Identify basic structures and functions of the urinary system.
State the three functions of the urinary system.
Describe disorders of the kidneys and urinary tract. Be able to define key terms, define symptoms and describe related medications and treatments, and nursing care and side effects.
Identify medications used to treat urinary tract disorders and nursing measures to promote effectiveness, including the following drug groups or treatments:
Kidneys are situated at the back (retroperitoneal) area of the abdominal cavity.
One on each side of the spinal column.
Function - excrete urine which contains the end products of metabolism (urea); help regulate the water, electrolyte and acid base content of the blood.
Kidneys have 2 layers – outer cortex and inner medulla
Functional unit is the nephron which filters water, nutrients, and minerals from the blood. There are one million nephrons in each kidney.
Kidney restores some water, nutrients, and minerals to the body – the rest is excreted as urine.
Ureters are the muscular tubes through which urine travels from the renal pelvis to the bladder.
There is one ureter descending from each kidney.
Ureters are about 10 inches in length.
Bladder is a muscular storage structure for the urine.
Expandable, stretchable because of the musculature.
Capacity is about 2 cups or about 500 ml.
Nerve endings stimulate the brain of need to empty when the bladder is stretched to about I cup or about 250 ml.
Capacity may extend to more than 500 ml.
Urethra is the tube through which urine travels from the bladder to external opening (meatus).
Female urethra a few inches long, extending from the bladder with the meatus located between the clitoris and the vagina opening.
Male urethra extends from the bladder the length of the penis to the tip.
Male urethra transports urine and seminal fluids.
Female urethra transports urine only.
Urinary anatomy and physiology: major functions
The main functions of the urinary system are to remove waste products from the blood, regulate the amount of water in the body, and maintain acid-base balance in the blood.
These functions are done by the kidneys filtering the blood.
Excretion of waste products-filter waste out of the blood:
Urea-a product of the metabolism of protein
minerals
water
Maintaining homeostasis-maintaining water balance in the body tissues by eliminating excess water.
Regulation of pH balance
pH is the acid-alkaline balance
normal pH of the body is neutral or very slightly alkaline (7.35 to 7.45 on the pH scale)
Disorders of the kidneys and the urinary tract
Refer to your textbook pg 376
Normal urine is clear and pale yellow.
1500 to 2000 ml are produced every 24 hours.
A single voiding expels about 300mI.
Urine is predominantly water, with 5% waste products.
Medical conditions or disorders may be detected through urine testing.
Frequency, amount voided, color are initial indicators of health.
Using testing equipment, the pH and sugar content can be tested relatively easily.
If there is low percent of water, the urine may be concentrated or dark and will have an increased "specific gravity”. Specific gravity is a method of "weighing" urine byproducts.
A high percent of water will appear as clear, colorless urine.
Catheterization is a means of placing a tube through the urethra into the bladder.
Usually a catheter is placed in order to drain the bladder or to obtain a urine sample for testing.
An "indwelling" catheter remains in place and is attached to an external collection bag.
Antiseptic or antibiotic solution may be instilled through catheter to irrigate the bladder of a patient who has a severe bladder infection.
Irrigation solution may also be instilled through a catheter to irrigate the bladder of a patient who has had bladder or prostate surgery.
Tests Refer to your textbook pg 376
Watch this video on “How to recognize the symptoms of a UTI”: Click Here
X-rays
Cystoscope-a telescope-like device is passed through the urethra and into the bladder to look at the structures directly; the view may be displayed on a monitor screen.
Catheter may be inserted to obtain urine directly from the bladder.
Urine sample-can be examined for:
Hematuria-blood in the urine
Pyuria-pus in the urine
Chemical analysis-looks for cells, microscopic blood, protein, pH, salts, sugar, etc.
Symptoms--change in act of urination. All these symptoms may be signs of urinary disorders, but may also be side effects of drugs given for other disorders.
