Renal Prelims PDF

ASSESMENT OF KIDNEY AND URINARY FUNCTION PREPARED BY MRS. CARMELA ASURO, RN MAN  OVERVIEW OF URINARY SYSTEM Consist of 2 kidneys, 2 ureter, 1 urinary bladder and 1 urethra. After kidney filter the blood, they return most of the water and other soluter to the blood stream. The remaining wate...

ASSESMENT OF KIDNEY AND URINARY FUNCTION PREPARED BY MRS. CARMELA ASURO, RN MAN  OVERVIEW OF URINARY SYSTEM Consist of 2 kidneys, 2 ureter, 1 urinary bladder and 1 urethra. After kidney filter the blood, they return most of the water and other soluter to the blood stream. The remaining water (urine), passes through the ureters and is stored in the urinary bladder  FUNCTIONS OF THE KIDNEY ✓Urine formation ✓Excretion of waste product ✓Regulations of electrolytes ✓Regulations of acid –base balance ✓Control of water balance ✓Control of blood pressure ✓Renal clearance ✓Regulations of re blood cell production ✓Synthesis of vitamin D to active form ✓Secretions of prostaglandin ✓Regulations of calcium and phophorous balance  STRUCTURE OF KIDNEY  Each kidney is enclosed in a renal capsule, which is surrounded by adipose tissue.  Internally, the kidneys consist of a renal cortex, renal medulla, renal pyramids, renal columns, major and minor calyces, and a renal pelvis.  Blood enters the kidney through the renal artery and leaves through the renal vein. NEPHRON The functional unit of the kidney is called the nephron About a million in each kidney Consist of 2 part: renal corpuscle, and renal tubule Renal corpuscle = glomerular (bowman’s capsule) glomerulus Renal tube Proximal convoluted tubules Nephron loop (descending & ascending) Distal convoluted tubules  FUNCTION OF NEPHRON Nephrons perform three basic tasks: glomerular filtration, tubular reabsorption, and tubular secretion. Together, the podocytes and glomerular endothelium form a leaky filtration membrane that permits the passage of water and solutes from the blood into the capsular space. Blood cells and most plasma proteins remain in the blood because they are too large to pass through the filtration membrane. The pressure that causes filtration is the blood pressure in the glomerular capillaries.  FUNCTION OF NEPHRON Epithelial cells all along the renal tubules and collecting ducts carry out tubular reabsorption and tubular secretion. Tubular reabsorption retains substances needed by the body, including water, glucose, amino acids, and ions such as sodium (Na+), potassium (K+) , chloride (Cl-), bicarbonate (HCO3-), calcium (Ca2+), and magnesium (Mg2+). Tubular secretion discharges chemicals not needed by the body into the urine. Included are excess ions, nitrogenous wastes, hormones, and certain drugs. The kidneys help maintain blood pH by secreting H+. Tubular secretion also helps maintain proper levels of K+ in the blood https://www.khanacademy.or g/science/high-school- biology/hs-human-body- systems/hs-the-digestive- and-excretory- systems/v/how-do-our- kidneys-work Substances Filtered, Reabsorbed, and Excreted in Urine per Day Physical Characteristics of Normal Urine  FUNCTIONS OF KIDNEY  Regulation of ions in blood  Sodium-Na+, potassium-K+, calcium-Ca2+, Cl-, phosphate HPO42-  Regulation of blood volume  adjust the volume of blood or eliminating it in the urine  Regulation of blood pH  Regulate by excrete a variable amount of H+ in the urine, conserve bicarbonate HCO3-  Production of hormones  Calcitrole- calcium homeostasis  Erythropoietin- production of RBC  Excretion of waste  Ammonia and urea- amino acid  Creatinine- creatinine phosphate  Drugs ect FOLLOW THIS LINK AND LEARN MORE ABOUT THE KIDNEY: https://www.google.com/search?sca_esv=561694184&rlz=1C1SQJL_enUS840US840&h l=en&sxsrf=AB5stBiQ5NTS1mg50GCLeJ2JjLTyiL1K8w:1693511615568&q=Khan+Academ y+kidney+function+and+anatomy&uds=H4sIAAAAAAAA_- NK4uLxzkjMU3BMTkxJza0UUkvMSyzJz61UyE9TKMlIVcjOTMlLrVRIzEtRyCwpVkgrzUsuycz PM2As0kDWB1MHkwdrgBoFAPKBBsNkAAAA&sa=X&ved=2ahUKEwiGi5Oy1oeBAxVBxD gGHUwKDAsQxKsJegQICxAB&ictx=0&biw=1098&bih=511&dpr=1.75#fpstate=ive&vld=c id:df2dab31,vid:ctGkLYuUCvU  URETERS The ureters transport urine from the renal pelves of the right and left kidneys to the urinary bladder 10 to 12 in long diameter from 1-10 mm The urinary bladder is posterior to the pubic symphysis the shape of urinary bladder depends on how much urine is contain. when empty, it look like a deflated balloon Capacity ~700-800 ml Smaller in female because, uterus occupies the space superior to the urinary bladder Toward the base of urinary bladder, the ureter drains into the urinary bladder via the ureteral opening and expels urine into the urethra (Micturation) Micturation – involves both voluntary and involutary muscles.  URETHRA The terminal portion of the urinary bladder to the exterior of the body. In both male and female, the urethra is the passageway for discharging urine from the body. The male urethra also serves as the duct through which semen is ejaculated. PREPARE FOR A QUIZ!!  NCM 112 MANAGEMENT OF PATIENT WITH RENAL DISORDER : INTRODUCTION Prepared by: Mrs. Carmela Asuro RN,MAN OBJECTIVE: 1. Discuss the role of the kidneys in regulating fluid and electrolyte balance, acid–base balance, and blood pressure. 2. Identify the assessment parameters used for determining the status of upper and lower urinary tract function 3. Describe the diagnostic studies used to determine upper and lower urinary tract function. 4. Initiate education and preparation for patients undergoing assessment of the urinary system.  