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BASIC ANATOMY


 

                          
Basically, the urinary system consists of the kidneys, bladder, the ureters (the tubes from the kidneys to the bladder) and the urethra (the tube from the bladder to the exterior of the body). Think of the urinary tract like the plumbing system in a house that have tubes allowing water and salts flowing through them. The body has two kidneys (best approximated in the middle of the back below the rib cage, about the same level as ones elbows), that has nephrons acting as filters for the blood.  On a daily basis, about 150 liters (33 gallons) of fluid pass through the kidneys and 99% of this is cleaned and reabsorbed. The waste (urine) product that is not absorbed is stored in the bladder for eventual elimination. The bladder also closes openings into the ureters so that urine cannot flow back into the kidneys.  About 96% of urine is water. It also contains some waste salts and a substance called urea. Urea is made during the breakdown of proteins in your liver. Urea may also leave your body in sweat. If urea builds up in your body, it is a sign that your kidneys are not working properly. Kidney failure can be fatal if it is not treated quickly.
If the nephrons of the kidneys are damaged and are not able to function, it could lead to kidney disease.  High blood pressure and diabetes are the two most common cause of damage to the kidneys. Prostate gland, kidney stones, glomerulonephritis, long term use of certain medicines, such as Tylenol and ibuprofen (ie. Advil) are also a few causes of kidney disease. Unfortunately, most people will not experience any kind of symptoms before the kidney problem is recognized. Yet some of the symptoms one might experience are:

  • Urinating less than normal.
  • Edema, fluid build up particularly of the lower extremities.
  • Lost of weigh without trying or not feeling hungry
  • Feeling nauseated
  • Feeling tired or sleepy

 If left untreated the kidney disease can lead to kidney failure which would cause an individual to undergo dialysis or liver transplant. 
Characteristics of Urine
:

  • Color - light yellow
  • Consistency – clear
  • Specific Gravity – 1.1010 – 1.030
  • Ph – 4.5 – 8.0
  • 24 hour urine output – 1,000 – 1,500 ml

TOPICS

Bladder Replacement
  1.     Ileal Conduit

  • Make sure to have tight fitting drainage bag.

  2.     Ileal Resrvoir

  • Lie on side when emptying the pouch.

  3.     Orthotopic Bladder

  • Artificial bladder. Encourage patient to bear down when voiding.

BUN (Blood Urea Nitrogen)

  • Normal value – 7 -.20 mg/dL.
  • A waste product produced in the liver after breaking down proteins and is excreted by the kidneys.
  • If increased in level, indicates renal disease or reduced blood flow such as in dehydration and UTI (Urinary Tract Infection)
  • Normal Bun : Creatinine ratio is 10:1 – a wide ration (example 70:1.8) indicated Pre-renal cause of kidney failure and  narrow ratio (example 45:3.4) indicates Intra-renal cause of kidney failure.

 

Catherization

  • Some reasons for catherization is for measuring urine output, collecting urine specimen, emptying the bladder or preventing bladder distention during certain surgery.
  • Use sterile technique when catheterizing.
  • Never forcefully push a catheter into a urethra though resistance at the external sphincter may be met when inserting a catheter into a male urethra.
  • After inserting the balloon, gently tug on the catheter to bring the balloon down the bladder neck and it is best to tape the tube on to the patient’s thigh in place, allowing enough slack for leg movement.
  • Drainage bag should be lower than the bladder to allow gravity drainage of urine. Make sure the drainage bag is not pulling on the catheter. 
  • Make sure tube is not twisted or kinked. Do not tug or pull the catheter.
  • Urine specimen should never be collected from the drainage bag. Specimen can be obtained through a specific port by using a 15second alcohol scrub at the port.
  • Do not apply powder or lotion to the catheter insertion site.
  • Always check the area around the urethra for inflammation or signs of infection, such as any swelling, redness, irritation at site and around the area.
  • For an INDWELLING Catheter - best way to prevent infection is washing area and catheter 2x/day with soap and water; Strict SURGICAL not MEDICAL asepsis is needed during insertion.

 

Continuous Bladder Irrigation

  • Some reasons for bladder irrigation are:

                      a.     To test the patency of the catheter lumen.
                      b.     To flush blood and other debris from the bladder.
                      c.     To help combat infection when antibiotic solutions are used.
                      d.     To instill certain pharmaceutical or radiographic contrast for diagnostic testing.

  • Solution should be  2-3  feet above abdomen
  • Do not clamp the tubings or else it would be intermittent.
  • Keep track of the returned solution which should be about approximately the same amount infused. Other than date, time, and solution of irrigation, note the consistency, amount and color of ouput. 
  • One can wrap a gauze around the connecting tube to maintain sterility.

