INDEX

Sl. No. Content Page no.

Anatomy and physiology of renal system

1. Introduction

2. Components of the renal system

A. Kidney

a. Organs associated with kidney

Gross structure of the kidney

b.
Microscopic structure of the kidney
c.
The Nephron

d. Functions of the kidney

Composition of urine
e.

Ureters
f.
Structure of Ureters

Function of Ureters
B.

Urinary Bladder
a.
Organs associated with the urinary bladder
b.
Structure of the bladder

Functions of the bladder

C.
Urethra
a. Difference between child and adult urinary system

b.
 c.

D.

3.

Sl. No. Content Page no.

CHILD WITH RENAL/ URINARY TRACT DISORDERS

I. Nephrotic Syndrome

1. Introduction

2. Definition

3. Incidence

4. Etiology

5. Classification

6. Pathophysiology

7. Clinical manifestations

8. Diagnostic evaluation

9. Prognosis

10. Management

a. Medical management

b. Nursing management

II. Hydronephrosis

1. Introduction

2. Definition
 3. Etiology

4. Classification

5. Pathophysiology

6. Clinical manifestations

7. Diagnostic evaluation

8. Prognosis

9. Management

a. Medical management

b. Surgical management

c. Nursing management

III. Bibliography
 RENAL SYSTEM

INTRODUCTION

The renal system consists of all the organs involved in the formation and release of urine.
It includes the kidneys, Ureters, bladder and urethra.

The kidneys are bean-shaped organs which help the body produce urine to get rid of
unwanted waste substances. When urine is formed, tubes called ureters transport it to the urinary
bladder, where it is stored and excreted via the urethra. The kidneys are also important in
controlling our blood pressure and producing red blood cells.   

COMPONENTS OF THE RENAL SYSTEM

KIDNEYS

One of the most complex,

beautifully “engineered” organs
of the human body, the kidneys
perform several essential tasks
including the excretion of waste
products, the maintenance of
homeostatic balance in the body
and the release of important
hormones.
Location and Basic Structure of the Kidneys

The kidneys lie on the posterior abdominal, one on each side of the vertebral
column, behind the peritoneum and below the diaphragm. Extends from the level of the
12th thoracic vertebra to 3rd lumbar vertebra. The right kidney lying a little lower than the
left, allowing room for the liver.

Each kidney is identical in structure and function. They are bean-shaped, reddish
brown in colour and measure about 10 cm long and 6.5 cm wide and 3 cm thick. Each
kidney comprises an outer cortex and an inner medulla. On the side of the kidney with
the smaller curve is an opening called the hilum, where blood vessels, nerves, and the
ureters enter the kidney. On one end of the ureters is a funnel-shaped expansion, called
the renal pelvis, where urine collects.

Organs associated with kidney

As the kidneys lie either side of the vertebral column each is associated with a
different group of structures.

Right kidney

Superiorly : the right adrenal gland

Anteriorly : the right lobe of the liver, the duodenum and the hepatic flecture
of the colon
Posteriorly : the diaphragm and muscles of the posterior abdominal wall.

Left kidney

Superiorly : the left adrenal gland

Anteriorly : the spleen, stomach, pancreas, jejunum and splenic flexure of the
colon
Posteriorly : the diaphragm and muscles of the posterior abdominal wall.

Gross structure of the kidney

 There are three areas of tissue which can be distinguished when a longitudinal section
of the kidney is viewed with naked eye.
A fibrous capsule surrounding the kidney
The cortex is the reddish brown layer of tissue immediately under the capsule
and between the pyramids.
The medulla is the innermost layer, consisting of pale conical shaped
striations called as renal pyramids.
 Hilum is the concave medial border of the kidney where the renal blood and lymph
vessels and nerves enter.
 The renal pelvis is the funnel shaped structure which acts as a receptacle for the urine
formed by the kidney. It has number of branches called calyces. At its upper end ,
each of which surrounds the apex of a renal pyramid.

Microscopic structure of the kidney

The kidney substance is composed of about one million functional units, the
nephrons, and a smaller number of collecting tubules. The collecting tubules transport
urine through pyramids to the pelvis. The uriniferous tubules are supported by a small
amount of connective tissue, containing blood vessels, nerves and lymph vessels.

The Nephron

The nephron consists of a tubule closed at one end, the other end opening into a
collecting tubule. The closed end is intended to form the cup-shaped glomerular capsule
(Bowman’s capsule) which almost completely encloses a network of arterial capillaries,
the glomerulus.

Continuing from the glomerular capsule the remainder of the nephron is about
3cm long and is described in three parts.

- The proximal convoluted tubule.

