1. Students to review and study renal anatomy and physiology prior to lecture.
Functions of the kidney:
Filtration – kidneys filter waste products from the blood, return needed
components through reabsorption
Regulation: Water balance, acid base balance, red blood cell production
Excretory: removal of potentially toxic end products from diet and drugs
Synthesis of hormones:
Renin- regulates BP
Activated vitamin D
• Ureters 12 to 18” long, extend from renal pelvis of kidney to bladder,
• Bladder- elastic sac, stores and excretes urine
• Detrusor muscle
2. Describe assessment methods for renal system.
Assessment of urinary system:
Demographic information, such as age, gender, race, and ethnicity, is important to
consider as nonmodifiable risk factors in the patient with any kidney or urinary
problem. A sudden onset of hypertension in patients older than 50 years suggests
possible kidney disease. Clinical changes with adult polycystic kidney disease
typically occur in patients in their 40s or 50s. In men older than 50 years, altered
urinary patterns accompany prostate disease.
Anatomic gender differences make some disorders worse or more common. For
example, men rarely have urinary tract infections unless there are abnormalities,
such as ureteral reflux or prostatic enlargement. Women have a shorter urethra and
more commonly develop cystitis (bladder infection) because bacteria pass more
readily into the bladder.
Ask the patient about any previous kidney or urologic problems, including tumors,
infections, stones, or urologic surgery. A history of any chronic health problems,
especially diabetes mellitus or hypertension, increases the risk for development of
kidney disease because these disorders damage kidney blood vessels.
Ask the patient about chemical exposures at the workplace or with hobbies.
Exposure to hydrocarbons (e.g., gasoline, oil), heavy metals (especially mercury and
lead), and some gases (e.g., chlorine, toluene) can impair kidney function. Use this
opportunity to teach patients who come into contact with chemicals at work or
during leisure time activities to avoid direct skin or mucous membrane contact with
these chemicals. Use of heroin, cocaine, methamphetamine, ecstasy, and volatile
solvents (inhalants) has also been associated with kidney damage.
Ask the patient with known or suspected kidney or urologic disorders about his or
her usual diet and any recent changes in the diet. Note any excessive intake or
omission of certain food categories. Ask about food and fluid intake. Assess how
much and what types of fluids the patient drinks daily, especially fluids with a high
calorie or caffeine content. Use this opportunity to teach the patient the importance
of drinking about 3 L of fluid daily (if another medical problem does not require
fluid restriction) to prevent dehydration and cystitis.
Identify all of the patient's prescription drugs because many can impair kidney
function. Ask about the duration of drug use and whether there have been any
recent changes in prescribed drugs. Drugs for diabetes mellitus, hypertension,
cardiac disorders, hormonal disorders, cancer, arthritis, and psychiatric disorders
are potential causes of kidney dysfunction. Antibiotics, such as gentamicin
(Garamycin, Cidomycin ), may also cause acute kidney injury. Drug-drug
interactions and drug–contrast dye interactions also are potential causes of kidney
Explore the past and current use of over-the-counter (OTC) drugs or agents,
including dietary supplements, vitamins and minerals, herbal agents, laxatives,
analgesics, acetaminophen, and NSAIDs. Many of these agents affect kidney function.
For example, dietary supplementation with synthetic creatine, used to increase
muscle mass, has been associated with compromised kidney function. High-dose or
long-term use of NSAIDs or acetaminophen can seriously reduce kidney function.
Some agents are associated with hypertension, hematuria, or proteinuria, which
may occur before kidney dysfunction.
Current Health Problems
The effects of kidney failure result in changes in all body systems. Therefore
document all of the patient's current health problems. Ask him or her to describe all
health concerns, because some kidney disorders cause systemic problems or
problems in other body systems. Recent upper respiratory problems, achy muscles
or joints, chronic disease, or GI problems may be related to problems of kidney
Assess the kidney and urologic system specifically by asking about any changes in
the appearance (color, odor, clarity) of the urine, pattern of urination, ability to
initiate or control voiding, and other unusual symptoms. For example, urine that is
reddish, dark brown or black, greenish, or different from the usual yellowish color
usually prompts the patient to seek health care assistance. Urine typically has a mild
but distinct odor of ammonia. An increase in the intensity of color, a change in odor
quality, or a decrease in urine clarity may suggest infection.
