1.

DEFINITION
Urology is the surgical specialty that focuses on the urinary tracts of males and
females, and on the reproductive system of males. Medical professionals specializing in
the field of urology are called urologists and are trained to diagnose, treat, and manage
patients with urological disorders. The organs covered by urology include the kidneys,
ureters, urinary bladder, urethra, and the male reproductive organs (testes, epididymis, vas
deferens, seminal vesicles, prostate and penis). Both Urologists and General Surgeons
operate on the adrenal glands.
In men, the urinary system overlaps with the reproductive system, and in women
the urinary tract opens into the vulva. In both sexes, the urinary and reproductive tracts are
close together, and disorders of one often affect the other. Urology combines management
of medical (i.e. non-surgical) problems such as urinary tract infections and benign prostatic
hyperplasia, as well as surgical problems such as the surgical management of cancers, the
correction of congenital abnormalities, and correcting stress incontinence. Urology is
closely related to, and in some cases overlaps with, the medical fields of oncology,
nephrology,

gynecology,

andrology,

pediatric

surgery,

gastroenterology,

and

endocrinology.

2. ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM

The body takes nutrients from food and converts them to energy. After the
body has taken the food that it needs, waste products are left behind in the bowel and in
the blood. The urinary system keeps the chemicals and water in balance by removing a
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type of waste, called urea, from the blood. Urea is produced when foods containing
protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea
is carried in the bloodstream to the kidneys.
2.1 Two Kidneys
A pair of purplish-brown organs located below the ribs toward the middle of the
back. Their function is to:
o

remove liquid waste from the blood in the form of urine.

keep a stable balance of salts and other substances in the blood.

produce erythropoietin, a hormone that aids the formation of red blood cells.

The kidneys remove urea from the blood through tiny filtering units called
nephrons. Each nephron consists of a ball formed of small blood capillaries, called a
glomerulus, and a small tube called a renal tubule. Urea, together with water and other
waste substances, forms the urine as it passes through the nephrons and down the renal
tubules of the kidney.

2.2 Two ureters

Narrow tubes that carry urine from the kidneys to the bladder. Muscles in the
ureter walls continually tighten and relax forcing urine downward, away from the
2

kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop.
About every 10 to 15 seconds, small amounts of urine are emptied into the bladder
from the ureters.
2.3 Bladder
A triangle-shaped, hollow organ located in the lower abdomen. It is held in
place by ligaments that are attached to other organs and the pelvic bones. The
bladder's walls relax and expand to store urine, and contract and flatten to empty urine
through the urethra. The typical healthy adult bladder can store up to two cups of
urine for two to five hours.
2.4 Two sphincter muscles
Circular muscles that help keep urine from leaking by closing tightly like a
rubber band around the opening of the bladder.
2.5 Nerves in the bladder
Alert a person when it is time to urinate, or empty the bladder.
2.6 Urethra
The tube that allows urine to pass outside the body. The brain signals the
bladder muscles to tighten, which squeezes urine out of the bladder. At the same time,
the brain signals the sphincter muscles to relax to let urine exit the bladder through the
urethra. When all the signals occur in the correct order, normal urination occurs.

3. PATHOPHYSIOLOGY
3.1 Medical Diagnosis
Chronic kidney failure occurs when disease or dis- order damages the kidneys so
that they can no longer adequately remove fluids and wastes from the body or maintain
proper levels of kidney-regulated chemicals in the bloodstream. Chronic kidney failure,
also known as chronic renal failure, affects over 250,000 Americans annually. It may be
3

caused by a number of diseases and inherited disorders, but the progression (end result) of
chronic kidney failure is always the same.
The kidneys, which serve as the body's natural filtration system, gradually lose their
ability to remove fluids and waste products (urea) from the bloodstream. They also fail to
regulate certain chemicals in the bloodstream and allow protein to leak into the urine.
Chronic kidney failure is irreversible and eventually leads to total kidney failure, known as
end-stage renal disease (ESRD). Without treatment and intervention to remove wastes and
fluids from the bloodstream, ESRD is inevitably fatal.
Diabetes

Decrease of nefron

Hypertension
Glomerulonephritis
.disfunction of glomerulus filtration

Polycystic kidney disease

Loss of kidney function, there is

an accumulation of water; waste;
and toxic. substances, in the body,
that are normally excreted by the
kidney

Chronic Renal Failure (CRF)

Table 1. Stages of Chronic Kidney Disease

Stage

Description

GFR*
mL/min/1.73m2

Slight kidney damage with normal or

increased filtration

More than 90

Mild decrease in kidney function

60-89

Moderate decrease in kidney function

30-59

Severe decrease in kidney function

15-29

Kidney failure

Less than 15 (or

dialysis)

*GFR is glomerular filtration rate, a measure of the kidney's function.