COMMON TERMINOLOGIES: ▪ aldosterone: hormone synthesized and released by the adrenal cortex; causes the kidneys to reabsorb sodium ▪ antidiuretic hormone: hormone secreted by the posterior pituitary gland; causes the kidneys to reabsorb more water; also called vasopressin ▪ anuria: total urine output less than 50 mL in 24 hours ▪ bacteriuria: bacteria in the urine; bacterial count higher than 100,000 colonies/mL ▪ creatinine: endogenous waste product of muscle energy metabolism ▪ diuresis: increased formation and secretion of urine ▪ dysuria: painful or difficult urination ▪ frequency: voiding more frequently than every 3 hours COMMON TERMINOLOGIES  glomerular filtration: plasma filtered at the glomerulus into the kidney tubules  glomerulus: tuft of capillaries forming part of the nephron through which filtration occurs  hematuria: red blood cells in the urine  micturition: urination or voiding  nephron:structural and functional unit of the kidney responsible for urine formation  nocturia: awakening at night to urinate  oliguria: total urine output less than 500 mL in 24 hours COMMON TERMINOLOGIES  proteinuria: protein in the urine  pyuria: white blood cells in the urine  renal clearance: volume of plasma that the kidneys can clear of a specific solute (eg, creatinine); expressed in milliliters per minute  renal glycosuria: recurring or persistent excretion of glucose in the urine  specific gravity: reflects the weight of particles dissolved in the urine; expression of the degree of concentration of the urine COMMON TERMINOLOGIES  tubularreabsorption: movement of a substance from the kidney tubule into the blood in the peritubular capillaries or vasa recta  tubularsecretion: movement of a substance from the blood in the peritubular capillaries or vasa recta into the kidney tubule  urea nitrogen: nitrogenous end-product of protein metabolism STRUCTURE OF THE KIDNEY  A pair of bean-shaped, brownish-red ; right kidney is slightly lower than the left due to the location of the liver LOCATION:  retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of the abdomen—  12th thoracic vertebra to the third lumbar vertebra WEIGHT :  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 (Porth &Matfin, 2009). KIDNEY: FUNCTIONS OF THE KIDNEY Urine formation https://www.youtube.com/watch?v=SFhvjPk_7I8 Excretion of waste products Regulation of electrolytes Regulation of acid–base balance Control of water balance Control of blood pressure URINE FORMATION: 1. GLOMERULAR FILTRATION 2. TUBULAR REABSORTION 3. TUBULAR SECRETION FUNCTION OF KIDNEY Renal clearance Regulation of red blood cell production Synthesis of vitamin D to active form Secretion of prostaglandins Regulates calcium and phosphorus balance https://www.youtube.com/watch?v=cc8sUv2SuaY  ASSESSMENT OF THE KIDNEY AND URINARY SYSTEM A. Health History Obtaining a urologic health history requires excellent communication skills, because many patients are embarrassed or uncomfortable discussing genitourinary function or symptoms(Bickley, 2007; Weber & Kelley, 2007) 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 or use of indwelling urinary catheters Dysuria and when during voiding (ie, at initiation or at termination of voiding) it occurs  HEALTH ASSESSMENT..CONT. Hesitancy, straining, or pain during or after urination Urinary incontinence (stress incontinence, urge incontinence,overflow incontinence, or functional incontinence) Hematuria 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 Female patients: number and type (vaginal or cesarean)of deliveries; use of forceps; vaginal infection, discharge, or irritation; contraceptive practices History of anuria (decreased urine production) orother renal problem Presence or history of genital lesions or sexually transmitted diseases 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 IDENTIFYING CHARACTERISTICS OF GENITOURINARY PAIN Type Location Character Associated s/s Possible etiology Kidney Costovertebral angle, may Dull constant ache; if sudden Nausea & vomiting, Acute obstruction, kidney extend to umbilicus distention of capsule, pain diaphoresis, pallor, signs of stone, blood clot, acute Male: along penis to is severe, sharp, stabbing, shock pyelonephritis, trauma meatus; female: urethra to meatus and colicky in nature Bladder Suprapubic area Dull, continuous pain, may be Urgency, pain at end of Overdistended bladder, intense with voiding, may voiding, painful straining infection, interstitial be severe if bladder full cystitis; tumor Ureteral Costovertebral angle, flank, Severe, sharp, stabbing pain, Nausea and vomiting, Ureteral stone, edema or lower abdominal area, testis, or colicky in nature paralytic ileus stricture, blood clot labium Prostatic Perineum and rectum Vague discomfort, feeling of Suprapubic tenderness, Prostatic cancer, acute or fullness in perineum, vague obstruction to urine flow; chronic prostatitis back pain frequency, urgency, dysuria, nocturia Urethral Male: along penis to Pain variable, most severe Frequency, urgency, dysuria, Irritation of bladder neck, meatus; female: urethra during and immediately nocturia, urethral discharge infection of urethra, to meatus after voiding trauma, foreign body in lower urinary tract  CHANGES IN VOIDING Problem Definition Possible etiology Frequency Frequent voiding—more than Infection, obstruction of lower urinary tract leading to residual urine and overflow, anxiety, diuretics, benign every 3 h prostatic hyperplasia, urethral stricture, diabetic neuropath Dysuria Painful or difficult voiding Infection, chronic prostatitis, urethritis, obstruction of lower urinary tract leading to residual urine and overflow, anxiety, diuretics, benign prostatic hyperplasia, urethral stricture, diabetic neuropathy Urgency Strong desire to void Lower urinary tract infection, inflammation of bladder or urethra, acute prostatitis, stones, foreign bodies, tumors in bladder Hesitancy Delay, difficulty in initiating voiding Benign prostatic hyperplasia, compression of urethra, outlet obstruction, neurogenic bladder Nocturia