The Genito-Urinary

System
Medical Surgical Nursing
Review
 Outline of review
 Recall the anatomy and physiology of the
Renal System
 Renal Assessment
 Renal Laboratory Procedure
 Common Conditions:
 UTI
 Kidney Stones
 ARF and CRF
 Outline of review
 BPH
 Prostatic cancer
 Kidney function
The Nephron produces Impaired urine production
urine to eliminate waste and azotemia
Secretes Erythropoietin ANEMIA
to increase RBC
Metabolism of Vitamin D Calcium and Phosphate
imbalances
Produces bicarbonate Metabolic ACIDOSIS
and secretes acids
Excretes excess HYPERKALEMIA
POTASSIUM
 Urological Assessment
 Nursing History
 Reason for seeking care
 Current illness
 Previous illness
 Family History
 Social History
 Sexual history
 Urological Assessment
Key Signs and Symptoms of
Urological Problems
EDEMA
associated with fluid retention
Renal dysfunctions usually
produce ANASARCA
 Urological Assessment
Key Signs and Symptoms of
Urological Problems
PAIN
 Suprapubic pain= bladder
 Colicky pain on the flank= kidney
 Urological Assessment
Key Signs and Symptoms of
Urological Problems
HEMATURIA
 Painless hematuria may indicate
URINARY CANCER!
 Early-stream hematuria= urethral
lesion
 Late-stream hematuria= bladder
lesion
 Urological Assessment
Key Signs and Symptoms of
Urological Problems
DYSURIA
 Pain with urination= lower UTI
 Urological Assessment
Key Signs and Symptoms of
Urological Problems
POLYURIA
 More than 2 Liters urine per day
OLIGURIA
 Less than 400 mL per day
ANURIA
 Less than 50 mL per day
 Urological Assessment
Key Signs and Symptoms of
Urological Problems
Urinary Urgency

Urinary retention

Urinary frequency
 Urological Assessment
PHYSICAL EXAMINATION
Inspection
Auscultation
Percussion
Palpation
 Urological Assessment
Laboratory examination
2. Urinalysis
3. BUN and Creatinine levels of the
serum
4. Serum electrolytes
 Urological Assessment
Laboratory examination
Radiographic
 IVP
 KUB x-ray
 KUB ultrasound
 CT and MRI
 Cystography
Implementation Steps for selected
problems
Provide PAIN relief
 Assess the level of pain
 Administer medications usually
narcotic ANALGESICS
Implementation Steps for selected
problems
Maintain Fluid and Electrolyte Balance
 Encourage to consume at least 2 liters
of fluid per day
 In cases of ARF, limit fluid as directed
 Weigh client daily to detect fluid
retention
 Implementation Steps for selected
problems
Ensure Adequate urinary elimination
 Encourage to void at least every 2-3
hours
 Promote measures to relieve urinary
retention:
 Alternating warm and cold compress
 Bedpan
 Open faucet
 Provide privacy
 Catheterization if indicated
 Urinary Tract Infection (UTI)

Bacterial invasion of the

kidneys or bladder
(CYSTITIS) usually
caused by Escherichia
coli
 Urinary Tract Infection (UTI)

 Predisposing factors include

2. Poor hygiene
3. Irritation from bubble baths
4. Urinary reflux
5. Instrumentation
6. Residual urine, urinary stasis
 Urinary Tract Infection (UTI)

PATHOPHYSIOLOGY
 The invading organism ascends the
urinary tract, irritating the mucosa and
causing characteristic symptoms
 Ureter= ureteritis
 Bladder= cystitis
 Urethra=Urethritis
 Pelvis= Pyelonephritis
 Urinary Tract Infection (UTI)

Assessment findings
 Low-grade fever
 Abdominal pain
 Enuresis
 Pain/burning on urination
 Urinary frequency
 Hematuria
 Urinary Tract Infection (UTI)

Assessment findings: Upper UTI

 Fever and CHIILS
 Flank pain
 Costovertebral angle tenderness
 Urinary Tract Infection (UTI)

Laboratory Examination
2. Urinalysis
3. Urine Culture
 Urinary Tract Infection (UTI)
Nursing interventions
 Administer antibiotics as ordered
 Provide warm baths and allow client to
void in water to alleviate painful
voiding.
 Force fluids. Nurses may give 3 liters of
fluid per day
 Encourage measures to acidify urine
(cranberry juice, acid-ash diet).
 Urinary Tract Infection (UTI)
 Provide client teaching and discharge
planning concerning
a. Avoidance of tub baths
b. Avoidance of bubble baths that
might irritate urethra
c. Importance for girls to wipe
perineum from front to back
d. Increase in foods/fluids that acidify
urine.
 Urinary Tract Infection (UTI)
Pharmacology
 1. Sulfa drugs
 Highly concentrated in the urine
 Effective against E. coli!

