Assessment of Renal and

Urinary Tract Function

Acute nephritic syndrome ( acute

glomerulonephritis)

Glomerulonephritis is an inflammation of the

glomerular capillaries that can occur in acute or
chronic forms.

Clinical manifestations
Hematuria (blood in the urine), which may be
microscopic (identifiable through microscopic
examination) or macroscopic or gross (visible
to the eye).
Azotemia ( an abnormal concentration of
nitrogenous wastes in the blood), and
proteinuria ( Excess protein in the urine).
The urine may appear cola-colored because of
RBCs and protein plugs or casts.

Clinical manifestations
Edema, hypertension
Hypoalbuminemia
Hyperlipedemia, fatty casts in the urine
Blood urea nitrogen and serum createnine
levels increased
Anemia

Nursing management
Carbohydrates are given liberally to provide
energy and reduce the catabolism of protein.
Intake and output are carefully measured and
recorded. Fluids are given according to the
patients fluid losses and daily body weight.
Patient education about the disease process,
explanations of laboratory tests

Clinical manifestations of
ARF
The skin and mucous membranes are dry from
dehydration, and the breath may have the odor of urine
(uremic fetor).
Central nervous system signs and symptoms include
drowsiness, headache, muscle twitching, and seizures.

Clinical characteristics of ARF

Blood urea nitrogen: increased ( 7-18 mg/dL)
Creatinine : increased ( above 0.6 to 1.2 mg/dL)
Urine output: decreased
Urine sodium: decreased
Urinary sediment : abnormal casts and debris
Urine osmolality: increased
Urine specific gravity: increased (above 1.010 to 1.025)

Prevention of ARF
Provide adequate hydration to patients at risk
for dehydration.
Prevent and treat shock promptly with blood

and fluid replacement.

Monitor central venous and arterial pressures

and hourly urine output of critically ill patients
to detect the onset of renal failure as early as
possible.

Prevention of ARF
Treat hypotension promptly.
Continually assess renal function.
Take precautions to ensure that the appropriate blood is
administered to the correct patient in order to avoid
severe transfusion reactions, which can precipitate renal
failure.

Prevent and treat infections promptly. Infections can

produce progressive renal damage.

Prevention of ARF
Give meticulous care to patients with
indwelling catheters to prevent infections from
ascending in the urinary tract. Remove

catheters as soon as possible.

To prevent toxic drug effects, closely monitor
dosage, duration of use, and blood levels of all
medications metabolized or excreted by the
kidneys.

Medical management
Pharmacological therapy : diuretics, calcium
replacement.
Nutritional therapy: replacement of dietary

protein with high-carbohydrate

Dialysis: hemodialysis, peritoneal dialysis.

Nursing

management

Monitoring fluid and electrolyte balance

Reducing metabolic rate
Promoting pulmonary function
Preventing infection
Providing skin care
Providing psychological support

Chronic renal failure

Chronic renal failure, or ESRD, is a progressive,
irreversible deterioration in renal function in which the
bodys ability to maintain metabolic and fluid and
electrolyte balance fails, resulting in uremia or azotemia
(retention of urea and other nitrogenous wastes in the
blood).
When a patient has sustained enough kidney damage to
require renal replacement therapy on a permanent basis,
the patient has moved into final stage of CKD (CRF,
ESRD)

Clinical manifestations
Neurologic
Weakness and fatigue; confusion; inability to
concentrate; disorientation
Tremors; seizures; restlessness of legs; burning of soles
of feet; behavior changes
Integumentary
Gray-bronze skin color; dry skin; pruritus; ecchymosis;
purpura
Thin, brittle nails; coarse, thinning hair

Clinical manifestations
Cardiovascular
Hypertension; pitting edema (feet, hands, sacrum);
periorbital edema
Engorged neck veins; pericarditis; pericardial effusion
Hyperkalemia; hyperlipidemia
Pulmonary
Crackles; thick sputum; depressed cough reflex; pleuritic
pain; shortness of breath; tachypnea
Uremic pneumonitis; uremic lung

Clinical manifestations
Gastrointestinal
Ammonia odor to breath (uremic fetor); mouth
ulcerations and bleeding
Anorexia, nausea, and vomiting
Constipation or diarrhea; bleeding from gastrointestinal
tract
Hematologic
Anemia; thrombocytopenia