Retention-inability to urinate-urine is made and bladder is full, but cannot be released.
Incontinence-inability to control urination.
Frequency-having to urinate very often.
Urgency-feeling a great urge to urinate unrelated to the amount of urine in the bladder.
Dysuria-painful or difficult urination-may be a burning sensation during urination.
Oliguria-little urine is produced.
Anuria-no urine is produced.
Major disorders Refer to your textbook pg 377
Obstructions
Malformed organs
Tumors
Injuries
Kidney stones-formed of salt crystals that collect together and form rock-like particles that usually pass down the ureters, causing intense pain, lodging in the bladder. Sometimes they are large enough to block the ureters. Sometimes they are crushed with an instrument during a cystoscopy, and flushed out of the bladder through the urethra.
Prostate (some people pronounce it prostRate, it is not prostRate but Prost-ate)-in males this organ surrounds the urethra at the base of the bladder. Enlargement may produce urinary obstruction. It is shaped like a donut and the urethra passes through the prostate as it exits the bladder. An enlarged prostate regularly occurs in older age, constricts the urethra, and interferes with urination.
Infections-urinary structures are prone to infection because they are lined with mucous membranes, carry waste products and metabolites to the outside of the body. Urinary tract infections are generically referred to as "UTI”. Prevent urinary tract infections by instructing resident and providing good peri-anal hygiene. Females should wipe/wash the area in the direction, from front (pubic) to back (anus), not back and forth.
Treat with antibiotics and analgesics for pain.
Elderly are especially susceptible to urinary infection, especially "nosocomial" infections. Nosocomial means that the infection was acquired at the facility.
Cystitis-bladder infection-that may cause bladder spasms, frequent urination, and burning upon urination. Can be acute or chronic and resistant to treatment.
Pyelonephritis-inflammation of kidney pelvis.
Nephritis-inflammation of the kidney, glomeruli, tubules, interstitial tissue. Can be acute or chronic and resistant to treatment.
Ureteritis-inflammation of the ureter(s).
Urethritis-inflammation of the urethra (may affect different portions).
Kidney failure also known as renal failure. Kidneys no longer perform essential functions, cannot filter urine and waste from the blood.
Refer to youyr textbook pg 378
Uremia is "blood poisoning" or ''toxic renal insufficiency"-waste products are not filtered out by the kidneys and build up in the blood stream; can reach toxic levels. Person must undergo dialysis to remove wastes, or IV antibiotics in hospital setting.
Drugs are not excreted as fast from the body, so a cumulative effect occurs as the drug level builds up.
Damage to the kidneys can occur from the use of drugs, particularly antibiotics. Infections are also damaging to the kidneys.
Diseases may affect or slow down processing by the kidneys because blood flow is blocked or flow through the kidneys is slow. Urine production is reduced or does not occur. Water and wastes remain in the body.
Imbalance of fluids, electrolytes, and pH Refer to your textbook pg 379
Water is the medium for all of the body's chemical reactions.
Average adult body is 60% water.
Elderly bodies are only about 50% water.
Most of the water in the body is inside cells.
About 1/4 of the water is interstitial fluid or blood plasma.
Body must maintain a balance between water taken in and water lost.
In some diseases the body cannot maintain this balance, so monitoring intake/output may be important as well as giving or restricting fluids.
Water is obtained from fluids, food and as the results of metabolic activity.
Intravenous fluids may be administered to correct fluid imbalances.
Water is lost from the body through urine, sweat, feces, respiration, vomiting, and wounds.
Intake can be accurately measured, but output can only be measured in part. Measuring sweat or water lost through the respiration is not easily accomplished.
Fluid balance is influenced by activity, body temperature and size.
Intake which is significantly greater than output will result in fluid overload over time.
Output which is significantly greater than input will result in dehydration over time.
Accurate intake and output or1&0 records help medical staff decide on treatment or therapies. Examples include IV fluids for dehydration and diuretics for edema.
