Genital urinary system
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Genital-Urinary System. Renal System Part 1. Behavioral Objectives:. Review the anatomy and physiology of the genito-urinary systems Describe the physical assessment of the GU systems Discuss the application of the nursing process as it relates to patients with disorders of the GU system

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Genital urinary system

Genital-Urinary System

Renal System Part 1


Behavioral objectives

Behavioral Objectives:

  • Review the anatomy and physiology of the genito-urinary systems

  • Describe the physical assessment of the GU systems

  • Discuss the application of the nursing process as it relates to patients with disorders of the GU system

  • Describe the purpose and methods for collecting sterile and “clean-catch” urine specimens.

  • Discuss the importance of monitoring and maintaining intake and output and appropriate documentation

  • Discuss common diagnostic tests, procedures and related nursing responsibilities for the patient with GU disorders.

  • Explain the purpose of dialysis and differentiate between peritoneal and hemodialysis


Introduction

Introduction

  • Essential to life

  • Every head to toe assessment must include…

    • Upper & lower urinary tract function


Anatomy kidney

Anatomy: Kidney

  • Kidneys

    • Shape

      • Bean

    • Color

      • Brown-red

    • How many / #

      • 2


Anatomy kidneys

Anatomy: Kidneys

Kidneys

  • Location

    • Posterior wall of the abdomen

    • Base of the rib cage

    • Surrounded by renal capsule

    • Right kidney is lower than the left


Anatomy kidney1

Anatomy: kidney

Do You Remember?

  • What lies on top of each kidney?

    • Liver

    • Pancreas

    • Meat balls

    • Adrenal gland


Genital urinary system

  • What hormones do the adrenal glands secrete?

    • (Not a multiple choice question!)

    • Hint

      • Sugar, Sex & Salt

    • Glucocorticoids

    • Androgens

    • Mineralcorticoids - aldosterone


Anatomy kidney2

Anatomy: Kidney

  • Two distinct regions:

    • Renal parenchyma

    • Renal pelvis

  • Renal parenchyma

    • Divided into 2 parts

      • Cortex

      • Medulla


Renal parenchyma

Renal parenchyma

  • Medulla

    • Inner portion

    • Contain

      • Loops of Henle

      • Vasa recta

      • Collecting ducts


Renal parenchyma1

Renal parenchyma

  • Medulla

    • Collecting ducts connect to Renal pyramids

      • Shape:

        • Triangle

      • Point toward

        • Hilum / pelvis

      • Ea. Kidney contains

        • 8-18 pyramids


Anatomy kidney3

Anatomy: Kidney

  • Medulla

    • Function

      • Drain urine from the Nephrons to the renal pelvis


Renal parenchyma2

Renal parenchyma

  • Divided into 2 regions

    • Medulla

    • Cortex

      • Contains

        • Nephrons

          • Functional unit of the kidneys


Anatomy kidney4

Anatomy: Kidney

  • Renal pelvis

    • Ureter

      • Renal pyramids drain urine into the ureter

    • Renal artery

    • Renal Vein


Blood supply to the kidney

Blood supply to the kidney

  • Aorta

  • Renal artery 

  • Afferent arteriole

  • Glomerulus

    • Capillary bed

  • Efferent arteriole

  • Venules and veins

  • Inferior Vena Cava


Can you do it

Can you do it?

  • Place the following in order to best describe blood flow threw the kidney.

    • Afferent arteriole

    • Aorta

    • Efferent arteriole

    • Glomerulus

    • Inferior Vena Cava

    • Renal artery

    • Vein

    • Venules

  • B-F-A-D-C-H-G-E


Question

QUESTION????

  • Where in the flow of blood threw the kidney does filtration take place?

    • Afferent arteriole

    • Aorta

    • Efferent arteriole

    • Glomerulus

    • Inferior Vena Cava

    • Renal artery

    • Vein

    • Venules


Anatomy nephrons

Anatomy: Nephrons

  • Functional unit*

  • FYI

    • 1 million Nephrons in ea. Kidney

    • Adequate renal function with 1 kidney


Anatomy nephrons1

Anatomy: Nephrons

  • Nephron

    • Glomerulus

    • Bowman’s capsule

    • Proximal convoluted tubule

      • Loops of Henle

      • Distal convoluted tubule


Anatomy ureters

Anatomy: Ureters

  • Urine:nephrons  renal pyramids  renal pelvis  ureter,

  • a long narrow muscular tube

  • Extends from renal pelvis  bladder

  • Two

  • Upper urinary tract


Anatomy ureters1

Anatomy: Ureters

  • 3 narrowed areas

    • promotes efflux

    • prevents reflux

      • micturition

    • Propensity for obstruction by renal calculi


Anatomy ureters2

Anatomy: Ureters

  • lining urothelium

    • prevents reabsorption of urine

  • The movement of urine is facilitated by peristaltic waves


Anatomy bladder

Anatomy: Bladder

BLADDER

  • Description

    • Muscular

    • hollow sac

  • Location

    • Behind pubic bone

  • Function

    • Reservoir for urine


Anatomy bladder1

Anatomy: Bladder

  • Normal capacity

    • 300-500 ml of urine

  • Capable of holding

    • 1500-2000 ml

  • CNS stim. “need to void”