Clinical manifestations
Reproductive
Amenorrhea; testicular atrophy; infertility; decreased
libido
Musculoskeletal
Muscle cramps; loss of muscle strength
Bone pain; bone fractures; foot drop

Medical management
Pharmacological therapy; calcium and phosphorus
binders, antihypertensive agents, anti-seizure agent,
erythropoietin.
Nutritional therapy; careful regulation of protein intake,
fluid intake, sodium intake ,and adequate intake of
vitamin supplemnets.
Dialysis; hemodialysis, and peritoneal dialysis

Nursing management
The main nursing diagnoses:
Excess fluid volume related to decreased urine output,
and retention of sodium and water.
Imbalanced nutrition; less than body requirements
related to anorexia, nausea, vomiting, dietary
restrictions.

Nursing management
Activity intolerance related to fatigue, anemia, and
dialysis procedure.

Deficient knowledge regarding condition and treatment

Management of Patients
With Urinary Disorders

Infections of the Urinary Tract

Urinary tract infections (UTIs) are caused by pathogenic
microorganisms in the urinary tract (the normal urinary
tract is sterile above the urethra).
UTIs are generally classified as infections involving the
upper or lower urinary tract

Infections of the Urinary Tract

Lower UTIs include bacterial cystitis (inflammation of

the urinary bladder), bacterial prostatitis (inflammation
of the prostate gland), and bacterial urethritis
(inflammation of the urethra).
Upper UTIs are much less common and include acute
or chronic pyelonephritis (inflammation of the renal
pelvis), interstitial nephritis (inflammation of the
kidney), and renal abscesses.

Risk factors for UTI

Inability or failure to empty the bladder completely
Obstructed urinary flow, from congenital anomalies,
urethral strictures, contracture of the bladder neck,
bladder tumors, calculi (stones) in the ureters or
kidneys, compression of the ureters, and neurologic
abnormalities

Risk factors for UTI

Decreased natural host defenses or immunosuppression
Instrumentation of the urinary tract (eg, catheterization,
cystoscopic procedures)
Inflammation or abrasion of the urethral mucosa

Risk factors for UTI

Contributing conditions (certain populations of patients
are more prone to UTIs than others), including those
with:
- Diabetes mellitus (increased urinary glucose levels
create an infection-prone environment in the urinary
tract),
- Pregnancy,
- Neurologic disorders,
- Gout,

CLINICAL MANIFESTATIONS OF LOWER

UTI
Frequent pain; supra-pubic or pelvic pain and back pain
may also be present
Burning on urination,
Frequency,
Urgency,
Nocturia,
Incontinence, and
Hematuria

Patient education for lower UTI

1- 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.
2- 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

Patient education for lower UTI

3- Voiding Habits
Void every 2 to 3 hours during the day and completely
empty the bladder. This prevents over-distention of the
bladder that predispose the patient to UTI.
Precautions expressly for women include the following:
Void immediately after sexual intercourse.

Patient education for lower UTI

4- Therapy
Take medication exactly as prescribed.
If bacteria continue to appear in the urine, long-term
antimicrobial therapy may be required .
If prescribed, test urine for bacteria with recommended
test devices.

Patient education for lower UTI

4- Therapy
Begin therapy as directed, and complete the full
prescribed course of medication.

Notify the health care provider if fever occurs or if signs

and symptoms persist.

Consult the health care provider regularly for followup, recurrence of symptoms, or infections nonresponsive
to treatment

Upper urinary tract infections

(pyelonephritis)
Pyelonephritis is a bacterial infection of the renal pelvis,
tubules, and interstitial tissue of one or both kidneys.
Pyelonephritis may be acute or chronic.

Clinical manifestations of pyelonephritis

Chills and fever,
Leukocytosis,
Pyuria,
Low back pain, flank pain.
Nausea and vomiting.
Headache, malaise

In addition, symptoms of lower urinary tract

involvement, such as dysuria and frequency

Nursing management of pyelonephritis

Fluid intake and output are carefully measured and
recorded.
Unless contraindicated, 3 to 4 L of fluids per day is
encouraged.
Assess the patients temperature every 4 hours.

Instruct patient to empty bladder regularly and

performing recommended perineal hygiene.

