ELIMINATION PATTERNS

RESPONSES TO ALTERED URINARY SYSTEM

Basic Concepts
Kidney, Important Roles:
1. maintain body fluid volume and composition
2. To filter waste products for elimination
 allow the body to meet human need for elimination.

Kidney, Other Functions:

 regulate blood pressure and acid-base balance
 produce erythropoietin for red blood cell (RBC) synthesis
 convert vitamin D to an active form

Ureters, bladder, and urethra: drainage route for the excretion of urine.

ANATOMY AND PHYSIOLOGY REVIEW

Kidneys
Location: 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

Adult Kidney: 4 to 5 inches (10 to 13 cm) long, 2 to 3 inches (5 to 7 cm) wide and about 1
inch (2.5 to 3 cm) thick. It weighs about 8 ounces (250 g).
Left kidney is slightly longer and narrow than the right kidney.
Larger-than-usual kidneys – may indicate renal obstruction or polycystic disease.
Smaller-than-usual kidneys – may indicate chronic kidney disease.

Functions:
Regulatory Functions – control fluid, electrolyte, and acid-base balance.
Processes that maintain fluid, electrolyte and acid-base balance are:
 Glomerular Filtration – is the first process in urine formation.
As blood passes from the afferent arteriole into the glomerulus, water, electrolytes,
and other particles (creatinine, urea nitrogen, glucose) filtered across the glomerular
membrane in the Bowman’s capsule to form glomerular filtrate.

Large particles (blood cells, albumin, and other proteins) - too large to filter through
the glomerular capillary walls  therefore these substances are NOT
NORMALLY present in the filtrate or in the final urine.

180 L of glomerular filtrate is formed each day.

average of normal glomerular filtration rate: GFR 125 mL/min
If the entire amount of filtrate were excreted as urine  death may
occur quickly with dehydration.
About 1 to 3 L is excreted each day as urine.

GFR – controlled by BP and blood flow.

When systolic pressure drops below about 70 mm Hg, these processes cannot
compensate and GFR stops.

 Tubular Reabsorption – 2nd process involved in urine formation. This reabsorption

of most filtrate keeps normal urine output at 1 to 3 L/day and prevents dehydration.

Antidiuretic Hormone (ADH) and Aldosterone – hormones influencing renal

function.
ADH – also known as vasopressin and affects arteriole constriction that alters blood
pressure > affects the amount of fluid and solutes that exist in the glomeruli
capillaries.

Aldosterone – promotes the absorption of sodium in the DCT (distal convoluted

tubule).

The kidney reabsorbs some of the glucose filtered from the blood but there is a limit to how
much glucose the kidney can reabsorb  this limit is called the renal threshold for
glucose reabsorption or the transport maximum for glucose reabsorption.
220 mg/dL - usual renal threshold for glucose  this means that a blood glucose level of
220 mg/dL or less, all glucose is reabsorbed and returned to the blood  with no glucose
present in final urine.

When blood glucose levels are greater than 220 mg/dL, some glucose stays in the filtrate
and is present in the urine. Normally, almost all glucose and any amino acids or proteins
are reabsorbed and are not present in the urine.

 Tubular Secretion – 3rd process involved in urine formation.

Like glomerular filtration, it allows substances to move from the blood into the early
urine.

Potassium and hydrogen ions are some of the substances that moved in this way to
maintain homeostasis of electrolyte and pH.

Hormonal Functions – control red blood cell (RBC) formation, blood pressure, and vitamin
D activation.
The kidneys produce renin, prostaglandin, bradykinin, erythropoietin, and activated vitamin
D.
Other kidney products, such as the kinins, change renal blood flow and capillary
permeability.
The kidneys also help break down and excrete insulin.

Renal Hormone Production

Renin – raises blood pressure because of angiotensin (local vasoconstriction) and
aldosterone (volume expansion) secretion.

Prostaglandins – regulate intrarenal blood flow by vasodilation or vasoconstriction. These

substances help regulate glomerular filtration, kidney vascular resistance and renin
production.

Renal/Urinary System Changes Associated with Aging

 kidney losses cortical tissue and gets smaller by 80 years of age
This is caused by reduced renal blood flow  reduced ability of older adult to filter
blood and excrete waste products.
 Blood flow to the kidney decreases by about 10% per decade as blood vessels thicken.

Glomerular filtration rate (GFR)  decreases with age, especially after age 45.
By age 65, the GFR is about 65mL/min (half rate of a young adult)  this decline is
more rapid in patients with diabetes, hypertension, or heart failure  as a result, the
older patient has a greater risk for fluid overload.

The tubular changes with aging  decrease the ability to concentrate urine 
resulting in nocturnal polyuria (increased urination at night).

Along with an age-related impairment in the thirst mechanism  these changes

increase the risk for dehydration and hypernatremia (increased blood serum sodium
levels).

Hormonal changes include a decrease in renin secretion, aldosterone levels, and

activation of vitamin D.

Urinary Changes
 Changes in the detrusor muscle elasticity lead to decreased bladder capacity
and reduced ability to retain urine.
 The urge to void may cause immediate bladder emptying because the urinary
sphincters lose tone and often become weaker with age.
 In women, weakened muscles shortened the urethra and promote incontinence.
 In men, an enlarged prostate gland makes starting the urine stream difficult and
may cause urinary retention.
NURSING PROCESS
Assessment
Patient History
Demographic Information
 Sudden onset of hypertension in patients older than 50 years = possible kidney
disease.
 In men older than 50 years, altered urine patterns accompany prostate disease.

Anatomic Differences
 Men rarely have UTI unless there are abnormalities such as ureteral reflux or
prostate enlargement.
 Women have a shorter urethra and more commonly develop cystitis (bladder
infection) because bacteria pass more readily into the bladder.

