A Nursing Case Study on Chronic Renal Failure
In Partial Fulfilment of the Requirements in
Introduction and Implications-5%
Developmental Data- 5%
Anatomy and Physiology-5%
TABLE OF CONTENTS
B.Past Health History11-12
Anatomy and Physiology of the Urinary System23-32
Predisposing and Precipitating Factors,
Symptomatology and Etiology39-43
B.Other Possible Tests54-55
i.Nursing Care Plan83-92
Kidneys are two bean-shaped organs, each about the size of your fist. They’re located at the back of your upper abdomen, on either side of your spine. Their main function is to eliminate excess fluid and wastes from your body by filtering them out of your blood. When your kidneys lose their filtering ability, dangerous levels of fluid and waste accumulate in your body — a condition known as kidney failure. One form of kidney failure — chronic kidney failure — usually develops slowly, with few signs or symptoms in the early stages. Many people with chronic kidney failure don’t realize they have a problem until their kidney function has decreased to less than 25 percent of normal. High blood pressure and diabetes are the most common causes of chronic kidney failure. The main goal of treatment of chronic kidney failure is to halt or delay progression of the disease.
Chronic kidney failure can progress to end-stage kidney disease, where the kidneys function at a fraction of normal capacity. At this point, you’ll need either artificial filtering (dialysis) or a kidney transplant to stay alive. The prevalence of kidney/renal diseases has been increasing in trend, especially the end-stage renal disease (ERSD) as reported in the Philippine Renal Disease Registry (PRDR). The rate of death due to end-stage renal disease has been in the top ten list of the mortality of the Department of Health (DOH). One Filipino develops chronic renal failure every hour or about 120 Filipinos per million populations per year. More than 5,000 Filipino patients are presently undergoing dialysis and approximately 1.1 million people worldwide are on renal replacement therapy.
This case study will give you an abundance of information regarding chronic renal failure. We have vigilantly studied the case of Mr. Client x, our chosen client, for us to be able to gain knowledge, apply our skills and develop our attitude to become competent nursing students. More so, this case study is completed for the benefit of our chosen client and as well as to patients who are afflicted and will be afflicted by the same health problem. OBJECTIVES
This case study is a requirement in our Perception – Stress and Illness concept where we had our related learning experience at Saint Dominic Ward (left wing) in San Pedro Hospital. The group aims to formulate a comprehensive case study about our chosen client, Sir Xxx Client x, and his diagnosis of Chronic Renal Failure. Upon the accomplishment of this case study, the group also aims to improve our skills, especially in research, attitude, and knowledge.
At the end of our 2 weeks of data gathering and completing the study, the group aims to accomplish the following:
Establish rapport and have a pleasant student nurse-client working relationship with our client, Sir Xxx Client x, and his significant others so that the group can gain their trust and can obtain pertinent information from them; formulate and present an introduction that is related to the case being studied; trace our client’s family tree and make corresponding legends that will show the hereditary diseases and the present status of our client’s family members; collect the necessary information about our client, his personal data, past health history and present conditions; define the final diagnosis;
identify the developmental tasks of our client using Erik Erikson’s Psychosocial Theory and Rober Havighurst’s Developmental Task Theory; assess the patient thoroughly from head-to-toe (cephalocaudal); identify and present the anatomy and physiology of the urinary system; illustrate and identify the parts of the urinary system; trace the pathophysiology of the disease process;
identify the precipitating and predisposing factors that may contribute to our client’s condition; present the symptoms with their corresponding rationale; interpret the results of diagnostic and laboratory examinations undergone by our client and identify the corresponding nursing considerations; enumerate the other possible diagnostic exams significant to our client’s condition; discuss the drugs given to the client, including their actions, indications, contraindications, side effects, adverse effects, and nursing responsibilities; present the actual and possible medical and surgical management; formulate and present the nursing care plans with their appropriate nursing diagnosis, cues, needs, objective of care, interventions and evaluation; enumerate the discharge planning using the M.E.T.H.O.D. system, for our client and his significant others to promote over-all well-being; present the prognosis of our
list and present the sources and references used in this study.
FAMILY HISTORY – NARRATIVE
The presented diagram is not complete because our client, does not anymore recall his relatives since he claimed that his relatives live at Negros Occidental and have since no contact with them.
Mr. Xxx Client x, our client is the second son in twelve offsprings of Mr. Wilferdo and Mrs. Angeles Gunay-Client x, both are deceased. Mr. Wilfredo died due to old age while Mrs. Angeles died due to heart attack (hypertension). Our client’s siblings are: Reynaldo, 59 years old, a hypertensive and diabetic; Teresita, deceased when she was only 11 years old due to vehicular accident; Renato, 52 years old who is battling cancer; Remegio, 50 years old; Socorro, deceased when she was in Grade 6 due to unknown cause; Lorna, 46 years old; and the youngest is Glenda, 38 years old.
