The kidneys

Each kidney contains at least 1 million nephrons, together with their collecting tubules or ducts. The nephron (Fig 29.2) is the functional unit of the kidney. Each nephron is composed of a vascular and tubular system that allows for the formation of urine. The nephrons are located in the renal tissue, with most in the cortex and some extending deep into the medulla of the kidney.

Figure 29.2 The nephron

The adult kidney weighs 120–170 g, is 10–13 cm in length, 5–6 cm wide and 3–4 cm thick. The kidneys are protected and supported by renal fascia and by layers of perirenal fat. They are positioned at approximately vertebral level of T12 to L3, the right kidney usually slightly lower than the left.

The functions of the kidneys are to maintain homeostasis. Homeostasis is the process that controls the body’s internal environment. External variables may change such as heat, cold, fluid, diet and stress but to sustain the body in a state of equilibrium, receptors in the body identify if something is off balance and trigger a negative feedback. The urinary system maintains homeostasis by:

In carrying out these functions the kidneys excrete urine. Urine is made up of water and dissolved substances that are in excess of the body’s need to function, and includes byproducts of metabolism, such as urea. These substances are transported into the bloodstream, which enters the kidney via a branch of the renal artery. The nephron is the functional unit of the kidney. Each nephron is composed of a vascular and tubular system that allows for the formation of urine. The nephrons are located in the renal tissue, with most in the cortex and some extending deep into the medulla of the kidney. The blood is filtered from there through the glomerulus, where glucose, minerals, urea, other soluble substances and water pass through to the renal tubule.

Kidney function is controlled by both the nervous and the endocrine systems which in turn control:

The ureters

The ureters are two narrow, thick-walled muscular tubes, 25–30 cm long, which originate in the renal pelvis of each kidney. They pass down the posterior abdominal wall and into the pelvic cavity to enter the posterior base of the bladder. The ureters enter the bladder at an oblique angle so that, as the bladder fills and contracts, urine is not forced back towards the kidneys. The walls of the ureters consist of an outer fibrous coat that is continuous with the renal capsule, a middle coat of involuntary muscle and a lining of transitional epithelium. The function of the ureters is to carry urine from the kidneys to the bladder, by means of peristaltic action. The involuntary muscle layer in the walls of the ureters contract from 1–5 times per minute to force urine into the bladder.

The urinary bladder

The urinary bladder is a hollow muscular organ that acts as a reservoir for urine and is supported by the detrusor muscle. The detrusor muscle is a layer of the urinary bladder wall made of smooth muscle fibres arranged in spiral, longitudinal and circular bundles; its competency is vital to maintaining continence. In the female it is in front of the uterus and in the male it sits in front of the rectum. The walls of the bladder consist of:

The trigone of the bladder is a triangle formed by the two ureteric orifices, where the ureters enter the bladder, and the urethral orifice at the neck of the bladder. A band of the detrusor muscle encircles this opening to form the internal urethral sphincter; incompetence of this sphincter may have an impact on continence.

Micturition (or voiding) is the act of passing urine. While the normal capacity of the adult urinary bladder is about 450 mL, the bladder is capable of expanding to hold larger amounts. The bladder fills slowly over a period of time and, when it holds about 300–500 mL, a desire to empty the bladder is experienced. A reflex initiated by impulses from stretch receptors in the bladder wall regulates the process of micturition. The sensory neurons transmit the impulses to the spinal cord, where they are relayed to the brain, which in turn stimulates parasympathetic neurons that innervate the bladder wall. When a client is ready to pass urine, these impulses cause the bladder muscles to contract, the internal urethral sphincter relaxes and the desire to urinate is activated. The person is then able to voluntarily relax the external sphincter and void at an appropriate time and place. Urine is usually excreted in amounts of 1–2 L in 24 hours.

The urethra

The urethra (Fig 29.3) is a muscular tube extending from the neck of the bladder to the external meatus. In the female the urethra is about 2.5–4 cm long and opens at the external urethral orifice in front of the vaginal opening. The external sphincter guards this opening. In the male, the urethra is about 15–20 cm long and opens at the tip of the penis. The male urethra has a double function: it forms a passage for urine as well as semen. It is guarded by an external sphincter immediately below the prostatic portion of the urethra. The function of the urethra is to provide a passage for urine from the bladder, out of the body.