History
 previous renal or urologic problems including tumors, infections, stones, or urologic
surgery.
 chronic health problems, especially diabetes mellitus or hypertension.
 chemical exposures at the workplace or with hobbies.
Exposure to hydrocarbons (ex. Gasoline, oil), heavy metals (especially mercury
and lead), and some gasses (ex. Chlorine, toluene) can impair kidney function.
Health teaching: Avoid direct skin or mucous membrane contact with these chemicals.

Use of heroin, cocaine, methamphetamine, ecstasy, and volatile solvents

(inhalants) has also been associated with renal damage.

 Ask if s/he has ever been told about the presence of protein or albumin in the urine.
 history of high blood pressure?
 Ask women about health problems during pregnancy (ex. Proteinuria, high blood
pressure, gestational diabetes, urinary tract infections).

Obtain information about:

 Recent travel to geographic regions that pose infections disease risks
 Recent physical injuries
 Trauma
 Sexual contacts
 A history of altered patterns of urinary elimination

Nutrition History
 Usual diet and any recent changes in the diet.
 Excessive intake or omission of certain food categories?
 Food and fluid intake?
 How much and what types of fluids the patient drinks daily? (fluids with a high
calorie or caffeine content).
 Teach the patient the importance of drinking about 3 L of fluid daily (if other
medical problem does not require fluid restriction) to prevent dehydration and
cystitis.
 High-protein intake or poor fluid intake can result in temporary renal problems 
increased risk for Calculi (stone) formation.

Medication History
 patient’s prescription drugs may lead to renal impairment.
 duration of drug use and whether have been any recent changes in prescribed
drugs.
 Drugs for diabetes mellitus, hypertension, cardiac disorders, hormonal disorders,
cancer, arthritis, and psychiatric disorders are potential causes of renal dysfunction.
 Antibiotics: Gentamicin - may also cause sudden renal dysfunction.
 Past and current use of OTC drugs or agents, including dietary supplements,
vitamins and minerals, herbal agents, laxatives, analgesics, acetaminophen, and
NSAIDs  many of these agents affect renal function.

Family History and Genetic Risk

 some disorders have a familial inheritance pattern.
Current Health Problems
 The effects of renal failure result in many changes in all body systems.
 Recent upper respiratory problems, achy muscles or joints, chronic fatigue, or GI
problems may be related to problems of kidney function.
 Any changes in appearance (color, odor, clarity) of the urine, pattern of urination,
ability to initiate or control voiding and other symptoms.
 Ask about changes in urination patterns such as nocturia (urination at night),
frequency, or an increase or decreased in amount of urine.
 The normal urine output for adults is about 1500 to 2000 mL/day, or within 500 mL
volume of fluid ingested in a day.
 Ask about any loss of urinary incontinence, especially when coughing, sneezing or
laughing. Patients may also report a persistent dribbling of urine.
 Pain associated with renal or ureteral irritation is often severe and spasmodic.
 Pain that radiates into the perineal area, groin, scrotum, or labia is described as
renal colic  this pain occurs with distention or spasm of the ureter such as in an
obstruction or the passing of stone.
 Renal colic pain may be intermittent or continuous and may occur with pallor,
diaphoresis, and hypotension.
 Uremia is the build-up of nitrogenous waste products in the blood  a result of
renal failure. Manifestations include anorexia, nausea and vomiting, muscle cramps,
pruritus (itching), fatigue and lethargy.

PHYSICAL ASSESSMENT
 Assess the general appearance of the patient
 Check for a yellowish skin color and the presence of any rashes, bruising, or other
discoloration.
 (+) edema, which with renal disorders may be detected in the pedal (foot), pretibial
(shin), and sacral tissues, and around the eyes.
 Auscultate the lungs to determine whether fluid is present.
 Weigh the patient and take his or her blood pressure as a baseline for later
comparisons.
 Assess the patient’s level of consciousness and level of alertness. Record any
deficits in concentration, thought processes, or memory.

Assessment of the Kidneys, Ureters, and Bladder

 Auscultate before percussion and palpation because these activities can enhance
bowel sounds and obscure abdominal vascular sounds.
 Inspect the abdomen and the flank regions with the patient in both the supine and
the sitting positions.
 Observe the patient for asymmetry (ex. Swelling) or discoloration (ex. Bruising or
redness) in the flank region, especially in the costovertebral angle (CVA).
 Listen for a bruit by placing a stethoscope over each renal artery on the
midclavicular line.
 Renal palpation is usually performed by a physician or advanced practice nurse.
It can help locate masses and areas of tenderness in or around the kidney.
If tumor or aneurysm is suspected, palpation may harm the patient.
 A distended bladder sounds dull when percussed.
 Patients with inflammation or infection in the kidney or nearby structures may
describe their pain as severe or as a constant, dull ache.

Assessment of the Urethra 

 Using a good light source and wearing gloves, inspect the urethra by examining the
meatus and the tissues around it.
 Record any usual discharges such as blood, mucus or pus.
 Record the presence of lesions, rashes, or other abnormalities of the penis or
scrotum or of the labia or vaginal opening.
 Urethral irritation is suspected when the patient reports discomfort with urination.

Diagnostic Evaluation
 Nursing Responsibility: Educate patient about the purpose, what to expect, and any
possible side effects
 Manage Anxiety. Voiding in the presence - cause guarding, a natural reflex inhibiting
voiding due to situational anxiety. B
Urinalysis and Urine Culture
urinalysis - clinical information about kidney function and helps diagnose other diseases
(DM) urine culture - determines whether bacteria are present in the urine
urine sensitivity - identify the antimicrobial therapy suited for the particular strains identified

 Urine color
Colorless to pale yellow dilute urine (diuretic use, DI, alcohol use, excess fluid
intake, glycosuria, and kidney disease)
Yellow to milky white Pyuria, infection, vaginal cream
Bright yellow Multiple vitamin preparations
Pink to red Hgb breakdown, RBC, gross blood, post-surgery
(bladder, prostate), medications
Orange to amber Concentrated urine (dehydration), excess bilirubin,
medication (nitrofurantoin)
 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)
 Microscopic examination: RBCs (hematuria), white blood cells (pyuria), casts
(cylindruria), crystals (crystalluria), and bacteria (bacteriuria)
 urine telomerase activity levels – detection of Bladder Ca

Abnormalities/Pertinent Findings:
Hematuria (more than 3 RBCs per high-power field) – acute infection (cystitis,
urethritis, or prostatitis), renal calculi, and neoplasm; bleeding disorders; malignant
lesions; and medications (warfarin (Coumadin) and heparin)

Proteinuria
Microalbuminuria (excretion of 20 to 200 mg/dL of protein in the urine) - early sign
of DM nephropathy.
Transient proteinuria - caused by fever, strenuous exercise, and prolonged
standing.
persistent proteinuria – glomerular diseases, malignancies, collagen diseases,
diabetes, preeclampsia, hypothyroidism, heart failure, exposure to heavy metals,
and the use of medications (NSAIDs and ACE inhibitors)

pH is a measure of urine acidity or alkalinity.

