MANAGEMENT OF PATIENT WITH URINARY DISORDERS

Lectured and summarized by: Dr. Gerardo A. Flores

INFECTIONS OF THE URINARY TRACT ( Acute and Chronic )

Caused by pathologic microorganism (the normal urinary tract is
sterile above the urethra)
Lower UTI (structure below the bladder)
• Cystitis (inflammation of the bladder)
• Prostitis (inflammation of the prostate gland)
• Urethritis (inflammation of the urethra)
Upper UTI (ureters and kidney)
• Pyelonephritis (inflammation of renal pelvis)
• Interstitial nephritis (inflammation of kidney)
• Renal abcess

Mechanism that maintain sterility of the bladder

• Physical barrier of the urethra
• Urine flow (downward)
• Uretero vesical junction (prevents urine reflux)
• Various antibacterial enzymes and antibodies
• Anti-adherent effect mediated by mucosal cell of the bladder

PATHOPHYSIOLOGY OF LOWER URINARY TRACT INFECTION

Bacterial invasion - Body Defense : shedding of bladder epithelial (remove

bacteria)
- GAG (Glycosaminoglycan) hydrophilic
protein exerts protective
effect against bacteria.
- NORMAL BACTERIAL flora of vagina &
urethra interferes with
adherence of e-coli
-IgA in urethra provides a barrier to
bacteria
REFLUX
-due to obstruction to urine flow urethra to bladder (urethrovesical reflux)
- Body defense:
- Cough,sneeze, straining
-increasebladder pressure – force
urine from
bladder to urethra
BACTERURIA:
Define:
Bacteria normally present- urethral area
CAUSATIVE AGENTS
E. coli - 54.7%
Pseudomonas
Enterococcus
ROUTES OF INFECTION
1.Ascending (up the urethra)= transurethral (fecal contamination)
-sexual intercourse/ massaging of urethra forces the bacteria up in
bladder
2.Hematogenous
3. Direct extension( (+) fistula from intestine)

CLINICAL MANIFESTATION

LOWER UTI: over 50% with bacteruria have no symptoms

- others: frequent pain & burning sensation on urination; urgency,
increase in frequency,
nocturia,incontinence & suprapubic or pelvic pain, hematuria, backpain

UPPER UTI: fever, chills, flank and low back pain

Nausea and vomiting, painful urination
(+) tenderness @ cortovertebral angle (+)kidney punch

ASSESMENT AND DIAGNOSTIC FINDING

TEST: colony count *ACOG=recommend pregnant for

bacteruria
Cellular studies ( in pregnant state bladder
does not
Urine culture empty as it normally
does)

COLONY COUNT: 10 to the 5th power CFU/ml urine

- clean catch midstream
- catheterization
- suprapubic needle aspiration

CELLULAR STUDIES:
Microscopic hematuria: greater than 4 RBC/ hpf
PYURIA: greater than 4 WBC/ hpf

URINE CULTURE
Recommended for all men and Diabetic with 3 episodes of UTI for the
past year ,
Post-menopausal, Pregnant, women who are sexually active, have new
partners
And who undergo instrumentation ( catheterization)
TESTING METHODS
MULTISTRIP DIPSTICK testing for WBC
- leukocytes esterase test: ( (+) Patient has pyuria )
- nitrate testing (Griess nitrite reduction test)
(+) if nitrate is reduce to nitrite
Test or evaluation for STD
Intravenous Pyelography(IVP) – for high risk and recurrent history of UTI
CT scan and Ultrasound
MEDICAL MANAGEMENT
-Pharma & Px education (infection prevention)
-CRANBERRY extract /juice

NURSING Dx
Deficient knowledge related to factor predisposing the patient to infection
Ex) Cancer, DM
NURSING INTERVENTION: Relieving pain
Management/ monitoring & managing potential
complication (RF/ Sepsis)
Teaching patient self care = hygiene, fluid intake,
voiding habit, complication
Recognition and management

