to survival.
But should the KIDNEYS fail…neither bone,
muscle, gland nor brain could carry on.”

KIDNEYS

ANAT O MY

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 CO
LU
M
NS

HILUS MEDULLA
CALYCES

PYRAMIDS
RENAL ARTERY AND VEIN

1. Outer renal fascia RENAL PELVIS

2. Middle adipose capsule
URETER
3. Inner renal capsule CORTEXjA

Distinct Regions:
RENAL
MEDULLA

1. Outer Renal cortex

2. Inner Renal medulla

RENAL
CORTEX

SUMMARY

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 • Functional and
Structural Unit
of the Kidneys

• Each kidney contains

800 thousand to 1.2
million nephrons

• Renal Corpuscles
• Renal Tubules
CLASSIFIED as:
A. Cortical
B. Juxtamedullary

o Glomerulus – Podocyte with

Basement
clusters of capillaries; Membrane
Site of Filtration Glomerulus

o Bowman ’ s capsule Bowman’s Capsule

– cup-shaped upper
end of the renal
tubules

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 These are canals that
reabsorbs selected
• Renal Corpuscles materials back into
the blood and secrete,
• Renal Tubules
collect, and conduct
urine.

• Filters plasma at the glomerulus

• Reabsorbs and secretes different
substances along tubular structures
• Filters a filtrate of protein – free plasma
• Regulates the filtrate to maintain body
fluid volume, electrolytes and pH within
acceptable limits

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 4.Regulation of Arterial Blood Pressure/
1. To regulate the volume or control H2O Balance
fluid and electrolyte balance
2. To excrete waste products from the 5.Production of erythropoietin
body
6.Activation of Vitamin D
3. Controls of acid-base balance

Major Functions of the Kidneys Major Functions of the Kidneys

URINE FORMATION

1. Filtration – (Blue Arrow) is the movement of materials

across the filtration membrane into the lumen of the
Bowman ’ s capsule to form filtrate

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2.Reabsorption –
Solutes are reabsorbed (purple arrow) across the wall
of the nephron by transport processes, such as active
transport and cotransport.
Water is reabsorbed (green arrow) across the wall of the
nephron by osmosis.

3. Secretion – Solutes are secreted (orange

arrow) across the wall of the nephron into
the filtrate.

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• Color: Clear- Amber Yellow
hematuria,diluted,concentrated etc • Ketones: Negative
• Appearance: Clear • Protein: None
hazy/cloudy etc • Glucose: None
• pH: 4.6 – 8.0 • RBC: None
indicates ability to maintain balanced pH
• WBC: None
• Odor: Aromatic
• Bacteria: Negative
• Specific Gravity: 1.005 – 1.030
reflects urine concentration

pH 6.0 pH 6.8
Appearance Clear Appearance Hazy
Color Light Yellow Color Amber
Odor Aromatic Odor Aromatic
Spec. Gravity 1.0015 Spec. Gravity 1.0020
Protein None Protein Trace
RBCs None RBCs 2/hpf
WBCs 2/hpf WBCs 15/hpf

URETERS

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Ureterovesical Junction Ureteropelvic Junction

Urinary Bladder

URETHRA

Assessment of Renal Function

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 ...Biographical Data
üAge
üGender
BIOGRAPHICAL AND üMarital Status
DEMOGRAPHIC DATA üRace
üOccupation
üGeographical Location
üSexual preferences/practices

...Symptom Analysis

CURRENT HEALTH, CHIEF Changes in Urinary Volume

COMPLAINT AND SYMPTOM a) Anuria
ANALYSIS b) Oliguria
c) Polyuria

...Symptom Analysis ...Symptom Analysis

Changes in Urine Characteristics Irritative/Obstructive Manifestations
a) Concentrated 5. Dysuria
b) Diluted 1.Frequency
6. Nocturia
c) Hematuria
2.Urgency 7. Incontinence
d) Pyuria
3.Hesitancy 8. Dribbling
e) Proteinuria
f) Pneumaturia 4.Retention

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 …Pain
TYPE LOCATION CHARACTER
KIDNEY CVA; Flank Dull, Constant
URETERAL Radiates to Severe, Sharp, Stabbing,
PAIN abdominal
area/umbilicus
Colicky in nature

BLADDER Suprapubic Dull, continuous

Intense with vodiing
URETHRAL Along Urethra Variable, may be during
or after voiding

FAMILY HISTORY
CHILDHOOD DISEASES
PAST HEALTH
HISTORYLIFESTYLE,
DIET, AND WORK
HISTORY

• Lower Abdomen should be flat and

nondistended, no masses
Physical Assessment • Urethral orifice should be pink and without
(Urinary System) discharge and lesions
Physical Assessment

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• The bell of the stethoscope maybe used
to auscultate over CVA and upper
abdominal quadrants.
• The abdominal aorta and renal arteries
are auscultated for a bruit.
Physical Assessment
• Tenderness in the Flank Area may be
detected by fist percussion (kidney
punch)
• Normally, a firm blow in the flank area
should not elicit pain.
Physical Assessment

• A landmark useful in
locating the Kidneys is the
costovertebral angle.
(Formed by the rib cage and
the vertebral column)
• Lower pole of Right Kidney
is maybe palpable, smooth
and non tender, no masses
• Left Kidney is non palpable.