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4. CAUSES, SIGN AND SYMPTOMS

Kidney failure is caused by acquired disease or hereditary disorders in the kidneys.
The four most common causes of chronic kidney failure include:
1.

Diabetes. Diabetes mellitus (DM), both insulin dependant (IDDM) and non-insulin
dependant (NIDDM), occurs when the body cannot produce and/or use insulin, the
hormone necessary for the body to process glucose. Long-term diabetes may cause
the glomeruli, the filtering units located in the nephrons of the kidneys, to gradually
lose function.

2.

Hypertension. High blood pressure is both a cause and a result of kidney failure. The
kidneys can become stressed and ultimately sustain permanent damage from blood
pushing through them at excessive pressures over long periods of time.

3.

Glomerulonephritis. Glomerulonephritis is an inflammation of the glomeruli, or

filtering units of the kidney. Certain types of glomerulonephritis are treatable, and
may only cause a temporary disruption of kidney functioning.

4.

Polycystic kidney disease. Polycystic kidney disease is an inherited disorder that

causes cysts to form in the kidneys. These cysts impair the regular functioning of the
kidney.
Less common causes of chronic kidney failure include kidney cancer, obstructions

such as kidney stones, pyelonephritis, reflux nephropathy, systemic lupus erythematosus,

amyloidosis, sickle cell anemia, Alport syndrome, and oxalosis.
Initially, symptoms of chronic kidney failure develop slowly. Even individuals
with mild to moderate kidney failure may have few symptoms in spite of increased urea
in their blood. Among signs and symptoms that may be present at this point are frequent
urination during the night and high blood pressure.
Most symptoms of chronic kidney failure are not apparent until kidney disease has
progressed significant- ly. Common symptoms include:
1. Anemia. The kidneys are responsible for the production of erythropoietin (EPO), a
hormone that stimulates red cell production. If kidney disease causes shrinking of the
kidney, this red cell production is hampered.
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2. Bad breath or a bad taste in mouth. Urea in the saliva may cause an ammonia-like
taste in the mouth.
3. Bone and joint problems. The kidneys produce vitamin D, which aids in the
absorption of calcium and keeps bones strong. In patients with kidney failure, bones
may become brittle, and in children, normal growth may be stunted. Joint pain may
also occur as a result of unchecked phosphate levels in the blood.
4. Edema. Puffiness or swelling around the eyes and legs.
5. Frequent urination.
6. Foamy or bloody urine. Protein in the urine may cause it to foam significantly. Blood
in the urine may indicate bleeding from diseased or obstructed kidneys, bladder, or
ureters.
7. Headaches. High blood pressure may trigger headaches.
8. Hypertension, or high blood pressure. The retention of fluids and sodium causes blood
volume to increase, which, in turn, causes blood pressure to rise.
9. Increased fatigue. Toxic substances in the blood and the presence of anemia may
cause feelings of exhaustion.
10. Itching. Phosphorus, which is typically eliminated in the urine, accumulates in the
blood of patients with kidney failure. This heightened phosphorus level may cause
itching of the skin.
11. Low back pain. Pain where the kidneys are located, in the small of the back below the
ribs.
12. Nausea, loss of appetite, and vomiting. Urea in the gastric juices may cause upset
stomach. This can lead to malnutrition and weight loss.
5. NURSING PROCESS
5.1 Assessment
a) Interview
Patient Identity

: Name, age, race, religion, education, occupation, address.

History of Present Illness: Loss of kidney function, there is an accumulation of water,

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waste, and toxic substances, in the body, that are normally

excreted by the kidney.
Past Nursing History

: Hystory of contagious diseases, hereditary diseases, allergic

history.