UPPER URINARY TRACT INFECTION

PYELONEPHRITIS – Bacterial invasion of the renal pelvis, tubules & interstitial

tissue of one or both
Kidneys.
- Route of Infection: Ascending ( from urethra to the kidneys)
- causes: ureterovesical reflux
Urinary tract obstruction
Bladder tumors
Strictures (infant)
BPH
Stones

Acute Pyelonephritis
- kidney becomes enlarge with interstitial infiltration of inflammatory
cell and abscess are
noted.
Chronic Pyelonephritis
- Scarred, contracted, non- functioning

CLINICAL MANIFISTATION
ACUTE: Patient appear ill and with chill, fever, pyuria, bacteruria, flank pain
& CVA tenderness,
Dysuria, frequency in voiding
ASSESMENT AND DIAGNOSTIC FINDINGS
Ultrasound/ CT/ IVP
Urine culture
MEDICAL MANAGEMENT
Antibiotic ( TMP- SMZ ,CIFROFLOXACIN,LEVOFLOXACIN for 10 to 14 days

CHRONIC :Usually none unless in acute exacerbation

- fatigue/ poor appetite/ polyuria/ thirst/ weight loss
Persistence & recurrent infection---- progressive scarring of
kidneys--- Renal Failure
ASSESSMEN T AND DIGNOSTIC FINDINGS
 Intravenous Pyelography
Blood Urea Nitrogen and Creatinine
COMPLICATIONS
-End Stage Renal Disease
- Hypertension ,\formation of Kidney stones

MANAGEMENT
- Antimicrobial drugs, Teaching patient on bladder emptying, Perineal hygiene

ACUTE GLOMERULONEPHRITIS
- Inflammation of the glomerullar capillaries
- Primarily a disease of older children 2 years or at any age
CAUSATIVE AGENTS; Group A Beta Hemolytic Streptococcos infection of the
throat
Infection of the skin Impetigo ( Staphylococcos). Viral,
Mumps
Chickenpox, EVB virus, HepB, HIV/AIDS

CLINICAL MANIFESTATIONS:
-primary presenting features : hematuria (micro/gross, cola-colored
urine)
Proteinuria
Increased BUN and creatinine as urine
output decreased
Anemia
Edema
HPN( Hypertension)
Flank pain

ASSESSMENT & DIAGNOSTIC FINDINGS

-Elevated ASO titer: kidneys are swollen, enlarged & congested

COMPLICATIONS:
-Hypertensive encephalopathy, heart failure, pulmonary edema, End
stage renal disease

MANAGEMENT:
-Treat symptoms, preserve kidney function, treat complications
-pharma drugs depend on causative agent : Penicillin for
streptococcal infection
Steroids for inflammation &
edema
Diuretics
Anti-hypertensive
Diet: Decrease dietary protein when BUN is elevated
Sodium restriction when with HPN, Edema & heart failure

CHRONIC GLUMERULONEPHRITIS
-Due to repeated episodes of AGN, hypertensive nephrosclerosis,
hyperlipidemia, chronic tubulointerstitial injury
 -the kidney is reduced to as little as 1/5 of its normal size

CLINICAL MANIFESTATIONS:
Signs and symptoms of renal insufficiency= periorbital edema
anemia
HPN
Retinal findings
Cardiopulmonary findings

ASSESSMENT & DIAGNOSTIC FINDINGS:

-Falling GFR below 50ml/min. (normalGFR= 100-200ml/min.)
-Hyperkalemia due to decrease potassium excretion
-Metabolic acidosis due to decrease acid secretion of kidney
-Anemia due to decrease erythropoeisis
-Hypoalbuminemia with edema due to protein loss through the
damaged glumerular membrane