Laboratory Tests
Urinalysis
§Urine Studies
Creatinine Clearance
§Blood Studies
Urine Culture

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 …Creatinine Clearance
…Urinalysis

• Also called 24 Hour Urine Collection

• It determine/examine the
• A laboratory test for estimating
properties of urine
glomerular filtration rate of the kidney.
microscopically.
• Normal Urine Creatinine:
14-26mg/kg in 24 hours

Procedure

• Collect 24 hour urine specimen

• Discard first urination when test is started.
• Save urine from all subsequent urinations for • Ensure that the serum Creatinine is
24 hour
determined during the 24 hour urine
collection
• Instruct patient to urinate at the end of 24
hour and add the specimen to collection

…Urine Culture Male Female

1. Wash hands
2. Cleanse the labia from front
to back
1. Wash hands 3. While keeping the labia
• Is an aseptic collection of urine 2. Cleanse the meatus separated, void a small
amount into the toilet
commonly used to diagnose urinary 3. Void a small amount
4. Without interrupting the
into the toilet urine stream, void directly
tract infection. into the specimen container
4. Void directly into
the specimen
container

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 Blood Studies
• Serum Creatinine
Normal: 0.6-1.2mg/dL (males)
0.4-1.0mg/dL (females) Diagnostic Tests
• BUN §Non Invasive
§Invasive

Normal: 6-20mg/dL (Adults)

…Radiography

a)Kidneys , Ureters, Bladder

b)Intravenous Pyelography

…KUB
• Is an x-ray examination which provides information
regarding the structure, size, and position of abdominal
organs.

• Urinary System - Calcifications of the renal calyces or

renal pelvis as well as any radiopaque calculi present in
the urinary tract may be visualized.

• There are NO food, fluid, medication restrictions unless

by medical direction.

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…IVP
• A test which uses IV radiopaque
contrast medium/dye to visualize
kidneys, ureters, bladder and
renal pelvis.
Pretest
• Assess for iodine sensitivity.
• Obtain consent
• Inform client he will lie on a table throughout
procedure.
• Administer enema the night before.
• Keep the client NPO for 8 hours pretest.
• Inform client about possible side effects like
throat irritations, flushing of face, warmth or a
salty taste that may be experienced during the
test

Post-Test
...MRI
• It is used to visualize the Urinary
•Force fluids. System.
•Assess venipuncture site for • It is very sensitive in differentiating
bleeding between cysts and neoplasm.
• Monitor V/S ; U/O • It creates a vascular map of arteries
and vessels when used
preoperatively.

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 ...Ultrasonography
• It can be used to evaluate the size of
the kidneys and diagnose solid
tumors and cysts.
• It helps in localizing and mapping the
kidneys before biopsy.
...Urodynamic Studies
• Are used to evaluate manifestations
of voiding dysfunction/abnormalities
related to pathology of the lower
urinary tract. (Bladder and Urethra)
...Urodynamic Studies
• Residual Urine (Post void Residual)
urine left in the bladder after voiding
• Uroflowmetry
measures volume of urine voided/sec
• Cystometrogram (CMG)
Evaluate bladder capacity and neuromuscular
fxns of the bladder, urethral pressures and
causes of bladder dysfunctions
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 ...Endoscopy Pretest

• It is used to evaluate and treat conditions

in the urinary tract.
• Provides direct visualization of the lower
urinary tract - areas not usually visible
with x-ray procedures.
• NPO/Restrict food and fluids for 8
hours.
• Make sure a written informed
consent has been signed prior to the
procedure and before administering
premedications.

Post Test
...Renal Angiography
1. Observe for bright red bleeding, which is not
normal
2. Explain that burning on urination, pink-tinged
• Test which uses a radiopaque
urine and urinary frequency are expected iodine contrast material
effects.
3. Offer warm sitz baths, and mild analgesics to
• Allows x-ray visualization of the
relieve discomfort. large and small arteries of the
renal vasculature and parenchyma
or the renal veins and their
branches.

