genitourinary system Flashcards
review: adequate urinary elimination
essential for body fluid homeostasis - the ability of the body to maintain its internal environment at a “steady state”
kidneys:
responsible for “making” the urine, maintaining this balance of what is taken into the body, what is allowed to remain in the body and what is eliminated from the body
functions of the kidneys (10)
- urine formation
- excretion of waste products
- regulation of electrolytes
- regulation of acid-base balance
- control of water balance
- control of BP
- renal clearance
- regulation of RBC production
- synthesis of vitamin D to active form
- secretion of prostaglandins
3 different phases of urine formation
1) glomerular filtration:
- as blood passes into the glomerulus, water, electrolytes, and other small particles (eg. creatinine, urea nitrogen, glucose) filtered across the glomerular membrane into the bowman’s capsule to start forming urine (referred to as the GFR)
2) tubular reabsorption:
- the reabsorption of most of the filtrate keeps normal urine output at 1-3 L/Day, prevents dehydration (most H2O/electrolyte are reabsorbed, kidneys absorb 220 mg/dL)
3) tubular secretion:
- allows substances to move from the blood into the urine
tubular resportion
- this reabsorption of most of the filtrate keeps normal urine output at 1-3L/day and prevents dehydration
TIP:
- most h2o/electrolytes are reabsorbed, kidneys absorb 220 mg/dL
tubular secretion
- allows substances to move from the blood into the urine
vasopressin (ADH) function
makes DCT and CD permeable to water to maximize reabsorption and produce a concentrated urine (opposite diuresis)
ureters
contraction of smooth muscle in the ureter move urine from the kidney pelvis to the bladder
- stretch receptors in the kidney pelvis regulate this movement
bladder
muscular sac that lies directly behind the pubic bone that stores urine, provides continence, and enables voiding
urethra
eliminates urine from the bladder through the urethral meatus
continence
ability to voluntarily control bladder emptying
- continence during bladder filling through the combination of detrusor muscle relaxation, internal sphincter muscle tone, and external sphincter contraction
micturition (voiding) (what, learned response/controlled by (2))
reflex of autonomic control that triggers contraction of the detrusor muscle (closing the ureter at the UVJ to prevent backflow) at the same time as relaxation of the external sphincter and the muscles of the pelvic floor
- learned response and is controlled by the cerebral cortex and brainstem
age related changes (kidney) (6)
- decreased GFR
- nocturia
- decreased bladder capacity
- weakened urinary sphincters and shortened urethra in women
- tendency to retain urine
- diminished thirst stimulation -> hypernatremia, fluid volume deficit
tip:
- discourage fluid intake at night
- pm lasix?
- perineal care, privacy, dysuria, reconcilitation with meds, confusion, uti, bladder distension
physical assessment kidneys (Gi/GU, skin, resp, cardiac, neuro)
1) GI/GU
- auscultate for renal bruits
2) inspect skin:
- check skin for the presence of any rashes, bruising, or yellowish discoloration; or edema in the pedal, pretibial, sacral or around the eyes
3) respiratory assessment:
- listen for crackles or adventitious sounds
4) cardiac assessment:
- listen for murmurs or rubs
5) neurological assessment:
- assess LOC, alertness, deficits in memory or concentration (build up waste products)
diagnostic labs kidneys (7)
- BUN: effectiveness of urea nitrogen (byproduct of protein breakdown in liver)
- CR: indicator of renal function, muscle/protein breakdown (lvl doesn’t increase unless 50% kidney function lost)
- BUN/CR ratio: kidney r/t or non, cardiac output, blood cell production, trauma, I/O
- osmolarity: overall particle concentration in blood, hydration status
- urine specific gravity: hydration status dependent (increase fluid intake -> decrease USG)
- urinalysis: test urine
- urine culture and sensitivity
tip:
- look at trends
proteinuria (what, levels, increased)
protein is not normally present in the urine
- levels >30 mg/hr or 200 mcg/min are abnormal
- increased membrane permeability is caused by infection, inflammation, or immunologic problems
microalbuminuria (normal levels, higher levels)
normal levels in a freshly voided specimen should range between 2.0 and 20 mg/mmol for men, 2.8 and 28 mg/mmol for women
- higher levels: indicate microalbuminuria, mild/early kidney disease (esp. in patients with diabetes mellitus)
creatinine clearance (calculated, measures, normal)
calculated from serum creatinine, age, weight, urine creatinine, gender, and race within 24 hour urine collection
- calculated measure of GFR and kidney function
- normal creatinine clearance: 107-239 mL/min (men), 87-107 mL/min (women)
tip:
- strict labs (urine collected, placed on ice ASAP)
- depends per hospital policy
glomerular filtration rate (GFR) (what, ______ _______ to measure your level.., calculated from, normal, _______ would occur if..)