    • 150-200 ml urine


Anatomy bladder2

Anatomy: Bladder

  • Neck of the bladder

    • Internal urinary sphincter

    • Involuntary control


Anatomy urethra

Anatomy: Urethra

  • Carries urine from the bladder & expels it from the body

  • External urinary sphincter

    • voluntary control


Physiology of the urinary system

Physiology of the Urinary System

  • Function of the kidneys

    • Urine formation

    • Excretion of waste products

    • Regulation of

      • Electrolytes

      • Acid-base control

      • RBC production

      • Ca+ & Ph

  • Control

    • water balance

    • blood pressure

  • Renal clearance

  • Synthesis of Vit. D


Physiology of the urinary system1

Physiology of the Urinary System

  • Urine formation

    • The nephrons form urine through a complex 3-step process

      • Glomerular filtration

      • Tubular reabsorption

      • Tubular secretion


1 glomerular filtration

1. Glomerular filtration

Step 1

  • Most of the elements of blood, except

    • large molecules

    • blood cells

  • forced out of the blood  capillaries of the glomerulus  Bowman’s capsule  filtrate

  • High capillary BP in the glomerulus.


1 glomerular filtration1

1. Glomerular filtration

  • Filtration at Glomerulus

    • Water

    • Na+

    • Cl-

    • Bicarbonate

    • K+

    • Glucose

    • Urea

    • Creatinine

    • Uric Acid


1 glomerular filtration2

1. Glomerular filtration

  • Glomerular filtration

    • Factors that can alter process:

      • Blood flow

      • Blood pressure


2 tubular reabsorption

2. Tubular reabsorption

Step 2

  • Filtrate  Proximal convoluted tubule 

  • Reabsorption (back into blood)

    • Most

      • Water

      • Na+

      • Cl-

      • Bicarb

      • K+

      • Uric Acid

    • All of the glucose

    • None of the Creatinine


3 tubular secretion

3. Tubular Secretion

  • Elements secreted from blood into tubule for excretion in urine

    • Some

      • Water

      • Na+

      • Cl-

      • Bicarbonate

      • K+

      • Uric acid

    • Most Urea


Genital urinary system

  • Filtrate 

    • Tubules 

    • Collecting duct 

    • Renal pelvis

    • Ureter 

    • Bladder 

    • Urethra


Glucose

Sweet pea!

Glucose

  • Normally all the glucose filtered through the glomeruli will be reabsorbed back into blood

    • No glucose in the urine

  • Glycosuria

    • Diabetes mellitus

    • h serum glucose levels overwhelm the nephron’s ability to reabsorb glucose


Protein

Protein

  • Filtered by glomeruli & returned to the blood by tubular reabsorption.

  • Slight proteinuria

    • OK

    • globulin, albumin

  • Persistent proteinuria

    • Glomerular damage


Anti diuretic hormone adh

Anti-diuretic hormone (ADH)

  • AKA

    • Vasopressin

  • Secreted by

    • Posterior Pituitary

  • Secreted in response to

    • changes in blood osmolality


Anti diuretic hormone adh1

Anti-diuretic hormone (ADH)

Normally

  • Water intake i

  • Blood osmolality 

    • h

  • Stim. pituitary to

    • ADH

      • h

  • ADH receptor site 

    • Kidney

  • Action

    • h reabsorption of H2O

    • i urine volume/output

    •  returns blood osmolality to normal


Anti diuretic hormone adh2

Anti-diuretic hormone (ADH)

Normally

  • Water intake h

  • Blood osmolality 

    • i

  • Stim. pituitary to

    • ADH

      • i

  • ADH receptor site Kidney

  • Action

    • i reabsorption of H2O

    • h urine volume (diuresis)