 2. Quinolones
 Nephrolithiasis/Urolithiasis
 Presence of stones
anywhere in the urinary tract
 Calcium
 oxalate
 and uric acid
 Nephrolithiasis/Urolithiasis
Pathophysiology
 Predisposing factors
a. Diet: large amounts of calcium and
oxalate
b. Increased uric acid levels
c. Sedentary life-style, immobility
d. Family history of gout or calculi
e. Hyperparathyroidism
 Nephrolithiasis/Urolithiasis
Pathophysiology
Supersaturation of crystals due to stasis

Stone formation

May pass through the urinary tract

OBSTRUCTION, INFECTION and

HYDRONEPHROSIS
 Nephrolithiasis/Urolithiasis
Assessment findings
2. Abdominal or flank pain
3. Renal colic radiating to the
groin
3. Hematuria
4. Cool, moist skin
5. Nausea and vomiting
 Nephrolithiasis/Urolithiasis
Diagnostic tests
1. KUB Ultrasound and X-ray: pinpoints
location, number, and size of stones
2. IVP: identifies site of obstruction
and presence of non-radiopaque
stones
3. Urinalysis: indicates presence of
bacteria, increased protein, increased
WBC and RBC (hematuria)
 Nephrolithiasis/Urolithiasis
Medical management
1. Surgery
 a. Percutaneous nephrostomy: tube is
inserted through skin and underlying
tissues into renal pelvis to remove
calculi.
 b. Percutaneous nephrostolithotomy:
delivers ultrasound waves through a
probe placed on the calculus.
 Nephrolithiasis/Urolithiasis
Medical management
2. Extracorporeal shock-wave
lithotripsy: delivers shock waves from
outside the body to the stone,
causing pulverization
3. Pain management : Morphine or
Meperidine
4. Diet modification
 Nephrolithiasis/Urolithiasis
Nursing interventions
 1. Strain all urine through gauze to
detect stones and crush all clots.
 2. Force fluids (3000—4000 cc/day).
 3. Encourage ambulation to prevent
stasis.
 Nephrolithiasis/Urolithiasis
Nursing interventions
 4. Relieve pain by administration of
analgesics as ordered and
application of moist heat to flank
area.
 5. Monitor intake and output
 Nephrolithiasis/Urolithiasis
Nursing interventions
 6. Provide modified diet,
depending upon stone
consistency: Calcium, Oxalate
and Uric acid stones
 Nephrolithiasis/Urolithiasis
Nursing interventions
Calcium stones
 limit milk/dairy products; provide
acid-ash diet to acidify urine
(cranberry or prune juice, meat,
eggs, poultry, fish, grapes, and
whole grains)
 Nephrolithiasis/Urolithiasis
Nursing interventions
Oxalate stones
 avoid excess intake of foods/ fluids
high in oxalate (tea, chocolate,
rhubarb, spinach); maintain
alkaline-ash diet to alkalinize urine
(milk; vegetables; fruits except
prunes, cranberries, and plums)
 Nephrolithiasis/Urolithiasis
Nursing interventions
Uric acid stones
 reduce foods high in purine
(liver, beans, kidneys, venison,
shellfish, meat soups, gravies,
legumes); maintain alkaline urine
 Nephrolithiasis/Urolithiasis
Nursing interventions
 7. Administer allopurinol (Zyloprim) as
ordered, to decrease uric acid
production
 Nephrolithiasis/Urolithiasis
8. Provide client teaching and discharge
planning concerning
 Prevention of Urinary stasis by maintaining
increased fluid intake especially in hot
weather and during illness; mobility;
voiding whenever the urge is felt and at
least twice during the night
 Adherence to prescribed diet
 Need for routine urinalysis (at least every 3
—4 months)
 Need to recognize and report signs/
symptoms of recurrence (hematuria, flank
pain).
 Acute renal failure

 Sudden interruption of
kidney function to regulate
fluid and electrolyte balance
and remove toxic products
from the body
 Acute renal failure
PATHOPHYSIOLOGY
2. Pre-renal failure