A pH value less than 7 is acidic and a value greater than 7 is alkaline.
= A diet high in certain fruits and vegetables result in a more alkaline urine.
= A high-protein diet produces more acidic urine.

Glucose is filtered in the glomerulus.

When the blood glucose rises above 220 mg/dL, the renal threshold for
reabsorption is exceeded and some glucose is present in the urine  common in
those patients with infection or those with long-standing diabetes mellitus.

Ketone bodies are formed from the incomplete metabolism of fatty acids.
Normally there are no ketones in the urine.

Proteins such as albumin, is not normally present in the urine.

Levels greater than 300 mg/24 hr, or 200 mcg/min, are abnormal.

Specific Gravity
 degree of concentration of the urine
 Normal: 1.010 to 1.025
 When fluid intake decreases, specific gravity normally increases.
 With high fluid intake, specific gravity decreases.
 Patients with kidney disease = urine-specific gravity does not vary with fluid
intake, and the patient’s urine is said to have a fixed specific gravity.
  urine-specific gravity: diabetes insipidus, glomerulonephritis, and severe renal
damage.
  specific gravity: diabetes, nephritis, and fluid deficit.
Osmolality
 most accurate measurement of the kidney’s ability to dilute and concentrate urine
 S. osmolality: 280 to 300 mOsm/kg
 Urine osmolality: 200 to 800 mOsm/kg
24-hour urine sample: 300 to 900 mOsm/kg

Renal Function Tests

Renal function test results may be within normal limits until the GFR is reduced to less than
50% of normal.

Creatinine Clearance – detects and evaluates progressions of kidney disease.

- Test measures volume of blood cleared of endogenous creatinine in 1 minute
- Provides an approximation of GFR

Creatinine Level – creatinine is the end-product of muscle energy metabolism

Normal: 0.6 – 1.2 mg/dL

BUN – urea is the nitrogenous end product of protein metabolism

Normal values: 10-20 mg/dL (3.6-7.1 mmol/dL)
Older adults: 60-90 yr: 8.23 mg/dL (2.9-11.1 mmol/L)
Older than 90 yr: 10-31 mg/dL (3.6-11.1 mmol/L)

BUN-to-Creatinine Ratio – evaluates hydration status.

Elevated ratio: hypovolemia
Intrinsic Kidney Disease: Normal ratio with elevated BUN

Imaging Assessment
X-ray of the kidneys, ureters, and bladder (KUB): plain film of the abdomen obtained
without any specific preparation; shows gross anatomic features and obvious stones,
strictures, calcifications, or obstructions in the urinary tract.

Computed Tomography –provide information about tumors, cysts, abscesses, masses,

obstruction, and renal blood vessels.

Ultrasonography – assessment of kidney size, cortical thickness, and status of the

calices. The test can identify obstruction in the urinary tract, tumors, cysts and other
masses without the use of a contrast dye.

Cystoscopy – may be for diagnosis and treatment; used to examine bladder trauma.
Cystoscopy may be used to remove bladder tumours or an enlarged prostate gland.

Cystourethroscopy – test used to examine urethral trauma.

Both procedures identify causes of urinary tract obstruction.

Analysis/ Nursing Diagnosis

 Impaired Urinary Elimination as evidenced by frequency, urgency, hesitancy, dysuria,
and nocturia
 Urge Urinary Incontinence as evidenced by frequency, urgency, loss of urine before
reaching toilet, and voiding in small or large amounts
 Urinary Retention as evidenced by sensation of bladder fullness, dribbling urine,
dysuria and bladder retention
 Stress Urinary Incontinence as evidenced by dribbling urine with increased abdominal
pressure, urinary urgency, and urinary frequency
 Acute Pain (Cognitive-Perceptual)
 Ineffective Health Maintenance (Health Perception-Health Management)

Care of the Patients with Urinary Problems

 Urinary problems are common and costly.
 Life-threatening complications are rare with urinary problems, patients may have
significant functional, physical and psychological changes that reduce quality of life.
Infections of the Urinary Tract
Urinary tract infections (UTIs) - by pathogenic microorganisms in the urinary tract
Note: Normal urinary tract is sterile above the urethra
2nd most common infection in the body
Classification (by location)
1. Upper Urinary Tract Disorder - less common
a. pyelonephritis (inflammation of the renal pelvis)
b. nephritis (inflammation of the kidney)
c. kidney abscesses
2. Lower Urinary Tract Disorder
a. cystitis (urinary bladder)
b. prostatitis (prostate gland)
c. urethritis (urethra) - manifestations of urethritis are burning or difficulty with
urination and a discharge from the urinary meatus.

Classification (depends on recurrence and duration)

1. Uncomplicated
Community-acquired infection – common in young women and not usually recurrent
2. Complicated – urologic abnormalities or recent catheterization
- often acquired during hospitalization.

