Urinary System

Identify presence of nitrites, WBCs,

and leukocyte esterase
o Urine for culture and sensitivity (if indicated)
Clean-catch sample preferred
Specimen by catheterization or suprapubic needle aspiration more accurate
Determine bacteria susceptibility to antibiotics
o Imaging studies
CT urography or ultrasonography when obstruction suspected
Collaborative Care - Drug Therapy
o Antibiotics
Selected on empiric therapy or results of sensitivity testing
Uncomplicated cystitis
Short-term course (1 to 3 days)
Complicated UTIs
Long-term treatment (7 to 14 days)
Trimethoprim/sulfamethoxazole (TMP/SMX)
Used to treat uncomplicated or initial UTI
Inexpensive
Taken twice a day
E. coli resistance to TMP-SMX
Nitrofurantoin (Macrodantin)
Given three or four times a day
Long-acting preparation (Macrobid) is taken twice daily
Ampicillin, amoxicillin, cephalosporins
Treat uncomplicated UTI
Fluoroquinolones
Treat complicated UTIs
Example: ciprofloxacin (Cipro)
o Antifungals
Amphotericin or fluconazole
UTIs secondary to fungi
o Urinary analgesic
Phenazopyridine (Pyridium)
Used in combination with antibiotics
Provides soothing effect on urinary tract mucosa
Stains urine reddish orange
o Can be mistaken for blood and may stain underclothing
o Prophylactic or suppressive antibiotics sometimes administered to patients with repeated UTIs
Nursing Management
o Nursing Assessment
Health history
Previous UTIs, calculi, stasis, retention, pregnancy, STIs, bladder cancer
Antibiotics, anticholinergics, antispasmodics
Urologic instrumentation

Urinary hygiene
Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency
Suprapubic/lower back pain, bladder spasms, dysuria, burning sensation on
urination
Objective data
Fever
Hematuria, foul-smelling urine, tender, enlarged kidney
Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT
scan, IVP
Nursing Diagnoses
Impaired urinary elimination
Readiness for enhanced self-health management
Planning
Patient will have
Relief from lower urinary tract symptoms
Prevention of upper urinary tract involvement
Prevention of recurrence
Nursing Implementation
Health promotion
Recognize individuals at risk
o Debilitated persons
o Older adults
o Underlying diseases (HIV, diabetes)
o Taking immunosuppressive drug or corticosteroids
Emptying bladder regularly and completely
Evacuating bowel regularly
Wiping perineal area front to back
Drinking adequate fluids
Avoid unnecessary catheterization and early removal of indwelling catheters
Aseptic technique must be followed during instrumentation procedures
Wash hands before and after contact
Wear gloves for care of urinary system
Routine and thorough perineal care for all hospitalized patients
Avoid incontinent episodes by answering call light and offering bedpan at
frequent intervals
Acute intervention
Adequate fluid intake
o Dilutes urine, making bladder less irritable
o Flushes out bacteria before they can colonize
o Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods
Potential bladder irritants
Evaluation
The patient with a UTI will
Experience normal urinary elimination patterns
Report relief of bothersome urinary tract symptoms
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Verbalize knowledge of treatment regimen emphasize importance of taking full

medication regime
Q&A: The nurse identifies that the patient with the greatest risk for a urinary tract infection is
a) A 37-year-old man with renal colic associated with kidney stones.
b) A 26-year-old pregnant woman who has a history of urinary tract infections.
c) A 69-year-old man who has urinary retention caused by benign prostatic hyperplasia.
d) A 72-year-old woman hospitalized with a stroke who has a urinary catheter because of urinary
incontinence.

Urinary Tract Calculi

1 to 2 million in United States have nephrolithiasis

More common in men
Average age at onset: 2055 years
Increased incidence
o White persons
o Family history of stone formation
o Previous history
o Summer months
Etiology and pathophysiology
o Stone formation
No single etiology for all cases
Factors involved
Metabolic
Genetic
Climate
Lifestyle
Occupational influences
Affected by
Urinary pH
Solute load
Other factors
Obstruction with urinary stasis
UTI
Genetics
Types
o Calcium phosphate
o Calcium oxalate
o Uric acid
o Cystine
o Struvite (magnesium ammonium phosphate)
Clinical manifestations
o Sudden severe pain due to obstruction
o Kidney stone dance
o Mild shock with cool, moist skin
o Pain moves to lower quadrant of abdomen as stone nears UVJ
o Testicular versus labial pain
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o Both sexes experience groin pain