NEPHROTIC SYNDROMES
-Primarily a Glumerular disease characterized by:
Proteinuria (increased protein in urine)- markedly
Hypoalbuminimia
Edema
Hyperlipidemia (high serum cholesterol & low density
lipoprotein)
CAUSE:
-Any intrinsic renal disease or systemic disease that affect glumerulus
(DM)
-Generally considered a disease of childhood, may also occur at any
age
-Causes includes CGN, DM, SLE
CLINICAL MANIFESTATIONS:
Edema (periorbital, sacrum, ankles,hand, ascitis)
Malaise
Headache
Irritability
DIAGNOSTIC FINDINGS:
Proteinuria greater than 3.5g/day
Increased WBC
COMPLICATIONS:
-Accelerated atherosclerosis due to hyperlipidemia
-infection due to deficient immune (proteinuria)
MEDICAL MANAGEMENT:
-The objective is to preserve renal function
-diuretics
-ACE inhibitor- reduce degree of proteinuria
-coticosteroids
-antineoplastic agents

Diet:protein 0.85/kg/day with emphasis on high biologic protein such

as dairy products, egg & meats
 Low in saturated fats

ACUTE RENAL FAILURE (ARF)

-sudden and almost complete loss of renal function over a period of hours to
days
-manifested by oliguria (less than 400ml/day)
Anuria (less than 50ml/day)
Rising BUN & creatinine
Retention of other metabolic waste (azotemia)

3 MAJOR CATEGORIES OR CONDITION CAUSING ARF

1. Pre-renal – occurs as a result of impaired blood flow that leads to
hypoperfussion of the kidney and a drop of GFR. Ex. Gastrintestinal
losses, vasodilation (shock,sepsis)
2. Intra-renal – occur in actual parenchymaldamage to the glumeruli
or kidney. Ex. Burns, crash injuries, infection, nephrotoxic agents
acute tubularnecrosis----loss of kidney function
3. Post-renal- occurs from obstruction somewhere distal to the kidney.

4 PHASES OF ACUTE RENAL FAILURE

1.Initiation: begins with initial insults and ends with oliguria
2.Oliguria- period is accompanied by increase serum concentration
usually excreted by the kidney (Urea, BUN, creatinine, uric acid, k,
magnesium , organic acid(< 400 ml)
3. diuresis- pt. gradually increasesurine output (sign of GFR recovery)
4. recovery- takes 3-4 months ( witch result returns to normal)

CLINICAL MANIFESTATIONS
Lethargy, appears very ill, nausea, vomiting, diarrhea , dry mucous
membrane
Uremic factor , CNS s/sx
Management
Identify cause and damage--- treat accordingly
PHARMA: hyperkalemia—treated by cation exchange resin
( kayexalate)- work by exchanging Na to K in the GIT
(sorbitol)- induce diarrhea type or water Loss effect
-- RETENTION ENEMA – by rectal catheter (kayexalate)

CHRONIC RENAL FAILURE

(ESRD)- progressive, irreversible deterioration in renal function in which the kidney s
ability to maintain fluid and electrolyte falls results to uremia or acoismia (retention
of urea and nitrogen waste product in the blood)

Cause: DM, GN, Hypertensive vascular disease, Polycystic kidney

Clinical Manifestations: CVD signs and symptoms, Dermatologic signs, GIT s/sx, CNS
s/sx
Assessment: GFR. Electrolyte analysis, Anemia
Management; Pharmacologic
SURGERY: kidney transplant
Nrsg. MNGT: pre op/ intra-op, and during post- operative period

IMMUNOSUPRESSIVE TREATMENT
- the survival of transplanted kidney depends on the ability to BLOCK THE BODY’S
immune response for the transplanted kidney and to overcome or minimize body’s
defense mechanism, immunosuppresive agents such as,immuran, azathiopine,
cyclosporan are administered

OTHER URINARY SYSTEM DISORDER

UROLITHIASIS ( “gravel”,”sand”) bladder stone

--refer to stones (calculi) in urinary tract
--formed when urinary concentration of substances are increased ( dueto
stasis/obstruction/inability to excrete.
-- ( calcium oxalate, calcium phosphate, uric acid.
OTHER CONDITIONS: excessive intakeof vit.D, milk and alkali, Hyperthyroidism,
Calcium
CLINICAL MANIFESTATIONS: S/SX of obstruction, infection, edema (RF)
DIAGNOSIS: by X-ray of KUB or Ultrsound
MANAGEMENT: Pain mgt. (NSAID)= hot bath apply to the flank
Surgical: by cystoscopy and by ESWL.