Excessive urination at night Decreased renal concentrating ability, heart failure, diabetes mellitus ,incomplete bladder emptying, excessive fluid intake at bedtime, nephrotic syndrome, cirrhosis with ascites Incontinence Involuntary loss of urine External urinary sphincter injury, obstetric injury, lesions of bladder neck, detrusor dysfunction, infection, neurogenic bladder, medications,neurologic abnormalities Enuresis Involuntary voiding during sleep Delay in functional maturation of central nervous system (bladder control usually achieved by 5 y of age), obstructive disease of lower urinary tract, genetic factors, failure to concentrate urine, urinary tract infection, psychological stress Polyuria Increased volume of urine voided Diabetes mellitus, diabetes insipidus, use of diuretics, excess fluid intake, lithium toxicity, some forms of kidney disease (hypercalcemic and hypokalemic nephropathy) Oliguria Urine output less than 500 mL/day Acute or chronic renal failure (see Chapter 44), inadequate fluid intake Anuria Urine output less than 50 mL/day Acute or chronic renal failure (see Chapter 44), complete obstruction Hematuria Red blood cells in the urine Cancer of genitourinary tract, acute glomerulonephritis, renal stones, renal tuberculosis, blood dyscrasia, trauma, extreme exercise, rheumatic fever, hemophilia, leukemia, sickle cell trait or disease Proteinuria Abnormal amounts of protein in Acute and chronic renal disease, nephrotic syndrome, vigorous exercise, the urine heat stroke, severe heart failure, diabetic nephropathy, multiple myeloma  Gastrointestinal 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 ;t his can make diagnosis difficult, especially in the elderly , who have decreased neurologic innervation to this area(Goshorn, 2005).  Unexplained ANEMIA Fatigue, shortness of breath, and exercise intolerance all result from the condition known as “anemia of chronic disease.”  PHYSICAL EXAMINATION Technique for palpating the right kidney : Place one hand under the patient’s back with the fingers under the lower rib. Place the palm of the other hand anterior to the kidney with fingers above the umbilicus. Push the hand on top forward as the patient inhales deeply. The left kidney is palpated similarly by reaching over to the patient’s left side and placing the right hand beneath the patient’s lower left rib.  From Weber, J. & Kelley, J. (2007). Health assessment in nursing (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.  The kidneys are not usually palpable. However, palpation of the kidneys may detect an enlargement that could prove to be very important (Bickley, 2007). Dullness to percussion of the bladder after voiding indicates incomplete bladder emptying (Bickley, 2007; Weber & Kelley, 2007). DIAGNOSTIC PROCEDURES :  Urinalysis and Urine Cultures  useful for documenting a UTI and identifying the specific organism present. A colony count of at least 105colony-forming units (CFU) per milliliter of urine on a clean-catch midstream or catheterized specimen is a major criterion for infection (Smythe, Moore & Goldsmith,2006). Components of urine examinations: ❖ Urine color - ❖ Urine clarity and odor ❖ Urine pH and specific gravity ❖ Test to detect protein, glucose, and ketone bodies ❖ Urine sediments: RBC , Pyuria, cast, crystals and bacteria  Renal Function Test Test Purpose Normal value Renal Concentration Tests Evaluates ability of kidneys to concentrate solutes in urine. 1.010–1.025 Specific gravity Concentrating ability is lost early in kidney disease; hence, these test 300–900 mOsm/kg/24 h, 50–1200 Urine osmolality findings may disclose early mOsm/kg random sample defects in renal function 24-Hour Urine Test Detects and evaluates progression of renal disease. Test Measured in mL/min/1.73 m2 Creatinine clearance measures volume of blood cleared of endogenous Age Male Female creatinine in 1 min, which provides an approximation of the Under 30 88–146 81–134 glomerular filtration rate. Sensitive indicator of renal disease 30–40 82–140 75–128 used to follow progression of renal disease. 40–50 75–133 69–122 50–60 68–126 64–116 60–70 61–120 58–110 70–80 55–113 52–105 Serum Tests 0.6–1.2 mg/dL (50–110 Creatinine level Measures effectiveness of renal function. mmol/L) Serves as index of renal function. Urea is Urea nitrogen (blood nitrogenous end-product of protein metabolism. 7–18 mg/dL urea nitrogen [BUN]) Patients >60 yrs: 8–20 mg/dL Evaluates hydration status. An elevated ratio is seen BUN-to-creatinine ratio in hypovolemia; a normal ratio with an elevated BUN and creatinine is seen with intrinsic renal About 10:1 disease.  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 (Labus , 2008).  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.Because of its sensitivity, ultrasonography has replaced manyother tests as the initial diagnostic procedure (Burrows-Hudson, 2005).  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 (Labus, 2008)  Nuclear Scans Nuclear scans require injection of a radioisotope into the circulatory system; the isotope is then monitored as it moves through the blood vessels of the kidney s. A scintillation camera is placed behind the kidney with the patient in a supine, prone, or seated position. Hypersensitivity to the radioisotope is rare. The technetium scan provides information about kidney perfusion. The123I-hippurate renal scan provides information about kidney function, such as GFR.  Intravenous Urography IV urography includes various tests such as excretory urography , intravenous pyelography (IVP), and infusion drip pyelography. A radiopaque contrast agent is administered by IV. An IVP shows the kidneys, ureter, and bladder via x-ray imaging as the dye moves through the upper and then the lower urinary system.  