    •  returns blood osmolality to normal


Osmolarity osmolality

Osmolarity & Osmolality

  • Osmolarity

    • # of particles dissolved in solution

  • Osmolality

    • Thickness of solution

  • Urine

  • Serum / blood


Regulation of water excretion

Regulation of water excretion

  • The amt. of urine formed is r/t the amt. of fluid intake

    • h fluid intake 

    • volume urine

      • h

      • Characteristic

        • Dilute

    • i fluid intake 

    • volume of urine

      • i

      • Characteristic

        • Concentrated

  • Normally: kidneys rid the body of about 75% of fluids taken in


Regulation of electrolytes excretion

Regulation of Electrolytes Excretion

  • Sodium

    • Normally serum Na+:

      • 135 - 145 mmol/L

    • Na+ filtered from the blood & reabsorbed from the tubule back into the blood

    • Na+ excretion is controlled by Aldosterone

    • h Aldosterone  h Na retention 

      • __?__ Serum Sodium level

      • h serum sodium level

    • Na+ most abundant electrolyte found outside the cells (extracellular)


Regulation of electrolytes excretion1

Regulation of Electrolytes Excretion

  • Potassium

    • K+ is the most abundant electrolyte found inside the cells (intracellular).

    • h Aldosterone  hK excretion 

      • __?__ serum K+ level

      • i serum K+ level


Regulation of electrolytes excretion2

Regulation of Electrolytes Excretion

  • Kidney’s not functioning normally

    • Na+ & K+ will not be adequately filtered from the blood

  • Retention of K+ is the most life-threatening effect of renal failure

  • Renal failure

    • Retention of K+ 

    • Hyperkalemia 

    • Cardiac dysrhythmias 

    • Death


Regulation of acid excretion

Regulation of acid excretion

  • Proteins are broken down into acids

    • phosphoric acid

    • sulfuric acid.

  • Acids in the blood 

    • ipH

  • Normally kidneys

    • Filter acids from the blood

      • Tubular filtration

      • Chemical buffer mechanism


Regulation of acid excretion1

Regulation of acid excretion

  • Tubular filtration

    • Acid is excreted into the urine through tubular secretion

    • Used until the bladder acidity

      • pH 4.5

    • Any excess acid must be neutralized


Regulation of acid excretion2

Regulation of acid excretion

Neutralize acids

  • binding them to chemical buffers

  • Be excreted without altering the pH

  • Important buffers

    • Phosphate ions

    • Ammonia

      • NH3


  • Regulation of red blood cell production

    Regulation of Red Blood Cell Production

    • Kidneys measure O2 tension of the blood (PaO2)

      • i PaO2 

      • (Hormone) herythropoietin

      • (Receptor site) bone marrow 

      • (Action) h production of RBC 

      • h Hgb 

      • h PaO2


    Genital urinary system

    • Normal RBC-Erythrocytes

      • Male: 4.7 - 6.1 million/mm3

      • Female: 4.2 - 5.4 million/mm3

    • Normal Hemoglobin

      • Male 14 - 18 g/dL

      • Female 12 - 16 g/dL


    Vitamin d synthesis

    Vitamin D Synthesis

    • Kidneys activate ingested Vitamin D 

    • Aid absorption of calcium


    Excretion of waste products

    Excretion of waste products

    • Urea, (waste product of protein metabolism)

      • Blood Urea Nitrogen

      • h BUN = renal dysfunction

    • Other waster products of metabolism are

      • Creatinine

      • Phosphates

      • Sulphates

      • Ketone

    • Along with BUN the serum Creatinine level is usually ordered whenever the MD suspects renal disease


    Excretion of waste products1

    Excretion of waste products

    • Uric acid (purine metabolism)

      • Hyperuricemia

        • gout,

    • Kidneys also are the primary means of ridding the body of Drug metabolism


    Auto regulation of blood pressure

    Auto-regulation of Blood Pressure

    • Vasa recta constantly monitor the blood pressure

    • i blood pressure 

      • hRenin

      • hangiotensin 2

      • h vasoconstriction 

      • h blood pressure.

    • h B/P

      • i Renin

    • Vasa recta failure to recognize h BP & stop/halt Renin secretion  primary causes of hypertension.


    Gerontological considerations

    Gerontological Considerations

    • Function of the urinary tract declines.