URINARY TRACT CANCER

(Ca.of the Bladder) = predominant cause “cigarette smoking”.
=metastasis-colon, rectum
=50-70 yrs. Old
= painless visible hematuria, alteration in voiding
NEPROSCLEROSIS
= hardening or sclerosis of the arteries of the kidney due to prolonged
Hypertension
= decreased blood flow---glumeruli destruction
URETHRITIS—inflammation of urethra --- ascending infection-- Gonoccocal or Non-
gonoccocal Uritritis or due Sexually transmitted disease

ASSESSMENT OF RENAL AND URINARY TRACT FUNCTION

Summarized and lecture by Dr. G. Flores

Urinary System Comprises: Kidneys, ureters, bladder and urethra

• Structures of which precisely maintain the internal chemical
environment of the body perform various excretory, regulatory and
secretory functions.
KIDNEYS
• Pain located retroperitoneally(behind and outside the peritoneal cavity)
on the posterior wall of the abdomen from 12ththoracic vertebrae to
3rd lumbar vertebrae (adult)
• Wt. 120-170gram: right kidney lower the left
 • size : 12 X 6 X 2.5cm
• protected by ribs, muscle, fascia, perirenal fat and renal capsule
• Region:
○ Parenchyma –divided into:
 cortex – contain the glomeruli tubules collecting ducts
peritubular capillaries
 Medulla – contain the pyramid which drain into calices –
renal pelvis
○ Renal pelvis

• Each contain about 1 million nephrons - cortical nephron (located at the

cortex)
- juxtemedulla nephron (located at the
medulla)
Glumerulus – compose of three filtering layers:
1. Capillary endothelium – filters fluid and
small molecules, limit passages of large
molecules such as blood (RBC) and
albumin (protein)
2. Basement membrane
3. Epithelium
• Function decreases at a rate of 1% each year by age 30 years old.

URETERS
- fibromuscular tube that connects kidney and bladder
- passage of urine
-24-30 cm long; originate to renal pelvis and ends in the bladder wall; left
slightly shorter
• Three narrowed areas in the ureter:
1. Uretero pelvic junction
2. Sacroiliac junction
3. Ureterovesical junction – the angling provides antegradeor
downward movement
- prevents vesicourethral reflux or retrograde,
backward movement of urine
URINARY BLADDER
• A muscular hollow sac behind the pubic bone (true pelvis)
• Capacity (adult): 300-600mL
• Has 2 inlets (ureters) and 1 outlet (urethrovesical junction)
• 4 layers of Urinary Bladder:
1. Adventitia (outermost)
2. Detrusor smooth muscle
3. Lamina propia (smooth muscle)
4. Urothelium (innermost) – specialized transitional cell epithelium,
containing a membrane that is impermeable to water (prevent
reabsorption of urine stored in bladder)
• Bladder neck contain: portion of internal sphincter (involuntary smooth
muscle) – urethral sphincter and external sphincter – under voluntary
control at the anterior urethral
URETHRA
• Arises from the base of the bladder
Male: it passes to the penis
Female: it open just anterior to the vagina
• In male the prostate gland which lies just below the bladder neck, surround
the urethra posteriorly and laterally.

Function of the Urinary System

Urine Formation
- urine is formed in the nephrons through a complex 3 steps process
1. GlomerularFiltration – blood flow to kidneys 1200mL/min , normally 20% of
blood passing through the glomeruli are filtered into the nephron
– filtrate consist of water/electrolytes, small molecular substances ---
amounting to about 180L/day
– efficient filtration depends on adequate blood flow (Pressure,
obstruction, Hypotension, decrease Oncotic pressure)
2. Tubular reabsorption – in tubular reabsorption, a substance moves free in the
filtrate back to vasa recta in tubular secretion, a substance moves from vasa
recta into tubular filtrate.
3. Tubular secretion- substances move from the filtrate back to vasa recta

• Of the 180L/day (45 gallon) of filtrate that the kidney produce each day, 99%
is reabsorb in the bloodstream resulting to 1000-1100 urine each day
• Reabsorption and secretion frequently involve passive and active transport
and may require use of energy.
• Filtrates in the collecting ducts become concentrated under the influence of
ADH and becomes urine and enters the renal pelvis.