Figure 29.3 Position of the female and male urethra

Changes in kidney structure

Atrophy of the kidneys because of destruction of the renal tissue can occur in many chronic renal diseases. Alternatively, the kidneys can become enlarged because of blockage of the ureters, enlargement of the prostate gland or from invasion of the kidneys by neoplastic cells. If there is an obstruction lower down in the urinary tract, the ureters may become enlarged in diameter as they fill with urine that cannot pass the obstruction.

Fluid and electrolyte imbalance

If the kidneys are unable to concentrate the urine by regulating reabsorption, the loss of a large amount of dilute urine may result in fluid imbalance. If they fail to excrete sufficient water, an increase in the total circulating fluid volume impedes cardiovascular function. Renal disease may result in abnormal retention or loss of sodium, potassium, calcium or phosphorus.

Elimination of wastes

Normal metabolism produces an excess of acids. To compensate, the kidneys excrete acids and return bicarbonate to the plasma and extracellular fluid. An acid–base imbalance (metabolic acidosis) will result if this function is impaired; that is, if there is an increased amount of acid or a decreased amount of base in the body. The kidneys must also continually filter and excrete nitrogenous wastes derived from protein metabolism.

Urine output

Alterations in urine output may be temporary or long term. Urine output may be decreased, as in obstruction of the ureter or acute or chronic renal failure, or it may be increased, as during the diuretic stage of acute renal failure. The passage of urine along the urinary tract may be impeded by an obstruction, such as a tumour or calculus.

Pain

Pain is more common in acute, rather than chronic, disorders of the kidneys and urinary tract. Pain that originates from the kidneys is generally experienced as a dull ache in the lower back and may radiate to the lower abdominal area. Pain associated with renal colic is sudden and severe. It is felt in the lower back and may radiate to the groin area. Nausea and vomiting frequently accompany this type of pain.

Suprapubic pain may result from spasms or over-distension of the bladder, as in acute retention of urine. An infection of the lower urinary tract, such as cystitis, commonly causes pain and burning during and/or after voiding. Strangury is the term used to describe slow and painful spasmodic discharge of urine frequently associated with a ‘burning’ sensation.

Changes in voiding pattern

There may be an increase in the frequency of voiding, problems controlling the passage of urine, difficulty in initiating micturition or a sense of urgency associated with the need to void.

Changes in output

Changes in the output of urine include voiding increased or decreased amounts and cessation of the production or secretion of urine.

Changes in the urine

Abnormalities of the urine associated with urinary system disorders include changes in the normal colour, clarity or odour of urine. The urine may be blood stained or dark amber, cloudy or smoky in appearance. Chronic renal disease can result in pale, almost colourless urine. A foul smelling ‘fishy’ odour is commonly present when there is a urinary tract infection (UTI).

Other manifestations

A client with a lower UTI commonly experiences pyrexia, malaise, nausea and vomiting and pelvic and abdominal discomfort, whereas those with renal disease may experience hypertension, oedema, anorexia, nausea and vomiting, skin changes and neurological symptoms such as headache or altered consciousness (Berman et al 2012; Marieb & Hoehn 2010; McCance & Huether 2010).

Nursing interventions

When a client is experiencing altered voiding patterns, the cause must be identified and treated. Difficulty in passing urine may result from an obstruction to the outflow of urine but may also be caused by other factors such as:

Nursing actions that may be implemented to induce micturition include:

If these actions fail to induce micturition and the client is uncomfortable because of a distended bladder, it may be necessary to implement further actions, such as inserting a urinary catheter.