measure of how well the kidneys are filtering the waste from the blood
- best test to measure your level of kidney function and determine your stage of kidney disease
- calculated from creatinine, age, body size, gender
- normal GFR averages: 125 mL/min
- if the entire amount of filtrate were excreted as urine, DEATH WOULD OCCUR QUICKLY FROM DEHYDRATION
tip:
- controlled by blood flow/perfusion (BP)
diagnostic tests urine (6)
- bladder scanner: noninvasive (measure urine, PVR)
- radiography of kidneys, ureters and bladder (KUB)
- ultrasound: kidney size, obstruction (stonel tumors)
- CT or MRI
- nuclear renal scan: kidney perfusion
- cystography & cystourethrography: outline bladders contour esp. when full (urine flow detection)
urinary tract infection (what, categorized, lower, upper)
described by their location in the tract
- categorized as uncomplicated or complicated (EXAM) (increased risk for tx. failure, serious outcomes, recent cath, urologic abnormalities, male, DM, neurogenic (loss of control d/t brain/spinal/nerve problem), renal insufficiency)
1) lower urinary tract:
- urethritis: urethral infection
- cystitis: bladder infection
- prostatitis: prostate gland infection
2) upper urinary tract
- pyelonephritis: kidney infection
infectious disorders: lower urinary tract s/sx (9)
- frequency
- urgency
- dysuria
- nocturia
- incontinence
- hematuria, pyruia, bacteruia
- suprapubic tenderness or fullness, back pain
- hesitancy or difficulty in initiating urine stream
- retention, feeling of incomplete bladder emptying
tip:
- R/O sepsis
- N/V/fevers/chills
- frequent falls
infectious disorders: lower urinary tract diagnostic labs (2)/tests (3)
diagnostic labs:
- urinalysis: first step lab assess -> leukocytesterase, nitrates
- urine culture and sensitivity: colonies/bacteria (more expensive)
diagnostic tests:
- pelvic US: f/u
- cystoscopy
- CT
tip:
- TSH (high/low) -> follow up w/ T3/T4, urine culture sensitivity
- TSH (normal) -> T3/T4
infectious disorders: lower urinary tract interventions (3, pharm (2))
- encourage fluid intake
- promote good diet: follow evidence (4 wk. 50mL cranberry juice, decrease ecoli adherence to urinary tract walls appropriately)
- warm sitz bath 2-3 times/day for 20 minutes
pharm:
- antibiotics: broad spectrum at first, then based off C&S results (nitrofurantoin, trimethoprim/sulfamethoxazole, or fosfomycin as first line therapy)
- analgesics: pain relief PRN
infectious disorders: lower urinary tract nursing interventions to prevent UTI (6)
- encourage patients to drink fluid liberally, as much as 2-3L/day if not contraindicated by other health problems
- encourage enough sleep, rest, and nutrition daily to maintain immunologic health
- teach the patient to empty bladder before and after intercourse
- teach patient to gently wash the perianal area before intercourse
- teach the patient to not routinely delay urination
- for women: teach to clean perineum from FRONT TO BACK, avoid using/wearing irritating substances such as douches, scented lubricants for intercourse, avoid spermicides as a method of contraception, bubble bath, tight-fitting underwear, scented toilet tissue, wear loose fitting cotton underwear
infectious disorders: lower urinary tract nursing interventions to minimize catheter related infection (7)
- maintain good hand hygiene
- strict aseptic technique during insertion and secure catheter to prevent movement
- perform meticulous daily perineal care with soap/water
- when emptying the urine bag, do NOT allow the tip of the outflow tube to touch the urine collection container. Use dedicated container for each patient or resident
- maintain closed system
- maintain unobstructed urine flow by keeping the tubing patent and urine collection bags below the level of the bladder at all times
- foley indicator: retention, surgery, trauma, large diuretics/infusions, intubation
infectious disorders: pyelonephritis (4)