- The medullary loop or loop of Henle

- The distal convoluted tubule, leading into a collecting tubules.

 The collecting tubules unite forming larger tubules that empty into the minor calyces.

After entering the kidney at the Hilum the renal artery divides into smaller arteries
and arterioles. In the cortex an arteriole, the afferent arteriole, enters each glomerular
capsule, and then subdivides into a cluster of capillaries, forming the glomerulus.

The blood vessel leading away from the glomerulus is the efferent arteriole; it
breaks up into a second capillary network to supply oxygen and nutritional material to the
remainder of the nephron. Venous blood drained from this capillary bed eventually leaves
the kidney in the renal vein which empties into the inferior vena cava. The blood pressure
in the glomerulus is higher than in other capillaries because the diameter of the afferent
arteriole is greater than that of efferent arteriole.

Functions of the Kidney

1. Formation Of Urine

The kidneys form urine which passes through the ureters to the bladder for excretion. The
composition of urine reflects the activities of the nephron in the maintenance of
homeostasis. Waste products of protein metabolism are excreted, electrolyte balance is
maintained and acid base balance is maintained.

The urine formed in three phases.

A. Simple filtration

Filtration takes place through the semi permeable walls of the glomerulus and
glomerular capsule. Water and a large number of small molecules pass through, some
of which reabsorbed later. Blood cells, plasma proteins and other large molecules
unable to filter and remains in the capillaries.
 B. Selective reabsorption
It is the process by which the composition and volume of the glomerular filtrate are
altered during its passage through the convoluted tubules, the medullary loop and the
collecting tubules. The purpose of this process is to reabsorb those filtrate
constituents needed by the body to maintain fluid and electrolyte balance and blood
alkalinity.

C. Secretion
Filtration occurs as the blood flows through the glomerulus. Substances, that are not
required and foreign materials, e.g. drugs may not be cleared off from the blood by
filtration because of the short time it remains in the glomerulus. Such substances are
cleared off by secretion into the convoluted tubules and exceeted from the body in the
urine.

Composition of urine
Water 96%
Urea 2%
Uric acid, creatinine, ammonia, sodium, potassium, chlorides, phosphates, sulphates,
oxalates 2%

Characteristics of urine
Urine is amber color due to presence of urobilin, a bile pigment altered in the
intestine, reabsorbed and then excreted by the kidneys.
Specific gravity is between 1020-1030 and the reaction is acid.
Normal urine production is 1000-1500 per day.

2. Water Balance And Urine Output

The balance between the fluid intake and output is controlled by kidneys. The minimum
urinary output consistent with the essential removal of waste material is about 500 ml per
day. The amount produced in excess of this is controlled by the ADH (Anti Diuretic
Hormone) released into the blood by the posterior lobe of the pituitary gland.
3. Electrolyte Balance
 Changes in the concentration of electrolytes in the body fluids may be due to changes
in the amount of water or electrolytes.
 Sodium is the most common cation in extracellular fluid and potassium is the most
common intracellular cation.
 Sodium is a normal constituent of urine and the amount excreted is regulated by the
hormone Aldosterone, secreted by the cortex of the adrenal gland.
URETERS
The ureters are the tubes that convey urine from the kidneys to the urinary
bladder. They are about 25 to 30 cm long with a diameter of about 3 mm.
The ureter is continuous with the funnel shaped renal pelvis. It passes downwards
through the abdominal cavity, behind the peritoneum in front of the psoas muscle into the
pelvic cavity, and passes obliquely through the posterior wall of the bladder. Because of
this arrangement the ureters are compressed and the opening accluded when urine
accumulates and the pressure raises in the bladder. This prevents reflux of urine as the
bladder fills and during micturation, when pressure increases as the bladder wall
contracts.

Structure
The ureter consists of three layers of tissue
 An outer covering of fibrous tissue, continues with the fibrous capsule of the kidney
 A middle muscular layer consisting of interlacing smooth muscle fibers that form a
syncytium spiraling round the ureter, some in clockwise and some in anti clockwise
directions and an additional outer longitudinal layer in the lower third.
 An inner layer of transitional epithelium

Functions
The ureters propel the urine from the kidneys into the bladder by peristaltic contraction of
muscular wall. Peristaltic waves occur at about 10 seconds intervals, sending little spurts
of urine into the bladder.
URINARY BLADDER
It is a reservoir for urine. It lies in the pelvic cavity and its seize and position vary,
depending on the amount of urine it contains. When distended the bladder raises into the
abdominal cavity

Organs associated with the bladder

In the female
Anteriorly : the symphysis pubis
Posteriorly : the uterus and upper part of the vagina
Superiorly : small intestine
Inferiorly : the urethra and the muscles forming the pelvic floor

In the male
Anteriorly : the symphysis pubis
Posteriorly : the rectum and seminal vesicles
Superiorly : small intestine
Inferiorly : the urethra and the prostate gland

Structure

Bladder is roughly pear shaped, but becomes more oval as it fills with urine. The
bladder opens into urethra at its lowest point, the neck.