Screening and investigations

Urine tests

Various sources of information can be collected through the use of daily charts such as fluid balance charts, bladder diaries which record voiding patterns and which may note, for example, an interrupted stream or difficulties in voiding as well as a history of the client’s elimination pattern. As the body’s normal metabolism produces wastes that must be eliminated regularly to maintain effective body function, the observation of urine and the client’s ability to eliminate it provides the nurse with an objective assessment data. The elimination of urine, or voiding, should be voluntary and painless. The frequency with which urine is passed varies with each individual. Factors that affect the frequency of voiding and the volume of urine include fluid input, bladder capacity, response to the need to void and the availability of toilet facilities. The frequency of voiding, and often the amount of urine voided, can be increased by a large fluid input, fear or anxiety, exposure to a cold environment and some disease states and decreased by a low fluid input, exposure to a hot environment and some disease states.

Preparation

Standard precautions apply for all collection of body fluids. If urine is to be collected for a screening urinalysis, the client is requested to void into a clean bedpan or urinal or a suitable clean receptacle (Fig 29.5.). The urine should not be contaminated by faeces or menstrual blood, as a false assessment may result. The urine is transferred from the toilet utensil into a clean container for observation and analysis immediately after collection. Correct and ongoing identification of sample is of paramount importance.

Figure 29.5 Positioning a bedpan A: Another method of placing a bedpan is used when the client is unable to help. The client lies on one side and the bedpan is placed firmly against the buttocks B: The nurse pushes down on the bedpan and towards the client C: The client is positioned on the bedpan so that the urethra and anus are directly over the opening

Observation

In health urine is clear, amber in colour and has a faint odour. Menstruation or any other vaginal discharge and certain medications, supplements or foods can alter the colour and odour of urine and certain diseases will vary the condition and clarity of the urine, so it is important to document what is observed and smelt. Further observations should note if the urine is cloudy or if there is sediment present (Table 29.2).

Table 29.2 Abnormalities of urine detected by observation

Observation	Deviation from normal	Possible cause
Colour	Pale	High fluid intake, other factors that dilute the urine, such as diuretic medication or disease, e.g. diabetes mellitus Indication of adequate hydration
	Dark or brown	Concentrated urine due to dehydration or presence of bile pigment, e.g. in liver or gallbladder disease, or indication of poor hydration
	Smoky	Presence of occult blood
	Red	Presence of frank blood
	Bright yellow, blue or green	Specifc medications
	Mucous plugs, viscous, thick	White blood cells, bacteria, pus or contaminants such as prostatic fluid or vaginal discharge may cause cloudy urine
Odour	Ammonia	Decomposing urine
	Foul-smelling ‘fshy’ odour	Infected urine
	Sweet smelling	Presence of glucose, e.g. in diabetes mellitus
Foreign substances	Pus	Urinary tract infection
	Stones, gravel	Calculi in urinary tract
Amount	Higher than normal in 24 hours	High fluid intake, diuretic medications, diseases e.g. diabetes mellitus
	Lower than normal in 24 hours	Obstruction to the flow of urine Diseases that reduce the normal production of urine e.g. renal failure

Urinalysis (laboratory)

Abnormal findings from a routine urinalysis often require further investigation by a laboratory and this will be ordered by the client’s doctor or nurse practitioner.

Adequate information about the client and the specimen must be provided. The label on the specimen container must contain the client’s name, registration number, the date and time of collection and the method used to collect the specimen; for example, catheter specimen of urine. When a specimen is despatched for laboratory analysis it must be accompanied by the appropriate signed request form with type of collection and the specific laboratory tests to be performed.

Specimens must be sent to the laboratory as soon as possible after collection; if delay is anticipated the specimen must be refrigerated as soon as possible. Depending on ambient temperature, urine left for more than 2 hours without some form of preservation such as refrigeration is unlikely to produce an accurate result and should be discarded due to decomposition of the urine and increased microbial activity.

If the client is responsible for collecting the urine specimen, the nurse should provide the client with the information necessary to ensure that the collection is performed correctly.

All urine excreted during a timed collection, for example, during a 24-hour period, is collected and sent for laboratory analysis to measure the quantity of various substances present, such as specific hormones. Table 29.3 describes the results on urinalysis.

Table 29.3 Results of urinalysis

Further diagnostic tests

Tests that may be performed to assist or confirm the diagnosis of urinary system disorders include the following.

