Structure

1. Urinary system
 Ureters are slender tubes that extend behind the peritoneum from the hilus of the kidney to enter the
bladder.
 The bladder is a smooth, collapsible, muscular sac located retroperitoneally in the pelvis that has
openings to the ureters and urethra.
 The urethra extends from the base of the bladder to the urinary meatus.
 The urinary meatus is the external opening of the urethra.

2. The kidneys
- are paired organs located on either side of the vertebral column. They are between the 12th thoracic
and 3rd lumbar vertebrae in the posterior abdomen behind the peritoneum.

a. External structures

 Hilum - area where nerves, blood vessels, and the ureter enter the kidney; gives the kidney its bean-
shaped appearance.
 Renal capsule - fibrous, transparent outer covering of the kidneys (excluding the hilum); gives the
kidney a glistening appearance

b. Internal structures

Cortex - outer portion containing the glomerulus, tubules, and part of the Henle's loop.
 Medulla - middle portion containing part of Henle's loop and the collecting ducts.
 Renal pyramids - collecting ducts with bases on the border between the cortex and medulla;
separated by the renal columns, which are extensions of the cortex tissue.
 Papillae - apices of pyramids, which extend toward the renal pelvis; urine travels through the papillae
to the renal pelvis.
 Renal pelvis - inner portion where urine is collected. The narrowed portion becomes the proximal
aspect of the ureter as it approaches the hilum.
 Minor and major calyces - recesses of the pelvis that receive urine from papillae of collecting ducts.

Nephron -The functional unit of the kidney, contains the ff:

 Glomerulus is the beginning of the nephron. It is a tuft of capillaries supplied by afferent arterioles and
drained by efferent arterioles within Bowman's capsule.
 Proximal tubule is the convoluted portion with a border of microvilli lining the lumen.
 Henle's loop has two major portions, the descending and ascending limbs. The descending loop narrows
as it dips from the cortex to the medulla.
 Distal tubule passes between afferent and efferent arterioles of glomerulus as it moves back into the cortex.
 Collecting duct passes through the cortex and medulla, receiving the terminal end of several nephrons.

Function I.

1. The urinary system

 Ureters transport urine to the bladder by peristaltic waves of smooth muscle. The ureterovesical junction
prevents backflow of urine (i.e., reflux).
 Bladder serves as a reservoir for urine until it is excreted from the body.
 Urethra carries urine by peristalsis from the bladder to the outside of the body.
 Urine formation is a result of three processes: filtration, reabsorption, and secretion.

 Glomerulus filters the blood, which results in a filtrate that includes waste products and such useful
substances as water, glucose, ions and amino acids.
 Useful substances in the filtrate are reabsorbed into the blood by the proximal and distal convoluted
tubules. v/
 Tubular secretion is reabsorption in reverse. The waste products are secreted into the filtrate in the tubules
and excreted in the urine.
Micturition (e.g, voiding) is under voluntary and involuntary control. The urge to void normally occurs when 150
to 300 ml urine has accumulated. The bladder normally contains no residual urine after voiding.

2. Kidney. Overall functions of the renal system include:

 blood pressure regulation by renin secretion
 red blood cell production regulation by erythropoietin secretion
 metabolism of vitamin D.
 Release of prostaglandin E

Assessment:

1. Health history
- Explore the client's health history for risk factors: exposure to certain nephrotoxins (e.g., Chemicals, tar,
plastics)
- History of smoking
- Multiple Pregnancies
- history of diabetes mellitus or hypertension.
- Elicit a description of the client's present illness and chief complaint, including onset, course, duration,
location, and precipitating and alleviating factors.
- Flank pain
- + CVA tenderness- costo vertebral
- Cardinal signs and symptoms indicating altered urinary and renal function include.
o Dysuria
o hesitancy
o flank pain
o urinary frequency
o urethral discharge
o hematuria
o incontinence
o nocturia