Bladder function/tone
Infections, irritation, repeat (chronic) infections or other damage or diseases can reduce the bladder's muscular tone and holding and contracting ability.
Related medications and treatments:
Antispasmodic-reduces bladder contractions and delays the initial urge to void in persons with neurogenic bladder. The bladder is not functioning properly due to damage to the nervous system usually caused by a spinal cord injury, diabetes, or Multiple Sclerosis.
Estrogen replacement/supplement therapy used in treatment of postmenopausal women, may restore urethral mucosal lining. This may increase the elasticity of the bladder as well.
Nursing care and side effects:
Behavioral interventions include bladder retraining, habit training for urge incontinence, and prompted toileting for cognitively impaired persons. Pelvic muscle exercise for stress incontinence may help maintain urinary continence.
Diagnostic testing may be used to discover the cause of urinary tract problems, which is important in determining appropriate therapies.
Other drugs used for urinary disorders
Refer to your textbook pg 381
Antibiotics
Some antibiotics are excreted through the kidneys. This means that the kidneys will absorb a very high concentration of the drug which will help with an infection of the urinary tract.
Urinary anti-infectives/antiseptics
Drugs which are only partly effective for the treatment of cystitis.
Related medications:
Nalidixic acid (NegGram).
Nitrofurantoin (Macrodantin, Macrobid)-give with food for absorption and reduction of G.1. upset; may turn urine rust-brown.
Methenamine, methylene blue, phenyl salicylate, benoic acid, atropine sulfate, and hyoscyamine (Urised) is a combination anticholinergic, anti-infective drug. Encourage fluids to relieve discomfort and improve effect.
Urine and feces may discolor, turning bluish or bluish-green.
Sulfamethoxazole (Azo Gantanol, Bactrim, Septra, Gantanol) and
phenazopyridine (Pyridium); sulfisoxazole and phenazopyridine (Gantrisin).
Encourage fluids. Do NOT administer if sulfonamide or sulfa allergy exists.
Watch for rashes, respiratory reaction.
Trimethoprim, sulfamethoxazole (Bactrim, Cotrim, Septra)-combination antibacterial including sulfonamide. Encourage fluids. May cause nausea, rashes.
Methenamine (Hiprex, Urex, Mandelamine)-acidic urine is important for effectiveness. Avoid milk, dairy products. Encourage consumption of protein and cranberry-based foods. Add Vitamin C if directed by physician. May need to check urine pH.
Urinary analgesics-relieves pain or urinary tract infections by soothing action directly on the mucosal lining of the urinary tract. May discolor urine (dark orangish, brown).
Related medications:
Phenazopyridine (Pyridium)-especially causes changes in urine color-anaesthetizes mucous membranes of the urinary tract.
Ethoxazine (Serenium)
Nursing care and side effects:
Side effects are minimal, but many drugs used to treat urinary infections color the urine a rust or red color-WARN THE RESIDENT.
Encourage lots of fluids and regular emptying of the bladder.
Diuretics-decrease the re-absorption of salts and water from the kidney tubules. Increases urine production. More urine is produced, so more fluid is removed from the body. There are several types of diuretics with different modes of action. Refer to your textbook pg 382
Related medications and treatments:
Thiazide type diuretics-keep the kidneys from reabsorbing sodium, potassium and chloride, so more of these salts remain in the tubules and attract water, which is then excreted. Causes a loss of potassium, which is needed for the body's chemical processes. No storage in the body for potassium, so it must be replaced every day in the diet. Low potassium levels-hypokalemia also makes the effect of any digitalis drug more potent, possibly causing digitalis toxicity.
Chlorothiazide (Diuril)
Hydrochlorothiazide (Hydrodiuril, Esidrix)
Potassium-sparing diuretics-prevent the loss of potassium, while increasing urinary output. These can lead to an excess of potassium-hyperkalemia. Hyperkalemia symptoms may include diarrhea, intestinal colic, irritability, nausea, cardiac arrhythmias. Patients are told to avoid food rich in potassium.