Congenital disorders

Certain disorders may be present at birth, although the manifestations may not become evident for some time. Vesico-ureteric reflux is a mechanical problem that may be congenital or acquired. Abnormal backflow of urine from the bladder to the ureter(s) increases the hydrostatic pressure in the ureters and kidneys. Reflux into the kidneys causes damage to the renal parenchyma and reflux nephropathy. In the congenital form the child is born with a short ureter, which often grows to normal size as the child develops and matures, so that the condition resolves. Acquired vesico-ureteric reflux may be caused by repeated UTIs, by inadequate functioning of the detrusor muscles in the bladder or from a high pressure within the bladder as a result of an obstruction (Hockenberry & Wilson 2010). Symptoms of the disorder generally appear only in the presence of a UTI and there may be no symptoms with chronic infection. The condition may not be diagnosed until signs of renal damage become evident.

Polycystic kidney disease is an inherited disorder characterised by grape-like clusters of fluid-filled cysts that enlarge the kidneys. There are two forms of this disorder; one affecting children and the other affecting adults. In its infantile form the disorder manifests as bilateral masses in the kidney areas, with symptoms of respiratory distress and cardiac failure. Adult polycystic disease is frequently asymptomatic until the client is about 40 years of age. Initial symptoms include hypertension, haematuria and low back pain. UTI is common and progression to renal failure is gradual.

Infectious disorders

Infection may occur in any part of the urinary tract, as urine provides an ideal medium for the growth of microorganisms. Most commonly they gain access to the urinary tract by ascending the urethra although, rarely, they may descend from the kidneys to the lower urinary tract.

Pyelonephritis is inflammation of the renal pelvis and may be an acute or chronic condition. Acute pyelonephritis results from bacterial infection of the kidneys, commonly as a consequence of a lower UTI. A client with acute pyelonephritis may experience severe pain or a continual dull ache in the kidney region, as well as pyrexia, nausea and vomiting and fatigue. Rigors may be present, and urination may be frequent and painful. The urine is generally cloudy, blood stained and offensive in odour. Chronic pyelonephritis can result in the formation of renal scar tissue, which may in turn lead to chronic renal failure. This condition most commonly occurs in clients who experience recurrent acute pyelonephritis as a result of a urinary tract obstruction or vesico-ureteric reflux.

Cystitis is inflammation of the urinary bladder, and is usually the result of bacterial contamination. Cystitis is more common in females than in males because of the short length and proximity of the urethra to the bowel and vagina. The urine is generally cloudy and offensive and may contain blood cells. Urethritis, inflammation of the urethra, may result from bacterial infection or traumatic irritation such as catheterisation.

Organisms responsible for infections are numerous: Escherichia coli is a common infective organism; altered hygiene habits, sexual activity or bowel disorders may contribute to the infective process. Other causative organisms may be transmitted sexually, such as Chlamydia trachomatis and Neisseria gonorrhoea.

Symptoms of urinary tract infections may include dysuria and the presence of pus in the urine but often manifest differently in different age groups (Brown 2002). Table 29.4 outlines the age-related symptoms of UTI.

Table 29.4 Age-related symptoms of UTI

adapted from Brown 2002

Degenerative disorders

Degenerative disorders include disorders in which there are degenerative changes in the renal structure or changes in the blood vessels that supply the kidneys. Degeneration occurs over a long period, and the client may not experience any symptoms until significant damage has occurred. Nephrosclerosis is necrosis of the renal arterioles, resulting from untreated or uncontrolled hypertension that impairs the blood supply of the kidneys. Renal damage occurs from a combination of fibrosis of the blood vessels walls and the resulting ischaemia. The client presents with high blood pressure, headaches, visual disturbances and altered neurological functioning. The urine contains protein and blood. If untreated, this condition can lead to renal and cardiac failure.

Analgesic nephropathy results from chronic ingestion of substances containing phenacetin. Aspirin–paracetamol combinations have also been found to cause similar renal tubule damage. The client complains of low back pain, haematuria and the symptoms of uraemia (nausea, vomiting, pruritus, muscle cramps). If end-stage renal failure develops, dialysis or kidney transplantation will be necessary (Berman et al 2012).