2. Physical examination
 Inspection
− Inspect the masses in the upper abdomen and flank area.
− Inspect the external meatus for signs of discharge, cleanliness, location, and size.
 Palpation.
− Palpate for the lower poles of the right and left kidney, noting enlargement.
 Percussion
− Percuss above the symphysis pubis for a distended bladder.
 Auscultation.
- Auscultate for bruits over the renal arteries.
 3. Laboratory and diagnostic studies
− Urinalysis involves assessment of:
o urine color
o opacity,
o odor,
o specific gravity 1.010-1.030,
o osmolality,
o pH 4.5-8. It also identifies the presence of glucose (-) , ketones (-), proteins (+) traces
only, red and white blood cells (-), sediment, and bacteria.
− Urine culture and sensitivity, which requires a midstream clean-catch urine specimen,
detects infective microorganisms,
− Blood analysis
o Plasma creatinine analysis provides an excellent indication of renal function.
o Blood urea nitrogen analysis evaluates renal function.
− Creatinine clearance evaluates glomerular filtration rate (GFR). Creatinine
clearance levels increase as renal function diminishes. (24 hr urine collection) preservative
or ilagay sa ref
− Vascular studies
o Radionuclide tests
▪ Renal scan provides anatomic information.
▪ Renogram provides information about renal blood flow, GFR, and
tubular secretion.
o Renal arteriography outlines renal vasculature.
o Renal venography outlines renal veins.
− Radiographs of kidneys, ureters, and bladder visualize the size, shape, and position of
urinary structures.
− Ultrasound studies identify gross renal anatomy.
− Computed tomography detects renal masses, vascular disorders, and filling defects
of the collecting system.
− I-V- and retrograde pyelography and cystourethrography provide information about
the size, shape, and position of urinary-tract structures and evaluate renal excretory
function. v/
− Hemodynamic studies evaluate motor and sensory function of the bladder and micturition
process.
− Cystoscopic examination allows direct endoscopic visualization of the entire un-nary tract.
− Bladder and kidney biopsy determines the nature and extent of disease.
Nursing Diagnoses

 Acute pain
 Risk for infection
 Impaired urinary elimination
 Deficient or excess fluid volume
 Imbalanced nutrition: less than body requirements
 Impaired skin integrity
 Activity intolerance
 Deficient knowledge
 Ineffective coping
REGULATION OF FLUID AND ELECTROLYTES

Fluid balance

✓ Sensible loss
✓ Insensible loss
✓ Balancing systems

Balancing Systems

Renal System

✓ If the body needs more fluid, it retains more.

✓ If the body needs less fluid, less is reabsorbed, and more is excreted

Antidiuretic Hormone

✓ a water-retaining hormone also known as vasopressin.

✓ when the hypothalamus senses a low blood volume and increased serum osmolality, it signals the
posterior pituitary gland, which stores ADH, secretes it into the bloodstream.
✓ ADH prompts the kidneys to retain water, which increases blood volume, decreases serum osmolality, and
increases the concentration of urine.
✓ decreased serum osmolality or increased blood volume inhibits the release of ADH and causes less water
to be reabsorbed, making the urine less concentrated.
Renin-angiotensin-aldosterone system
Atrial natriuretic peptide
✓ A cardiac hormone also helps maintain fluid balance.
✓ If blood volume and pressure rise, the atrial walls stretch, prompting release of AND.
✓ ANP shuts off the renin-angiotensin-aldosterone system, thus decreasing blood pressure and reducing
intravascular blood volume.
✓ suppressing serum renin levels
✓ decreasing aldosterone release from the adrenal glands
✓ increasing glomerular filtration, which increases urinary excretion of sodium and water
✓ decreasing ADH release from the posterior pituitary gland

Thirst - arises after even small fluid losses/losing body fluids or eating salty foods, leads to an increase in extracellular
fluid osmolality. This increase dries the mucus membranes in the mouth, which stimulates the thirst center in the
hypothalamus.