 

Creatinine

  • Normal value – 0.7 – 1.4 mg/dL
  • This is an end product of muscle and protein metabolism. Thus, a person who has done any physical activity may have an increased Creatinine value.
  • If increased, usually 50% of the nephrons are already damaged.
  • Normal Bun : Creatinine ratio is 10:1 – a wide ration (example 70:1.8) indicated Pre-renal cause of kidney failure and  narrow ratio (example 45:3.4) indicates Intra-renal cause of kidney failure.

Cystitis (see Urinary Tract Infection)

  • An inflammation of the bladder where there is an increase in frequency in urination with a burning sensation.
  • Common in women who have a shorter urethra
  • Urine C & S (culture and sensitivity) is usually done to determine the bacteria that causing the inflammation, usually E.Coli
  • Advise individual to wipe from front to back after defacating.

Dialysis

  • An artificial way of removing the blood’s waste product and extra fluid whenever the kidney is no longer able to do its job on its own. The two main types of dialysis are hemodialysis and peritoneal dialysis.
  • One must monitor the potassium and sodium levels.
  • Check daily weight that individual’s I & O
  • Dialyzer used is an electrolyte solution similar to normal plasma

            A. Peritoneal

  • High dextrose concentration can add calories to daily intake and may cause constipation. One can offer stool softener.
  • Check for the exit site for any sign of infection and a sterile dressing should be applied on the site.
  • Weigh patient before and after dialysis
  • Cloudy output is a sign of peritonitis.
  • Pain and blood tinge fluid around intra-abdominal catheter during inflow are common during first few exchanges. SHOULD NOT BE CLOUDY.
  • One may feel full when the diasylate has been infused and a Tugging sensation is normal when diasylate is being drained.
  • One can warm up the diasylate in heating pad, which can be regulated, instead of the microwave, which has an unpredictable warming pattern.
  • Unhibited bladder (usually caused by damage to frontal lobe brain)

TYPES Of Peritoneal Dialysis

  • Continuous – An automated machine is used at night.
  • Continuous ambulatory (CAPD) – a self-dialysis done by the individual
  • Automated – uses a machine with a chamber for dialysate infusion, dwell and outflow.
  • Intermittent – either automated or manual

            B. Hemodialysis

                         

  • Bruit should be auscultated and thrill palpated, both are adequate signs of  circulation.
  • Avoid using arm with the fistula for BP monitoring, any blood drawings, or IV administration.

 Side by side comparison:

 

Hemodialysis

Peritoneal dialysis

How often is dialysis done?

Uses a man-made dialyzer to filter the blood about three times a week. Daily hemodialysis requires treatments six times a week. The dialyzer is connected to a dialysis access (see picture above) via a tube, called a shunt or catheter.

Uses the belly lining, called peritoneal lining, via a catheter placed on a belly as a dialysis access. Peritoneal dialysis can be done manually throughout the day or with a machine at night.

How long for each treatment?

Three to five hours. Daily hemodialysis takes about two hours.

Takes about 30 to 40 minutes to manually exchange the dialysis solution and about four to five times a day. If you use an automated cycler, you must be attached to the machine for 10 to 12 hours at night.
If one has a problem with the outflow, reposition the client.

Where are treatments done?

Usually done in a dialysis center or in hospital but it's possible to do hemodialysis at home.

Can be done at home, work or any other clean place. An automated cycler can be used at home or at your destination if you travel.

Who does the treatments?

Usually a nurse or dialysis technician handles your treatments.
Nurse should check for the “thrill” and listen to the bruit
Avoid using the arm with the access when obtaining BP or when drawing blood specimens.

You, with assist as needed, can handle your own treatments.

Type of access

A vascular access point is done usually in ones forearm or upper arm in order to get access for the hemodialysis needles.
AV fistula, AV graft

A  thin tube (peritoneal catheter) is inserted in ones abdomen.
Sterile dressing should cover the insertion site and always check for signs of infection.

 

Discharge
  1.     Water and painless bleeding.

  • May indicate endometrial cancer.

  2.     Frothy discharge.

  • May indicate trichomonas infection

  3.     White discharge

  • May indicate candida albicans.

  4.     Purulent discharge

  • May mean pelvic inflammatory disease

End Stage Renal Disease (ESRD)

  • Patient may already be on dialysis.

Glomerulonephritis

  • Damage to the glomerulus due to an inflammation within the glomerular structure.
  • Actue gloverulonephritis is an infection that usually occurs when one gets streptococcal infection.
  • One may experience fever, chills, flank pain and oliguria.
  • May have hematuria and proteinuria. So, low protein diet is recommended.
  • If oliguric, watch for I and O and restrict sodium intake

Interstitial Cystitis

  • Absence of bacteria in the urine makes this cystitis different from other cystitis
  • Patient experiences frequent urination and passing only a small amount of urine. Patient may have pressure or painful bladder that may lead one to think one has Urinary Tract Infection (UTI) but the antibiotics are not helping. Again, the absence of bacteria in the urine culture distinguishes this from UTI.