Retrograde Pyelography In retrograde pyelography, catheters are advanced through the ureters into the renal pelvis by means of cystoscopy. A contrast agent is then injected. Retrograde pyelography is usually performed if IV urography provides inadequate visualization of the collecting systems.  Cystography Cystography aids in evaluating vesicoureteral reflux (backflow of urine from the bladder into one or both ureters) and in assessing for bladder injury. A catheter is inserted into the bladder, and a contrast agent is instilled to outline the bladder wall. The contrast agent may leak through a small bladder perforation stemming from bladder injury, but such leakage is usually harmless. Cystography can also be performed with simultaneous pressure recordings inside the bladder.  Voiding Cystourethrography - uses fluoroscopy to visualize the lower urinary tract and assess urine storage in the bladder. It is commonly used as a diagnostic tool to identify vesicoureteral reflux. A urethral catheter is inserted, and a contrast agent is instilled into the bladder. When the bladder is full and the patient feels the urge to void, the catheter is removed,and the patient voids.  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 used 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.  Endourology, or urologic endoscopic procedures, can be performed in one of two ways: using a cystoscope inserted into the urethra, or percutaneously, through a small incision. The cystoscopic examination is used to directly visualize the urethra and bladder. The cystoscope, which is inserted through the urethra into the bladder, has an optical lens system that provides a magnified, illuminated view of the bladder. The use of a high-intensity light andinterchangeable lenses allows excellent visualization and permits still and motion pictures to be taken.  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 brushing 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 renal failure, persistent proteinuria or hematuria, transplant rejection, and glomerulopathies. NURSING CARE PLAN Assessment Nursing Diagnosis Planning Implementation Evaluation LETS GET READY TO MAKE OUR NCP!!! Urinary Tract Infections   Most infections involve the lower urinary tract A urinary  Women are at greater risk of tract developing a UTI than men are. infection  Urinary tract infections don't always cause signs and symptoms, but when (UTI) is an they do they may include: ❑ A strong, persistent urge to urinate infection in ❑ A burning sensation when urinating any part of ❑ Passing frequent, small amounts of the urinary ❑ urine Urine that appears cloudy system — ❑ Urine that appears red, bright pink kidneys, or cola-colored — a sign of blood in the urine ureters, ❑ Strong-smelling urine bladder and ❑ Pelvic pain, in women — especially in the center of the pelvis and urethra. around the area of the pubic bone  Risk Factors for UTI a. Inability or failure to empty the bladder completely b. Obstructed urinary flow c. Immunosuppression may weak immune system d. Instrumentation of the urinary tract mga may catheter etc e. Inflammation of the urethral mucosa f. Contributing conditions - Congenital anomalies Diabetes Mellitus - urethral strictures Pregnancy - Contracture of the bladder Neurologic Disorders neck Gout - Bladder tumor - Calculi in the ureter or kidney  Lower UTI’s Urethra Urethritis Urinary Bladder Cystitis Prostate Gland Prostatitis Uncomplicated UTI’s are community acquired Complicated UTI’s usually occur in people with urologic abnormalities or recent catheterization and are often hospital acquired Several mechanism maintain the sterility of the bladder: The physical barrier of the urethra Urine flow/ efflux of urine Ureterovesical junction competence Antiadherent effects by the mucosal cells Glycosaminoglycan ( GAG) – hydrophilic protein, normally exerts non adherent protective effect against various bacteria. GAG molecules attracts water molecules, forming a water barrier that serves as a defensive layer between the bladder and the urine. UROTHELIUM – transitional cell epithelium that prevents re-absorption of urine  Normal bacterial flora of the vagina and urethral area also interfere with adherence of Escherichia coli. Urinary Immunoglobin A (IgA) in the urethra may also provide barrier to bacteria Urinary Tract Infection Classification of UTIs Lower UTI’s Upper UTI’s Complicated Complicated Uncomplicated Uncomplicated Lower UTI’s :  usually caused by Escherichia coli (E. coli),  Sexual intercourse may lead to cystitis  All women are at risk of cystitis because of their anatomy — specifically, the short distance from the urethra to the anus and the urethral opening to the bladder.  Urethritis  This type of UTI can occur when bacteria spread from the anus to the urethra.  because the female urethra is close to the vagina, sexually transmitted infections, such as herpes, gonorrhea can cause urethritis. Complications of UTI  Permanent kidney damage from an acute or chronic kidney infection (pyelonephritis) due to an untreated UTI.  Increased risk in pregnant women of delivering low birth weight or premature infants.  Urethral narrowing (stricture) in men from recurrent urethritis, previously seen with gonococcal urethritis.  