bacterial infection in the kidney and renal pelvis
- bacteria trigger the inflammatory response, and local edema results
- fibrosis and scar tissue develop from the inflammation
- results in filtration, resorption, and secretion are IMPAIRED and kidney function is reduced
pyelonephritis s/sx (6)
- fevers, chills
- tachycardia, tachypnea
- flank, abdominal back, CVA pain
- N/V
- general malaise
- burning, urgency, frequency, nocturia
TIP:
- AMS, affects other organs
pyelonephritis diagnostic labs (2)/tests(2)
labs:
- urinalysis
- urine culture and sensitivity
tests:
- US
- CT
pyelonephritis interventions (1, pharm (2))
1) nutrition therapy
- fluid intake is recommended at 2L/day, sufficient to result in dilute (pale yellow) urine
2) pharm:
- antibiotics: based on culture and sensitivity
- pain mgmt: analgesics
urinary incontinence disorders (what, common types (5))
incontinence: involuntary or uncontrolled loss of urine from the bladder
common types:
- stress
- urge
- overflow
- functional
- mixed form
factors contributing to urinary incontinence (4)
1) drugs:
- CNS depressants, such as opioid analgesics; diuretics causing frequent voiding; multiple drugs can contribute to changes in mental status or mobility; anticholingeric drugs or drugs with anticholinergic side effects
2) disease:
- CVA and other neurologic disorders decrease mobility, sensation, or cognition; arthritis decreases mobility and causes pain; parkinson disease causes muscle rigidity and an inability to initiate movement
3) depression:
- decreases the energy necessary to maintain continence; decreased self esteem and feelings of self worth decrease the importance to the patient of maintaining continence
4) inadequate resources:
- patients who need assistive devices (eg. eyeglasses, cane, walker) may be afraid to ambulate without them or without personal assistance; products that help patients manage incontinence are often costly, no one may be available to assist the patients to the bathroom or help with incontinence products
urinary incontinence labs (1)/tests(3)
labs:
- urinalysis: urine dip stick (outpatient, preliminary results, leukocytes, nitrates, RBC/WBC)
tests:
- post void residuals w/ bladder scanning: (<50mL - middle age, <50-100 - older age)
- voiding cystourethrogram (VCUG): neurodynamic test (size, shape, function)
- CT: abnormalities in kidneys/ureters
urinary incontinence interventions (pharm (5))
pharm:
- antispasmodics: to reduce incontinence by causing bladder muscle relaxation
- anticholinergics: suppress involuntary bladder contraction, increase urine volume and may increase the bladder capacity
- alpha adrenergic agonists: increase contractile force of the urethral sphincter, increasing resistance to urine outflow
- beta blockers: relax the detrusor smooth muscle to increase bladder capacity and urine storage
- antidepressants: to strengthen the urinary sphincters (with anticholinergic actions too) (not as common, TCAs/SNRIs)
stress incontinence (what, s/sx (5))
the involuntary loss of urine during activities that increase abdominal and detrusor pressure (stress)
- patients cannot tighten the urethral sufficiently to overcome the increased detrusor pressure; leakage of urine results
s/sx:
- urine loss with physical exertion, cough, sneeze, or exercise
- usually only small amounts of urine are lost with each exertion
- normal voiding habits (</= 8 times per day, </= 2 times per night)
- post void residual usually </= 50mL
- pelvic examination shows hyper mobility of the urethra or bladder neck with valsalva maneuvers (holding breath, strain 15-20 seconds, breath out to slow BP)
stress incontinence interventions (5)
- kegel exercises: women, strength pelvic foot muscles
- vaginal cone therapy: use with pelvic muscle exercises
- pessary therapy: collette uterus
- nutrition therapy: obese (worse with increase pressure in abd.) (caffeine, fluid intake)