Lower Urinary Tract Infections

Mechanisms that maintain sterility of the bladder:
1. physical barrier of the urethra
2. urine flow
3. ureterovesical junction competence
4. antibacterial enzymes and antibodies
5. antiadherent effects mediated by the mucosal cells of the bladder

Contributing Conditions: female gender, DM, pregnancy, neurologic disorders, gout

 Decreased natural host defenses or immunosuppression
 Inability or failure to empty the bladder completely
 Inflammation or abrasion of the urethral mucosa
 Instrumentation of the urinary tract (like catheterization, cystoscopic procedures)
 Congenital abnormalities: Urethral strictures, Contracture of the bladder neck,
Bladder tumors, calculi (stones) in the ureters or kidneys, and compression of the
ureters

Pathophysiology
bacteria gain access to the bladder > attach and colonize the epithelium of the urinary tract
> evade host defense mechanisms > initiate inflammation

Infection occurs because of the following:

 Disruption in the activity of GAG (Glycosaminoglycan) - a hydrophilic protein; exerts
a nonadherent protective effect; attracts water molecules to form a water barrier
(defensive layer between the bladder and the urine)
 Disruption of the normal bacterial flora of the vagina and urethral area
 Reflux (urethrovesical reflux) - an obstruction to free-flowing urine. With coughing,
sneezing, or straining, the bladder pressure increases, which may force urine from
the bladder into the urethra. When the pressure returns to normal, the urine flows
back into the bladder, bringing into the bladder bacteria from the anterior portions of
the urethra.
 Ureterovesical or vesicoureteral reflux refers to the backward flow of urine from the
bladder into one or both ureters. When the ureterovesical valve is impaired by
congenital causes or ureteral abnormalities, the bacteria may reach the kidneys and
eventually destroy them.
 Bacteriuria is the term used to describe the presence of bacteria in the urine.
Cystitis
Cystitis – is an inflammation of the bladder. It can be caused by irritation or, more
commonly, by infection from bacteria, viruses, fungi or parasites.

 Infectious cystitis is the most common of the UTIs.

 Non-infectious cystitis is caused by irritation from chemicals or radiation.
 Interstitial cystitis is an inflammatory disease that has no known cause.
 Bacteriuria is the presence of bacteria in the urine and can occur with any urologic
infection.
 If bacteriuria is without symptoms of infection, it is called colonization.
 Colonization, asymptomatic bacteriuria, is more common in older adults.

Etiology and Genetic Risk

 Genetically, invading bacteria with special adhesions are more likely to cause
ascending UTIs that start in the urethra or bladder and move up into the ureter and
the kidney.
 The most common organisms in infectious cystitis are from the intestinal tract.
 About 90% of UTIs: Escherichia coli.
 Less common organisms include: Staphylococcus saprophyticus, Kleibsiella
pneumonia, and organisms from the Proteus and Enterobacter species.

 In most cases, organisms first grow in the perineal area, then move into the urethra as
a result of irritation, trauma, or catheterization of the urinary tract, and finally ascend to
the bladder.
 Catheters are the most common factor placing patient at risk for UTIs in the hospital
setting.
 Within 48 hours of catheter insertion, bacterial colonization begins.
 About 50% of patient with indwelling catheters become infected within 1 week of
catheter insertion.

Organisms other than bacteria also can cause cystitis.

 Fungal infections such as caused by Candida, can occur during long-term antibiotic
therapy because antibiotics change normal protective flora.
 Patients, who are severely immunosuppressed, are receiving corticosteroids or
other immunosuppressive agents, or having diabetes mellitus, acquired immune
deficiency syndrome (AIDS) are at a higher risk for fungal UTIs.

 Noninfectious cystitis may result from chemical exposure, such as to drugs (ex.
Cyclosphosphamide [Cytoxan, Procytox]), from radiation therapy, and from
immunologic responses, as with systemic lupus erythematosus (SLE).

 Urosepsis is the term used to describe for the spread of infection from the urinary
tract to the bloodstream.

 Sepsis from any source is a systemic infection that leads to overwhelming organ
failure, shock and death.

Health Promotion and Maintenance

 Although cystitis is common, in many cases it is preventable.
 In health setting reducing the use of indwelling urinary catheters is the major
prevention strategy.
 When catheters must be used, strict attention to sterile technique during insertion
can reduce the risk for UTIs and adequate perineal and catheter care.
 Catheters must be removed as early as possible.
 Changes the fluid intake patterns, urinary elimination patterns, and hygiene patterns
can help prevent or reduce cystitis in the general population.
 Teach all people to have a minimum fluid intake of 3 L daily unless fluid restriction is
needed for another health problems.
 Encourage people to drink more water rather than sugar-containing drinks.
 Teach people to avoid urinary stasis by urinating every 3 to 4 hrs rather than waiting
until the bladder is full.
 Encourage everyone either to bathe daily or thoroughly wash perineal and urethral
areas daily.
Physical Assessment/Clinical Manifestations
 Frequency, urgency, and dysuria are the common manifestations of a urinary tract
infection (UTI), but other manifestations may be present.
 Hesitancy or difficulty in initiating urine stream
 Low back pain
 Nocturia
 Incontinence
 Hematuria
 Pyuria – pus in the urine
 Bacteriuria
 Retention
 Suprapubic tenderness or fullness
 Feeling of incomplete bladder emptying

Rare clinical Manifestations

 Fever
 Chills
 Nausea and vomiting
 Malaise
 Flank pain
 Urine may be cloudy, foul smelling or blood tinged.
 Vaginal discharges and irritation – are more indicative of vaginal infection.
 Women often report burning with urination

Laboratory Assessment
 Urinalysis – the presence of 100,000 colonies/mL or the presence of three or more
WBCs (pyuria) with RBCs (hematuria) – indicates infection.
 Urine culture – confirms the type of organism and the number of colonies.
 Serum WBC count may be elevated.

Other Diagnostic Assessment:

 If urinary retention and obstruction of urine outflow are suspected, urography,
abdominal sonography or computed tomography (CT) – may be needed to locate
the site of obstruction or the presence of calculi.
 Cystoscopy may be performed when the patient has recurrent UTIs (more than 3 to
4 years).
 Cystoscopy is needed to accurately diagnose interstitial cystitis.