Excretory of Waste Products

-major waste product of protein metabolism and urea – 25-30g is produce and
excreted daily – all must be exacted – accumulate
- other waste eliminated / excreted: Creatinine, Phosphate, Sulfates
- Purine Metabolism : Uric Acid
- Excrete drug metabolites
REGULATION OF ELECTROLYTE EXCRETION
- Normal: Amount of energy excreted per day is exactly equal to the amount
of ingested
- Example: Diet: 6-8 g/day of NaCl (salt) and Protein, Chlorides = Nearly all
are excreted in urine
• Water from the filtrate follows the reabsorbed sodium to maintain osmotic
balance
• If more Na is excreted than ingested = dehydration
If less Na is excreted than injected = fluid retention
• The regulation of Na volume excreted depends on ALDOSTERONE, a hormone
synthesized and released from the Adrenal Cortex.
Increased Aldosterone in blood, less sodium excreted in urine
(Increased Renal Reabsorption of Na)
 •The release of Aldosterone is under the control of ANGIOTENSIN II.
Angiotensin II is controlled by RENIN, an enzyme that is released from
specialized cell in the kidney.
Ex, activating RAA in fall of pressure in renal arterioles such as
HYPOTENSION, SHOCK, DEHYDRATION
• Aldosterone causes the kidney to excrete potassium = retention is the life
threatening effect of renal failure.
REGULATION OF ACID EXCRETION
➢ Sulphuric and Phosphoric acids are non-volatile. This cannot be eliminated by
the lungs = excreted by kidney accumulation result / lower blood pH (Acidic)
and this inhibits cell functions
➢ Kidney excrete acid directly to urine until the urine pH reaches 4.5. utilize
chemical buffers so that the pH will not futher decrease (Phosphate ions,
Amonia – ammonium)
➢ Acids are excreted in bound forms =will not lower pH of urine
REGULATION OF WATER EXCRETION
• Low intake = low urine
• High fluid intake= large diluted urine
Example: person normally ingested 1.2L/day. All is excreted but 500ml
in urine; other routes lung, feces

OSMOLALITY : the degree of dilution or concentration of urine

: the number of particles (electrify and other molecules) dissolved per
kilogram of urine
Normal: 300milliosmo/L
Diluted urine: low osmolality
Concentrated : high osmolality
• Test is valuable to determine kidneys ability to concentrate and dilute urine
SPECIFIC GRAVITY
➢ A measurement of kidneys ability to concentrate urine
➢ Compares the weight of (particles) urine to weight of distilled water which
has a specific gravity of 1.000
Normal Specific Gravity: 1.010 – 1.025 when fluid intake is normal
Specific Gravity increases when intake decreases; decreases
specific gravity when intake increases
Example:
– Disease cause to decrease specific gravity = Diabetes
Insipidus, Glumerulonephritis, renal failure
– Disease cause to increase specific gravity = DM, nephrosis,
excessive fluid loss (dehydration)

ANTI-DIURETIC HORMONE (VASOPRESSIN)

- regulate water excretion and urine concentration in the tubules
- secreted by posterior pituitary gland in response to change in osmolality of
blood (same as urine)
• Decrease water intake = increase blood osmolality = stimulates ADH release
= increase reabsorption of water = minimizes osmolality of blood
• Increase water intake = decrease blood osmolality= suppress secretion or
inhibits ADH = less water reabsorption = diuresis (increase urine volume)
 • Early signs of kidney disease is its inability to dilute and concentrate urine.
AUTO REGULATION OF BLOOD PRESSURE
• Vasa recta constantly monitor BP as blood begins its passage in the kidney
• When BP decreases juxtaglomerular cells secrete rennin convert angiotensin
(in liver) to angiotensin I = Angiotensin II (powerful vasoconstriction) increase
BP
○ Failure of feedback mechanism = primary care of Hypertension ACE
decrease BP stimulate secretes , aldosterone (Adrenal cortex) =
increase BPdue to poor perfusion or increase osmolality