4. Intra-renal failure

6. Post-renal failure
 Acute renal failure
PATHOPHYSIOLOGY
Prerenal CAUSE:
 Factors interfering with perfusion
and resulting in diminished blood
flow and glomerular filtrate,
ischemia, and oliguria; include
CHF, cardiogenic shock, acute
vasoconstriction, hemorrhage,
burns, septicemia, hypotension,
anaphylaxis
 Acute renal failure
PATHOPHYSIOLOGY
Intrarenal CAUSE:
 Conditions that cause damage to the
nephrons; include acute tubular
necrosis (ATN), endocarditis, diabetes
mellitus, malignant hypertension,
acute glomerulonephritis, tumors,
blood transfusion reactions,
hypercalcemia, nephrotoxins (certain
antibiotics, x-ray dyes, pesticides,
anesthetics)
 Acute renal failure
PATHOPHYSIOLOGY
Postrenal CAUSE:
 Mechanical obstruction anywhere
from the tubules to the urethra;
includes calculi, BPH, tumors,
strictures, blood clots, trauma, and
anatomic malformation
 Acute renal failure
Three phases of acute renal failure

3. Oliguric phase

5. Diuretic phase

7. Convalescence or recovery phase

 Acute renal failure
Four phases of acute renal failure
(Brunner and Suddarth)
2. Initiation phase
3. Oliguric phase
4. Diuretic phase
5. Convalescence or recovery phase
 Acute renal failure
Assessment findings: The Three Phases of Acute
Renal Failure
1. Oliguric phase
 Urine output less than 400 cc/24 hours
 duration 1—2 weeks
 Manifested by dilutional hyponatremia,
hyperkalemia, hyperphosphatemia,
hypocalcemia, hypermagnesemia, and
metabolic acidosis
 Diagnostic tests: BUN and creatinine
elevated
 Acute renal failure
Assessment findings: The Three Phases of
Acute Renal Failure
2. Diuretic phase
 Diuresis may occur (output 3—5
liters/day) due to partially regenerated
tubule’s inability to concentrate urine
 Duration: 2—3 weeks; manifested by
hyponatremia, hypokalemia, and
hypovolemia
 Diagnostic tests: BUN and creatinine
slightly elevated
 Acute renal failure
Assessment findings: The Three
Phases of Acute Renal Failure
3. Recovery or convalescent phase:
 Renal function stabilizes with gradual
improvement over next 3—12 months
 Acute renal failure
Laboratory findings:
2. Urinalysis: Urine osmo and sodium
3. BUN and creatinine levels increased
4. Hyperkalemia
5. Anemia
6. ABG: metabolic acidosis
 Acute renal failure
Nursing interventions
 Monitor fluid and Electrolyte Balance
 Reduce metabolic rate
 Promote pulmonary function
 Prevent infection
 Provide skin care
 Provide emotional support
 Acute renal failure
Nursing interventions
1. Monitor and maintain fluid and
electrolyte balance.
 Measure l & O every hour. note
excessive losses in diuretic phase
 Administer IV fluids and electrolyte
supplements as ordered.
 Weigh daily and report gains.
 Monitor lab values; assess/treat fluid
and electrolyte and acid-base
imbalances as needed
 Acute renal failure
Nursing interventions
2. Monitor alteration in fluid volume.
 Monitor vital signs, PAP, PCWP,
CVP as needed.
 Weigh client daily.
 Maintain strict I & O records.
 Acute renal failure
Nursing interventions
2. Assess every hour for hypervolemia
 Maintain adequate ventilation.
 Restrict FLUID intake
 Administer diuretics and
antihypertensives
 Acute renal failure
Nursing interventions
3. Promote optimal nutritional status.
 Weigh daily.
 Administer TPN as ordered.
 With enteral feedings, check for residual
and notify physician if residual volume
increases.
 Restrict protein intake to 1 g/kg/day
 Restrict POTASSIUM intake
 HIGH CARBOHYDRATE DIET, calcium
supplements
 Acute renal failure
Nursing interventions
4. Prevent complications from
impaired mobility (pulmonary
embolism, skin breakdown, and
atelectasis)
5. Prevent fever/infection.
 Assess for signs of infection.
 Use strict aseptic technique for wound
and catheter care.
 Acute renal failure
Nursing interventions
6. Support client/significant others and
reduce/ relieve anxiety.
 Explain pathophysiology and relationship
to symptoms.
 Explain all procedures and answer all
questions in easy-to-understand terms
 Refer to counseling services as needed
7. Provide care for the client receiving
dialysis
 Acute renal failure
Nursing interventions
8. Provide client teaching and discharge
planning concerning
 Adherence to prescribed dietary regimen
 Signs and symptoms of recurrent renal
disease
 Importance of planned rest periods
 Use of prescribed drugs only
 Signs and symptoms of UTI or respiratory
infection need to report to physician
immediately
 Chronic Renal Failure
 Gradual, Progressive
irreversible destruction of the
kidneys causing severe renal
dysfunction.
 The result is azotemia to
UREMIA
 Chronic Renal Failure
Predisposing factors:
 DM= worldwide leading cause
 Recurrent infections
 Exacerbations of nephritis
 urinary tract obstruction
 hypertension
 Chronic Renal Failure