Spironolactone (Aldactone)
Triamterene (Dyrenium)
"Loop" diuretics-strong diuretics that prevent the re-absorption of sodium and potassium. Hypokalemia symptoms include anorexia, silent intestinal ileus, weakness, soft flabby muscles and confusion. Potassium supplements may be ordered with these.
Furosemide (Lasix)
Bumetanide (Bumex)
Carbonic anhydrase inhibitors
Acetazolamide (Diamox)
Combination type-combine a Thiazide-type diuretic with a potassium-sparing diuretic
Triamterene and hydrochlorothiazide (Dyazide)
Spironolactone with hydrochlorothiazide (Aldactazide)
Nursing care and side effects:Refer to your textbook pg 384
Some diuretics cause excessive potassium loss and should be given with potassium replacements or conscientious dietary replacement.
Foods rich in potassium are bananas, oranges.
Give these drugs early in the day.
Make it easy and comfortable for the patient to urinate frequently.
Make sure the call light is within reach at all times so the resident will be able to call for help if needed.
Monitor the effectiveness of the diuretic by weighing the resident regularly. Weigh at the same time of day and with the same type of clothes on, if possible.
A daily weight change of more than plus or minus two lbs. Is significant. Report to licensed nurse immediately.
Watch for signs of potassium depletion-hypokalemia-confusion, gas, muscle weakness, muscle cramping, and/or an irregular heartbeat.
Encourage the resident to eat a variety of foods.
Be alert for symptoms of electrolyte imbalances-nausea, thirst, fatigue, dry mouth, and others mentioned above.
Be alert for hypotension, especially orthostatic hypotension.
Diuretics often lower blood pressure, so watch for dizziness, fatigue, muscle weakness and orthostatic hypotension.
Electrolytes-dissolved mineral salts or "macrominerals" Refer to your textbookpg 383
Electrolytes must be in proper balance for the body's chemistry to function.
Electrolytes are solutions which conduct electricity, containing electrically charged particles called ions.
Chemicals cling to these ions and are transported through the body's fluids, into and out of the cells and the bloodstream.
Electrolytes are:
Potassium - K
Calcium - Ca
Sodium-Na
Magnesium - Mg
Chloride - CI
Bicarbonate
Sulfate
Electrolytes and water must be in balance with each other.
Electrolyte imbalances (bold, capitalization to help remember, distinguish):
Hypokalemia-too little potassium
Hyperkalemia-too much potassium
Hyponatremia-too little sodium
Hypernatremia - too much sodium
Hypocalcemia-too little calcium
Hypercalcemia-too much calcium
Bases-acid relationship-pH is the ratio of bases to acids.
Body fluids are very slightly alkaline, and cannot tolerate very much deviation from this pH without death resulting.
Kidneys regulate the amounts of acids and bases that are excreted in the urine, so they help control the pH of the blood and body fluids.
Acidosis is too much acidity for the body cells to function.
Alkalosis-too much alkalinity for the body cells to function.
Related medications and treatment:
Potassium replacement drugs-replace potassium (K) lost when certain diuretics are used. Can cause stomach irritation.
KCL-abbreviation for "potassium chloride”.
Slow-K--has a wax matrix form for slow release.
K-Lyte
Nursing care and side effects:
Give with food to help prevent gastric irritation.
Do not give the wax matrix form with hot food or liquid to prevent melting.
Follow directions carefully when diluting liquid forms of drug.
Pay close attention to your textbook pg 387 regarding Representative Drugs for the Cardiovascular System
Also read the in your textbook pg 389 the practice procedure for instilling medications into the bladder.
You need to read the Legal and Ethical Issues of Wrong Drugs on pg 387 of your textbook.
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Please view the Powerpoint slide show on Drugs for the Urinary System and Fluid Balance.
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Unit 11 