Electrolytes

✓ Help regulate water distribution

✓ Govern acid-base balance,
✓ Transmit nerve impulses.
✓ Contribute to energy generation and blood clotting

Potassium (3.5 - 5.1 mEq/L)

- The main intracellular fluid (ICF) cation
- Regulates cell excitability
- Permeates cell membranes, thereby affecting the cell's electrical status
- Helps control ICF osmolality and, consequently, ICF osmotic pressure
Magnesium (1.6 - 2.6 mg/dl)
- Å leading ICF cation
- Contributes to many enzymatic and metabolic processes, particularly protein synthesis
- Modifies nerve impulse transmission and skeletal muscle response (unbalanced
- Mg * concentrations dramatically affect neuromuscular processes)

Phosphorus (2.7 - 4.5 mg,'dl)

- The main ICF anion
- Promotes energy storage and carbohydrate protein, and fat metabolism
- Acts as a hydrogen buffer

Sodium (135 - 145 mEq/L)

- The main extracellular fluid (ECF) cation
- Helps govern normal ECF osmolality (A shift in Na concentration triggers a fluid volume change to restore
normal solute and water ratios.)
- Helps maintain acid-base balance
- Activates nerve and muscle cells
- Influences water distribution (with chloride)

Chloride (96 - 106 mEq/L)

- The main ECF anion
- Helps maintain normal ECF osmolality
- Affects the body's pH
- Plays a vital role in maintaining acid-base balance; combines with hydrogen ions to produce hydrochloric
acid

Calcium 8.6 - 10 mg/dl)

- A major cation in teeth and bones
- Found in fairly equal concentrations in ICF and ECF
- Also found in cell membranes, where it helps cells adhere to one another and
- maintain their shape
- Acts as an enzyme activator in cells (muscles must have Ca to contract)
- Aids coagulation
- Affects cell membrane permeability and firing level
Bicarbonate
- Present in ECF
- v/ Functions mainly to regulate acid-base balance
pH
- pH is a calculation based on the percentage of hydrogen ions in a solution and the amount of acids and
bases in the solution.
 A solution with a pH below 7 is an acid.
 A solution with a pH above 7 is a base.
- Arterial blood is usually used to measure pH.
 If the hydrogen ion concentration bf the blood increases/carbonic acid increases or the
bicarbonate level decreases, pH may decrease. A decrease in pH below 7.35 signals acidosis.
 If the bicarbonate level increases or the hydrogen ion concentration of the blood
decreases/carbonic acid decreases, pH may increase. An increase in pH above 7.45 signals
alkalosis.
 URINARY AND RENAL DISORDERS

Urinary Tract Infection

Description

- Inflammation and infection of urinary tract structures are classified as upper urinary tract infections (UTIs)
or lower UTIs.
- Upper UTIs are known as pyelonephritis (e.g, inflammation of the kidney).
- Lower LITIs include:
o cystitis (e.g. inflammation ofthe bladder wall), the most common type
o ureteritis (e.g, inflammation cfthe ureter)
o urethritis (e.g. inflammation of the urethra).
- Women develop UTI more frequently than men because of their shorter urethras. Approximately 25% of
all women experience UTIs at some time. Incidence among women increases with aging. Incidence among
men peaks after age 50.

Pathophysiology

- An upper UTI is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys
that occurs because of reflux of urine into the ureters.
- A lower UTI is an infection that typically ascends from the urethra to the bladder and possibly to the ureter_
- Other pathways of upper and lower include blood and lymph.

Acute Renal Failure

- Results when the kidneys are unable to remove metabolic waste and perform their regulatory functions.
- Acute renal failure (ARE) is a rapid loss of renal function due to damage to the kidneys.
- Three major categories of ARF are
o prerenal (hypoperfusion, as from volume depletion disorders, extreme vasodilation, or impaired
cardiac performance);
o intrarenal (parenchymal damage to the glomeruli or kidney tubules, as from burns, crush injuries,
infections, transfusion reaction, or nephrotoxicity, which may lead to acute tubular necrosis [ATNI);
and
o postrenal (urinary tract obstruction, as from calculi, tumor, strictures, prostatic hyperplasia, or blood
clots).