Common Nursing Diagnoses and Collaborative Problems

 Acute pain related to bladder spasm
 Deficient Knowledge (risk factors for cystitis and drug regimen) related to
information misinterpretation or unfamiliarity with information resources
 Urge Urinary Incontinence related to irritation of bladder stretch receptors causing
spasm (ex. Bladder infection)
 Risk for Impaired Skin Integrity related to moisture from incontinence
 Risk for Sepsis

Interventions:
Nonsurgical Management
Drug therapy
 antiseptics or antibiotics, analgesics and antispasmodics
 Antifungal agents are prescribed for fungal infections.
 Amphotericin B is most often given in daily bladder instillations, and ketoconazole
(Nizoral) is given orally.
 Antispasmodic drugs decrease bladder spasm and promote complete bladder
emptying.
 Antibiotic therapy is used for bacterial UTIs.
 3-day course of trimethoprim/sulfamethoxazole or fosfomycin is effective in treating
uncomplicated, community-acquired UTIs in women.
 Longer antibiotic treatment (7 to 21 days) is required for hospitalized patients, those
with complicating factors, such as pregnancy, indwelling catheters, or stones, and
those with diabetes or immunosuppression
  Long-term antibiotic therapy is used for chronic, recurring infections caused by
structural abnormalities or stones.
 Trimethoprim 100 mg daily may be used for long-term management of the older
patient with frequent UTIs.
 For women who have recurrent UTIs after intercourse, one low-dose tablet of
trimethoprim (TMP).
 Estrogen used as an intravaginal cream may prevent recurrent UTIs in
postmenopausal woman.

Urinary Elimination Management

 The goal is to maintain an optimal urinary elimination pattern.
 Nursing interventions for the management of cystitis focus on comfort

Nutrition Therapy
 The diet should include all food groups and include more calories for the increased
metabolism caused by infection.
 Urge patient to drink enough fluid to maintain diluted urine throughout the day and
night unless fluid restriction is needed for another health problems.
 The daily drinking of 50 mL of concentrated cranberry juice appears to decrease the
ability of bacteria to adhere to the epithelial cells lining the urinary tract.
 Cranberry juice must be consumed for 3 to 4 weeks to be effective.
 Avoiding caffeine, carbonated beverages, and tomato products may decrease
bladder irritation during cystitis.

Comfort Measures
 A warm sitz bath taken two or three times a day for 20 minutes may provide comfort
and some relief of local symptoms.
 If burning with urination is severe or urinary retention occurs, teach the patient to sit
in the sitz bath and urinate into the warm water.

Surgical Management
 Surgery for cystitis treats the conditions that increase the risk for recurrent UTIs (ex.
Removal of obstructions and repair of vesicoureteral reflux).
 Procedures may include cystoscopy to identify and remove calculi or obstructions.

UPPER URINARY TRACT INFECTIONS

PYELONEPHRITIS – is a bacterial infection in the kidney and renal pelvis  upper urinary
tract.

Pathophysiology:
 presence of active organisms in the kidney or the effects of kidney infection.

Acute pyelonephritis – is the active bacterial infection; Involves acute tissue inflammation,
tubular cell necrosis, and possible abscess formation.

Chronic pyelonephritis – results from repeated or continued upper urinary tract infection
or the effects of such infections.
= Occurs with a urinary tract defect, obstruction, or, most commonly, when urine refluxes
from the bladder back to the ureters.

Etiology and Genetic Risk:

 Single episodes of acute pyelonephritis – may result from the entry of bacteria,
especially during pregnancy, obstruction, or reflux.
 Chronic pyelonephritis – usually occurs with structural deformities or obstruction
with reflux.
 Acute or chronic pyelonephritis – occurs often in patients who have undergone
manipulation of the urinary tract (ex. Placement of catheter), those with diabetes
mellitus or chronic renal stones, or those who overuse analgesics.
 Escherichia coli – is the most common pyelonephritis-causing organism.
 Enterococcus fecalis – is common in hospitalized patients.
 Both organisms are in the intestinal tract.
 Other organisms: Proteus mirabilis, Klebsiella, and pseudomonas aeruginosa.
 When the infection is bloodborne, common infecting organisms include:
Staphylococcus aureus and the Candida and Salmonella species.
Incidence and Prevalence:
 Chronic pyelonephritis is commonly associated with vesicoureteral reflux or other
anatomic abnormalities and is more common in women.
 After 65 years of age, rates of pyelonephritis for men increase greatly because of
the increased incidence of prostitis.

Clinical Manifestations:
Acute Pyelonephritis
 Fever
 Chills
 Tachycardia and tachypnea
 Flank, back, or loin pain
 Tender costal vertebral angle (CVA)
 Abdominal, often colicky, discomfort
 Nausea and vomiting

 General malaise and fatigue

 Burning, urgency, or frequency of urination
 Nocturia

Chronic Pyelonephritis
 Hypertension
 Inability to conserve sodium
 Decreased urine concentrating ability (nocturia)
 Tendency to develop hyperkalemia and acidosis

Laboratory Assessment:
 Urinalysis – shows positive leukocyte esterase and nitrite dipstick test and the
presence of WBC and bacteria.
 = Occasional RBC, WBC casts and protein may be present.
 Urine culture
 Blood cultures
 Other blood tests: C-reactive protein and erythrocyte sedimentation rate.

Imaging Assessment:
 X-ray of the kidneys, ureters, and bladder (KUB) and IV urography
 Cystourethrogram is indicated to some patients
 Radionuclide scintillation (ex. Gallium scan)

Common Nursing Diagnoses and Collaborative Problems:

 Acute Pain (flank and abdominal) related to inflammation and infection
 Infection or Risk for Infection related to inadequate primary defences (urinary stasis)
or instrumentation
 Deficient Knowledge regarding medical diagnosis and therapy related to
unfamiliarity with information resources
 Activity Intolerance related to fatigue, debilitation, and generalized weakness
associated with infection
 Fear (of Development of Chronic Kidney Disease) related to inability to control
recurrent infections
 Potential for Sepsis and Septic Shock

Interventions:
Nonsurgical Management:
 Interventions include the use of drug therapy, nutrition and fluid therapy, and
teaching to ensure the patient’s understanding of the treatment.
Drug Therapy:
 Antibiotic therapy – at first broad spectrum antibiotics (ciprofloxacin, gentamicin) for
2 weeks course.
  Urinary antiseptic drugs (ex. Nitrofurantoin [Macrodantin]) – a more specific
antibiotic is prescribed after urine and blood culture and sensitivity results are
known.