    • GFR declines

    • Prone to develop hypernatremia & fluid volume deficit

    • At risk for adverse drug effects


    Assessment

    Assessment

    Risk Factors

    • h age

    • Instrumentation of urinary tract

    • Immobility

    • Diabetes mellitus

    • HTN

    • Gout, hyperparathyroidism, Crohn’s disease

    • Benign prostatic hypertrophy

    • Obstetric injury


    Assessment health history

    Assessment: Health history

    • Chief complaint

    • Pain

    • Hx of UTI’s

    • Fever or Chills

    • instrumentation

    • Dysuria

    • Hesitancy, straining

    • Urinary incontinence

    • Hematuria

    • Nocturia

    • Hx of kidney stones

    • Hx of STD’s

    • Tobacco, alcohol, drugs

    • Meds

    • Females

      • # & types of deliveries

      • Hx vaginal infections


    Physical exam

    Physical Exam

    • Abdomen, supropubic region, genitalia and lower back, the lower extremities

    • Palpate kidney

      • Feel the rounded lower border of the kidney

        • Right kidney


    Physical exam1

    Physical Exam

    • Palpation of bladder

      • Performed after voiding if suspect urinary retention


    Terms matching

    Terms - matching

    • Urgency

    • Pyuria

    • Proteinuria

    • Polyuria

    • Oliguria

    • Nocturia

    • Incontinence

    • Hesitancy

    • Hematuria

    • Frequency

    • Euresis

    • Dysuria

    • Anuria

    • Frequent voiding – more than every 3 hours

    • Strong desire to void

    • Painful or difficult voiding

    • Delay, difficulty in initiating voiding

    • Excessive urination at night

    • Involuntary loss of urine

    • Involuntary voiding during sleep

    • Increased volume of urine voided

    • Urine output less than 400 ml/day

    • Urine output less than 50 ml/day

    • Red blood cells in the urine

    • Abnormal amounts of protein in the urine

    • Pus in the urine


    Genital urinary system

    • The presence of peritoneal fluid build up is described as which one of the following?

      • “I’m so nervous I have to void” phenomenon

      • Bruits

      • Generalized edema

      • Peritoneal dialysis

      • Ascites


    Diagnostic evaluation urinalysis

    Diagnostic Evaluation:Urinalysis

    • Color; clarity; odor; urine pH and specific gravity

      • Colorless to pale yellow

        • dilute (diuretics, alcohol, diabetes Insipidus, excess fluid intake)

    • Yellow to milky white

      • Pyuria, infection

  • Bright yellow

    • Multiple vitamin

  • Pink to red

    • RBC, menses, Bladder or prostate surgery, beets, meds

  • Blue, blue green

    • dyes, meds

  • Orange to amber

    • Dehydration, bile, excess bilirubin or carotene, meds

  • Brown to black

    • Old red blood cells, dehydration,


  • Diagnostic evaluation urine culture and sensitivity

    Diagnostic Evaluation: Urine Culture and Sensitivity

    • ID microorganism(s)

    • Sensitivity report

    • Time

      • 2-3 days (48-72 hours)


    Specific gravity

    The weight of urine

    The specific gravity of distilled water

    1.000

    Normal urine specific gravity

    1.003 – 1.030

    Urine specific gravity is related to the level of hydration.

    h fluid intake  h H20 excretion  ispecific gravity

    i fluid intake i H20 excretion  hspecific gravity

    Specific Gravity


    Diagnostic evaluation sterile urine specimens

    Diagnostic Evaluation:Sterile urine specimens

    • Safety

      • Standard precautions

      • Biohazard bag for transport

    • Collection

      • Indwelling Foley Catheter

        • Not from the drainage bag

        • Aspiration port

      • Catheter – straight cath

        • A small amount of urine is allowed to run out of the catheter into a basin, then the urine is allowed to run into a sterile specimen bottle.


    Diagnostic evaluation clean catch or clean voided specimen

    Diagnostic Evaluation:Clean-catch or Clean-voided specimen

    • Clean-voided

      • uncontaminated by skin flora.

      • Female

        • Cleanse: front to back

      • Male

        • Cleanse: tip of the penis downward

    • Collect a "clean-catch"

      • Start to void

      • Midstream catch

      • Collect 1 to 2 oz of urine


    Renal clearance

    Renal Clearance

    • Purpose

      • Assess the Kidney’s ability to clear solutes from the plasma

    • Procedure

      • 24 hr urine collection

      • 12 hr serum Creatinine level

    • Creatinine

      • waste product of skeletal muscle contraction


    Renal clearance1

    Renal Clearance

    • One function of the kidney is to excrete Creatinine. If the Creatinine clearance level (the amount of Creatinine excreted by the kidney) decreases, what does that tell you about the function of the kidney?


    Renal clearance2

    Renal Clearance

    • i renal function 

      • iCreatinine clearance

    • Creatinine clearance evaluates

      • glomerular filtration rate (GFR)

    • Detects and evaluates progression of renal disease


    Can you critical think

    Can you Critical Think????