Neoplastic disorders

Tumours that arise in the urinary system may be benign or malignant. Kidney tumours are generally malignant and usually well advanced before haematuria, the first and most common sign, appears. Later features include pain as the tumour enlarges and presses on adjacent structures, nausea and vomiting, loss of weight and metastatic symptoms such as bone pain. Wilms’ tumour is a rare malignant tumour of the kidneys that occurs primarily in children (Kidney Health Australia 2012).

Bladder tumours are generally malignant, and more common than kidney tumours. Most occur in men over age 50. Evidence shows that prolonged exposure to certain substances such as aniline dyes is associated with increased incidence of bladder cancer. A variety of other carcinogenic substances, such as artificial sweeteners, are linked to bladder cancer. The prime manifestation of a bladder tumour is intermittent haematuria.

Prostate cancer is the most common cancer other than skin cancer in Australian men over the age of 50. Cancer of the prostate is commonly diagnosed through a screening blood test which indicates raised prostate specific antigen (PSA) (Andrology Australia 2011). As the tumour develops it causes the prostate gland to increase in size and causes difficulty in initiating micturition, a feeling that the bladder is not empty after voiding and dribbling of urine after micturition. Acute retention of urine may occur if the flow from the bladder is severely obstructed. Surgical intervention for conditions relating to the prostate can lead to erectile dysfunction and continence issues.

Obstructive disorders

Obstruction of the urinary tract may be caused by factors other than the presence of tumours and calculi.

Benign prostatomegaly (enlargement of the prostate gland surrounding the male urethra) may compress the urethra and cause urinary obstruction. The cause of hypertrophy of the prostate gland is not fully understood but is probably related to hormonal mechanisms. It is more common in men over age 50. The first sign that there may be prostate problems may be when a man experiences the urge to pass urine more frequently, experiencing hesitancy and/or an interrupted stream. Sexual dysfunction is often experienced as the prostate enlarges (Maliski et al 2008). Some men may experience pain at the base of the scrotum and penis (Andrology Australia 2011). A digital rectal examination performed by the client’s medical officer can ascertain if the prostate is enlarged.

Hydronephrosis, or dilation of the renal pelvis, may result from obstruction of the urinary tract. The build-up of pressure behind the area of obstruction eventually results in damage to the kidneys, and renal dysfunction. Causes of hydronephrosis include prostatomegaly, urethral stricture, calculi, congenital abnormalities and neurogenic bladder. The client usually presents with dull lower back pain and tenderness, decreased urine flow, dysuria and haematuria. Infection or renal failure can occur if the problem is not corrected.

Calculi are stones that form in the kidneys and urinary tract. Most stones form in the kidneys and pass down into the ureters or bladder. They are usually composed of calcium salts or uric acid. Multiple small calculi may remain in the renal pelvis or pass down the ureter, while a staghorn calculus remains in the kidneys. Although the precise cause is unknown, predisposing factors in the formation of calculi include some medications, dehydration, metabolic factors, infection, prolonged immobility and urinary stasis (Walton 2008).

The major symptom of calculi is pain, felt as a dull ache while the stone remains in the kidney. Stones which are localised to the kidneys may be treated with extracorporeal shock wave lithotripsy (ESWL). Stones which pass into the ureter may be treated with ESWL or, if lower down, may be removed using ureteroscopy.

If a stone passes into the ureter, the client may experience excruciating colicky pain that is frequently accompanied by nausea and vomiting.

Traumatic disorders

Injuries to the kidney or urinary tract can have serious consequences. Because the kidney receives a large amount of blood from the abdominal aorta via the renal arteries, even a small laceration can cause massive haemorrhage. Injuries to the kidney include contusion, haematoma and laceration. The renal artery or renal vein may be ruptured. Symptoms include haematuria, back and abdominal pain and symptoms of hypovolaemic shock if the injury is severe. Bladder trauma may be associated with pelvic fractures or result from a blunt or penetrating injury. Symptoms of bladder injury include haematuria, dysuria, decreased urinary output, suprapubic pain and tenderness. Scrotal or perineal swelling may occur if urine escapes from the damaged bladder into surrounding tissues.