Sepsis, a potentially life-threatening complication of an infection, especially if the infection works its way up your urinary tract to your kidneys. REFLUX An obstruction to the free flowing urine is known as URETHROVESICAL REFLUX Backward flow of urine from the urethra into the bladder Increase bladder pressure caused by sneezing, coughing or straining Forces urine from bladder to urethra When pressure returns to normal urine flow back into the bladder bringing bacteria  VESICOURETERAL REFLUX Backward flow of urine from the bladder to the ureters Bacteriuria – defined as more than 105 colonies of bacteria per ml of urine Bacteria enters the body in three ways: * transurethral route (ascending infection) * bloodstream ( hematogenous spread) * fistula from the intestine ( direct extension) Urosepsis – sepsis from infected urine Gerontologic Conditions Bacteriuria increases with age and disability Women> men UTI is the most common cause of acute bacterial sepsis in patients >65 years old Antibacterial activity of prostatic secretions decreases  Upper UTI’s ▪ Pyelonephritis – Is a bacterial infection of the renal pelvis, tubules an interstitial tissue of one or both kidneys ❑ Causes : upward movement of bacteria or systemic spread (incompetent ureterovesical valve) ❑ Obstruction : bladder tumors, benign prostatic hyperplasia, urinary stones urine stasis urine retention; bladder cannot entirely empty  Pyelonephritis ❑ Acute: kidneys are enlarge with interstitial infiltrations of inflammatory cells; abscess on renal capsule; atrophy and destruction of tubules and glomeruli may result ❑ Chronic: kidneys becomes scarred, contracted and non functioning Nephron LOSS  ACUTE PYELONEPHRITIS CHRONIC PYELONEPHRITIS Clinical Manifestation : Usually has no symptoms a. Chills unless acute exacerbation occurs b. Fever Clinical Manifestation : c. Leukocytosis a. Fatigue b. Headache d. Bacteriuria c. Poor appetite e. Pyuria d. Polyuria f. Low back pain e. Excessive thirst g. Flank pain f. Weight loss h. Nausea and vomiting Medical management : i. Headache a. Long term use of prophylactic antibiotics j. Malaise b. Renal replacement k. Painful urination  Diagnostic Findings a. Urinalysis :microscopic analysis of the urine shows signs of infection. Excess of white blood cells and bacteria. b. Urine culture :Within days, bacteria in urine may grow on a culture dish, allowing the best antibiotic to be chosen. c. Blood cultures. d. Computed tomography (CT scan) e. Kidney ultrasound. help identify abscesses, stones, and blockages.  Medical Management  Antibiotic therapy  Relieve obstruction  Analgesics  Nephrostomy - a tube inserted through the skin on the back into the kidney abscess to drain  Renal function test monitoring Nursing Management ❑ Fluid monitoring (I & O) ❑ 3-4 L /day unless contraindicated ❑ Monitor v/s ❑ Health Teaching o Prevent recurrence of infection ❖ Adequate fluids ❖ Regular bladder emptying o Perineal hygiene o Drug compliance Adult Voiding Dysfunction o Urinary Incontinence o Urinary Retention o Neurogenic Bladder  Definition : involuntary loss of urine in the bladder Types : Stress Urge Functional Iatrogenic Mixed Urinary Incontinenc Incontinence Incontinence Incontinenence Incontinence e Stress Incontinence o Involuntary loss of urine through an intact urethra as a result of sneezing, coughing or changing position o Predominantly affects women who have had vaginal deliveries, decreasing pelvic ligaments and pelvic floor support of the urethra and decreasing estrogen levels in the urethral walls and bladder base o In men, after radical prostatectomy, bladder wall irritability Urge Incontinence o Is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed o Patient is aware of the need to void that cannot be suppressed and unable to reach the toilet in time Functional Incontinence o refers to those instances in which lower UT function is intact but other severe cognitive impairment makes it difficult for the patient to identify the need to void o Physical impairment make it difficult or impossible for the patient to reach the toilet in time for voiding.  Iatrogenic Incontinence o refers to the involuntary loss of urine due to extrinsic factors, predominantly medications Mixed Urinary Incontinence o encompasses several types of urinary incontinence o Involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing  Medical Management 1. Behavioral Therapy 2. Pharmacologic Therapy 3. Surgical Management  Behavioral Therapy a. Fluid management – 1500 to 1600ml in increments b. Standardized Voiding Frequency 1. Timed Voiding- void by the clock 2. Prompted Voiding- timed voiding carried out by family when patient has cognitive impairments 3. Habit Retraining- timed voiding with interval that is more frequent than the individual would normally choose (restores urge sensation)  4. Bladder Retraining – “bladder drill”; incorporates time voiding schedule and urinary urge inhibition exercise to inhibit voiding or urine leakage in an attempt to remain dry for a set of time 5. Pelvic Muscle Exercise (PME)- also known as Kegel’s Exercise (10-30 repetitions) 6. Vaginal Cone Retention Exercise – 15 minutes BID by contracting the pelvic muscles  7. Transvaginal or Transrectal Electrical Stimulation -electrical stimulation is known to elicit a passive contraction of the pelvic floor musculature at high frequency – stress incontinence at moderate frequency – mixed incontinence at low frequency – urinary urgency, frequency and urge incontinence 8. Neuromodulation- trans V or trans Rectal nerve stimulation of the pelvic floor inhibits detrusor over activity and hypersensory bladder signals and strengthen weak spinchter Pharmacologic Therapy a. Anticholinergic – inhibits bladder contraction and are considered first line medications for urge incontinence b. Tricyclic anti depressants – decrease bladder contraction and increase bladder neck resistance c. Pseudoephedrine Sulfate- acts on alpha adrenergic receptors causing urinary retention d. Hormone therapy- estrogen  Surgical Management Most procedures involve lifting and stabilizing the bladder a. Anterior vaginal repair – stress incontinence b. Retropubic suspension c. Needle suspension to reposition the urethra Procedures to Compress the urethra and increase resistance to urine flow a. Sling procedures b. Placement of periurethral bulking agents – artificial collagen  periurethral bulking agents – semi permanent procedure in which small amounts of artificial collagen are placed within the walls of the urethra to enhance the closing pressure of the urethra  ARTIFICIAL URINARY SPHINCTERS - to close the urethra and promote continence  Periurethral cuff  Cuff Inflation pump THANK YOU!! YEYYY!!  