Mr. Wilfredo Client x, patient’s father is the fourth in a brood of twelve children of Mr. Sotero and Mrs. Donata Porques- Client x, both deceased due to old age. And,
Mrs Angeles- Gunay Client x, is the mother of our client, she is the fourth child among eight offsprings of Mr. Tranquilino and Mrs. Rita Salazar- Gunay, who are both deceased of a cause which our client cannot remember.
Chronic Renal failure or ESRD (End Stage Renal Disease), is a progressive, irreversible deterioration in renal function in which’s body’s capability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia (Retention of urea and other microorganisms wastes in the
CRF or ESRD may be caused by systemic disease, such as diabetes mellitus; hypertension; chronic glomerulonephritis; pyelonephritis; obstruction of the urinary tract; hereditary lesions, as in polycystic kidney disease; vascular disorders; infections; medications; or toxic agents.
( Jay H. Stein. Internal Medicine. Fourth Edition. Mosby F.A. Davis Company) Chronic renal failure is a gradual and progressive loss of the ability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes. Unlike acute renal failure with its sudden, reversible failure of kidney function, chronic renal failure slowly gets worse. It most often results from any disease that causes gradual loss of kidney function. It can range from mild dysfunction to severe kidney failure. Progression may continue to end-stage renal disease (ESRD). Chronic renal failure usually occurs over a number of years as the internal structures of the kidney are slowly damaged. In the early stages, there may be no symptoms. In fact, progression may be so gradual that symptoms do not occur until kidney function is less than one-tenth of normal. Chronic renal failure and ESRD affect more than 2 out of 1,000 people in the U.S. Diabetes and hypertension (high blood pressure) are the two most common causes and account for approximately two-thirds of the cases of chronic renal failure and ESRD. Chronic renal failure results in the accumulation of fluid and waste products in the body, causing azotemia and uremia. Azotemia is the buildup of nitrogen waste products in the blood. It may occur without symptoms.
Uremia is the state of ill health resulting from renal failure. Most body systems are affected by chronic renal failure. Fluid retention and uremia can cause many complications. (http://www.nlm.nih.gov/medlineplus/ency/article/000471.htm#) Chronic renal failure (CRF, or “chronic kidney failure”, CKF, or “chronic kidney disease”, CKD) is a slowly progressive loss of renal function over a period of months or years and defined as an abnormally low glomerular filtration rate, which is usually determined indirectly by the creatinine level in blood serum.
CRF that leads to severe illness and requires some form of renal replacement
therapy (such as dialysis) is called end-stage renal disease (ESRD).
Chronic renal failure is the gradual loss of irreversible destruction of the kidneys over a long period of time. It may result from chronic kidney failure disease, such as bilateral pyelonephritis or congenital polycystic kidney disease, or from systemic disorders such as hypertension or diabetes. As mentioned earlier, long term exposure to nephrotoxins is asymptomatic until it is well advanced because the kidneys normally have considerable reserve function. Once advanced, the progress of chronic renal failure may be slowed but cannot be stopped because the scar tissue and loss of functional organization tend to cause further degenerative changes. (Suzanne C. Smeltzer. Medical-Surgical Nursing. Lippincott Williams. 10th Edition.
A Wolters Kluwer Company) Chronic renal failure, the body regulates body fluid volume, solute concentration and dilution, acid-base balance, excretion of waste products, and secretion of hormones that control red blood cell production, blood pressure, and calcium metabolism. Progressive and irreversible loss of nephrons (Chronic renal failure) decreases GFR and affects these vital processes with changes manifests throughout all organ systems. The kidneys however, exhibit remarkable adaptive abilities, and symptomatic changes resulting from increased creatinine, urea, potassium, and alteration in salt and water balance usually do not become apparent until the renal function declines to less than 25%. (http://health.allrefer.com/health/end-stage-renal-disease-info.html) DEVELOPMENTAL DATA
ERIK ERICKSON’S THEORY
Our client is Xxx Client x, 56 years old. According Erikson’s eight psychosocial stages of development, he belongs to adulthood stage (25-65 years old). The central task involved in this stage is Generativity vs Stagnation. Positive resolution to this stage of psychosocial theory includes feeling of creativity, productivity, concern for others, and willing to share himself with another person. On the other hand, the negative resolution of this stage of psychosocial theory includes the feeling of self indulgence, self concern, and lack of interest and is not willing to commit.