Ask about changes in urination patterns, such as incontinence (involuntary bladder
emptying), nocturia (urination at night), frequency, or an increase or decrease in the
amount of urine. The normal urine output for adults is about 1500 to 2000 mL/day,
or within 500 mL of the volume of fluid ingested daily. Ask about how closely the
urine output is to the volume of fluid ingested. The patient usually does not know
the exact amount of urine produced. A bladder diary may provide useful data. Also
Initiating urine flow is difficult
•A burning sensation or other discomfort occurs with urination
•The force of the urine stream is decreased (in men)
•Persistent dribbling of urine is present
The onset of pain in the flank, in the lower abdomen or pelvic region, or in the
perineal area triggers concern and usually prompts the patient to seek assistance.
Ask about the onset, intensity, and duration of the pain, its location, and its
association with any activity or event.
Renal colic pain may be intermittent or continuous and may occur with pallor,
diaphoresis, and hypotension. These general symptoms occur because of the
location of the nerve tracts near or in the kidneys and ureters.
The physical assessment of the patient with a known or suspected kidney or
urologic disorder includes general appearance, a review of body systems, and
specific structure and functions of the kidney and urinary system.
Assess the patient's general appearance, and check the skin for the presence of any
rashes, bruising, or yellowish discoloration. The skin and tissues may show edema,
especially in the pedal (foot), pretibial (shin), and sacral tissues and around the
eyes, which is associated with kidney disease. Use a stethoscope to listen to the
lungs to determine whether fluid is present. Weigh the patient and measure blood
pressure as a baseline for later comparisons.
Assess the level of consciousness and level of alertness. Record any deficits in
memory, concentration, or thought processes. Family members may report subtle
changes. Cognitive changes may be the result of the buildup of waste products when
kidney disease is present.
Assessment of the Kidneys, Ureters, and Bladder
Assess the kidneys, ureters, and bladder during an abdominal assessment.
Auscultate before percussion and palpation because these activities can enhance
bowel sounds and obscure abdominal vascular sounds.
Inspect the abdomen and the flank regions with the patient in both the supine and
the sitting positions. Observe the patient for asymmetry (e.g., swelling) or
discoloration (e.g., bruising or redness) in the flank region, especially in the area
Listen for a bruit by placing a stethoscope over each renal artery on the
midclavicular line. A bruit is an audible swishing sound produced when the volume
of blood or the diameter of the blood vessel changes. It often occurs with blood flow
through a narrowed vessel, as in renal artery stenosis.
Kidney palpation is usually performed by a physician or advanced practice nurse. It
can help locate masses and areas of tenderness in or around the kidney. Lightly
palpate the abdomen in all quadrants. Ask about areas of tenderness or pain, and
examine nontender areas first. The outline of the bladder may be seen as high as the
umbilicus in patients with severe bladder distention. If tumor or aneurysm is
suspected, palpation may harm the patient.
Because the kidneys are located deep and posterior, palpation is easier in thin
patients who have little abdominal musculature. For palpation of the right kidney,
the patient is in a supine position while the examiner places one hand under the
right flank and the other hand over the abdomen below the lower right part of the
rib cage. The lower hand is used to raise the flank, and the upper hand depresses the
abdomen as the patient takes a deep breath (Fig. 68-9). The left kidney is deeper
and often cannot be palpated. A transplanted kidney is readily palpated in either the
lower right or left abdominal quadrant. The normal kidney is smooth, firm, and
A distended bladder sounds dull when percussed. After gently palpating to
determine the outline of the distended bladder, begin percussion on the lower
abdomen and continue in the direction of the umbilicus until dull sounds are no
longer produced. If you suspect bladder distention, use a portable bladder scanner
to determine the amount of retained urine.
If the patient reports flank pain or tenderness, percuss the nontender flank first.