Family Health History

b) Physical Examination
B1

: Breathing (Respiratory System)

Symptoms : short bearth, takipnea, dyspnea, increased frequency.

B2

: Bleeding (Cardiovascular system)

Symptoms : hipertention, hipotention, edema, pale.

B3

: Brain (Nervous system)

Symptoms : headache.
B4

: Bladder (Genitourinary system)

Symptoms : oliguria, poliuria.

B5

: Bowel (Gastrointestinal System)

Symptoms : abdomen distention.

B6

: Bone (Bone-Muscle-Integument)

Symptoms : pain in bone.

c) Diagnostic test
Urine Tests:
Urinalysis: Analysis of the urine affords enormous insight into the function of the
kidneys. The first step in urinalysis is doing a dipstick test. The dipstick has reagents
that check the urine for the presence of various normal and abnormal constituents
including protein. Then, the urine is examined under a microscope to look for red and
white blood cells, and the presence of casts and crystals (solids).
Only minimal quantities of albumin (protein) are present in urine normally. A
positive result on a dipstick test for protein is abnormal. More sensitive than a dipstick
test for protein is a laboratory estimation of the urine albumin (protein) and creatinine
in the urine. The ratio of albumin (protein) and creatinine in the urine provides a good
estimate of albumin (protein) excretion per day.
Twenty-four hour urine tests: This test requires you to collect all of your urine
for 24 consecutive hours. The urine may be analyzed for protein and waste products
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(urea nitrogen, and creatinine). The presence of protein in the urine indicates kidney
damage. The amount of creatinine and urea excreted in the urine can be used to
calculate the level of kidney function and the glomerular filtration rate (GFR).
Glomerular filtration rate (GFR): The GFR is a standard means of expressing overall
kidney function. As kidney disease progresses, GFR falls. The normal GFR is about
100-140 mL/min in men and 85-115 mL/min in women. It decreases in most people
with age. The GFR may be calculated from the amount of waste products in the 24hour urine or by using special markers administered intravenously. An estimation of
the GFR (eGFR) can be calculated from the patient's routine blood tests. Patients are
divided into five stages of chronic kidney disease based on their GFR (see Table 1
above).
Blood Tests:
Creatinine and urea (BUN) in the blood: Blood urea nitrogen and serum creatinine
are the most commonly used blood tests to screen for, and monitor renal disease.
Creatinine is a product of normal muscle breakdown. Urea is the waste product of
breakdown of protein. The level of these substances rises in the blood as kidney
function worsens.
Estimated GFR (eGFR): The laboratory or your physician may calculate an estimated
GFR using the information from your blood work. It is important to be aware of your
estimated GFR and stage of chronic kidney disease. Your physician uses your stage of
kidney disease to recommend additional testing and suggestions on management.
Electrolyte levels and acid-base balance: Kidney dysfunction causes imbalances in
electrolytes, especially potassium, phosphorus, and calcium. High potassium
(hyperkalemia) is a particular concern. The acid-base balance of the blood is usually
disrupted as well. Decreased production of the active form of vitamin D can cause
low levels of calcium in the blood. Inability to excrete phosphorus by failing kidneys
causes its levels in the blood to rise. Testicular or ovarian hormone levels may also be
abnormal.
Blood cell counts: Because kidney disease disrupts blood cell production and shortens

the survival of red cells, the red blood cell count and hemoglobin may be low
(anemia). Some patients may also have iron deficiency due to blood loss in their
8

gastrointestinal system. Other nutritional deficiencies may also impair the production
of red cells.

Other tests:
Ultrasound: Ultrasound is often used in the diagnosis of kidney disease. An

ultrasound is a noninvasive type of imaging test. In general, kidneys are shrunken in

size in chronic kidney disease, although they may be normal or even large in size in
cases caused by adult polycystic kidney disease, diabetic nephropathy, and
amyloidosis. Ultrasound may also be used to diagnose the presence of urinary
obstruction, kidney stones and also to assess the blood flow into the kidneys.
Biopsy: A sample of the kidney tissue (biopsy) is sometimes required in cases in

which the cause of the kidney disease is unclear. Usually, a biopsy can be collected
with local anesthesia by introducing a needle through the skin into the kidney. This is
usually done as an outpatient procedure, though some institutions may require an
overnight hospital stay.