Kegel Exercise

  • A way to strengthen the muscles of the pelvic floor by tightening the pelvic muscles for at least 3 seconds then relaxing for a total of about 45 times.
  • To do the exercise, ask someone to pretend to hold the urine.

Kidney Transplant

  • Increase in blood pressure is an initial sign of organ rejection.
  • 2 pound weight loss, urine output of 50ml/hr, low serum creatinine are all normal.

Lithotropsy (see Renal Calculi)

  • Patient should strain urine after procedure for any stone.
  • Lithotripsy is an ultrasound treatment that breaks the kidney stones into pieces small enough in order to pass in the urine.

Nephrotic syndrome

  • Occurs when the kidney is unable to properly filter the waste and excess water in the blood leading to loss of protein (proteinuria) and minerals in the urine. Also, patient will have low albumin in the blood.
  • Swelling around the eyes, feet and hands may be the early signs. The swelling is due the loss of albumin in the blood.
  • Fluid retention is best determined by daily weighing more so than I/O
  • Common complication is venous thrombosis.
  • Patient may be receive immunosuppressant drugs. So, to limit the exposure to infection, one can limit the number of visitors for the patient.
  • Patient may need high protein diet.
  • Postoperatively - if problem with urination, for males if acute, ask to stand for normal position; for females, again if acute, maybe can apply warm water on bladder area. 
  • After nephrolithotomy, place the client on the opposite side of the operation

 

Nutrition

  • A person with renal problem generally must limit protein, potassium and sodium intake
  • Can have unsalted vegetables, white rice

 

Pelvic Inflammatory Disease (PID)

  • The infection and inflammation of the upper reproductive organs of women [i.e. fallopian tubes (salphingitis), uterine lining (endometritis), ovaries (oophoritis)]
  • PID is quite difficult to diagnose since in its early stages, there may be no symptoms. But, the common signs area lower abdominal pain, fever, irregular vaginal bleeding, purulent cervical discharge and even pain with intercourse (dyspareunia)
  • Usually caused by a sexually transmitted disease (STD), commonly, gonorrhea and Chlamydia.

 

Prostate  / Prostatic Hypertrophy

           

  • Enlargement of the prostate gland.
  • Like the Appendix, the prostate is not a vital organ and one can live without it. It’s a walnut shape gland that surrounds the bottom part of the bladder and the first inch of the urethra.
  • Its main function is to produce fluid that mix and helps nourish the semen. It also produces the fluid that lubricates the urethra lining and it produces the prostate specific antigen (PSA).
  • Unusually high level of PSA (Prostate Specific Antigen) is seen in the bloodstream if there is a prostate infection, inflammation, enlargement or in cancer.
  • Prostate cancer is common after the age 50, common with Afro-American men and to those who has a family member who had it and to those who have a high fat diet.
  • Other than the PSA, the prostrate can be checked for abnormalities in shape and size by Digital rectal exam (DRE), where a lubricated finger by ones doctor is inserted in the rectum in order to examine the prostate. A transrectal ultrasound can be done to further evaluate the prostate and if suspicious areas are identified, eventually, a prostate biopsy is recommended to determine if there are any cancer cells.
  • Early symptoms of prostate enlargement are dribbling urine that is increases in frequency and urgency, pain may occur during urination, blood in urine (hematuria), or painful ejaculation.
  • A patient who has had a prostatectomy whose indwelling catheter has just been removed may experience some mild pain that should go away in a few days.  Patient may also experience an urgency to urinate.
  • If antiseptics do not work, then it may require suprapubic cystostomy (an opening into the bladder to divert the urine via a catheter) or by doing a prostatectomy (removal of the prostate) via TURP (see below) or performing a Suprapubic resection (through the bladder).

 

Pyelonephritis

  • Inflammation of the kidney due to bacterial infection, usually E. Coli.
  • One experiences fever, malaise and flank pain and CVA tenderness.

Renal Calculi (Kidney Stones)

  • Usually caused by formation of crystals that create a mass causing one to experience severe flank pain that may radiate to the groin. It may be accompanied by gastrointestinal symptoms, chills, fever and blood in urine.
  • Oral hydration to flush the calculi should be about 200ml/hr. Increasing water intake helps dilute the stones and reduce the formation of stones.
  • Dinking of caffeine containing beverage can increase the urinary calcium.
  • Since the most common are made from calcium oxalate, it is good to advise a patient to minimize eating spinach, rhubarb, nuts, chocolate, tea, bran, peanuts, strawberries  all of which could increase urinary oxalate levels.
  • Vitamin D increases Calcium absorption, thus, avoid vitamin D enriched food
  • Animal protein, dairy, poultry can also increase urinary calcium.
  • Potassium has been seen to reduce the risk of forming kidney stones.