Urine for C&S (Culture and Sensitivity)
Creatinine Clearance- tests how well creatinine is cleared from the blood;
calculated measure of GFR
- Good indicator of renal function
- Normal range 80-139mL/min/m2
• BUN- renal excretion of urea nitrogen, by product of protein metabolism in
• Influenced by other factors: infection, bleeding, dehydration, protein intake,
• Normal 10-20 mg/dl
• Elevation suggestive of kidney dysfunction
• Creatinine- end product of muscle and protein metabolism
• **Excellent indicator of kidney function**
• Normal 0.6-1.3
• Does not increase until 50% renal function is lost
• No other pathologic condition raises creatinine level except renal disease
• Kidneys, Ureters, Bladder (KUB): X-Ray study to check size, shape, position of
kidneys; check for abnormalities; no prep usually
• Pelvic Ultrasound: Non-invasive; uses sound waves; detects abnormalities;
• CT Scan: With or without contrast; detects abnormalities; may require NPO
and bowel prep if contrast used.
• IV Prep: Allergies to dye
• Intravenous Urography (old term IVP) ( Intravenous pyelogram) x-ray of
urinary tract utilizing contrast agent.
• Prep NPO 8 hours prior
• Sensation with injection
• Allergies: Dye; Iodine; seafood or shellfish
Visualization of renal blood vessels
Can identify stenosis, HTN, trauma, etc.
X-ray in special procedures
Prep- bowel cleaning, light evening meal, NPO, IV, sedation,
Femoral artery, catheter, inject radiopaque dye
Post procedure- BR 4-6 hours, frequent VS, site for bleeding, check
peripheral pulses, reaction to dye, fluids
Visual inspection of the interior of the bladder, can bx, remove stones,
X-ray or OR, local or general
Cystoscope is inserted into bladder through urethra
Prep: mild sedation, fluids, consent
Fill bladder, warn pt. of sensation to void, may have spasms
Post procedure bedrest, monitor vitals, urine output, urine for bleeding,
Urodynamics (Examines the process of voiding):
• Cystometrogram- evaluates bladder capacity, pressure, voiding reflexes,
detrusor muscle quality.
• Patient supine, catheter inserted, fluid instilled into bladder and measures
pressure, volume at first urge to void
• Done at bedside or in office
• Post void residual -pt. empties bladder and catheterize to establish volume
• Bladder scan
• Assess pain level.
• Administer analgesics, antispasmodics, and antibiotics as ordered.
• Assess voiding patterns.
• Assess level of fear.
• Explain all procedures to patient.
• Instruct patient in relaxation techniques.
• Assess patient’s understanding of the procedure.
• Provide description of tests in language patient can understand.
• Assess patient’s understanding of test results.
• Reinforce information provided to patient.
3. Explain nursing care and management of patients with Renal disorders.
Acute inflammatory/infectious process of one/both kidneys
Affects renal pelvis and parenchyma, kidney becomes edematous.
Affects tubules, scar tissue can replace normal tissue, tubules atrophy,
abscesses may form
Most common organism is E coli
Risk factors : pregnancy, obstruction, reflux, catheter use, DM, kidney
S/S: chills, fever, leukocytosis, back pain, flank pain, CVA tenderness,
n/v, bacteriuria, pyuria, h/a, general malaise, painful urination
Diagnostic tests: CBC, UA, C/S, KUB, IV urography
Medical Management:IV antibiotic initially, then po, analgesics,
antipyretics, antiemetic, identify cause
Maintain pain, encourage fluids, strict I/O, VS q 4 hours, bedrest until
afebrile, observe for edema and signs of renal failure, administer and
monitor drug therapy
Patient teaching: adequate fluid intake, empty bladder regularly,
perineal hygiene, meds exactly as prescribed
Occurs as a result of repeated bouts of acute pyelonephritis
S/S: fatigue, h/a, poor appetite, polyuria, excessive thirst, weight loss;
progressive scarring of kidney resulting in renal failure if persistent
and recurring infection.
Dx: IV urogram; creatinine clearance, serum Bun/Cr levels
Management: Prophylactic antimicrobials
Urinary Tract Calculi:
Urolithiasis: stones in urinary tract
Nephrolithiasis: stones in kidney
Stones form when chemicals and other elements of urine become
concentrated and form crystals
Affects 500,000 people in US each year
Occurs predominantly in 20’s-50’s
Affects more men than women
About 75% of calculi contain calcium as one component of the stone
complex- may be calcium oxalate or calcium phosphate
Uric acid (8%)
Metabolic factors- elevated uric acid (gout),hypercalcemia, defective
oxalate metabolism (genetic or dietary), renal tubular necrosis,
polycystic kidney disease
Renal Colic* severe pain in flank area begins suddenly, N/V, pallor,
diaphoresis, flank pain on side of affected kidney, may radiate to groin
if stone is in ureter of bladder.
