Gu Blackboard Outline

Nursing 304 Nursing Care of Select GU Health Deviations A. Urinary System Structure 1. Upper Urinary System a. Kidneys—2 bean shaped organs; Adrenal gland on top of each kidney 1. Lie in retroperitoneal space between 12th thoracic and 3rd lumbar vertebrae. CVA—lower border of 12th rib and spine 2. 4-6 oz each; size of fist. 3. Circulation--Kidneys receive 20 to 25% of resting cardiac output, averaging more than 1 Liter per minute; Must have blood entering kidney to make urine 4. Glomerulus—semipermeable membrane for purpose of Filtration Filtration--movement of fluid through a biologic membrane as a result of hydrostatic pressure differences on both sides of the membrane. a. b. c. d. e. f.

RBC, WBC, Protein should NOT pass through glomerulus Toxic wastes should pass through glomerular membrane H+ ions pass through glomerular membrane Uric acid passes through glomerular membrane Electrolytes pass through glomerular membrane Fluid passes through glomerular membranea.

5. Nephron is the functional unit of kidney; aprox. 1,000,000 nephrons in each kidney; Nephrons reabsorb 99% of fluid from glomerular filtrate. Nephrons function to maintain plasma homeostasis by Reabsorbing, Ignoring, and Secreting--cleans blood plasma of unnecessary substances; 2. Ureters 1. Each kidney has one and each about 12 inches long 2. Peristalsis propels urine from renal pelvis to bladder 3. Lower Urinary Tract a. Bladder 1. muscular resevoir for temporary storage of urine 2. Provides continence and enables micturition (voiding) a. Continence affected by nervous system (brain and spinal cord) and muscular integrity b. Micturition--contraction and relaxation of muscles and sphincters;voluntary learned response controlled by cerebral cortex and brain stem b. Urethra to meatus 1. 6 - 8 inches in males 2. 1.5 inches in females B. Function of Renal System—Maintain homeostasis by excretion, regulation, and metabolism. Ability to maintain hemeostasis dependent on (1) Circulatory system--blood volume and

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blood pressure, and (2) Nervous and Endocrine system which must detect a loss of homeostasis and adjust accordingly

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1. Maintain homeostasis of: a. plasma water-- Na and H20 reabsorption through production of aldosterone. Kidneys retain fluid in presence of ADH (produced in and excrete fluid in absence of ADH b. plasma electrolytes c. plasma pH (Acid-Base Balance)--Normal pH = 7.35 - 7.451 2.

to breakdown)

Excrete water soluble waste products a. BUN--urea from liver--the end product of protein metabolism; ammonia is converted to urea in the liver; amount of urea excreted is directly related amount of protein in diet. Also increased by internal bleeding (RBC b. d. e. f.

Uric acid--the end product of purine metabolism Creatinine--end product of muscle metabolism; a better measure of filtration Bacterial toxins Metabolize certain medications--DM patient with renal disease will need his Insulin adjusted because kidney will not metabolize insulin as well anymore.

3. Endocrine secretions a. Renin--a hormone stored in the JGA sensitive to volume flow through kidney; secreted in response to low perfusion through kidney and causes vasoconstriction, stimulates secretion of aldosterone from adrenal gland which causes retention of Na and water and thus an increase in BP. b. Erythropoietin 4. Plays a role in metabolism of Vitamin D--Vitamin D is converted to active form in kidney; works with parathyroid to increase intestinal absorption of Ca and Phosphate, mobilize Ca from bones, and increases renal tubular absorption of Ca and PO4. 5. Renal Prostaglandins—thought to be secreted in response to renal ischemia and vasoconstriction. They cause vasodilation and increased blood flow; They counter the effects of ADH and promote excretion of sodium and water. NSAIDS are believed to inhibit renal prostaglandins and thus can lead to acute renal failure.

C. Assessment of Urinary System 1. History

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2. Physical Assessment a. Inspection

b. Auscultation for bruits over aorta and renal arteries [mid clav. line] (+ = narrowing) c. Palpation of kidneys d. Determination of pain e. Integumentary status--color (yellow, gray or pale with renal disease), dry skin with CRF and fluid volume depletion; crystal deposits with CRF (uremic frost) f. Fluid status--I and O, wt gain/loss, mucus membranes, edema (peripheral, periorbital, sacral) g. Neurologic status h. Musculoskeletal status--tone, ability to handle urinary elimination needs, i. CV status--BP specific to urinary tract j. Resp. Status--Acid-Base balance, ketoacidosis, uremic fetor

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3. Diagnostic Tests of Urinary/Renal Function a. Visual inspection of urine

b. Urinalysis--simple, non-invasive test of renal function 1. Specific gravity

2. pH--4.5 - 8 3. Presence of abnormal constituents a. albumin, hemoglobin b. RBCs c. WBCs and Bacteria (infection) 1. Clean Catch

2. Culture a. in voided spec., UTI if bacteria > 100,000/ml; b. in sterile cath spec., UTI if bacteria > 10,000/ ml d. Sodium

e. Glucose

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f. Ketones

g. Protein c. Blood tests 1. BUN --Normal 7 – 20 (definitely less than 30)