Xxx Client x has achieved Generativity over Stagnation since he attained these following things: he has a stable job, he is productive in financial terms, he is sharing everything that he have to his family and friends, he have put his children to school, and he is happily married for 26 years. He verbalized to us during one of our nurse-client interactions that he is content.
According to Robert Havighurst, individuals of 30-60 years old are considered to be in the middle age group. An individual in this age group learns to engage oneself to social responsibility, establishes economic standard of living, assists children to become responsible and happy adults, develops leisure time activities, relate oneself to one’s spouse, accepts and adjusts to physiological changes of middle age and as well as to aging parents.
Our client admitted that he is content with his life. He is financially stable because of his banana grower-export business and he has a good relationship with his wife. They have been happily married for 36 years. He is also aware that he is not getting any younger and has signs of aging. All of his children have already graduated and are all financially stabled and have their own life.
I – General Survey
Our patient, Xxx Client x was assessed last August _, 2007. He was received lying on bed, awake, conscious, and responsive to any kind of stimuli and not in any form of respiratory distress. With venoclysis of D5 NM one liter infusing well at left metacarpal vein and a side drip of D5W + Dobuject 2 amps. He is well groomed and was already 56 years old. He stands 5 feet and 6 inches tall and weighs 64 kilograms. His physique was in that of a endomorph’s. He is wearing a hospital gown, clean and properly tied. There was no body odor noted upon assessment.
During our interview to our client, we observe that he has a cooperative attitude. He spoke in a comprehensible manner although his pace in speech was a little bit slow. He exhibited a logical thought of organization in the way he answered our questions. II – Vital Signs
The initial vital signs show that his temperature was within the normal range of 36.6°C. His blood pressure was 100/70 mmHg having a pulse rate of 80 beats per minute and a cardiac rate of 84 beats per minute. His respiratory rate was 18 cycles per minute.
III – Skin
Patient’s overall skin color is brown. Increased pigmentation is noted in some parts of his body specifically in his legs. His skin is dry, slighty rough, warm to touch and with loose skin turgor. His nails were smooth in texture and his nail beds are pinkish in color with a capillary refill of 2 seconds. His body hair is well distributed.
IV – Head
•Hair, scalp and face
Upon assessing his head, we noted that it is normocephalic and symmetric in shape. He has a thin, black hair that is evenly distributed with few white hair noted. No lice, lesions and dandruff noted upon inspection. Nodule, masses and depression are absent upon palpation. His face portrays emotions appropriately. He has symmetrical face structure as well as facial movements. He was able to elevate or lower his eyebrows, frown, close tightly the eyes, puff the cheek and show teeth.
•Eyes and vision
During inspection, both iris of the eyes are brown in color, scleras are slightly yellowish in color. Eyebrows were evenly distributed, skin intact.
Eyebrows symmetrically aligned with equal movement. Eyelashes equally distributed, curled slightly outward. His pupils are equally round and reactive to light stimulation. He was able to move his eyes downward, upward and sideward direction. He has pinkish conjunctiva. No lesions and discharges noted.
•Ears and hearing
Ear color same as facial skin, symmetrical and aligned with the outer canthus of the eye. The external pinnae recoils are symmetrical without presence of discharges. Minimal amount of cerumen noted. Normal voice tones are audible. He has a good hearing acuity.
•Nose and sinuses.
His nose was symmetrical and straight. No tenderness and lesions noted. The mucosa was pink without discharges noted. Frontal, maxillary and temporal sinuses are not tender. •Mouth and oropharynx
The lips of our client appeared dry and cracked. It was rough in texture. He was able to purse his lips. Tongue is in central position, pink, moist slightly rough, and with thick, whitish coating. Teeth are yellowish in color. Tongue moves freely with no palpable nodules. Oropharynx color is pink and had smooth posterior wall. Tonsils were pink and no discharges noted.
V – Neck
•Muscles and lymph nodes
Neck muscles were equal in size; head is centered with coordinated head movements. Head can flex and hyperextend. Nodes were not palpable. Trachea is in the midline posterior and jugular veins are not evident. •Thyroid gland
No visible mass noted. No lobes noted.
They were palpable and not bounding. Symmetrical pulse volume; veins are not
VI – Anterior Thorax
•Chest shape and size
During respiration, we observed that he has symmetrical rising and falling of the chest. •Heart
In the heart, no pulsations were heard during auscultation. Apical pulse was located at the fifth intercoastal space along the midclavicular line. •Breasts and axillae
Breasts were symmetrical. Skin intact and bilaterally the same. Areola color was dark brown and equal in size. There were no discharges, no tenderness, mass or nodules noted. Nipples were erected and have no masses.