MANAGEMENT OF PATIENT WITH URINARY DISORDER PREPARED BY : MRS. CARMELA C. ASURO, MAN,RN Objective: 1. Identify factors contributing to upper and lower urinary tract infections (UTIs). 2. Use the nursing process as a framework for care of the patient with a UTI. 3. Differentiate between the various adult dysfunctional voiding patterns. 4. Develop a patient education plan for a patient who has mixed (stress and urge) urinary incontinence. 5. Identify potential causes of an obstruction of the urinary tract and management of the patient with this condition. Terminologies bacteriuria: more than 105 colonies of bacteria per milliliter of urine cystectomy: removal of the urinary bladder cystitis: inflammation of the urinary bladder frequency: voiding more often than every 3 hours ileal conduit: transplantation of the ureters to an isolated section of the terminal ileum, with one end of the ureters brought to the abdominal wall interstitial cystitis: inflammation of the bladder wall that eventually causes disintegration of the lining and loss of bladder elasticity  pyelonephritis: inflammation of the renal pelvis pyuria: white blood cells in the urine micturition: voiding or urination neurogenic bladder: bladder dysfunction that results from a disorder or dysfunction of the nervous system; may result in either urinary retention or bladder overactivity, resulting in urinary urgency and urge incontinence nocturia: awakening at night to urinate overflow incontinence: involuntary urine loss associated with overdistention of the bladder due to mechanical or anatomic bladder outlet obstruction  prostatitis: inflammation of the prostate gland ureterovesical or vesicoureteral reflux: backward flow of urine from the bladder into one or both ureters urethritis: inflammation of the urethra urethrovesical reflux: backward flow of urine from theurethra into the bladder urinary incontinence: involuntary or uncontrolled loss of urine from the bladder sufficient to cause a social or hygienic problem urosepsis: sepsis resulting from infected urine, most often a UTI  Overview of the Urinary Tract The urinary system's function is to filter blood and create urine as a waste by-product. The organs of the urinary system include the: kidneys, renal pelvis, ureters, bladder and urethra.  Two ureters. These narrow tubes carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters. Bladder. This triangle-shaped, hollow organ is located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder's walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours.  Two sphincter muscles. These circular muscles help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder. Nerves in the bladder. The nerves alert a person when it is time to urinate, or empty the bladder. Urethra. This tube allows urine to pass outside the body. The brain signals the bladder muscles to tighten, which squeezes urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax to let urine exit the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs. Facts about urine Normal, healthy urine is a pale straw or transparent yellow color. Darker yellow or honey colored urine means you need more water. A darker, brownish color may indicate a liver problem or severe dehydration. Pinkish or red urine may mean blood in the urine. https://www.hopkinsmedicine.org/health/wellness-and-prevention/anatomy-of- the-urinary-system#:  INFECTIONS OF THE URINARY TRACT Classifying Urinary Tract Infections Urinary tract infections (UTIs) are classified by location: the lower urinary tract (which includes the bladder and structures below the bladder) or the upper urinary tract (which includes the kidneys and ureters). They can also be classified as uncomplicated or complicated UTIs. Lower UTIs :Cystitis, prostatitis, urethritis Upper UTIs :Acute pyelonephritis, chronic pyelonephritis, renalabscess, interstitial nephritis, perirenal abscess Uncomplicated Lower or Upper UTIs :Community-acquired infection; common in young women and not usually recurrent Complicated Lower or Upper UTIs : Often nosocomial (acquired in the hospital) and related to catheterization; occur in patients with urologic abnormalities, pregnancy, immunosuppression, diabetes mellitus, and obstructions and are often recurrent  Risk Factors for Urinary Tract Infection Inability or failure to empty the bladder completely Obstructed urinary flow caused by: Congenital abnormalities, Urethral strictures, Contracture of the bladder neck ,Bladder tumors,Calculi (stones) in the ureters or kidneys, Compression of the ureters Decreased natural host defenses or immunosuppression Instrumentation of the urinary tract (eg, catheterization, cystoscopic procedures) Inflammation or abrasion of the urethral mucosa Contributing conditions such as: ✓ Diabetes mellitus (increased urinary glucose levels create an infection-prone environment in theurinary tract) ✓ Pregnancy ✓ Neurologic disorders ✓ Gout ✓ Altered states caused by incomplete emptying of the bladder and urinary stasis The mechanisms that works together to prevent infection and they include: The process of urinating washes most bacteria out of the urethra In females: Mucus secreting cells in the urethra help trap bacteria so it can’t move upward In males: the length of the urethra and the prostate and associated glands create secretions to shield bacteria from invading Several