Nutrition Therapy
 Ensuring that the patient’s nutritional intake has adequate calories from all food
groups for healing to occur.
 Fluid intake is recommended at 2 to 3 L/day unless another health problems
requires fluid restriction.

Surgical Management:
 Surgical interventions are used to correct structural problems causing urine reflux or
obstruction of urine outflow or to remove the source of infection.
 IV antibiotics are given to achieve adequate blood levels or sterile blood culture
results.
Surgical procedures:
 Pyelolithotomy – is needed for removal of a large stone in the renal pelvis that
blocks urine flow and causes infection.
 Nephrectomy – removal of the kidney, which is the last resort when all measures to
clear the infection have failed
 Ureteroplasty – ureter repair or revision  performed to patients with poor ureter
valve closure or dilated ureters.
 Ureteral reimplantation (through another site in the bladder wall) – preserves kidney
function and eliminates infections.

UROLITHIASIS
Urolithiasis – is the presence of calculi (stones) in the urinary tract.
 Stones often do not cause symptoms until they pass into the lower urinary tract,
where they can cause excruciating pain.

 Nephrolithiasis – is the formation of stones in the kidney.

 Ureterolithiasis – is the formation of stones in the ureters.

Types of Stones:
 About 75% of stones contain calcium as one part of the stone complex, which may
be calcium oxalate (2nd most frequent crystal to cause stone) or calcium phosphate.
 Struvite (15%) also called triple phosphate composed of Ca, Mg, Ammonium PO4.
 Uric acid (8%) cause by increased urate excretion, fluid depletion, and
 Cystine (3%) inherited defect in renal absorption of amino acid and make up the
less common stones.

Types of Kidney Stones

Three Conditions Involved in Stone Formation:
 Slow urine flow – resulting in supersaturation of the urine with the particular element
 (Ex: calcium) that first becomes crystallized and later becomes stones.
 Damage to the lining of the urinary tract (Ex: abrasions from crystals)
 Decreased inhibitor substances in the urine that would prevent supersaturation and
crystal aggregation.

 High urine acidity  forms uric acid and cystine stones.

 High urine alkalinity  forms calcium phosphate and struvite stones
 Drugs (triamterene, indinavir and acetazolamide) – contribute to stone formation.

 When the stones occludes the ureter and blocks the flow of urine, the ureter dilates
 causing enlargement of the ureters called hydroureter.

 Hematuria (bloody urine) may result from damage to the urothelial lining.

 If the obstruction is not removed, urinary stasis can cause infection and impair
kidney function on the side of the blockage  hydronephrosis (enlargement of the
kidney )and permanent kidney damage may develop.

Etiology and Genetic Risk

  90% of patients who form stones have a metabolic risk factor  excessive amounts
of calcium are absorbed through the intestinal tract.
 Urinary stasis, urinary retention, immobility, and dehydration
 Diuretics (except the use of thiazides for calcium oxalate)

Incidence/Prevalence
 The incidence of stone disease is high and varies with geographic location, race,
and family history.
 The incidence is higher in men. Struvite stones are twice as common in women.

Assessment/Clinical Manifestations
 Severe pain, commonly called renal colic – is the major manifestation of stones.
 Flank pain – suggests that the stone is in the kidney or upper ureter.
 Flank pain that extends toward the abdomen or to the scrotum and testes or the
vulva – suggests that the stones are in the ureters or bladder.

 Nausea, vomiting, pallor and diaphoresis – often accompany the pain

 Frequency and dysuria – occur when a stone reaches the bladder.
 Oliguria (scant urine output) or anuria (absence of urine output) – suggests
obstruction, possibly at the bladder neck or urethra.

Examine the patient to detect bladder distention

 The patient may appear pale, ashen, and diaphoretic and suffer from excruciating
pain.
 Increase temperature and pulse
 Decrease BP

Diagnostic Findings:
 Urinalysis – performed to patients with suspected calculi.
 Hematuria is a common finding: blood may make the urine appear smoky or rusty.
 RBCs are usually caused by stone-induced direct trauma on the lining of the ureter,
bladder or urethra.
 WBC and bacteria may be present as a result of urinary stasis.
 Increased turbidity (cloudiness) and odor indicate that infection may also be
present.
 Microscopic examination of the urine may identify crystals from which stones can
form.
 Urinary pH is measured to determine the acidity or alkalinity.
 Serum WBC count is elevated with infection.
 Increases in the serum calcium, serum phosphate, or serum uric acid levels
 X-rays of the kidneys, ureter and bladder (KUB); IV urograms; or computed
tomography (CT) – stones are easily seen.
 Noncontrast helical CT – has the highest sensitivity for identification of urinary
stones.
 IV urography – is useful for identifying whether the urinary tract is obstructed.
 Renal ultrasonography – creates images of structures of varying density like solid
structures such as stones are extremely dense; therefore the images of stones are
clear.

Pain Relief Measures

Nonsurgical and surgical approaches are used to assist the patient with a kidney stone
achieve an acceptable degree of pain relief.

Nonsurgical Management
Drug Therapy – is needed most in the first 24 to 36 hours when pain is most severe.
 Opioid analgesics – are often needed to control the severe pain cause by stones in
the urinary tract.
 Morphine (Statex) – are often given IV for rapid pain relief.
 NSAIDs such as ketorolac (Toradol)
 Spasmolytic drugs such as oxybutynin chloride (Ditropan) and propantheline
bromide (Pro-banthine, Propanthel)
Complementary and Alternative Therapy
 Relaxation techniques such as hypnosis and imagery, therapeutic or healing touch,
and acupuncture.
 Assisting the patient with positioning can often aid in pain reduction.
 Breathing techniques such as those used in childbirth, can also help patient to
relax.