Obstruction: oliguria or anuria- emergency
Dx tests: U/A -RBC’s, WBC’s; C&S; serum WBC, calcium, uric acid,
KUB, IV urogram, Renal Ultrasound, CT
Relief of symptoms
Removal or destruction of calculi
Prevention of future stone formation
Nursing Management- pain management, strain all urine, I/O,
encourage ambulation, high fluid intake to keep urine dilute (output at
least 2L/day), daily weights, assess fluid status/renal function,
antibiotics, post surgical care,
Relief of symptoms:
Acute attacks- pain management, bedrest and hydration
Opioid analgesics- Morphine Sulfate-IV
Spasmolytic agents- Ditropan, Pro-Banthine
Non pharmacologic therapies: hot baths; moist heat
• Based on type of stone
• Calcium phosphate stones: fluids, protein, Na
• Calcium oxalate stones: limit oxalate intake; high fluids
• Uric acid stones: purine diet, limit protein
• Cystine stones: protein, fluids
Extracorporeal Shock Wave Lithotripsy (ESWL)
Non invasive procedure;uses externally generated waves to pulverize
or shatter stones/calculi into small fragments which are then excreted
in the urine
Used for stones too large to pass spontaneously, multiple stones, or
Minimally Invasive Surgical Procedures:
• Ureteroscopy: visualizes stone and removes it.
Minimally Invasive Surgical Procedures:
• Stenting- a small tube is placed in the ureter by ureteroscopy.
• Stent dilates the ureter and enlarges the passageway for the stone
Percutaneous ureterolithotomy or nephrolithotomy
Needle passed into collecting system of kidney, endoscope to visualize,
stones removed with forceps or a basket device , or lithotripsy to crush
Open Surgical Procedures:
• Only done in 1-2% of patients
• Nephrolithotomy(kidney), pyelolithotomy(renal pelvis),
• Larger flank incision; longer recovery
• Ureterostomy- diverts urine directly to the skin surface through a
• Conduit- collects urine in a portion of the intestine, which is then
opened onto skin as a stoma.
• Sigmoidostomy- diverts urine to the large intestine. No stoma required.
Ileal Reservoir- diverts urine into a surgically created pouch that functions as
a bladder. Pt. removes urine by regular self-catheterization
Monitor color, odor, consistency of urine
Teach use of external pouching systems (skin care, pouch care,
Teaching self-catheterization (clean technique at home; sterile in
Assist pt. with psychosocial aspect of urinary diversion
Monitor carefully for s/s of UTI*
*Remember signs and symptoms different in elderly population*
Acute kidney Injury:
Rapid decrease in renal function
Leads to azotemia-an accumulation of metabolic waste in the blood
Uremia- azotemia becomes symptomatic
Urine output decreases to oliguria(<400ml/day)
Develops over hours to days with progressive inc in BUN, creatinine
Classified into 3 groups based on cause Prerenal, Intrarenal and
Cause sometimes unknown
Hypotension, hypovolemia, C.O. and CHF, kidney or urinary tract
obstruction, obstruction of renal arteries or veins
May be reversed if above conditions are treated before permanent
Types of kidney Injury:
Etiology is outside the kidney that impairs renal blood flow, leading to
ischemia in the nephrons and leads to a decrease in renal perfusion
Accounts for 60-70% cases of A.R.F.
Prerenal can lead to intrarenal
Hypovolemia, Heart failure primary causes
Etiology is actual damage to renal tissue resulting in malfunction of
glomeruli or renal tubules
Preceded by ATN (acute tubular necrosis)
Prolonged ischemia, nephrotoxins, renal artery or vein stenosis, acute
Caused by actual obstruction of urinary flow
Accounts for 1-10% of cases
BPH, renal calculi, trauma, cancers
Begins with the precipitating event and continues until oliguria develops. May
last hours to days.
There is a gradual accumulation of nitrogenous wastes, such as increasing
serum creatinine and BUN.