o UTI symptoms
Diagnostic studies
o Noncontrast spiral CT (CT/KUB)
o Ultrasonography
o Intravenous pyelorography (IVP)
o Complete urinalysis to assess for
Hematuria
Crystalluria
o Retrieval and analysis of stones
o Serum calcium, phosphorus, sodium, potassium, bicarbonate, uric acid, BUN, creatinine
measurements
History
o Previous episodes
o Prescribed and OTC medications
o Dietary supplements
o Family history
Collaborative care
o Acute attack
Treat pain: opioids
Infection -antibiotics
Obstruction
Tamsulosin (Flomax)
Terazosin (Hytrin)
o Teach management of acute episode
Drug information
monitor urinary pH
Strain all urine
Ambulation
o Prevention of further stone development
Patient and family history
Geographic residence
Nutritional assessment
Activity patterns
Immobilization or dehydration
o Indications for endourologic stone removal, lithotripsy, or open surgical stone removal include
Stones too large for passage
Association with bacteriuria
Causing impairment in renal function
Causing persistent pain, nausea, or paralytic ileus
Nursing implementation
o Teach methods to prevent recurrence
Change of lifestyle and dietary habits
Adequate fluid intake: to produce approximately 2 L of urine per day
o Dietary restriction (e.g., purines)
o Low Na diet
Evaluation
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o Maintain free flow of urine with minimal hematuria

o Report satisfactory pain relief
o Verbalize understanding of disease process and measures to prevent recurrence

Acute Kidney Injury

o Acute kidney injury (AKI), previously known as acute kidney failure, is the term used to
encompass the entire range of the syndrome, including a very slight deterioration in kidney
function to severe impairment.
o AKI is characterized by a rapid loss of kidney function. This loss is accompanied by a rise in
serum creatinine level and/or a reduction in urine output. The severity of dysfunction can range
from a small increase in serum creatinine or reduction in urine output to the development of
azotemia (an accumulation of nitrogenous waste products [urea nitrogen, creatinine] in the
blood).
o AKI can develop over hours or days with progressive elevations of blood urea nitrogen (BUN),
creatinine, and potassium, with or without a reduction in urine output.
Etiology and Pathophysiology

o
Phases of ARF
o Oliguria Phase
o Diuretic Phase
o Recovery Phase
o ** If a patient does not recover from AKI it can progress to CKD

o
Clinical Manifestations
o Oliguric phase
Urinary changes
Urinary output less than 400 mL/day
Occurs within 1 to 7 days after injury
Lasts 10 to 14 days
Urinalysis may show casts, RBCs, WBCs
Waste product accumulation
Elevated BUN and serum creatinine levels
Neurologic disorders
Fatigue and difficulty concentrating
Seizures, stupor, coma
Fluid volume
With decreased urine output, fluid retention occurs
o Neck veins distended
o Bounding pulse
o Edema
o Hypertension
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Fluid overload can lead to heart failure, pulmonary edema, and pericardial and
pleural effusions
Metabolic acidosis
Serum bicarbonate level decreases
Severe acidosis develops
o Kussmaul respirations
Sodium balance
o Increased excretion of sodium
o Hyponatremia can lead to cerebral edema
Potassium excess
o Usually asymptomatic
o ECG changes
o Diuretic phase
Daily urine output is 1 to 3 L
May reach 5 L or more
Monitor for hyponatremia, hypokalemia, and dehydration
o Recovery phase
May take up to 12 months for kidney function to stabilize
Q&A: Which assessment would indicate to the nurse that a patient has oliguria related to an intrarenal
acute kidney injury?
a) Urinary sodium levels are low.
b) The serum creatinine level is normal.
c) Oliguria is relieved after fluid replacement.
d) Urine testing reveals a specific gravity of 1.010.
Rationale: The urine specific gravity in oliguria of intrarenal acute kidney injury will be
fixed at 1.010. This value reflects tubular damage with loss of concentrating ability by the
kidneys. The serum creatinine level is above normal in oliguria of intrarenal acute kidney
injury. Urinary secretion of sodium increases with oliguria of intrarenal acute kidney
injury. Prerenal oliguria related to hypovolemia will usually respond to fluid replacement.
Diagnostic studies
o Thorough history
o Serum creatinine
o Urinalysis
o Kidney ultrasonography
o Renal scan
o Computed tomography (CT) scan
o Renal biopsy
o Contraindicated
Magnetic resonance imaging (MRI)
Magnetic resonance angiography (MRA) with gadolinium contrast medium
Nephrogenic systemic fibrosis
Contrast-induced nephropathy (CIN)
Collaborative care
o Primary goals
Eliminate the cause
Manage signs and symptoms
o Prevent complications
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o Ensure adequate intravascular volume and cardiac output

o Closely monitor fluid intake during oliguric phase
o Hyperkalemia
Insulin and sodium bicarbonate
Calcium carbonate
Sodium polystyrene sulfonate (Kayexalate)
o Indications for renal replacement therapy (RRT)
Volume overload
Elevated serum potassium level
Metabolic acidosis
BUN level higher than 120 mg/dL (43 mmol/L)
Significant change in mental status
Pericarditis, pericardial effusion, or cardiac tamponade
o Renal replacement therapy (RRT)
Peritoneal dialysis (PD)
Intermittent hemodialysis (HD)
Continuous renal replacement therapy (CRRT)
Cannulation of artery and vein
Nursing Management
o Planning
The patient with AKI will
Completely recover without any loss of kidney function
Maintain normal fluid and electrolyte balance
Have decreased anxiety
Comply with and understand the need for careful follow-up care
o Nursing implementation
Monitor intake and output
Monitor electrolyte balance
Measure daily weight
Replace significant fluid losses
Use nephrotoxic drugs sparingly
o Evaluation
The expected outcomes are that the patient with AKI will
Regain and maintain normal fluid and electrolyte balance
Comply with the treatment regimen
Experience no untoward complications
Have complete recovery
Gerontologic Considerations
o More susceptible to AKI
Polypharmacy
Hypotension
Diuretic therapy
Aminoglycoside therapy
Obstructive disorders
Surgery
Infection
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ADDITIONAL ELECTROLYTE DISTURBANCES WITH CRD