Clinical Stages

 Initiation period: initial insult and oliguria.

 Oliguric period (urine volume less than 400 ml_/day): Uremic symptoms first appear, and
hyperkalemia may develop.
 Diuresis period: gradual increase in urine output signaling beginning of glomerular filtration's recovery.
Laboratory values stabilize and Start to decrease.

Recovery period: improving renal function (may take 3 to 12 months).

Clinical Manifestations

 Critical illness and lethargy with persistent nausea, vomiting, and diarrhea.
 Skin and mucous membranes are dry.
 Central nervous system manifestations: drowsiness, headache, muscle twitching, seizures.
 Urine output scanty to normal; urine may be bloody with low specific gravity.
 Steady rise in blood urea nitrogen (BUN) may occur depending on degree of catabolism; serum creatinine
 values increase with disease progression.
 Hyperkalemia may lead to dysrhythmias and cardiac arrest.
 Progressive acidosis, increase in serum phosphate concentrations, and low serum calcium levels may be
noted.
 Anemia from blood loss due to uremic Gl lesions, reduced red blood cell life-span, and reduced
erythropoietin production.

Chronic Renal Failure (End Stage Renal Disease)

 When a patient has sustained enough kidney damage to require renal replacement therapy on a permanent
basis, the patient has moved into the final stage of chronic kidney disease, also referred to as chronic
 renal failure (CRF) or end-stage renal disease (ESRD).
 The rate of decline in renal function and progression of ESRD is related
 to the underlying disorder, the urinåry excretion of protein, and the
 presence of hypertension.
 The disease tends to progress more rapidly in patients who excrete
 significant amounts of protein or have elevated blood pressure than in
 those without these conditions.

1. Reduced Renal RRR- 40%-75% malfunctional

2. Renal Insufficiency- 75-90% Malfunctional- Loss of Ability to concentrate urine
3. Stage 3 ESRD – BUN/CREA sobreang increase, uremia, urea in the blood, azotemia.

Clinical Manifestations

 Cardiovascular: hypertension, pitting edema (feet, hands, sacrum), periorbital edema, pericardial
friction rub, engorged neck veins, pericarditis, pericardial effusion, pericardial tamponade, hyperkalemia,
hyperlipidemia
 Integumentary: gray-bronze skin color, dry flaky skin, severe pruritus, ecchymosis, purpura, thin brittle nails,
coarse thinning hair
 Pulmonary: crackles; thick, tenacious sputum; depressed cough reflex; pleuritic pain; shortness of
breath; tachypnea; Kussmaul-type respirations; uremic pneumonitis
Gl: ammonia odor to breath, metallic taste, mouth ulcerations and bleeding, anorexia, nausea and
vomiting, hiccups, constipation or diarrhea, bleeding from Gl tract
 Neurologic: weakness and fatigue, confusion, inability to concentrate, disorientation, tremors, seizures,
asterixis, restlessness of legs, burning of soles of feet, behavior changes
 Musculoskeletal: muscle cramps, loss of muscle strength, renal osteodystrophy, bone pain, fractures, foot
drop
 Reproductive: amenorrhea, testicular atrophy, infertility, decreased libido
 Hematologic: anemia, thrombocytopenia

✓ Goals of management are to retain kidney function and maintain homeostasis for as long as possible.
✓ All factors that contribute to ESRD and those that are reversible (eg, obstruction) are identified and treated

Hyperphosphatemia and hypocalcemia are treated with medications that bind dietary phosphorus in the Gl tract
(eg, calcium carbonate, calcium acetate, sevelamer hydrochloride); all binding agents must be administered with
food. Hypertension is managed by intravascular volume control and antihypertensive medication Heart failure and
pulmonary edema are treated with fluid restriction, low sodium diet, diuretics, inotropic agents (eg, digoxin or
dobutamine), and dialysis. Metabolic acidosis is treated, if necessary, with sodium bicarbonate supplements or
dialysis.