PATHOPHYSIOLOGY
As renal functions decline

Retention of end-products of
metabolism
 Chronic Renal Failure
PATHOPHYSIOLOGY
STAGE 1= reduced renal reserve, 40-
75% loss of nephron function
STAGE 2= renal insufficiency, 75-
90% loss of nephron function
STAGE 3= end-stage renal disease,
more than 90% loss. DIALYSIS IS
THE TREATMENT!
 Chronic Renal Failure
Assessment findings
 1. Nausea, vomiting; diarrhea or
constipation; decreased urinary
output
 2. Dyspnea
 3. Stomatitis
 4. Hypertension (later), lethargy,
convulsions, memory impairment,
pericardial friction rub
 Chronic Renal Failure
Dermatologic dry skin, pruritus, uremic
frost
CNS seizures, altered LOC,
anorexia, fatigue
CVS Acute MI, edema,
hypertension, pericarditis
Pulmo Uremic lungs

Hema Anemia

Musculoskeletal loss of strength, foot

drop, osteodystrophy
 Chronic Renal Failure
Diagnostic tests:
 a. 24 hour creatinine clearance
urinalysis
 b. Protein, sodium, BUN, Crea
and WBC elevated
 c. Specific gravity, platelets, and
calcium decreased
 D. CBC= anemia
 Chronic Renal Failure
Medical management
 1. Diet restrictions
 2. Multivitamins
 3. Hematinics and erythropoietin
 4. Aluminum hydroxide gels
 5. Anti-hypertensive
 6. Anti-seizures
 DIALYSIS
 Chronic Renal Failure
Nursing interventions
1. Prevent neurological
complications.
 Assess every hour for signs of
uremia (fatigue, loss of appetite,
decreased urine output, apathy,
confusion, elevated blood
pressure, edema of face and feet,
itchy skin, restlessness, seizures).
 Chronic Renal Failure
Nursing interventions
1. Prevent neurological complications.
 Assess for changes in mental
functioning.
 Orient confused client to time, place,
date, and persons; institute safety
measures to protect client from
falling out of bed.
 Monitor serum electrolytes, BUN, and
creatinine as ordered
 Chronic Renal Failure
Nursing interventions
2. Promote optimal GI function.
 Assess/provide care for stomatitis
 Monitor nausea, vomiting, anorexia
 Administer antiemetics as ordered.
 Assess for signs of Gl bleeding
 Chronic Renal Failure
Nursing interventions
 3. Monitor/prevent alteration in fluid
and electrolyte balance
 4. Assess for hyperphosphatemia
(paresthesias, muscle cramps,
seizures, abnormal reflexes), and
administer aluminum hydroxide gels
(Amphojel) as ordered
 Chronic Renal Failure
Nursing interventions
5. Promote maintenance of skin
integrity.
 Assess/provide care for pruritus.
 Assess for uremic frost (urea
crystallization on the skin) and bathe
in plain water
 Chronic Renal Failure
Nursing interventions
6. Monitor for bleeding complications,
prevent injury to client.
 Monitor Hgb, hct, platelets, RBC.
 Hematest all secretions.
 Administer hematinics as ordered.
 Avoid lM injections
 Chronic Renal Failure
Nursing interventions
7. Promote/maintain maximal
cardiovascular function.
 Monitor blood pressure and report
significant changes.
 Auscultate for pericardial friction
rub.
 Perform circulation checks routinely.
 Chronic Renal Failure
Nursing interventions
7. Promote/maintain maximal
cardiovascular function.
 Administer diuretics as ordered and
monitor output.
 Modify drug doses
8. Provide care for client receiving
dialysis.
 DIALYSIS
 a procedure that is used to remove
fluid and uremic wastes from the
body when the kidneys cannot
function
 DIALYSIS
 Two methods