VII – Upper Extremities
There’s a symmetrical range of movement and equal muscle strength. He has a loose skin turgor. Nails were smooth in texture with capillary refill of 2-3 seconds.
VIII – Abdomen
He has a uniform skin color on her abdomen and an abdominal girth of 48 inches. He has a protruded umbilicus. Globular-shaped abdomen and massive ascites noted.
Audible bowel sounds, 23 bowel sounds/minute. There is
an absence of arterial bruits.
IX- Posterior thorax
Full and symmetric chest expansion; quiet and rhythmic respiration and bilateral falling of the chest; clear breath sounds upon auscultation.
Spinal column straight and vertically aligned; right and left shoulders and hips are at the same height.
X – Lower Extremities
Toenails were long but smooth. Nailbeds are pink with a prompt capillary refill of 2 seconds. There’s a symmetrical range of movement and equal muscle strength. Skin is dry, scaly and rough with increased pigmentation.
XII – Genito-urinary system
Pubic hair is kinky. Pubic skin is intact. No inflammation, swelling or discharge noted. He was able to void slightly cloudy, yellow urine at a very small amount. No enlargement or tenderness noted in the inguinal lymph nodes.
XII – Cranial Nerves
Client verbalized of being able to identify and differentiate the smell of cologne and alcohol with eyes closed. II. Optic
It was observed that the client was still able to read newsprint 15 inches away. III. Oculomotor
Our client was able to move both eyes in unison; with parallel alignment as it follows an object in 6 cardinal positions. Pupils were equally reactive to light stimulation or accommodation. IV – Trochlear
Our client was able to shift both eyes in harmony with corresponding arrangement as they chase an entity in the 6 principal positions. He is able to move his eyeballs downward and laterally. V – Trigeminal
While looking upward, our client was able to exhibit blinking reflex when the lateral sclera of the eye was slightly touched. Skin of face’s tactile sensation was good. Client was able to clench teeth when instructed to do
so. VI – Abducens
Our client was able to move both eyes in unison with parallel alignment as they follow an object in the six cardinal positions. VII – Facial
He was able to exhibit symmetrical facial movements. Also, he was able to perform the following: smile, rising of eyebrows, frown, puffing the cheeks and closing eyes tightly when told to do so. VIII – Auditory
Our client was still able to hear the ticking of the wristwatch at about 3 inches away from his ears. This runs true for both of the ears of our client. IX – Glossopharyngeal
Our client was able to move his tongue from side to side and up or down.
X – Vagus
Our client was able to talk clearly. His speech was not hoarse. XI – Accessory
Our client was able to turn his head from side to side.
XII – Hypoglossal
Our client was able to protrude his tongue and move it from side to side.
ANATOMY AND PHYSIOLOGY OF THE URINARY SYSTEM
The urinary system is composed of the kidneys, ureters, bladder, and urethra. The parts of the urinary system maintain the internal chemical environment of the human body. It has (3) three main functions: excretory, regulatory, and secretory.
It is located retroperitoneally on the posterior wall of the abdomen from T12 to L3. It is protected by the ribs, muscles, fascia, perirenal fat (surrounds and holds it in place against muscles of trunk), and renal capsule, which surrounds the kidneys.
-This region contains:
Glomerulus- tuft of capillaries forming part of the nephron through which filtration occurs – the gloremular membrane normally allows filtration of fluid and small molecules yet limits passage of larger molecules, such as blood cells and albumin Distal convoluted tubule- a portion of kidney nephron between the loop of Henle and the collecting duct system. Proximal convoluted tubule- the portion of the duct system of the nephron leading from Bowman’s capsule to the loop of Henle. Cortical collecting ducts- cortical collecting ducts” receive filtrate from multiple connecting tubules and descend into the renal medulla to form medullary collecting ducts. Peritubular capillaries- are tiny blood vessels that travel along side nephrons allowing reabsorption and secretion between blood and the inner lumen of the nephron. Ions and minerals that need to be saved in the body are reabsorbed into the peritubular capillaries through active transport, secondary active transport, or transcytosis.