factors work to create a bactericidal effect: high osmolality and low PH of the urea, uromodulin presence (a protein synthesized in the kidneys), and the epithelial cells of the urinary tract When the bladder contracts, the ureterovesical junction (functional one-way valve where the ureters lead into the bladder) closes, thus preventing urine from ascending upwards into the upper urinary tract In the distal urethra, the urethral sphincter prevents the upward movement of bacteria  If bacteria were to successfully invade, the immune system recruits toll-like receptors (TLR4) which recognize the pathogen and further recruits neutrophils and macrophages to induce phagocytosis. The ability of the pathogen to produce infection is influenced by the virulence of the specific pathogen and individual’s specific immune response. If the immune system does not respond quick enough, the pathogen may be able to excessively multiply and inundate the individual’s defense mechanism, causing a UTI (McCance & Huether, 2019).  EXAMPLES OF MEDICATIONS USED TO TREAT UTIs AND PYELONEPHRITIS Drug Classes Generic (Brand) Name Major Indications Antibiotic Cephalexin (Keflex) Genitourinary infections Cephalosporin (first generation) Antibiotic Ampicillin (Principen) UTI—not commonly used alone due to Escherichia coli resistance Pyelonephritis Antibiotic Amoxicillin (Amoxil) UTI—not commonly used alone due to E. coli resistance Trimethoprim-sulfamethoxazole Cotrimoxazole (TMP-SMZ, UTI combination Bactrim Septra ) Pyelonephritis Antibiotic Nitrofurantoin (Macrodantin, UTI Urinary tract anti-infective Furadantin) Fluoroquinolone Ciprofloxacin (Cipro) UTI Antibiotic Pyelonephritis Fluoroquinolone Levofloxacin (Levaquin) Uncomplicated UTI Urinary analgesic agent Phenazopyridine (Pyridium) For relief of burning, pain and other symptoms associated with UTI  Nursing process for patient with Lower UTI Assessment Nursing Diagnosis Planning Nursing Evaluation Intervention History of signs ▪ Acute pain related to Major goals for the ▪ Relieving Pain Expected patient and symptoms infection within the patient may include ▪ Monitoring and outcomes may include: presence of urinary tract relief of pain and Managing Experiences relief of pain, frequency, ▪ Deficient knowledge discomfort, Potential pain urgency, hesitancy, about factors increased Complications Explains UTIs and and changes in predisposing the knowledge of ▪ Promoting Home their treatment urine patient to infection preventive measures and Community- Experiences no pattern of and recurrence, and treatment Based Care complications voiding detection and modalities, and urine is assessed prevention of absence of for volume, recurrence, and complications color, pharmacologic concentration, therapy cloudiness, and odor PATIENT EDUCATION Before and After Urodynamic Testing A physician or nurse will conduct an in-depth interview. Questions related to your urologic symptoms and voiding habits will be asked. You will be asked to describe sensations felt during the procedure. During the procedure, you might be asked to change positions (eg, from supine to sitting or standing). You may be asked to cough or perform the Valsalva maneuver (bear down) during the procedure. You will probably need to have one or two urethral catheters inserted so that bladder pressure and bladder filling can be measured. Another catheter may be placed in the rectum or vagina to measure abdominal pressure. You may also have electrodes (surface, wire, or needle)placed in the perianal area for electromyography(EMG). This may be uncomfortable initially during insertion and later during position changes.  Your bladder will be filled through the urethral catheter one or more times during the procedure. After the procedure, you may experience urinary frequency, urgency, or dysuria from the urethral catheters. Avoid caffeinated, carbonated, and alcoholic beverages after the procedure because these can further irritate the bladder. These symptoms usually decrease or subside by the day after the procedure. You might notice a slight hematuria (blood-tinged urine) right after the procedure (especially in men with benign prostatic hyperplasia). Drinking fluids will help to clear the hematuria. If the urinary meatus is irritated, a warm sitz bath may be helpful. Be alert for signs of a urinary tract infection after the procedure. Contact your physician if you experience fever, chills, lower back pain, or continued dysuria and hematuria. If you receive an antibiotic medication before the procedure, you should continue taking the complete course of medication after the procedure. This is a measure to prevent infection. PATIENT EDUCATION Preventing Recurrent Urinary Tract Infections Hygiene Shower rather than bathe in tub because bacteria in the bath water may enter the urethra. After each bowel movement, clean the perineum and urethral meatus from front to back. This will help reduce concentrations of pathogens at the urethral opening and, in women, the vaginal opening. Fluid Intake Drink liberal amounts of fluids daily to flush out bacteria. Avoid coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants. Voiding Habits Void every 2 to 3 hours during the day and completely empty the bladder. This prevents overdistention of the bladder and compromised blood supply to the bladder wall. Both predispose the patient to UTI. Precautions expressly for women include voiding immediately after sexual intercourse.  