Oliguric Phase :
urine output less than 400 mL/day (100-400mL/24Hrs) that does not respond
to diuretics or fluid challenge
With hypoperfusion, compensatory mechanisms cause urine volumes
to fall, leading to reduced renal blood flow and increasing renal
Typically lasts 10-14 days but can last for several weeks esp in older
clients or with preexisting renal insufficiency
Urinary changes, fluid retention, metabolic acidosis
Labs: Increased BUN, Serum Creatinine, hyponatremia, hyperkalemia, bicarb
deficiency, (metabolic acidosis)
Diuretic Phase :( high-output phase)
Often has prompt onset, urine flow increasing rapidly over a period of
several days. Diuresis can result in an output of up to 5-10L/day of
Kidneys recover, start to excrete wastes but not able to concentrate
Creatinine clearance still may be low with increasing BUN & Creatinine
Usually occurs 2-6 weeks after the onset of oliguric phase and continues
until the BUN levels ceases to rise
May last 1-3 weeks
Increase in GFR
Major improvement in first 1-2 weeks
Complete recovery may take up to12 months to improve fully
• Appears critically ill and lethargic
• Skin, mucous membranes dry
CNS: drowsiness, headache, muscle twitching, seizures
• Urine: output varies, hematuria, low or fixed specific gravity; inability
to concentrate urine; prerenal: amounts Na in urine; intrarenal: Na
• Diagnostic tests
• Lab values
Prevent and treat shock promptly
Monitor central venous and arterial pressures; hourly output
Treat hypotension promptly
Continually assess renal function
Prevent and treat infections promptly
Pay attention to wounds, burns, etc.
Meticulous care to patients with catheters
• Diuretic therapy, volume expanders in hypotensive patients; control
HTN; restrict fluids during oliguric phase; hyperkalemia (most
dangerous); daily weights; monitor edema; I/O; diet modifications
(moderate protein restriction, carb, K restricted); allow pt. to
verbalize concerns; avoid nephrotoxic drugs.
• Kayexalate to treat hyperkalemia
• IV Dextrose 50%, insulin, and calcium replacement if pt. is
hemodynamically unstable to shift potassium back into cells
• Medication doses may have to be reduced in ARF(dig, ACE inhibitors,
• Diuretics to control fluid volume
carbohydrates, mod protein restriction, K restricted, phosphorous
restricted, Na restriction
Monitor serum electrolytes, cardiac function, resp. status,
musculoskeletal status, I/O, edema, JVD, daily weights
Hyperkalemia most life-threatening complication of renal failure
Allow patient to verbalize feelings, provide emotional support,
erythropoietin for anemia, avoid nephrotoxic drugs, meticulous skin
care, cough and deep breathe, frequent rest periods
Benign Prostatic Hyperplasia:
Occurs in approximately ½ of men 50 and older; 90% of men 80 years
Obstructs outflow of urine by encroaching on vesical orifice
Causes incomplete emptying of bladder and urinary retention
UTIs as a result of urinary stasis
• Difficulty in starting stream (hesitancy) and continuing urination
• Interruption of stream
• in caliber and force of urinary stream
• Sensation of incomplete bladder emptying
• Dribbling, frequency, nocturia
• Complications: acute urinary retention; UTI; sepsis; calculi; renal
failure caused by hydronephrosis; pyelonephritis
• Digital rectal exam: uniform, elastic, nontender enlargement
• U/A, urodynamic studies, BUN/CR, CBC, PSA
• Transabdominal and transrectal ultrasound
• Surgery, meds
5- α-Reductase inhibitors-shrink prostate gland, improve urine flow;
prevent conversion of testosterone to dihydrotestosterone leading to
decrease in size of prostate
Alpha-1 selective blocking agents-relax smooth muscle of bladder neck
and prostate, creating less urinary resistance and improved urinary
Minimal invasive procedures:
• Transurethral Microwave Therapy: outpatient; microwaves delivered
directly to prostate through transurethral probe.
• Transurethral Needle Ablation: outpatient; increases temp of prostate
→ necrosis →tissue removed.
• Laser procedures (HoLEP); Intraprostatic urethral stents.
TURP (transurethral resection of the prostate):
Small pieces removed
Complication- Bleeding /Hemorrhage (24 hours)
Continuous Bladder Irrigant (CBI):
CBI flow rate adjusted to keep urine light pink or clear
Notify MD for bleeding