Dialysis

Movement of fluid/molecules across a semipermeable membrane from one compartment to another

Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure
Treat drug overdoses
Begun when patients uremia can no longer be adequately managed conservatively
Initiated when GFR (or creatinine clearance) is less than 15 mL/min
Dialysis
Two methods of dialysis available
o Peritoneal dialysis (PD)
o Hemodialysis (HD)
ESKD treated with dialysis because
o There is a lack of donated organs
o Some patients are physically or mentally unsuitable for transplantation
o Some patients do not want transplants
Osmosis and Diffusion across Semipermeable Membrane

o
Peritoneal Dialysis
o Peritoneal access is obtained by inserting a catheter through the anterior abdominal wall
o Technique for catheter placement varies
o Usually done via surgery
o Tenckhoff Catheter

o
o
o
o

Waiting period of 7 to 14 days preferable

Two to 4 weeks after implantation, exit site should be clean, dry, and free of redness/tenderness
Once site healed, patient may shower and pat dry
Dialysis Solutions and Cycles
Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25%
Electrolyte composition similar to that of plasma
Solution warmed to body temperature
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o Three phases of PD cycle

Inflow (fill)
Dwell (equilibration)
Drain
o Called an exchange
Inflow
Prescribed amount of solution infused through established catheter over about 10
minutes
After solution infused, inflow clamp closed to prevent air from entering tubing
Dwell
Also known as equilibration
Diffusion and osmosis occur between patients blood and peritoneal cavity
Duration of time varies, depending on method
Drain
Lasts 15 to 30 minutes
May be facilitated by gently massaging abdomen or changing position
o Complications
Exit site infection
Peritonitis
Hernias
Lower back problems
Bleeding
Pulmonary complications
Protein loss
o Effectiveness and Adaptation
Short training program
Independence
Ease of traveling
Fewer dietary restrictions
Greater mobility than with HD
Hemodialysis
o Obtaining vascular access is one of most difficult problems
Types of access
Arteriovenous fistulas and grafts
Temporary vascular access
o Vascular Access for Hemodialysis

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o Dialyzers
Long plastic cartridges that contain thousands of parallel hollow tubes or fibers
Fibers are semipermeable membranes
o Hemodialysis Procedure
Two needles placed in fistula or graft
One needle is placed to pull blood from the circulation to the HD machine
The other needle is used to return the dialyzed blood to the patient
o Components of Hemodialysis

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Continual Renal Replacement Therapy (CRRT)

o Alternative or adjunctive method for treating AKI
o Means by which uremic toxins and fluids are removed
o Acid-base status/electrolyte balance adjusted slowly and continuously
o Often used in hemodynamically unstable patients
o Hemofilter change every 24 to 48 hours
o Ultrafiltrate should be clear yellow
o Specimens may be obtained for evaluation
o Most common approaches: venovenous
Continuous venovenous hemofiltration (CVVH)
Continuous venovenous hemodialysis (CVVHD)
Q&A: A patient undergoes peritoneal dialysis exchanges several times each day. What should the nurse
plan to increase in the patients diet?
a) Fat
b) Protein
c) Calories
d) Carbohydrates

Kidney Transplantation

Very successful
One-year graft survival rate
o Cadaver transplants: 90%
o Live donor transplants: 95%
Advantages of kidney transplantation over dialysis
o Reverses many of the pathophysiologic changes associated with renal failure
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o Eliminates dependence on dialysis

o Less expensive than dialysis after the first year
Kidney Transplantation

o
Immunosuppressive Therapy
o Goals
Adequately suppress the immune response
Maintain sufficient immunity to prevent overwhelming infection
Complications
o Rejection
Acute rejection
Occurs days to months after transplantation
Chronic rejection
Process that occurs over months or years and is irreversible
Infection
CV Disease
Malignancies
Recurrance of Renal Disease
Steriod-Related Complications
Q&A: Six days after kidney transplantation from a deceased donor, a patient develops a temperature of
101.2 F (38.5 C), tenderness at the transplant site, and oliguria. The nurse recognizes that these
findings indicate
a) Acute rejection, which is not uncommon and is usually reversible.
b) Hyperacute rejection, which will necessitate removal of the transplanted kidney.
c) An infection of the kidney, which can be treated with IV antibiotics.
d) The onset of chronic rejection of the kidney with eventual failure of the kidney.

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