Therapy Take medication exactly as prescribed. Special timing of administration may be required. If bacteria continue to appear in the urine, long-term antimicrobial therapy may be required to prevent colonization of the periurethral area and recurrence of infection. For recurrent infection, consider acidification of the urine through ascorbic acid (vitamin C), 1000 mg daily, or cranberryjuice. If prescribed, test urine for presence of bacteria following manufacturer’s and health care provider’s instructions. Notify the primary health care provider if fever occurs or if signs and symptoms persist. Consult the primary health care provider regularly for follow-up.  Upper Urinary Tract Infection ACUTE PYELONEPHRITIS – bacterial infection of the renal parenchyma that can be organ- and/or life-threatening and that often leads to renal scarring. The bacteria in these cases have usually ascended from the lower urinary tract but may also reach the kidney via the bloodstream. Clinical Manifestations acutely ill with chills and fever, leukocytosis, bacteriuria,pyuria. Low backpain, flank pain, nausea and vomiting, headache, malaise, painful urination pain and tenderness in the area of the costovertebral angle.  CHRONIC PYELONEPHRITIS - Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis Clinical Manifestations usually has no symptoms of infection unless an acute exacerbation occurs. Noticeable signs and symptoms may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss. Persistent and recurring infection may produce progressive scarring of the kidney, resulting in renal failure  ADULT VOIDING DYSFUNCTION Condition Voiding Dysfunction Treatment Neurogenic Disorders Cerebellar ataxia Incontinence or dyssynergia Timed voiding; anticholinergic agents Cerebrovascular accident Retention or incontinence Anticholinergic agents; bladder retraining Dementia Incontinence Prompted voiding; anticholinergic agents Diabetes mellitus Incontinence and/or incomplete bladder Timed voiding; EMG/biofeedback; pelvic floor nerve emptying stimulation; anticholinergic/antispasmodic agents; well- Multiple sclerosis Incontinence or incomplete bladder emptying controlled blood glucose levels Timed voiding; EMG/biofeedback to learn pelvic muscle Parkinson’s disease Incontinence exercises and urge inhibition; pelvic floor nerve stimulation; antispasmodic agents Anticholinergic/antispasmodic agents Spinal Cord Dysfunction Acute injury Urinary retention Indwelling catheter Degenerative disease Incontinence and/or incomplete bladder EMG/biofeedback; pelvic floor nerve stimulation; emptying anticholinergic agents Non-Neurogenic Disorders Inability to initiate voiding in public bathrooms Relaxation therapy; EMG/biofeedback “Bashful bladder” Urgency, frequency, and/or urge incontinence EMG/biofeedback; pelvic floor nerve stimulation; bladder Overactive bladder drill ; anticholinergic agents Acute urine retention Catheterization Post-general surgery Incontinence Mild: biofeedback; bladder drill ; pelvic floor nerve Postprostatectomy Incontinence with cough, laugh, stimulation Stress incontinence sneeze, position change Moderate/severe: surgery—artificial sphincter Mild: biofeedback: bladder drill ; periurethral bulking with collagen Moderate/severe: surgery  Urinary Incontinence Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sneezing, coughing,or changing position (Miller, 2009). Iatrogenic incontinence refers to the involuntary loss of urine due to extrinsic medical factors, predominantly medications. One such example is the use of alpha-adrenergic agents to decrease blood pressure. Mixed urinary incontinence, which encompasses several types of urinary incontinence, is involuntary leakage associated with urgency and also with exertion, effort, sneezing,or coughing (Miller, 2009). Causes of Transient Incontinence: DIAPPERS Delirium Infection of urinary tract Atrophic vaginitis, urethritis Pharmacologic agents (anticholinergic agents, sedatives,alcohol, analgesic agents, diuretics, muscle relaxants,adrenergic agents) Psychological factors (depression, regression) Excessive urine production (increased intake, diabetes insipidus,diabetic ketoacidosis) Restricted activity Stool impaction Urinary Retention The inability to empty the bladder completely during attempts to void. Chronic urine retention often leads to overflow incontinence (from the pressure of the retained urine in the bladder). Residual urine is urine that remains in the bladder after voiding. In a healthy adult younger than 60 years of age, complete bladder emptying should occur with each voiding. In adults older than 60years of age, 50 to 100 mL of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. Urinary retention can occur postoperatively in any patient, particularly if the surgery affected the perineal or anal regions and resulted in reflex spasm of the sphincters. General anesthesia reduces bladder muscle innervation and suppresses the urge to void, impeding bladder emptying.  Urinary retention ✓ diabetes, ✓ prostatic enlargement, ✓ urethral pathology (infection, tumor, calculus), ✓ trauma (pelvic injuries), ✓ pregnancy, ✓ neurologic disorders such as stroke, spinal cord injury, multiple sclerosis, Parkinson’s disease. ✓ Some medications cause urinary retention either by inhibiting bladder contractility or by increasing bladder outlet resistance (Karch, 2008). PATIENT EDUCATION Strategies for Promoting Urinary Continence Increase your awareness of the amount and timing of all fluid intake. Avoid taking diuretics after 4 PM. Avoid bladder irritants, such as caffeine, alcohol, and aspartame (NutraSweet). Take steps to avoid constipation: Drink adequate fluids, eat a well-balanced diet high in fiber, exercise regularly, and take stool softeners if recommended. Void regularly, five to eight times a day (about every 2 to 3 hours): First thing in the morning Before each meal Before retiring to bed Once during the night if necessary Perform all pelvic floor muscle exercises as prescribed,every day. Stop smoking (smokers usually cough frequently, which increases incontinence).