Medical Surgical Nursing II Chapter 63

1
Medical Surgical Nursing IIChapter 63

• Introduction to the Urinary Tract

2
A P

• Upper Urinary Tract
• kidneys
• renal pelves
• ureters

• Lower Urinary Tract
• bladder
• urethra
• pelvic floor muscles

3
Anatomy and Physiology

• The Urinary Tract
• Upper and lower tract
• Location and span
• Blood supply

Figure 63-1 Kidneys, ureters, and bladder
4
Functions of the KidneyBox 63-1

• excrete excess water nitrogenous waste products
  of protein metabolism
• assist in maintaining acid-base balance of the
  body plasma electrolytes
• production of renin to raise the BP
• produces erythropoietin to regulate RBC
  production

5
Functions of Other Urinary Tract Structures

• Transport of urine ureters pelves
• Storage of urine bladder
• Excretion of urine - urethra

6
Nephron

• Smallest functional unit of the kidney
• Each kidney contains about 1 million nephrons
• Nephrons consist of the
• glomerulus
• afferent efferent arterioles
• Bowmans capsule
• distal proximal convoluted tubules
• loop of Henle
• collecting tubule

7
Anatomy and Physiology
Figure 63-3 Representation of a nephron
8
Urine Formation

• Glomerular filtration-filtration of plasma by the
  glomerulus. Filtered substances include water,
  sodium, chloride, bicarb, potassium, glucose,
  urea, creatinine, uric acid
• Tubular reabsorption-the filtrate enters the
  Bowmans capsule, moves through the tubular
  system of the nephron is either reabsorbed or
  excreted as urine
• Tubular secretion-formed urine drains from the
  collecting tubules, into the renal pelves, down
  each ureter to the bladder

9
Assessment

• History of chief complaint, see box 63-2
• Medications taken
• Voiding patterns, table 63-1
• Risk factors for renal or urologic disorders, box
  63-3

10
Physical Examination

• Have the client void before examination
• Inspect abd back for scars, symmetry, abd
  movements, pulsations
• Percussion of bladder
• if empty will sound tympanic
• if full will sound dull
• Checking for CVA tenderness, fig 63-5
• Evaluate for s/s of periorbital edema, edema of
  extremities, cardiac failure mental changes

11
Assessment

• Diagnostic Tests
• Radiography
• X-ray KUB to reveal the size and position,
  stones, renal mass, and signs of bladder
  dysfunction
• X-ray pelvis, chest, or other area to reveal
  metastatic bone lesions

• Ultrasonography
• Identifies shape, size location, collecting
  systems, and adjacent tissues
• Advantages
• Noninvasive
• No dye used
• No fasting or bowel prep

12
Assessment

• Diagnostic Tests
• CT and MRI scan
• Diagnoses renal pathology
• Determines kidney size
• Evaluates tissue densities
• Angiography
• Provides details of arterial supply
• Procedure-cath passed through the femoral artery
  into the aorta the renal vessels dye instilled
  serial xrays taken
• The nurses role allergy to iodine? Labs for
  kidney function void before procedure pressure
  dressing applied after pulses checked bedrest
  for 4-8 hours monitor IO

13
Assessment

• Diagnostic Tests
• Cystoscopy
• Visual examination of inner bladder using
  cystoscope
• Structure of cystoscope
• Used to identify cause of painless hematuria,
  urinary incontinence or retention
• Procedure local anesthetic general or spinal
  anesthesia sometimes biopsy samples taken take
  urine culture prior to procedure
• Preventive measures antiobiotics given to
  prevent UTI
• Nurses role v/s, watch IO

14
Assessment

• Diagnostic Tests
• Intravenous pyelogram and retrograde pyelogram
• Evaluates structure and function of KUB
• Procedure
• IV pyelogram
• Retrograde pyelogram
• Radiopaque dyes
• Nurses role
• See nursing guidelines 63-1

15
Assessment

• Diagnostic Tests
• Biopsy
• Diagnoses cancer
• Assesses prostatic enlargement
• Monitors progression of renal disease
• Evaluates treatment of renal transplant rejection
  
• Risk of postprocedure bleeding
• Nurses role
• encourage adequate fluid intake
• maintain limited activity for several days to
  avoid bleeding
• complete prophalactic antibiotics
• report s/s of infection, UTI, or bleeding

16
Assessment

• Diagnostic Tests
• Cystogram and voiding cystourethrogram
• Evaluates abnormalities in bladder structure and
  filling
• Rapid series of x-rays and instruction to void
• Contraindicated if client has UTI

17
Assessment

• Diagnostic Tests
• Urodynamic studies
• Evaluates bladder and urethral function
• Assesses causes of reduced urine flow and urinary
  retention
• Uroflowmetry determination of the urinary flow
  rate noninvasive compares urine flow rate of
  the client with normal flow rates urinary
  patterns see table 63-3 postvoid residual done
  per catheterization
• Cystometrogram evaluates the bladder tone
  capacity client voids a catheter is inserted
  sterile saline instilled various measurements
  done

18
Assessment

• Diagnostic Tests
• Laboratory tests
• Urinalysis
• Study of components and characteristics of urine
• Monitors effects of treatment
• Urine culture and sensitivity
• Procedure
• Precautions

19
Assessment

• Diagnostic Tests
• Laboratory tests (contd)
• 24-hour urine collection
• Procedure
• Urine specific gravity
• Measures kidneys ability to concentrate and
  excrete urine
• Specific gravity Urine volume
• Urine protein
• Identifies renal disease

20
Assessment

• Diagnostic Tests
• Creatinine clearance test
• Determines kidney function and creatinine
  excretion
• Breakdown of phosphocreatine
• Procedure
• 4, 12, or 24 hour urine sample obtained blood
  sample
• Blood chemistries
• BUN creatinine
• Deterioration in renal function

21
Nursing Process of Client for Renal or Urologic
Disorder

• Assessment
• Nurses role
• Determine past experiences and expectations
• Complete preparations
• Review history and allergies
• Record vital signs and weight
• Ask the client to void
• Check for informed consent
• Teach and reassure client and family members

22
Nursing Process of Client for Renal or Urologic
Disorder

• Diagnosis, Planning, and Interventions
• Nurses role
• Provide privacy, reassurance, and information
• Maintain professional and empathic attitude
• Evaluation of Expected Outcomes
• Decrease in fear, better understanding, and
  compliance with instructions

23
General Considerations

• Nutritional Considerations
• Dietary intake that affects urine
• Acid ash or basic ash diet used to alter urine pH
• acid-ash diet  one of meat, fish, eggs, and
  cereals with little fruit or vegetables and no
  cheese or milk.
• High-protein, low-carbohydrate diet
• Megadoses of vitamin C can affect occult blood
  specimens
• Asparagus can produce pungent urine odor

24
General Considerations

• Pharmacologic Considerations
• Nephrotoxicity
• Effect on outcome of urinalysis and appearance
  Nitrofurantoin causes brown urine
• False-positive hematuria result if
  povidone-iodine used to clean area prior to ua
  dipstick
• Aminoglycosides can cause nephrotoxicity
• Diuretic therapy can cause alkaline urine
• Gerontologic Considerations
• Repeated directions and supervision
• Age-related changes in kidney function
• Identify and report signs of nephrotoxicity