The bladder wall is composed of three layers

 The outer layer of loose connective tissue, containing blood and lymphatic vessels
and nerves, covered on the upper surface by the peritoneum

 The middle layer consisting of a mass of the interlacing smooth muscle fibers and
elastic tissue loosely arranged in three layers. This is called detrusor muscle and it
empties the bladder when it contracts
  The lining of transitional epithelium

Functions
 Acts as a reservoir for urine
 Stimulation of micturition through contraction of detrusor muscle.

URETHRA
It’s a canal extending from the neck of the bladder to the exterior, at the external
urethral orifice. Its length differs in male and female. The male urethra associated with
the urinary and reproductive system and approximately 18cm in length. The female
urethra is approximately 4 cm long it runs downwards forwards behind the symphysis
pubis and opens at the external urethral orifice just in front of the vagina. The external
urethral orifice is guarded by the external urethral sphincter which is under voluntary
control.

The urethral wall consists of three layers of tissue

 A muscle layer continues with that of the bladder consisting of elastic tissue and
smooth muscle fibers, under autonomic nerve control.

 Sub mucus spongy layer containing blood vessels and nerve.

 The mucus membrane lining which is continuous with that of the bladder in the
upper part and stratified squamus epithelium continuous externally with the skin
of the vulva.

DIFFERENCE BETWEEN CHILD AND ADULT URINARY SYSTEM

The function of the kidney of the infant and an adult differs.

 Although the infant’s kidneys have been thought to be immature, during health they do not
operate at a functional level that is appropriate for the size of the body
 When infants are under stress, however their functional reserves are reduced compared
with those of adults.

 kidney function of the infant 6 to 12 months of age is nearly like that of the adult

 Premature infants smaller than 34 weeks gestation have decreased reabsorption of glucose,
sodium, bicarbonate, and phosphate.

 The full term infant normally can reabsorb sodium, but under conditions of salt loading
cannot excrete the excess sodium and may develop hypernatremia, increased extra cellular
fluid volume, and edema.

 Young infant cannot concentrate their urine as well as older children and adults. After the
first few weeks of life the acidifying capacity of the kidney reaches the adult level.

 When infants have acidosis, however, they can increase acid secretion only a small
amount so that they become susceptible to acidemia.

 Chronic renal failure usually does not follow acute renal failure in the child as it does in
the adult, the young kidney can grow and increase the number of functioning cells.
Chronic renal failure occurs rarely but it may become clinically apparent during the period
of rapid adolescent growth, when the kidney cannot keep up with increasing body size.
 HYDRONEPHROSIS

INTRODUCTION

Hydronephrosis is a condition in which one or both of the kidneys become stretched and
swollen. This is usually because:

 there is a blockage somewhere in the urinary system (along the urine flow path),
which is the usual cause, or

 urine is flowing from the bladder back to the kidneys

It can sometimes cause a pain in the side, or there may be no symptoms at all.

DEFINITION

Hydronephrosis is distension and dilation of the renal pelvis and calyces, usually caused
by obstruction of the free flow of urine from the kidney, leading to progressive atrophy of the
kidney.

ETIOLOGY

 Blockage in the area where the ureter and kidney meet, known as the uretero-
pelvic junction
  Obstruction occurs in the uretero-vesical junction where the ureter meets the
bladder.

 Vesico-ureteral reflux, in which urine in the bladder reenters the ureters and
sometimes the kidneys.-

 Stones, surgery or a urinary tract injury.-

PATHOPHYSIOLOGY OF HYDRONEPHROSIS

Due to etiological factors the outward flow of urine is blocked.

First shows evidence of hyperactivity and hypertrophy dilatation and atony.

Muscular loss of peristaltic activity

Atrophy of the renal parenchyma

Compression of the arcuate vessels

Ischemic atrophy renal calyces

Distension and dilation of the renal pelvis and calyces leads to symptoms

SIGNS AND SYMPTOMS

The signs and symptoms of Hydronephrosis depend upon whether the obstruction is acute
or chronic, partial or complete, unilateral or bilateral. Unilateral Hydronephrosis may occur
without any symptoms, while acute obstruction can cause intense pain.