Other Management Techniques

 Avoid overhydration and underhydration in the acute phase to help make the
passage of stone less painful.
 Strain the urine and teach the patient to strain it to monitor for stone passage.
 Send the stone to the laboratory for analysis because preventive therapy is based
on stone composition.

Lithotripsy, also known as extracorporeal shock wave lithotripsy (ESWL) – is the use
of sound, laser, or dry shock waves to break the stones into small fragments.
 The patient receives conscious sedation during the procedure.
 Continuous ECG monitoring for dysrhythmia and fluoroscopic observation for stone
destruction is maintained.
 After lithotripsy, strain the urine to monitor the passage of stone fragments.
 Bruising may occur on the flank of the affected side after ESWL.
 Cystine stones are often resistant to ESWL.

Surgical Management:
Minimally invasive surgical (MIS) procedures include stenting, retrograde ureteroscopy, and
percutaneous ureterlithotomy and nephrolithotomy.

Stenting – is performed with a stent, where a small tube that is placed in the ureter by
ureteroscopy.
 The stents dilate the ureter and enlarges the passageway for the stone or stone
fragments.
 A foley catheter may be placed to facilitate passage of the stone through the
urethra.

Retrograde ureteroscopy – is an endoscopic procedure. The uretoscope is passed

through the urethra and bladder into the ureter. Once the stone is seen, it is removed using
grasping baskets, forceps, or loops.
= A foley catheter may be placed to facilitate passage of stone fragments through the
urethra.

Percutaneous ureterolithotomy and nephrolithotomy – is the removal of a in the ureter

or kidney through the skin.
 The patient lies prone on the side and receives local or general anesthesia.
 Monitor patient for complications after procedure that includes bleeding at the site
or through the tube, pneumothorax, and infection.

Open Surgical Procedures – when other stone removal attempts have failed or when risk
of a lasting injury to the ureter or kidney is possible.

 Open ureterolithotomy – into the ureter.

 Pyelolithotomy – into the kidney pelvis.
 Nephrolithotomy – into the kidney.

Postoperative Care:
 Follow routine procedures for assessment of patient who has received anesthesia.
 Monitor the amount of bleeding from incisions and in the urine.
 Maintain adequate fluid intake.
 Strain the urine to monitor the passage of stone fragments.
 Teach the patient how to prevent future stones through dietary changes.

Infection Prevention
Interventions include:
 Giving antibiotics, either to eliminate an existing infection or to prevent new
infections and
  Maintaining adequate nutrition and fluid intake  because infection always occurs
with struvite stone formation.

Drug therapy is the most common intervention.

 Broadspectrum antibiotics such as aminoglycosides (ex. Gentamicin (Garamycin)
and cephalosporin (Keflex, Novo-Lexin)
 Acetohydroxamic acid (Lithostat) and hydroxyurea (Hydrea)
 Serum creatinine levels are monitored in patients receiving acetohydroxide acid 
stopped if creatinine levels are above 2 mg/dL.

Nutrition Therapy:
 Ideally includes adequate calorie intake with a balance of all food groups.
 Encourage a fluid intake sufficient to dilute urine to a light color throughout the 24-
hour day (typically 2 to 3 L/day) unless another health problem requires fluid
restriction.

.
CHRONIC KIDNEY DISEASE
Pathophysiology:
Chronic kidney disease (CKD) – is a progressive, irreversible kidney injury and kidney
function that does not recover.
 When kidney function is too poor to sustain life, CKD becomes end-stage kidney
disease (ESKD).

The following terms used with renal failure include:

 Azotemia – build-up of nitrogen-based wastes in the blood.
 Uremia – azotemia with clinical symptoms
 Uremic syndrome

Key Features of Uremia:

 Metallic taste in the mouth
 Anorexia
 Nausea
 Vomiting
 Muscle cramps
 Itching
 Fatigue and lethargy
 Hiccups
 Edema
 Dyspnea
 Paresthesia

Stages of Chronic Kidney Disease:

 The kidneys fail in an organized fashion involving five stages based on estimated
glomerular filtration rate (GFR).
 Progression toward ESKD in at-risk patients starts with a gradual decrease in GFR.
 In the first stage – the person may have a normal GFR (greater than 90 mL/min)
with normal kidney function and no obvious kidney disease.
 Although no manifestations of renal failure are usually present at this stage, if the
patient is stressed with infection, fluid overload or dehydration  renal function at
this stage can appear reduced.
 In the next stage, mild CKD – GFR is reduced, ranging between 60 to 89 mL/min.
 Kidney nephron damage has occurred and there may be slight elevations of
metabolic wastes because not enough healthy nephrons remain to compensate
completely for damaged nephrons.
 Increased output of dilute urine may occur at this stage of CKD and, if the problem
is untreated at this stage  can cause severe dehydration.
 Careful management of fluid volume, blood pressure, electrolytes, dietary intake,
and other diseases (ex. Heart disease, diabetes) can prevent further damage and
slow progression.

 In moderate CKD, GFR reduction continues and ranges between 30 to 59 mL/min.

  Nephron damage has continued, and the remaining nephrons cannot manage
metabolic wastes, fluid balance, and electrolyte balance.
 Dietary restrictions of fluid, proteins and electrolytes are needed.

 Over time, patients progress to severe CKD (the fourth stage), GFR ranges
between 15 to 29 mL/min and end-stage kidney disease (ESKD, the fifth stage),
and GFR is less than 15 mL/min.
 Excessive amounts of urea and Creatinine build up in the blood, and the kidneys
cannot maintain homeostasis.
 Severe fluid, electrolyte, and acid-base imbalances occur.
 Without renal replacement therapy  fatal complications are likely to occur.