    • Mrs. Notafeela Sowell had a renal clearance test done 3 times this week. Is her renal disease getting better or worse?

      • Monday: Renal clearance = 70 ml/min

      • Wednesday: Renal clearance = 80 ml/min

      • Friday: Renal clearance = 90 ml/min


    Diagnostic evaluation intake and output

    Diagnostic Evaluation: Intake and Output

    • I&O

      • All fluids taken orally

      • Form

        • Time

        • Amount

    • Output

      • Urine

      • drainage from nasogastic tube

      • drainage tubes

      • Chest tubes

      • Wound tubes


    Apply it

    Apply it!

    • Mr. Noah Awl is recovering from Prostatectomy due to benign hypertrophy of the Prostate. Mr. Awl is on strict intake and Output. He requests a cup of ice chips because his throat hurts (due to intubation). You give him a 200cc cup of ice chips and he eats them all. How much to you make on the Intake?

      • 100cc

      • 150 cc

      • 200cc

      • 300 cc

      • 400 cc


    Dialysis overview

    Dialysis: Overview

    • Purpose

      • Remove fluids and waste products from the body

    • Definition

      • Mechanical means of removing waste from the blood

    • Types:

      • Hemodialysis

      • Peritoneal dialysis


    Dialysis process

    Dialysis: Process

    • Process

      • Diffusion and osmosis across a semi permeable membrane into a dialysate solution

        • prescribed specific to the individual clients needs


    Dialysis process1

    Dialysis: process

    • Diffusion

      • Toxins & wastes are removed by diffusion

      • Move from an area of higher concentration to an area of lower concentration


    Genital urinary system

    • This photo shows the diffusion of fluids. I added a few drops of blue food coloring in a vase of water, and took a picture after a few seconds. Diffusion is the process of a substance moving from high concentration to low concentration. The cause of diffusion is random molecular motion of the fluids, in other words, molecules of both the food coloring and the water move at random causing them to mix. In this case, the diffusion of the food coloring goes from high concentration to low concentration. 


    Genital urinary system

    • Osmosis

      • Excess water is removed by osmosis

      • Water move from an area of higher solute concentration (blood) to an area of lower solute concentration (dialysate)


    Hemodialysis

    Hemodialysis

    • A machine with an artificial semi-permeable membrane used for the filtration of the blood.


    Hemodialysis1

    Hemodialysis

    • A graft or fistula is surgically prepared to access the clients circulatory system


    Hemodialysis2

    Hemodialysis

    • With each hemodialysis treatment, the catheter is inserted into the graft of fistula


    Hemodialysis3

    Hemodialysis

    • The clients blood is circulated past the semi permeable membrane

    • Excess fluids are removed by osmosis


    Hemodialysis4

    Hemodialysis

    • Waste products are removed from the blood by diffusion


    Hemodialysis5

    Hemodialysis

    • Nursing interventions

      • Weighted before and after

      • Strict asepsis technique


    Hemodialysis nursing interventions

    HemodialysisNursing interventions:

    • Assess fistula or graft

      • A thrill

        • felt

      • A bruit

        • heard

      • Pulse peripheral

    • Protect Grafts

      • Not an IV port!

      • No BP in graft arm


    Genital urinary system

    The nurse is preparing to teach a client about his new shunt for hemodialysis. What should be included in this teaching?

    • Avoid overusing the arm with the shunt to protect from accidental harm.

    • Always use this arm for blood pressure readings

    • If you feel any vibrations over the skin of the shunt, call the doctor.

    • There’s nothing special to the care of the shunt. Pretend it isn’t there.


    Hemodialysis nursing interventions1

    HemodialysisNursing interventions:

    • Meds are given after

    • Usually performed 3 time a week

    • Usually take 3-6 hours


    Peritoneal dialysis

    Peritoneal Dialysis

    • Uses the peritoneal lining of the abdominal cavity


    Peritoneal dialysis1

    Peritoneal Dialysis

    • A catheter is placed by the MD into peritoneal space


    Peritoneal dialysis2

    Peritoneal Dialysis

    • The dialysate,

      • In sterile container similar

      • Instilled aseptically into the abdominal cavity.

    • The container remains connected to the catheter

      • rolled up

      • dialysate remains in the abdominal cavity for a specified length of time.

    • The container is then unrolled and lowered

      • below the abdominal cavity

      • Dialysate drains back into the container


    Peritoneal dialysis3

    Peritoneal Dialysis

    • Usually 2 liters of dialysate

    • Less expensive, easier to perform and less stressful

    • Complication

      • INFECTION

    • Usually 4 x day – 7day/wk


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