 Asymptomatic (in some cases)

 Pain is felt in the renal area

 Hematuria
  Urinary infection, dysuria frequency

 Renal calculi

 Azotemia

 Unexplained vague GI symptoms

 Some large Hydronephrosis can be palpable

DIAGNOSTIC STUDIES
 History collection
 Physical examination: An enlarged kidney may be palpable on examination.
Suprapubic tenderness along with a palpable bladder is strongly suggestive of acute
urinary retention
 Blood tests can show raised Creatinine and electrolyte imbalance.
 Urinalysis may show an elevated pH due to the secondary destruction of nephrons
within the affected kidney.
 Ultrasound allows for visualization of the ureters and kidneys and can be used to
assess the presence of Hydronephrosis and / or hydroureter.

 IVU (intravenous urogram) is useful for assessing the position of the obstruction.
 Antegrade or retrograde pyelography will show similar findings to an IVU but
offer a therapeutic option as well.
 CT 99% of stones are visible on CT and therefore CT is becoming a common choice
of initial investigation. CT is not used however, when there is a reason to avoid
radiation exposure, e.g. in pregnancy.

PROGNOSIS

Early detection and prompt treatment has good prognosis. Left untreated, bilateral
obstruction (occurring to both kidneys rather than one) has a poor prognosis.

MANAGEMENT
 MEDICAL MANAGEMENT

Treatment of Hydronephrosis focuses upon

 The removal of the obstruction
 Drainage of the urine that has accumulated behind the obstruction.
 The antibiotics are used to prevent the Hydronephrosis from causing
kidney infections.
SURGICAL MANAGEMENT

 Nephrostomy

Acute obstruction of the upper urinary tract is usually treated by the insertion of a
Nephrostomy (an artificial opening created between the kidney and the skin which allows
for the drainage of urine directly from the upper part of the urinary system) tube.

 Ureteric Stent

Chronic upper urinary tract obstruction is treated by the insertion of a Ureteric stent
(a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the
kidney)

 Pyeloplasty

Pyeloplasty is the surgical reconstruction or revision of the renal pelvis to drain and
decompress the kidney. Most commonly it is performed to treat an uretero-pelvic junction
obstruction if residual renal function is adequate.

 Suprapubic Catheter
 Lower urinary tract obstruction is usually treated by insertion of a urinary catheter or
a Suprapubic catheter.

 Fetal surgery for congenital Hydronephrosis.

Fetal surgical treatment is done for the correction of posterior urethral valve
obstruction and ureteropelvic junction obstruction.

NURSING MANAGEMENT

NURSING DIAGNOSIS

Pre-Operative Nursing Diagnosis

1. Hyperthermia related to infectious process.

2. Impaired nutritional status less than body requirement related to hospitalization.

3. Disturbed elimination pattern incontinence of urine and related to retention of urine

4. Deficient knowledge of parents related to the plan of treatment, surgical procedure and
prevention of complications.

5. Disturbed family process related to hospitalization of the child.

6. High risk for urinary tract infection related to presence of urinary obstruction.

Post-Operative Nursing Diagnosis

1. Ineffective airway clearance related to effects of anesthesia, and pain

2. Acute pain related to incision, and the surgical procedure

3. Impaired physical mobility of the upper extremities related to surgery

4. Risk for imbalanced fluid volume related to the surgical procedure

5. Deficient knowledge of home care procedures

6. Risk for infection related to the presence of surgical wound.

NURSING INTERVENTIONS
  Temporary urinary drainage may be achieved by a Nephrostomy or
ureterostomy. Other options are ureteral, urethral, or Suprapubic catheterization. When
there is no infection, immediate surgery is not necessary even if there is complete
obstruction and anuria.

 Urologists often place a ureteral stent, which is performed along with a

cystoscopy and retrograde pyelography.

 Stents can bypass an obstruction and dilate the ureter for further
evaluation and treatment such as a percutaneous Nephrostomy tube, which may be placed
when a retrograde stent cannot be passed because of an obstruction in the ureter.

 Advances in endoscopic and percutaneous instrumentation have reduced

the surgical role, although some cases of Hydronephrosis still require treatment with open
surgery. Many surgeons will wait until acid-base, fluid, and electrolyte balances are
restored before operating. Surgery includes options such as prostatectomy for benign
prostatic hypertrophy, tumor removal, and dilation of urethral strictures.

Psychosocial

Although Hydronephrosis is a treatable condition, the patient is likely to be upset

and anxious. Many find GU examinations embarrassing.

Urinary catheterization can also be a stressful event, particularly if it is performed

by someone of the opposite gender.

If the patient’s renal condition has been permanently affected, determine the
patient’s ability to cope with a serious chronic condition.