5.2 Nursing Diagnosis

a. Problem: Accumulation of water; waste; and toxic substances, in the body, that are
normally excreted by the kidney.
Etiology: Chronic kidney failure occurs when disease or dis- order damages the
kidneys so that they can no longer adequately remove fluids and wastes from the body
or maintain proper levels of kidney-regulated chemicals in the bloodstream.
b. Problem: Social Interaction
Etiology: Difficult to determine condition, for example unable to work, maintain the
function in family. Insufficient or excessive quantity or ineffective quality of social
exchange.
c. Problem: Elimination of urine
Etiology: Decrease of urine frequency, oliguria, anuria.
9

d. Problem: Imbalanced nutrition/ fluids

Etiology: Increase of body weight in a few time (edema), decrease of body weight
(malnutrition), anorexia, vomit.
5.3 Intervention
No. Nursing Diagnosis
1.

Accumulation

Goal

Statement Intervention

Rationale

(NOC)
(NIC)
of - Long term goals: - Auskultasi heard - S3/S4

water, waste, and

water, waste, and

and

toxic substances, in

toxic

sound.

the body related to

in the body can

Evaluation

altered pattern of

separated

oedema

urinary elimination.

distribute well in
own

substances,

part

and
after

treatment.
- Short term goals:
water, waste, and
in

of
and

dypsnea.
- Assesst

of

Notice

Hemodialysis

substances,
the

body

separated

and

distribute well in
own part. Give a
comfort condition
to the patient.

tonus

muffled, tachycardia.
irregular

heart

frequency,
tachypnea, dyspnea.
- Hypertension causes
interference

hypertension.

doing

toxic

pulmonary

with

for

postural changes,

of

aldosteron

renin

angiotensin system.

for example sit,

- Hypertention

lay, stand.
- Examine

CRF can causes IM,

complaints

of

chest pain. Notice

of

and

location

radiation.
- Evaluate of heart

CRF

patient

causes

can

pericarditis,

tamponade.
- There are suddenly
hypotention,

sounds,

blood

paradoxic

artery,

pressure,

pulse

narrowing

artery

perifer,

congesti

vascular,
temperature

pressure,

decrease

perifer artery, pale.

and

sensory.
- Assest

the

activity,

the

respond

of

- Fatigue and anemia

following CRF.

- Unbalance

can

activity.
10

- Beware

of

disturb

electrical

laboratory

conduction and heart

examination. For

function. Useful for

example

identification

Electrolit

and

chest roengten.
- Administer

heart

failure.
- Decrease

vascular

resistance

systemic

antihypertention.

and renin output for

For

decrease myocardial

example:

Prazozin

works and help to

(minipress).

prevent CRF.
- Electrolyte

- Help

in

pericardiocentesis
suitable

accumulation
pericardium

in
layers

can influence heart

indication.

charge

and

contraction

of

myocardiac

can

disturb and potential

to be heart failure.
- Prepare

for

dyalisis.

- Decrease of ureum
toxin and improve
electrolyte
imbalance and fluid
overbalance

can

prevent

heart

manifestation include
hypertension
2.

Social

pericardial effusion.
- Alert with changes

interaction - Long term goals: - Assesst

related to impaired

Physic and mental

disturbance

social interaction.

patient

thinking.

more

can
calm

be
and

and

of

- Ensure from the

give

chance

for

evaluated

and

intervention.
- Give compare
11

for

comfort

after

nurse

give

nearest

about the brain of

explanation about
the condition.
- Short term goals:
Patient

can

rest

calmly and more

relax

after

24

hours nursing care.

family

development.

to nearest family
about

the

condition

of
- Minimalisation

patient.
- Give

environmental,

the

fact

help in introducesing

- The

potensial

confrontation

- Comunication
with

confusion.

simple

santance.
- Make a scadule
a

- Help in defend actual

orientation.

good
- Insomnia can disturb

activity.
- Adekuat rest.

cognitive skills.

Elimiation of urine - Long term goals: - Auskultasi heard - S3/S4

water, waste, and

and

urinary elimination.

toxic

substances,

sound.Mevaluatio

irregular

in the body can

n of oedema and

frequency,

distribute well in
own

part

after

doing
Hemodialysis
treatment.
- Short term goals:

pulmonary

with

related to altered

and

make

against reaction.
- Can helping decrease

brief.

for

for decrease sensory.