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 Preparation/ Procedure
• Establish intravenous access. Anticoagulants are
discontinued.
• Client should remove jewelry/metal objects
• Client is positioned supine.
• Arterial site is cleansed: Femoral artery
• A radiopaque contrast material is injected through
a catheter
• Rapid and series of radiographic films are taken to
record circulation.

Post Test
• Apply pressure over the site for 15
minutes. Apply pressure dressing.
• Monitor catheter site for bleeding,
inflammation, hematoma formation.
• Monitor vital signs and urine output.

...Renal Biopsy
• It is the excision of a tissue sample
from the kidney for microscopic
analysis to determine cell
morphology and the presence of
tissue abnormalities.

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 Pre Test
•Make sure that a written consent has been signed prior
the procedure and before administering medications.
•NPO for 6-8 hours.
•Obtain history of patient’s immune system and any
bleeding disorders based on previously performed
laboratory tests (especially bleeding time, complete
blood count, platelets, PT, PTT, BUN and Creatinine)
•Obtain medication history especially patients who are
taking anticoagulant.
Post Test
• Apply pressure to the site for 5-20 minutes. Observe
site for bleeding.
• Tissue samples are placed in formalin solution.
• Closely monitor vital signs.
• Blood maybe seen in the urine after the first few post
procedural voiding.
• Monitor I and O.
• Administer medications. (analgesics and antibiotics)

PHARMACOLOGY DIURETICS

DIURETICS
URINARY ANALGESIC
URINARY ANTI INFECTIVES

Action: Action:
• Inhibits reabsorption of water, potassium, • Blocks Sodium reabsorption in the DCT, which
sodium and chloride in the ascending Loop of prevents water reabsorption;
Henle • Increases urine output;
• Increasing water excretion. • Decreases blood volume
• Potassium maybe also excreted
Example:
Furosemide (Lasix) Example:
Bumetanide (Bumex) Chlorothiazide (Diuril)

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 Action
• Acts by increasing osmotic
pressure in the glomerular
Action: filtrate inside the renal tubules.
• This causes less reabsorption of
• Acts by blocking aldosterone receptors in the fluid and electrolytes by tubules
kidneys, thus causing excretion of water and and increased loss of fluid,
sodium and potassium retention. chloride, and sodium.
Example:
• Mannitol (Osmitrol)
Example:
• Spironolactone (Aldactone)

Action:
• Promotes renal excretion of sodium, • A resin that exchanges sodium ions for
potassium, bicarbonate and water in the renal potassium ions in the large intestines.
tubules
• Used in the treatment of hyperkalemia.

Example:
Example:
• Acetazolamide (Diamox)
• Polystyrene Sulfonate
(Kayexalate)

Descriptions Example:
• Exert an antibacterial effect on renal tissue, • Nitrofurantoin (Macrodantin)
ureters, and bladder • Sulfonamides (Sulfadiazine)
• Used to treat local UTI
• Available in oral and IV Side effects:
preparations n/v; skin rash; CNS disturbances
Blood dyscrasias

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 Description
• An dye excreted in the urine
which provides a topical
analgesic effect to the
urinary tract.
URINARY TRACT INFECTION
Etiology and Risk Factors
Most commonly due to infection
by the bacteria Escherichia coli.
Example:
• Phenazopyridine (Pyridium)
Side Effects
• Urine may become reddish-
orange and can stain fabrics
• Stop drug if sclera or skin
turn yellow – a sign of drug
accumulation
Risk Factors
• Female
• Short, straight urethra
• Proximity of meatus to vagina
to anus
• Sexual Intercourse
• Use of diaphragm/spermicidal
compounds for birth control
• Pregnany
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 Risk Factors Risk Factors
• Female • Both
• Male –Aging
–Uncircumcised –Urinary Tract Obstruction
–Prostatic hypertrophy –Neurogenic bladder dysfunction
–Anal intercourse –Vesicoureteral reflux
–Genetic Factors
–Catheterization

PYELONEPHRITIS

It is the inflammation of the renal pelvis

and parenchyma caused by bacterial
infection.