RENAL CLEARANCE
➢ Refers to the ability of the kidney to clear solute from plasma
➢ A 24hr collection is the primary test of the renal clearance use to evaluate
how well the kidney perform the excretory function
CREATININE CLEARANCE
➢ Endogeneous waste of skeletal muscle excreted in urine
➢ Good measure of the glomerular filtration rate (N:100-200mL/min)
➢ To calculate creatine clearance a 24hr urine specimens is collected
Formula:[ Volume of urine(mL/min) x urine creatine (mg/dL) ] / serum
creatinine (mg/dL)
*midway through the collection serum creatinine is measured
REGULATION OF RBC PRODUCTION
➢ When kidney sense a decrease in oxygen tension in renal blood flow, they
release erythropoietin = stimulate the bone marrow to produce RBC =
thereby increase the amount haemoglobin available to carry oxygen.

VITAMIN D SYNTHESIS
➢ Kidney are responsible for the final conversion of inactive Vit. D to its active
form, 1.25-dihydroxycholecalciferon
➢ Vit. D is necessary for maintaining normal calcium balance in the body

SECRETION OF PROSTAGLADIN
➢ Kidney also produces PGE and prostacycline (PGI) which have vasodilator
effect and are important in maintaining renal blood flow

URINE STORAGE
➢ Bladder is the reservoir of urine
➢ In adult bladder filling and emptying is modified by conducted sympathetic
and parasympathetic NS control mechanism involving the destrusor muscle
and bladder outlet
➢ In infants : mediated by micturation center in the pons area of the brain stem
➢ By 3-4yrs old : the cerebral cortex is mature enough to cause awareness of
bladder filling
*stretch receptor in the bladder wall activate to cause desire to void
➢ First sensation of bladder fullness is transmitted to CNS when capacity
reaches to 200-300mL in adult =mitral desire to void
➢ Strong desire ; functional capacity = 300mL
;anatomic capacity 1000-1500mL when under anesthesia=
pressure 60mmHg
 ➢ Can store urine 2-4hrs at a time during the day = 6-8hrs at night due to the
release ADH (vasoregulator) due to less intake = concentrated urine

BLADDER EMPTYING
➢ MICTURATION : Normal: approximately 8xaday
➢ Normal residual urine : less than 50mL (middle age adult)
50 – 100mL (older adult)