Disorders of multiple cause

Chronic renal failure is the gradual loss of functional nephrons and may be due to several causes, including chronic kidney infections, polycystic kidneys, renal vascular disease, hypertension and obstructive diseases such as calculi, nephrotoxic agents and diabetic nephropathy. The condition produces major changes in all body systems.

It consists of four phases: diminished renal reserve, renal insufficiency, renal failure and end-stage renal disease. During the first phase, renal damage occurs but the client may be asymptomatic. With renal insufficiency the kidneys still function, but urinary concentration is impaired and blood urea levels are elevated. The renal failure stage produces uraemia, metabolic acidosis, electrolyte imbalance and impaired urine dilution. In the end stage, renal function is severely impaired and most other body systems are affected. When renal function is impaired to such an extent that conservative treatment is no longer effective, dialysis therapy and/or kidney transplantation are necessary (Health Insite 2012).

Life span issues

Children: micturition is normally under voluntary control by about 2–3 years of age; however, children often experience enuresis into their school years. There are a variety of interventions to assist children experiencing this situation and effective data collection including incidence, external factors such as stress or emotional trauma, absence of infection, pharmacology or disease profiles is necessary. Children frequently outgrow the symptom but the psychosocial implications can have a long-term negative impact (Caldwell et al 2009; Cox 2009).

Adolescence: incontinence can be continuous throughout childhood as a result of infection, toilet avoidance, (especially at school), constipation or disease. This stage of development is also a time when some adolescents become sexually active and incontinence related to a bladder infection (cystitis) and associated vaginitis or epididymitis may be experienced. Some adolescents are often reluctant to seek help and the need for sensitivity in responding to this age group is vital (Weaver 2008).

Pregnancy and postpartum incontinence: the effectiveness of pelvic floor exercises in helping to improve the musculature of the pelvic region has long been acknowledged and use of these exercises has resulted in improvement in the post childbirth incidence of incontinence (Day & Goad 2010). During pregnancy, mechanical and hormonal factors cause changes in renal physiology, most commonly resulting in frequency of voiding and stress incontinence. Many postpartum changes, including damage to the pelvic floor during vaginal delivery, have long-term continence effects and these are less acknowledged, with many mothers assuming that involuntary loss of urine is normal after the birth of a baby. This condition has an adverse effect on the mother—from physiological, psychological and sexual perspectives (Kok et al 2008).

Menopause: urge and stress incontinence increases in women post menopause, and complications such as obesity and type 2 diabetes can exacerbate the symptoms (Mishra et al 2008).

Older adults: while continence issues in adolescents and adults is experienced mainly by women, prostatic enlargement in men and the resultant effects of surgery increase the incidence of incontinence in men. The increase in metabolic syndrome in men and women, obesity and neurological changes also contribute to incontinent events. There is frequently a mixed aetiology (causes) in this age group.

Nursing interventions

Interventions can only be effective when a thorough assessment has been completed. Incontinent issues are highly individualised and the nurse needs to respond to each individual client’s needs. Therefore, care plans must be initiated in consultation with the patient or their significant others (see Nursing care plan 29.1).

Specific interventions

Reasons for catheterisation

One of the most common nosocomial infections in hospital is urinary tract infection and many of these can be attributed to catheterisation (De Jaeger 2011). As a result, catheterisation is now performed only when considered absolutely necessary, which may include when:

Use the Bright Sky Catheter Compass™ to help you identify the type of catheter that best suits the client (see www.brightsky.com.au).

Insertion of a catheter

The procedure of catheter insertion is called catheterisation and is performed using sterile equipment and aseptic technique. Standard precautions are maintained by all personnel involved. As a catheter can cause trauma to the urethral or bladder mucosa and is a potential source of UTI, it is inserted only when absolutely necessary. The basic requirements are:

If the catheter is to be indwelling, you also need:

In addition to preparing the equipment, it is necessary to prepare the client by ensuring adequate lighting and privacy, placing the client in a supine position with legs extended and promoting comfort and privacy during the procedure. See Procedural Guidelines 29.2 and 29.3.