Two Main Types

a. Acute
b. Chronic

oWomen – pregnant, practice poor genital Pathophysiology

hygiene, sexually active, anatomic difference Bacteria enters the renal pelvis
(urethra is shorter and urinary meatus is closer to
rectum.) Causing Inflammatory Response

oMen – may arise as a complication of prostate Edema, Swelling, Increased in WBC

enlargement
Spreading to the Cortex
oUrinary Obstruction
Caliceal abnormalities and cortical
scarring
oCystitis, Neurogenic bladder
Decreased number of functioning
oCatheterization, Cystoscopy, nephrons
Urologic instrumentation

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 Clinical Findings
• Objective
• Subjective
v Nausea and vomiting
v Pain:
v Lab data:
v flank, one or both sides; dysuria, pyuria
Clinical Findings o Blood - increased WBC
v Loss of appetite
o Urine – increased WBC,
v Fever, chills hematuria, proteinuria,
v Urinary frequency and urgency positive cultures, foul
v Urine – cloudy, bloody, malodorous smelling
o IVP – may manifest structural
changes

Diagnostic Tests/Lab Findings Pharmacology

1.Urinalysis and 1. Antibiotics depending on the
Culture and sensitivity, (+) bacteria culture and sensitivity result
2. CBC – (+) WBC
3. X-ray; KUB 2. Analgesic (Pyridium)
4. BUN, Creatinine
5. IVP, UTZ 3. Antipyretic

Nursing Diagnosis Nursing Outcomes/Goals

1. Altered urinary elimination related Overall goals:
to kidney disease/infection
1. Normal renal function
2.Pain related to inflammation/kidney 2. Normal body temperature
damage 3. Prevent complications
4. Relief from pain
3. Hyperthermia related to
5. Prevent recurrence of symptoms
inflammation

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Nursing Interventions §Observe hydration status:
Goal: vI and O, daily weight; skin
Combat infections, prevent recurrence, turgor.
alleviate symptoms
vurine – check for protein
§Medications
vBlood –monitor for
§Fluids: 1500 – 2000ml/day
hypertension, tachycardia
v to flush kidneys
v relieve dysuria §Hygiene
v reduce fever v Meticulous perineal care
v to prevent dehydration

Nursing Interventions Nursing Interventions

Goal:
§ Cooling measures: TSB for fever qPromote physical & emotional rest

§ Diet: § Activity:
v Sufficient calories and protein to v Bed rest or as tolerated;
prevent malnutrition encourage ADL’s as tolerated
v Acid-ash diet to prevent renal § Emotional support
calculi v Encourage expression of fears,
v Increase fluids v Include family in care; answer
questions

Nursing Interventions
Goal: Health Teaching
Chronic Pyelonephritis
§Medications: • Causes about 2 to 3% of end-stage renal disease
v take regularly, watch out for side effects
§Personal care: Chronic pyogenic infection of the kidneys
v perineal hygiene,
v avoid urethral contamination;
v avoid tub baths Atrophy and calyceal deformity with overlying
v Stress the need for frequent hand washing parenchymal scarring
§Possible recurrence with pregnancy
§Void at the first urge to prevent bladder
distention and stasis

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 HYDRONEPHROSIS
Is the distention of the renal pelvis and
calyces of a kidney due to pressure
from accumulating urine.
The pressure impairs, and may
eventually interrupt kidney function.
One or both kidneys may be affected.
Pathophysiology
It is caused by urinary tract obstruction.
(Calculus, tumor, scar tissue, congenital
structural defects, and kink in the ureter)
Accumulating urine exerts pressure on the
renal pelvis wall
• Over time, sustained or intermittent high
pressure causes irreversible nephron
destruction.
• Infection is always a risk secondary to
urinary stasis.
HYDRONEPHROSIS
Is the distention of the renal pelvis and
calyces of a kidney due to pressure
from accumulating urine.
The pressure impairs, and may
eventually interrupt kidney function.
One or both kidneys may be affected.
Clinical Findings
The signs and symptoms depend on the site of
obstruction, the cause and the rapidity with
which the condition developed.
The person may complain of:
vintense flank pain,
vnausea and vomiting,
voliguria, anuria and hematuria.
Palpation and percussion of abdomen may reveal
distention of the kidneys.
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 Diagnostic Tests/Lab Findings

1. Serum Creatinine/BUN - Increased

2. Urinalysis and Culture – (+)Infection

3. Serum Electrolytes – Increased

4. IVP;UTZ – Dilated ureters, kidneys

Nursing Outcomes
Treatment aims to:
•Relieve obstruction and
•Prevent infection

Treatment/Pharmacology:
•Surgery – to relieve obstruction and restore
adequate drainage

IVP •Antibiotics – to prevent infection

RESULT •Antispasmodics – for colicky spasm

Nursing Diagnosis Nursing Interventions/Patient

Teaching
v Teach the importance of adequate fluids
§Risk for Altered Renal Perfusion
v Explain the importance of notifying the
physician at the first sign of inability to void or
§Pain urinary infection
v Be sure the patient, family and caregiver
understands all medications prescribed
§Risk for infection related to Urinary including dosage, route, action, and adverse
Stasis effects.
v Care of indwelling catheters.
v Explain measures to prevent UTI

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