 

Renal Failure

  • MAP dropping below 80 would mean lack of filtration of kidneys. MAP = Mean Arterial Pressure. See MAP topic under Cardiac.
  • Low filtration of kidney means a decrease in urine output (< 400ml/day – limit fluid intake) which leads to an increase in BUN and Creatinine values, indicating an increase in serum protein (albuminemia)
  • Can cause potassium level to increase, thus, Kayexelate may be ordered for an individual.
  • Leads to pulmonary edema and CHF and HTN (Hypertension).
  • Can cause azotemia (also referred to as uremia, an increase in Urea and nitrogenous waste in the blood), which can only be corrected by dialysis (see Dialysis above).

 

Transurethral Resection of Prostate (TURP)

  • A procedure where a thin tube is inserted in the urethra in order to remove prostate tissue. Often used for men with chronic bacterial prostatitis that are resistant to antibiotic or to those with prostatic calculi or those who has experienced repeated UTI due to some other prostate problem such as benign prostatic hyperplasia (BPH).
  • Hemorrhage and shock are the two major complications.
  • Dark red urine and a few clots are normal BUT bright red urine with many clots indicates bleeding and may require surgery.
  • Urine may be bright red for 12 hours

 

Urinary Diversions

  • To divert the normal urine path via urethra, usually from individuals with bladder tumors, strictures or trauma in the urethra and ureters, neurogenic bladder or interstitial cystitis.
  • For all types of Urinary diversion, nurse should be sensitive to how the individual has adjusted to the care and body image resulting from the urinary diversion.

TYPES of Urinary Diversion

1. Ileal Conduit - the most common urinary diversion

    • The portion of the ileum is used as a conduit where the ureters are redirected into the portion of the ileum and the distal end is brought out through the skin to form a stoma.

2. Ureterosigmoidostomy – as the name suggests the Ureters are detached from the bladder and anastomosed to the sigmoid colon, thus, urine and stool are both evacuated through the anus.

3. Cutaneous uterostomy – a stoma is formed from the the ureters and it brought out through the skin.

    • Stoma is usually found on the right side of the abdomen.

4. Koch pouch – a segment of the ileum is isolated thus creating a pouch where ureters are transplanted into; a valve prevents leakage of the urine.  The urine is drained using a catheter. So, urine is collected in the pouch until catheterized. Make sure to drain pouch at regular intervals.

5. Nephrostomy – a flank incision is done and a nephrostomy tube is inserted into the renal pelvis; Penrose drain is attached.

Urinary Track Infection

  • Occurs when a bacteria, often the Escherichia coli (E.Coli), enters the urinary tract, via the urethra, and begins to grow and multiply in the bladder. (Note: E.Coli is a bacteria that is commonly found in the GI tract).
  • Infections can also be acquired through sexual contact and such infections are usually caused by gonorrhea and Chlamydia. Thus, it is recommended for women to void after intercourse.  
  • Best to prevent by teaching to wash perianal area from front to back, particularly for women since the anus is so close to the female urethra. Another anatomical disadvantage for women is the fact that female urethra is shorter than men, thus, the distance the bacteria has to travel to reach the bladder and begin to multiply is shorter for women.
  • Women who use diaphragms for birth control are also of greater risk
  • Patients on prolonged use of catheters in the bladder are of greater risk. 
  • It is advisable for a woman to urinate after intercourse and to drink full glass of water to help flush the bacteria.
  • Encourage patient to take cranberry juice (it is more alkaline and is excreted with acidic urine after being metabolized by the body) since it may have infection-fighting properties and it can also cause the urine to be more acidic making it less susceptible for bacterial growth.
  • Avoid citrus juices or anything that contain caffeine since they tend to aggravate the urgency to urinate and can irritate the bladder.
  • Avoid douching and powders that can irritate the urethra.
  • Encourage the patient to void frequently at least every 3 hours
  • Patient may experience the following symptoms:

                   a. Strong urgency to urinate
                   b. Burning sensation on urination because of the inflammation or infection of the urethra. Men may notice penile discharge.
                   c. Dribbling amount of urine
                   d. Presence of blood (hematuria) in urine or if urine appears very cloudy and strong smelling.
                   e. Flank pain and fever usually indicates that the infection involves the kidneys. This may be accompanied with nausea and vomiting
.

 

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