ASSESSMENT FOR GUT DYSFUNCTION

➢ Unexplained anemia, manifested by fatigue, SOB, exercise intolerance
➢ Pain due to obstructed urine flow, inflammation and swelling of tissue
➢ Changes in voiding, frequency, urgency, dysuria, hesitancy, incontinence,
eneuresis, polyuria, oliguria, hematuria
➢ GIT symptoms: occur because of shared autonomic and sensory innervation
: Nausea/Vomiting/Diarrhea, abdominal pain/
discomfort/distention
PHYSICAL EXAMINATION
(Head-to-toe assessment)
Emphasis in abdomen, suprapubic region, genitalia, lower back and lower
extremities
➢ Direct palpation of kidney: determines size and mobility
➢ Tenderness of the costovertebral angle
➢ Auscultation for bruits (low pitch murmurs that indicate renal artery stenosis
or an aortic aneurism)
➢ Presence of peritoneal fluid
➢ Percussion of bladder and residual urine (from midline umbilicus downward)
➢ DRE for BPH (yearly exam to men greater than 50yrs old = PSH level
➢ Inguinal area palpated = (+) enlarged nodes/ hernia/ varicocoele
➢ Look/papate: Urethrocoele (bulging of anterior vaginal wall into urethra)
: Cystocoele ( herniation of the bladder wall into vaginal vault)
: Pelvic prolapsed (Cervix bulging in the vaginal vault)
: Enterocoele (hernation bowel into the posterior vaginal wall)
: Rectocoele (herniation of rectum into the vaginal wall)
➢ Edema/ change in body weight (face independent part of the body, ankle,
scrotum)
➢ 1kg increase= 1000mL of fluid retension
DIAGNOSTIC EXAMINATION
➢ Urinalysis (+) hematuria (+) pyuria, (+) bacteriuria
➢ Urine culture
➢ Renal function test: serum creatinine, BUN, creatinine clearance
➢ X-ray (KUB – delinate size, shape, position of the kidney, abnormalities and
calculi
➢ Ultrasound
➢ CT/MRI – provide cross section views of kidney, urinary function
Example: nephrolithiasis,metastatic disease
➢ Nuclear scan – use to evaluate acute renal function, renal masses, pre and
post-renal transplant
➢ Urography, cystography
➢ Biopsy
DYSFUNCTIONS OF URINARY TRACT: Management
1.Urinary Incontenence
a. Risk Factor: Pregnancy/vaginal delivery/ episiotomy
:stroke, age-related change in urinary tract,
medication,diuretic,immobility,sedation
Management: anti cholinergic agent: Oxybutymin; Tx is according to
the underlying
cause
Dicycloverine
Treatment : fluid management
Standard voiding frequency
:time and voiding
:habit retraining
:bladder retraining (“drill”)
:PME (Kegels exercise)
2. Neurogenic bladder
➢ a dysfunction that result from a lesion of NS
➢ cause by spinal cord injury, multiple sclerosis, congenital anomalies (spina
bifida) myelomeningomyecoelo, infection, DM,
➢ Patho: loss of conscious sensation and cerebral motor control bladder muscle
does not contract
➢ Management: pharmacologic: urecholine – increase force of contraction in the
bladder
: surgical
:catheterization
DIALYSIS
• Hemodialysis
• Peritoneal Dialysis
➢ Acute dialysis
➢ Chronic dialysis / maintenance dialysis – indicated for ESRD
- patient with no renal function can be
maintained by dialysis for years
Hemodialysis (6-8hrs)
Used to: Patient acutely ill and require short term dialysis (days to weeks)
: Patient with ESRD to require long term and maintenance therapy
Dialyzer: (“artificial kidney”) serves as synthetic semi-permeable membrane,
replacing the glomeruli and tubules

PRINCIPLE OF HEMODIALYSIS
➢ Objective: to extract toxic nitrogeneous substances from blood and to
remove excess fluid (water)
➢ Diffusion, osmosis, ultrafiltration are the principle in which hemodialysis
is base.
➢ Diffusion – movement of solute from area of high concentration to low
concentration in the dialysate
➢ Toxins of waste in the blood is remove by diffusion
(dialysate is a solution is made by of all important electrolyte on the ideal
extracellular concentration)
 ➢ Osmosis – excess water is remove by osmosis in which the water move from
area of higher concentration to an area (blood) to an area of lower solute
concentration ( the dialysate bath)
➢ Ultrafiltration – define as water moving under high pressure to an area of low
pressure

Peritoneal Dialysis (36-48hrs)

➢ Principles : the peritoneum as the semi-permeable membrane
: dialysate fluid is introduce into the abdominal cavity by catheter
: waste (urea/creatinine) are cleared by diffusion and osmosis
high concentration (peritoneal blood supply) across the semi-
permeable membrane(peritoneum) = peritoneal cavity
: ultrafiltration (removal of water) is through osmotic gradient
created by using a dialysate fluid with a higher glucose concentration

COMPLICATION OF PERITONEAL DIALYSIS

1. Peritonitis
2. Bleeding
3. Leakage
4. Low term : hypertriglycerimia, abdominal hernia

NURSING MANAGEMENT
➢ Directed on financial job related, waning sexual desire and impotency,
depression from being clinically ill, fear of dying, burden to family
➢ Meeting psychosocial needs
○ Expression of feeling
○ Counselling
○ Referral to specialist
○ Help in effective coping