- Give instruction to
reality.

people, and the

other.
- Give

of

environment respons

relaxing.
- Orientation about

separated

the

patient.
- Physical
- Give information

environmental

3.

evaluation

dypsnea.
- Assest

muffled, tachycardia.
heart

tachypnea, dyspnea.
of - Hypertension causes

hypertention.
Notice

tonus

interference
for

postural changes,

aldosteron

of
renin

angiotensin system.

for example sit,

lay, stand.

- Hypertension

and
12

water, waste, and - Examine

toxic
in

substances,
the

body

separated

and

distribute well in
own part. Give a
comfort condition
to the patient.

CRF can causes IM,

complaints

of

chest pain. Notice

of

location

radiation.
- Evaluate of heart

CRF

patient

causes

can

pericarditis,

tamponade.
- There are suddenly
hypotention,

sounds,

blood

paradoxic

artery,

pressure,

pulse

narrowing

artery

perifer,

congesti

vascular,

decrease

perifer artery, pale.

temperature

and

sensory.
- Assest

the

activity,

the

respond

of

activity.
- Beware

of

examination. For
example

Electrolit

- Fatigue and anemia

following CRF.

- Unbalance
disturb

can
electrical

conduction and heart

laboratory

and

chest roengten.
- Administer
antihypertention.
For

pressure,

example:

function. Useful for

identification

heart

failure.
- Decrease

vascular

resistance

systemic

and renin output for

decrease myocardial
works and help to

Prazozin

prevent CRF.

(minipress).

- Electrolyte
- Help

in

accumulation

in

pericardiocentesis

pericardium

layers

suitable

can influence heart

indication.

charge

and

contraction

of

myocardiac

can
13

disturb and potential

to be heart failure.
Prepare for dyalisis.

Decrease
toxin

of

and

electrolyte

ureum
improve

imbalance

and fluid overbalance

can

prevent

heart

manifestation include
hypertention
4.

Imbalanced

- Long term goals: - Assesst a diet

- Give some food
nutrition related to
Necessity
of
and continued.
altered
nutrition/
nutrition in our
- Give a list of a
fluids
body can balance.
food and drink
- Short term goals:
which
can
Necessity
of
consume
with
nutrition in our
patient.
body can fullfiled
- Washing hand and
after
giving
cleaning mouth.
nursing care.
- Measure the body
weight.

and

pericardial effusion.
- Help in identification
deficiency and diet
programe.
- Anorexia minimilze
and

vomit

related

with uremik.
- Give intervention to
control

in

diet

programe.
- Give a treatment
mouth and refreshing
mouth which often
feel uncomfort.
- Patient fast.

5.4 Evaluation
1. S (Subjective):
Patient has not feel pain.
Patient feel comfort.
2. O (Objective):
The normal GFR is about 100-140 mL/min in men and 85-115 mL/min in women.
Urine test showed that the function of the kidneys was normal.
14

3. A (Assessment):

Goal match: the body can separated and distribute well in own part after doing
Hemodialysis treatment.

Goal not match: the body cant separated and distribute well in own part after
doing Hemodialysis treatment.

Goal parsialy match: The body can separated and distribute not so well in own
part after did Hemodialysis treatment.

New problem: The Chronic Renal Failure causes complication with another organ.

4. P (Planning):

Goal match: We can continue the treatment. If the condition have stabil, we can
stop the treatment (hemodialysis).

Goal not match: We cant do the new treatment because Chronic Renal Failure is
the last desease.

Goal parsialy match: Continue the treatment or modifiy with another treatment.
For example: Did hemodialysis with new equipment.

New problem: Evaluation all of the treatment and make new strategy.

REFERENCES
Doenges, ME. 1999. Rencana Asuhan Keperawatan. Jakarta: EGC
Gibson, John. 1995. Anatomi dan Fisiologi Modern. Jakarta: EGC
Nurjanah, Intansari. 2005. Aplikasi Proses Keperawatan. Yogyakarta: Mocomedia

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Nursalam. 2006. English In Nursing Midwifery Sciences and Technology. Surabaya:

Airlangga University
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http://www.renalinfo.com/us/how_kidneys_work_and_fail/kidney_failure/symptoms_of_kidn
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