 1. Hemodialysis

 2. Peritoneal dialysis
 DIALYSIS
 Diffusion
 Osmosis
 Ultrafiltration
 DIALYSIS
Nursing management
2. Meet the patient's psychosocial
needs
3. Remember to avoid any
procedure on the arm with the
fistula (HEMO)
 Monitor WEIGHT, blood pressure
and fistula site for bleeding
 DIALYSIS
Nursing management
3. Monitor symptoms of uremia
4. Detect complications like infection,
bleeding (Hepatitis B/C and HIV
infection in Hemodialysis)
5. Warm the solution to increase
diffusion of waste products
(PERITONEAL)
6. Manage discomfort and pain
 DIALYSIS
Nursing management
7. To determine effectiveness, check
serum creatinine, BUN and
electrolytes
 Male reproductive disorders
 BPH
 Prostatic cancer
 Male reproductive disorders
DIGITAL RECTAL EXAMINATION- DRE
 Recommended for men annually with
age over 40 years
 Screening test for cancer
 Ask patient to BEAR DOWN
 Male reproductive disorders
TESTICULAR EXAMINATION
 Palpation of scrotum for nodules and
masses or inflammation
 BEGINS DURING ADOLESCENCE
 Male reproductive disorders
Prostate specific antigen (PSA)
 Elevated in prostate cancer
 Normal is 0.2 to 4 nanograms/mL
 Cancer= over 4
 Male reproductive disorders
BENIGN PROSTATIC HYPERPLASIA
 Enlargement of the prostate that
causes outflow obstruction

 Common in men older than 50 years

old
 Male reproductive disorders
BENIGN PROSTATIC HYPERPLASIA
Assessment findings
 DRE: enlarged prostate gland that is
rubbery, large and NON-tender
 Increased frequency, urgency and
hesitancy
 Nocturia, DECREASE IN THE VOLUME
AND FORCE OF URINE STREAM
 Male reproductive disorders
BENIGN PROSTATIC HYPERPLASIA
Medical management
3. Immediate catheterization
4. Prostatectomy
5. TRANSURETHRAL RESECTION of the
PROSTATE (TURP)
6. Pharmacology: alpha-blockers, alpha-
reductase inhibitors. SAW palmetto
 BPH
NURSING INTERVENTION
2. Encourage fluids up to 2 liters per day
3. Insert catheter for urinary drainage
4. Administer medications – alpha adrenergic
blockers and finasteride
5. Avoid anticholinergics
6. Prepare for surgery or TURP
7. Teach the patient perineal muscle
exercises. Avoid valsalva until healing
 BPH
NURSING INTERVENTION: TURP
 Maintain the three way bladder
irrigation to prevent hemorrhage
 Only initially the drainage is pink-
tinged and never reddish
 Administer anti-spasmodic to prevent
bladder spasms
 Prostate Cancer
 a slow growing malignancy of the
prostate gland
 Usually an adenocarcinoma
 This usualy spread via blood stream to
the vertebrae
 Prostate Cancer
 Predisposing factor
 Age
 Prostate Cancer
 Assessment Findings
2. DRE: hard, pea-sized nodules on the
anterior rectum
3. Hematuria
4. Urinary obstruction
5. Pain on the perineum radiating to the
leg
 Prostate Cancer
 Diagnostic tests
 Prostatic specific antigen (PSA)
 Elevated SERUM ACID
PHOSPHATASE indicates SPREAD or
Metastasis
 Prostate Cancer
Medical and surgical management
2. Prostatectomy
3. TURP
4. Chemotherapy: hormonal therapy to
slow the rate of tumor growth
5. Radiation therapy
 Prostate Cancer
Nursing Interventions
2. Prepare patient for chemotherapy
3. Prepare for surgery
 Prostate Cancer
Nursing Interventions: Post-
prostatectomy
2. Maintain continuous bladder
irrigation. Note that drainage is pink
tinged w/in 24 hours
3. Monitor urine for the presence of
blood clots and hemorrhage
4. Ambulate the patient as soon as urine
begins to clear in color