- behavior modification: schedule toileting, log/diary pt. s/sx, PT/OT)
urge incontinence (what, s/sx)
involuntary loss of urine associated with a strong desire to urinate that cannot be suppressed
- AKA overactive bladder (OAB)
s/sx:
- abrupt, strong urge to void
- may have loss of large amounts of urine with each occurrence
urge incontinence interventions (3, pharm (4))
- behavioral interventions with timed voiding schedules (bladder train, habit training)
- kegel exercises
- nutrition therapy: space fluid intake, avoid caffeine, ETOH
pharm:
- anticholinergics
- anticholinergics + smooth muscle relaxants
- tricyclic antidepressants + anticholinergic and alpha adrenergic agonist activity
- onabotulinumtoxinA (botox)
overflow incontinence (what, s/sx (3))
involuntary loss of urine associated with over-distention of the bladder when the bladder’s capacity has reached its maximum
- AKA underactive bladder
s/sx:
- bladder distention, often up to the level of the umbilicus
- constant dribbling of urine
- residual urine >50mL
- retention from obstruction
overflow incontinence intervention (3 + pharm)
1) behavioral inteventions
- simple trigger techniques (water, stroke abdomen/inner thigh)
- bladder compression (press over bladder to help with emptying
- intermittent self catheterization (long term concerns, incomplete -> can reuse if clean technique)
2) pharm:
- bethanechol chloride (urecholine) to increased bladder pressure, short term only
3) surgery to relieve the obstruction
functional incontinence (what, s/sx (2))
leakage of urine caused by factors other than disease of the lower urinary tract, such as severe physical or cognitive impairment
s/sx:
- quantity and timing of urine leakage vary (linked to functional incontinence)
- patterns are difficult to discern
functional incontinence interventions (5)
- safety precautions
- treat reversible causes
- habit training
- containment (absorbent pads and briefs - skin protection)
- catheterization (condom cath., intermittent catheters, indwelling catheters - unless indicated, critically ill, end of life care)
mixed urinary incontinence (what, cause, s/sx, interventions)
combination of stress, urge, and overflow incontinence
- cause: depends on each separate disorder
- s/sx: usually associated with urgency and also with exertion, effort, sneezing, or coughing (stress incontinence)
- interventions: combination of techniques (depends on causes s/sx)
obstructive disorders: urolithiasis
presence of calculi (stones) in the urinary tract
obstructive disorders: nephrolithiasis (3)
- formation of stones in the kidney
- stones are formed in the urinary tract when urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increase
- certain factors favor the formation of stones, including infection, urinary stasis, and periods of immobility
obstructive disorders s/sx (9)
- renal colic or ureteral colic pain (painful)
- flank (males: equivalent to childbirth)
- hematuria: blood with urine
- nausea/vomiting: extreme pain
- pallor
- diaphoresis
- oliguria or anuria (obstruction r/t)
- hydronephrosis: excess fluid kidney d/t backup urine
- staghorn stone (s/sx depends on where obstruction is)
obstructive disorder diagnostic labs(4)/tests(3)
labs:
- urinalysis: RBC (trauma caused from stone)
- urine culture and sensitivity
- CBC
- CMP
tests:
- US
- KUB xray
- CT (noncontrast)
obstructive disorders: urolithiasis and nephrolithiasis (3)
- when urethral strictures or obstruction is very low in the urinary tract it causes bladder distention before hydroureter and hydronephrosis
- hydroureter: a dilation of the ureter from an obstruction of urine (sometimes can occur without an obstruction)
- hydronephrosis: swelling of a kidney d/t buildup of urine from an obstruction of urine; the kidney enlarges as urine collects in the renal pelvis and kidney tissue and causes kidney damage
obstructive disorders interventions (5 + pharm (3))
1) pain mgmt:
- NSAIDs such as ketorolac (toradol) or ketoprofen (nexcede) in acute phase & opioid analgesics to control severe pain
- spasmolytic drugs, such as oxybutynin (ditropan) and propantheline bromide (propanthel)
- thiazide diuretic and allopurinol to aid in stone expulsion
2) maintain adequate hydration
3) preventing infection and urinary obstruction
4) lithotripsy: extracorpal shock wave (breaks stone to small pieces, monitor excretion of stones, strainer to catch release of stones from ureters)
5) surgery: stent -> pain, infection monitor, catheter for monitor
obstructive disorders: preventing future urolithiasis (4)
- high intake of fluids (3 L/day or more)
- dietary changes (decreased protein, calcium, fats)
- exercise (ambulate (promote passage of stone) -> decreased osteoporosis (bone resorption)
- drug therapy to prevent obstruction: hypercalciuria (thiazide diuretics, hydrochlorothiazide), hyperoxaluria/hyperuricemia (allopurinol, febuxostat)
benign prostatic hypertrophy (what, s/sx (5))
prostate undergoes tissue hyperplasia that causes the prostate gland to enlarge
- as the prostate gland enlarges, it extends upward into the bladder and inward, causing bladder outlet obstruction (older biological males, urination decreased, “weak stream”
s/sx:
- difficulty in starting (hesitancy) and continuing urination
- reduced force and size of urinary stream (“weak” stream)
- sensation of incomplete bladder emptying
- post voiding dribbling or leaking
- hematuria, nocturia
BPH diagnostic labs (2)/tests (5)
labs:
- urinalysis: uti, microscopic hematuria (WBC/nitrates/leukocytes)
- prostate specific antigen (PSA): no true diagnostic tests
tests:
- post void residuals (PVR)
- transabdominal US
- transrectal US (TRUS)
- biopsy
- urodynamic pressure flow studies: diagnose bladder output obstruction (detrusor muscles)
BPH interventions (4 + pharm (2))
1) dietary changes: decreased caffeine, ETOH, urinate when needed esp. with diuretics
2) pharm:
- 5 alpha reductase inhibitor (5-ARI): changes testosterone, stimulates prostate growth (finasteride - Proscar, dutasteride - avodart)
- alpha 1 selective blocking agents: relax prostate muscles, improve urine flow (tamsulosin - flomax, alfuzosin - uroxatral, doxazosin - cardura)
3) nonsurgical interventions: catheterization
4) surgery: if preliminary, TURP: enlarge portion prostate removed endoscopically/resection
- monitor infection, underlying diseases, ambulate, pain Q4H PRN, safe environment post surgery, reorient pt., check lines, continuous bladder irrigation (clots)
urothelial cancer (what, s/sx (4))
malignant tumors of the urothelium - the lining of transitional cells in the kidney, renal pelvis, ureters, urinary bladder, urethra
- most urothelial cancers occur in the bladder and termed “bladder cancer”
s/sx:
- hematuria
- frequency
- dysuria
- lower back pain
urothelial cancer diagnostic labs (2)/tests (4)
labs:
- urinalysis
- urine cytology
tests:
- cystoscopy
- XRAY
- CT
- MRI
urothelial cancer interventions (2)
1) surgery:
- simple excision or partial
- excision plus intravescial chemotherapy
- transurethral resection of the bladder tumor (TURBT) or partial cystectomy
- radial cystectomy with urinary diversion (men - remove bladder prostate + vesicles) (women- remove bladder, lower ureter, fallopian tubes, etc.)
2) chemotherapy and radiation therapy are used in addition to surgery
urothelial cancer alternatives for urinary elimination are used after cystectomy with a stoma (4)
- illeal conduit: new tube created from intestine that allows the kidneys to drain and urine to exit the body
- cutaneous ureterostomy: surgeon detaches the ureters from the bladder and brines one or both to the surface of the abdomen
- indiana/continent pouch: connection of the end of the small intestine to the skin of your abdomen (allows for waste to be excreted)
- ureterosigmoidostomy: ureters which carry urine from the kidneys are diverted into the sigmoid colon