Etiology and Genetic Risks:

 The causes of CKD are complex. More than 100 different disease processes can
result in progressive loss of kidney function.

2 Main causes of ESKD are:

 Hypertension
 Diabetes mellitus
 In addition, infection and genetic kidney diseases can lead to ESKD.
 African-American patients are four-times more likely to develop ESKD and seven
times more likely to have hypertensive ESKD.

Incidence/Prevalence:
 The number of patients being treated for CKD is increasing.
 More than 24% of patients with ESKD die during the first year of treatment.
 ESKD occurs more often in men than in women.
 The greatest increase in ESKD is in patients 65 years of age and older.

Physical Assessment/Clinical Manifestations:

 Chronic kidney disease (CKD) causes changes in many body systems.
 Most manifestations are related to changes in fluid volume, electrolyte and acid-
base imbalances, and build up of nitrogenous wastes.

Neurologic Manifestations
 Observe for problems ranging from lethargy to seizures or coma  which indicate
uremic encephalopathy.
 Lethargy and daytime drowsiness
 Inability to concentrate or decrease attention span
 Seizures
 Coma
 Slurred speech
 Asterixis
 Tremors, twitching, or jerky movements
 Myoclonus
 Ataxia (alteration in gait)
 Paresthesia

 Dialysis is used to treat CKD when neurologic problems result.

 Manifestations of encephalopathy are resolve with dialysis.

Cardiovascular Manifestations of CKD and uremia result from:

 Fluid volume excess, hypertension, heart failure (HF), pericarditis, and potassium-
induced dysrhythmias.
 Assess for signs of reduced sodium and water excretion.
 Circulatory fluid overload, if untreated leads to HF, pulmonary edema, peripheral
edema and hypertension.
 Assess the heart and rhythm; listen for extra sounds (particularly an Sз), irregular
patterns, or a pericardial friction rub.

 Assess the jugular veins for distention and assess for edema of the feet, shins, and
sacrum and around the eyes.
 Shortness of breath with exertion and at night  suggests fluid volume excess.
Respiratory manifestations of CKD also vary:
 Uremic fetor or uremic halitosis – the breath smells like urine.
 Deep sighing, yawning and shortness of breath.
 Observe the rhythm, rate and depth of breathing
o Tachypnea – increased rate of breathing.
o Hyperpnea – increased depth of breathing
o Kussmaul respirations – extreme increases in rate and depth of ventilation
 occur with severe metabolic acidosis.
 A few patients have pneumonitis, or uremic lung.
o assess for thick sputum, reduced coughing, tachypnea, and fever.
o A pleural friction rub may be heard.
o Patients often have pleuritic pain with breathing.
o Auscultate the lungs for crackles

Hematologic Manifestations.
 Anemia
o Check for indicators of anemia such as fatigue, pallor, lethargy, weakness,
shorter of breath and dizziness.
 Abnormal bleeding
o Observe for bruising, petechiae, purpura, mucous membrane bleeding in the
nose or gums, abnormal vaginal bleeding, or intestinal bleeding (black, tarry
stools [melena]).

GI Manifestations
 Anorexia
 Nausea
 Vomiting
 Metallic taste in the mouth
 Changes in taste acuity and sensation
 Uremic colitis (diarrhea)
 Constipation
 Uremic gastritis (possible GI bleeding)
 Uremic fetor (breath odor)
 Stomatitis
 Diarrhea
 Stools are tested for occult blood.

Musculoskeletal Manifestations
 Muscle weakness and cramping
 Bone pain
 Pathologic fractures
 Renal osteodystrophy – from poor absorption of calcium and continuous bone
calcium resorption.

Urinary Manifestatiions
Polyuria, nocturia (early)
Oliguria, anuria (later)
Proteinuria
Hematuria
Diluted, straw-like appearance

Skin Manifestations of CKD occur as a result of uremia:

 Yellowish coloration – as pigments is deposited in the skin.
 Darkening of the skin – as reported by some African Americans.
 Anemia of CKD causes sallowness – which appears as a faded suntan on light-
skinned patients.
 Severe pruritus (itching) – a distressing problem of uremia.

 Uremic frost – a layer of urea crystals from evaporated sweat, may appear on the
face, eyebrows, axilla, and groin of patients with advances uremic syndrome.
 Assess for bruises (echymoses), purple patches (purpura) and rashes.
Laboratory Assessment:
 Monitor the blood values for Creatinine, BUN, sodium, potassium, calcium,
phosphate, bicarbonate, haemoglobin, and hematocrit.
 Also monitor GFR for trends.
 Urinalysis
o Early stages of CKD, urinalysis shows excessive protein, glucose, RBCs,
WBCs and decreased or fixed specific gravity.
o Urine osmolarity is decreased.

Imaging Assessment: 
 Few x-tray findings are abnormal with CKD.
 Bone x-rays of the hand can show renal osteodystrophy.
 With long-term ESKD, the kidneys have shrunk and may be 8 to 9 cm or smaller 
this small size results from atrophy and fibrosis.
 If CDK progresses suddenly, a kidney ultrasound or computed tomography (CT)
scan without contrast medium may be used to rule out an obstruction.

Interventions:
 The nutritional needs and diet restrictions for the patient with CKD vary according to
the degree of remaining kidney function and the type of replacement therapy used.

Nutrition Therapy:
 The purpose of nutrition therapy is to provide the food and fluids needed to prevent
malnutrition.

Common changes include:

 Control of protein intake
 Fluid intake limitation
 Restriction of potassium, sodium, and phosphorus intake
 Taking vitamin and mineral supplements
 Eating enough calories to meet metabolic need.

Pharmacologic Therapy:
 Phosphate binding agents such as calcium acetate, calcium bicarbonate, sevelamer
hydrochloride (renagel).
 Calcium and vitamin D supplements
 Antihypertensive drugs and cardiac medications
 Antiseizure agents such as diazepam, phenytoin
 Erythropoietin – Epogen IV or given SQ 3 times a week.