Bladder irrigation

Bladder irrigation or washout may be performed to ensure patency of the catheter, to remove sediment or blood clots or to introduce an antibiotic or bacteriostatic agent. Bladder irrigation may be continuous or intermittent. To prevent urinary tract obstruction continuous irrigation may be necessary to flush out small blood clots that can form after prostate or bladder surgery. During bladder irrigation, sterile equipment and aseptic technique are used to avoid introducing microorganisms. A triple lumen catheter is needed to perform bladder irrigation. One lumen is used to introduce the irrigating solution into the bladder, a second lumen allows the fluid to drain out and the third lumen allows the instillation of fluid into the balloon that holds the catheter in the bladder.

For continuous irrigation, a container of irrigating solution is suspended on a stand and the tubing from the container is attached to the catheter. Drainage tubing from the catheter is attached to a urine collection bag positioned below the level of the client’s bladder. A clamp is used to regulate the rate at which the solution flows into the bladder. During irrigation the inflow and outflow tubing is checked to ensure the free flow of fluid. The outflowing fluid is checked for changes in the appearance and presence of blood clots. Both the inflowing and the outflowing fluid must be measured and documented and the collection bag emptied as necessary. The outflow volume should be greater than the inflow volume—allowing for urine production.

Intermittent irrigation involves the gentle introduction of small amounts of prescribed solution. Using a syringe, the solution is introduced into the distal end of the catheter. Small amounts, 30–50 mL for example, are introduced in succession and usually allowed to drain out by gravity. The technique is repeated until the prescribed amount of solution has been used, or until the return fluid is clear. The solution being introduced and returned is measured and documented, and the return fluid observed for changes in appearance or presence of blood clots.

Removal of a catheter

Depending on how long a catheter has been in position, the medical officer may prescribe bladder retraining before its removal. Bladder retraining involves clamping the catheter for specified periods, such as 2–4 hours, then releasing it to empty the bladder. This technique is repeated for several hours to help restore the bladder’s muscle tone. Removing a catheter requires aseptic technique. Key aspects related to the procedure and after care include:

Intermittent catheterisation

Intermittent catheterisation is either a one-off procedure to assess the urine within the bladder or the insertion and removal of a catheter several times a day to empty the bladder. Intermittent catheterisation is widely used in neurogenic bladder dysfunction such as spinal cord injury, spina bifida, multiple sclerosis or motor neuron disease. Intermittent catheterisation reduces the incidence of UTI and improves quality of life and allows for self-catheterisation, giving greater independence to the client (Newman & Wilson 2011). Side effects can include bleeding, urethritis, stricture and the potential for UTI. Men may have difficulty inserting the catheter past the prostate while women may have difficulty identifying the urethra (Colpman 2010).

Nursing interventions

Nursing care after the insertion of an indwelling catheter is similar for both male and female clients and is planned and implemented to promote comfort, maintain the flow of urine and minimise the possibility of a UTI. The nurse needs to ascertain whether the catheter is to be clamped and released at specified intervals to provide intermittent drainage or if it is to be connected to a drainage bag for continuous drainage. If intermittent drainage has been prescribed, the end of the catheter is clamped. At specified intervals, for example, every 4 hours, the clamp is released to enable the urine that has accumulated in the bladder to drain. Aseptic technique should be used during this procedure to prevent the entry of microorganisms into the open catheter. An intermittent drainage regimen is commonly implemented before removal of an indwelling catheter, to promote and restore any lost bladder tone.

If continuous drainage has been prescribed, actions to promote free flow of urine and prevent stasis of urine include:

Figure 29.6 Closed urinary drainage system

(deWit 2005; redrawn from Potter & Perry 2008)

Urinary diversion

A client whose bladder has been removed, for example because of malignancy, will require urinary diversion. Various surgical techniques that divert the flow of urine are available (Fig 29.7):

Figure 29.7 Urinary diversion A Ureterosigmoidostomy B Cutaneous ureterostomy C Ileal conduit

Care of the client with a urinary stoma is similar to the care required by a client who has a stoma created for the passage of faeces. The main aspects of care are the selection and management of ostomy appliances, care of the stoma and surrounding skin and provision of psychological support.