Urinary incontinence
Urinary incontinence is involuntary loss of urine from the
bladder
There are many types of UI; stress, urge, functional,
mixed.

Causes of transient Urinary incontinence :

DIAPPERS

Delirium
Infection of urinary tract
Atrophic vaginitis, urethritis
Pharmacologic agents ( sedatives, alcohol, analgesics,
diuretics, muscle relaxants)
Psychological factors (depression, regression)
Excessive urine production (increased intake, diabetic
ketoacidosis)
Restricted activity
Stool impaction

Urinary retention
Urinary retention is 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).

Urinary retention
Residual urine is urine that remains in the
bladder after voiding. In a healthy adult
younger than age 60, complete bladder

emptying should occur with each voiding.

In adults older than age 60, about 50 to 100

mL of residual urine may remain after each
void because of the decreased contractility of
the detrusor muscle.

Causes of Urinary retention

Urinary retention can occur postoperatively
in any patient, particularly if the surgery
affected the perineal or anal regions .General

anesthesia reduces bladder muscle innervation

and suppresses the urge to void.

Causes of Urinary retention

Prostatic enlargement,
urethral pathology ( tumor, calculus), trauma
Pregnancy,

Nursing management of Urinary retention

1-Providing privacy, ensuring an environment
and a position conducive to voiding.
2-Assisting the patient with the use of the

bathroom or commode, rather than a bedpan.

3-Applying warmth to relax the sphincters (ie,
sitz baths, warm compresses to the perineum,
showers), giving the patient hot tea, and
offering encouragement and reassurance.

Nursing management of Urinary retention

4-Simple trigger techniques, such as turning
on the water faucet while the patient is trying
to void, may also be used.

Other examples of trigger techniques are

stroking the abdomen or inner thighs, tapping
above the pubic area, and dipping the patients
hands in warm water.

Urolithiasis AND NEPHROLOTHIASIS

Urolithiasis and nephrolithiasis refers to stones
(calculi) in the urinary tract and kidney ,
respectively.

The occurrence of urinary stones occurs

predominantly in the third to fifth decades of
life and affects men more than women.

Urolithiasis AND NEPHROLOTHIASIS

Stones are formed in the urinary tract when
urinary concentrations of substances such as
calcium oxalate, calcium phosphate, and uric

acid increase.
Calculi may be found anywhere from the
kidney to the bladder. They vary in size from
minute granular deposits, called sand , to
bladder stones as large as an orange

Risk factors OF Urolithiasis and

Nephrolithiasis
Infection
Urinary stasis
Immobility
Increased calcium concentration in blood

Clinical manifestations
Intense , deep ache in the costovertebral
region. Pain originating in the renal area
radiates anteriorly and downward toward the

bladder in the female and toward the testis in

the male. It is associated with nausea and
vomiting.

Clinical manifestations
Hematuria
Pyuria
Diarrhea and abdominal discomfort may occur.

Clinical manifestations
Stones lodged in the ureter (ureteral
obstruction) cause acute, excruciating, colicky,
wavelike pain, radiating down the thigh and to
the genitalia. This is called ureteral colic.
Often, the patient has a desire to void, but little
urine is passed, and it usually contains blood.

Clinical manifestations
Stones lodged in the bladder usually produce
symptoms of irritation and may be associated
with UTI and hematuria. If the stone obstructs
the bladder neck, urinary retention occurs.

Dietary Recommendations for

Prevention of Kidney Stones
Avoid protein intake; restricted to 60gm/day to
decrease urinary excretion of calcium and uric
acid.
A sodium intake of 3 to 4 g/day is
recommended. Sodium competes with calcium
for reabsorption in the kidneys.
Low-calcium diets are not generally
recommended.
Avoid intake of oxalate-containing foods (eg ,
spinach, strawberries , peanuts)

Dietary Recommendations for

Prevention of Kidney Stones
During the day, drink fluids (ideally water)
every 1 to 2 hours .
Drink 2 glasses of water at bedtime and
additional glass at each nightime awakening to
prevent concentration of urine during night.
Avoid activities leading to sudden increases in
body temperatures.
Contact your primary health care provider at
the first sign of UTI.

Relieving pain
Opioid analgesic are administrated as
prescribed.
The patient is encouraged to assume a position

of comfort.
Monitor the pain level and report to the
physician any increase in severity.