2. BUN/Creatinine Ratio--Normal 10:1

3. Creatinine (end product of muscle metabolism-- is not reabsorbed after being filtered; and is independent of protein metabolism. a. Serum creatinine 0.6 - 1.2;

b. 24 hr. Creatinine Clearance

d. Bladder scan—to determine urine left in bladder after voiding (normal < 50 mL) e. Renal Ultrasound . f. Radiologic Tests 1. KUB

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2 IVP

3. Retrograde Pyelogram

4. Renal Angiography

5. Renal Scan

6. MRI 7. CT

g. Surgical Procedures 1. Cystoscopy (Cysto

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2. Renal Biopsy

D. Health Deviations of Urinary System--Pathophysiology and Nursing Interventions 1. Extrarenal Disease Processes a. DM b. Atherosclerosis and arteriosclerosis c. HTN d. Shock or hypotension e. Cardiac disease with circulatory insufficiency f. Peripheral Vascular Disease 2. Infections a. UTI 1. DX

2. Types a. Lower UTI 1. Urethritis

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2. Cystitis

Elderly S&S—increased fatigue, confusion, anorexia, low temperature

b. Upper UTI 1. Pyelonephritis

a. Acute Pyelonephritis

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b. Chronic Pyelonephritis

c. More common in women than men, in absence of obstruction and instrumentation. d. Causes

e. Symptoms

f. DX of chronic glomerulonephritis

g. TX of chronic glomerulonephritis

3. Treatment of UTI a. Antibiotics (Yeast vaginitis frequently occurs secondary to antibiotics, and is more difficult and more costly to treat than the original UTI.); Must finish prescribed course Amoxacillin Ampicillin

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Bactrim Cipro Flagyl Garamycin Levaquin Macrodantin b. Analgesics Pyridium (urinary analgesic—urine orange) available OTC Urised (urinary analgesic—greenish blue urine) c. Antispasmodics (B& O suppository) Ditropan

d. Dietary Needs with UTI

d. Client goals: relief of pain & discomfort, knowledge of prevention, treatment regimen compliance, absence of complications e. Nursing Care to achieve goals

3. Urethral Syndrome a. Causes

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b. Risk factors

c. Symptoms

d. Urethral Syndrome in Men:

e. Diagnosis of Urethral Syndrome

f. Treatment of Urethral Syndrome

4. Interstitial Cystitis

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5. Glomerulonephritis

a. Acute Glomerulonephritis

b. Chronic Glomerulonephritis

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6. Urinary catheterization --Don't rush in--let this be last resort.

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Practical Tips Concerning GU Intake and Output very important. NOTICE outputs, don't just wait until the end of your shift to find out your pt has only put out 30cc. Very embarrassing and rightly so! Notice output each time you go into pt's room. If you see that output is decreased, might need to put on Urimeter, so you can better observe hourly outputs. Daily weights very important in terms of fluid balance. Pt will gain 1# for every 500cc retained. Look for sacral edema. Might be there before legs, esp. on bedridden pt. Check vital signs before and after diuretics. Assess breath sounds at beginning and ending of your shift, and prn in between if needed. Things can change in a short time. Watch medication therapeutic levels--peaks and troughs: some 30 minutes after and others 1 hr after for peaks. Troughs before--30 min to 1 hr. All urine samples need to be taken to lab immediately or at least refrigerate. Exception: cultures need to be fresh, not refrigerated. In a 24 hr. specimen, even the loss of one voiding alters results--and should start over. Voiding can be enhanced with running water, pouring warm water over perineum (measure first); get patient into optimal voiding position--upright, sitting for females, standing for males (if ok with MD). Crede method to enhance voiding and bladder emptying. Infection prevention--especially with females: Front to back cleansing; Cotton crotch panties; Non-tight jeans, etc.; Wash and void before and after sex. Incontinence: Don't decrease Intake to prevent Incontinence. Diapers--must be changed frequently. On GU pts., monitor T q 4 hrs. Check 1 hr after Antipyretics--you may find pt dripping wet and in need of drying. Also, may need to call MD and get order for something else. Normal fluid intake is 1500 - 2000 cc per day. Increased means 2500 - 3000 cc per day. Typical Renal Diet: 20-40 Gm Protein, 500mg Na, 40 meq K, 600-1000cc of fluid plus urine output for last 24 hrs. Insensible fluid loss is normally about 900cc per day; This increases with exercise and fever. Acid-Ash Diet: cranberry, plum, prune juice--inhibit bacterial growth, but acidic urine can interfere with antibiotics. Be sure to teach pt. to take all of antibiotics prescribed. Many will stop once they feel better--to save some for next time--then develop a resistant strain of bacteria.

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Follow up exams, UA, etc, very important also.--Many won't return because they feel better and don't see any reason to come back, then they develop a resistant strain and become sicker than before. Provide verbal and written instruction to pts and families.

ALWAYS EMPTY BLADDER BEFORE GETTING INTO CAR!!