Dialysis

Chronic kidney disease (CKD) and dialysis treatment is a serious health issue requiring a multifaceted approach to treatment, including medication, monitoring of fluid and diet intake and a plan which incorporates the concerns and impact on family and carers (Bonner & Douglas 2008). Dialysis is a specialised nursing function which centres on delaying progression of disease and preventing further complications and administering and maintaining the dialysis program. It involves the transfer of solutes across a semi-permeable membrane, and the removal of waste products, excess salts and fluid from the blood. The method of dialysis is determined by the client’s condition and may be performed by the client at home if the facilities are available, in a specialised unit or a in mobile dialysis unit in rural and remote settings.

There are two types of dialysis: peritoneal dialysis (Figs 29.8 and 29.9) and haemodialysis.

Figure 29.8 Peritoneal dialysis

(Greenberg A (2009) Primer on Kidney Diseases, 5th edn. Philadelphia, Saunders, Fig 55.3.)

Figure 29.9 Continuous ambulatory peritoneal dialysis (CAPD) A: A bag of dialysate is attached to a tube in the client’s abdomen so that the fluid flows into the peritoneal cavity B: While the dialysate remains in the peritoneal cavity, the individual can roll up the bag, place it under their clothes and go about their normal activities C: The bag is unrolled and suspended below the pelvis, which allows the dialysate to drain from the peritoneal cavity

In peritoneal dialysis the client’s peritoneum provides the semi-permeable membrane. The procedure may be performed on an intermittent or continuous basis. A catheter is placed in the abdominal cavity, and dialysate is instilled through the catheter. Through diffusion and osmosis, waste products together with excess electrolytes and fluid are transported from the blood into the dialysate.

In haemodialysis the semi-permeable membrane is contained within a dialysis machine. Haemodialysis is performed an average of three times per week for a period of 4–6 hours. This method requires regular and convenient access to the client’s blood circulation. Several systems are available that provide this access, including an arteriovenous shunt or the creation of an arteriovenous fistula. An arteriovenous shunt is an artificial passageway that allows blood to flow from an artery to a vein without going through a capillary network (Fig 29.10A). An arteriovenous fistula is created surgically to provide vascular access for haemodialysis (Fig 29.10B). During haemodialysis, the client’s blood is passed through the artificial kidney (haemodialysis machine) and then returned to the client’s own circulation. The client’s blood is anticoagulated during haemodialysis to prevent clotting in the tubing and machine. Although dialysis is a lifesaving treatment, it is nonetheless accompanied by risk.

Figure 29.10 A: Arteriovenous shunt B: Arteriovenous fistula

(Game et al 1989)

Nursing intervention

Once a client commences dialysis they have to deal with considerable changes to their lifestyle. These changes may impact on the client psychologically, resulting in depression, anxiety, feelings of guilt and fear of death. They may have to deal with changes in the role in family, changes in employment status, financial concerns and a reduced social network (Bonner & Douglas 2008). Many clients self-manage their dialysis. The time and support needed varies greatly from client to client; the nurse’s role is to be in partnership with the client to generate optimum health outcomes by:

Table 29.5 Complications of dialysis

Renal transplant

Renal transplant is a surgical procedure replacing a patient’s failed kidney with a healthy kidney from a donor. The recipient’s own kidney may be either left or removed. The donor ureter is anastomosed either to the recipient’s ureter or to the recipient’s bladder. The transplanted kidney usually begins to produce urine within a very short time after the operation.

Close monitoring of the client after surgery is essential to assess renal function and to detect early signs of rejection of the new kidney. To help prevent graft rejection, which may occur within 1–30 days or up to several years after the transplant, immunosuppressive drugs are administered. As immunosuppressive drugs increase the risk of infection, protective isolation techniques may be implemented. A successful kidney transplant enables the client to lead a life free from the restrictions associated with dialysis therapy. However, immunosuppressive therapy will need to be continued as well as close monitoring of renal function and general health status. There are ethical, cultural and religious divides concerning the transplantation of organs and these issues need to be treated with sensitivity.