-This region contains:
Loop of Henle- the portion of the nephron that leads from the proximal convoluted tubule to the distal convoluted tubule. The loop has a hairpin bend in the renal medulla. The main function of this structure is to reabsorb water and ions from the urine. Medullary collecting ducts- are divided into outer and inner segments, the latter reaching more deeply into the medulla. The variable reabsorption of water and, depending on fluid balances and hormonal influences, the reabsorption or secretion of sodium, potassium, hydrogen and bicarbonate ion continues here. Vasa recta- form a series of straight capillaries (recta is from the Latin for “straight”) that descend from the cortex into the medulla. These vessels branch off of the efferent arterioles of juxtamedullary nephrons (those nephrons closest to the medulla), enter the medulla, and surround the loop of Henle.
-The kidneys continuously cleanse the blood and adjust its composition that is why they have a very rich blood supply. -Summary of the pathway of renal blood vessels:
Nephrons – the structural and functional units of the kidneys and are responsible for forming the urine product
1.)Cortical nephrons – found in the cortex of the kidney
2.)Juxtamedullary nephrons – adjacent to the medulla; they are distinguished by their long loops of Henle and the vasa recta, long capillary loops that dip into the medulla of the kidney. -2 main structures:
-Urine is formed in the nephrons through a three-step process: (i) Glomerular filtration
As blood flows into the glomerulus from an efferent arteriole, filtration occurs. The filtered fluid (filtrate or ultrafiltrate) then enters the renal tubules. The filtrate normally consists of water, electrolytes, and other small molecules because water and small molecules are allowed to pass (sodium, chloride, bicarbonate, potassium, glucose, urea, creatinine, and uric acid) whereas larger molecules stay in the bloodstream. As long as the systemic blood pressure is normal, filtrate will be formed. If arterial blood pressure drops too low, decreased oncotic pressure in the blood, or increased pressure in renal tubules from obstruction, the glomerular pressure becomes inadequate to force substances out of the blood into the tubules, and filtrate formation stops. (ii) Tubular reabsorption
A substance moves from the filtrate back into the peritubular capillaries or vasa recta Most reabsorption occurs in the proximal tubule. It begins as soon as the filtrate enters the proximal convoluted tubule. Some
reabsorption is done passively (water passes by osmosis), but the reabsorption of most substances depends on active transport processes (uses membrane carriers and are very selective). Nitrogenous waste products are poorly reabsorbed, this include: urea, uric acid, and creatinine. (iii) Tubular secretion
A substance (hydrogen, potassium ions and creatinine) moves from the peritubular capillaries or vasa recta into tubular filtrate to be eliminated in urine.
2.)Excretion of Waste Products
-The kidney functions as the main excretory organ of the body, eliminating the body’s metabolic waste products, such as: urea, creatinine, phosphates, uric acid, and sulfates.
3.)Regulation of Electrolyte Excretion
-The volume of electrolytes excreted per day is exactly equal to the amount ingested. Sodium
– by regulating the amount of sodium (and therefore water) reabsorbed, the kidney can regulate the volume of body fluids – Sodium excreted in excess of the amount ingested results in dehydration; sodium excreted in an amount less than that ingested results in fluid retention – The regulation of the amount of sodium excreted depends on aldosterone, a hormone sythesized and released from the adrenal cortex. In the presence of increased aldosterone in the blood, less sodium is excreted in the urine because aldosterone fosters renal reabsorption of sodium. Potassium
– The most abundant intracellular ion.
– To maintain a normal potassium balance in the body, the kidneys are responsible for excreting more than 90% of the total daily potassium requirements. – Several factors influence potassium loss through the kidneys: aldosterone cause potassium excretion by the kidney, acid-base balance, the amount of dietary potassium intake, and the flow rate of the filtrate in the distal tubule. 4.)Regulation of Acid Excretion
-The breakdown of proteins results in the production of acid compounds, in particular phosphoric and sulfuric acid. The normal daily diet also includes a certain amount of acid materials. Phosphoric and sulfuric acids are non-volatile and because accumulation of these acids in the blood would lower its pH (blood more acidic) and inhibit cell function, they must be excreted in the urine. -Through the buffering process, the kidney is able to excrete large quantities of acid in a bound form without further lowering the pH of the urine. 5.)Regulation of Water Excretion
(1) Osmolality – the number of particles (electrolytes and other molecules) dissolved per kilogram. When a person is dehydrated or retaining fluid, less water is excreted, and proportionately more particles are present in the urine, giving the urine a concentrated appearance and a high osmolality. When a person excretes a large volume of water, the particles are diluted. The urine appears dilute and the osmolality is low. Osmotically active: when these substances (glucose and proteins) are filtered, they pull water across the glomerulus and tubules and increase the volume of urine. (2) Urine Specific Gravity – compares the weight of urine to the weight of distilled water (3) Antidiuretic Hormone – controls the amount of water that is reabsorbed ADH is secreted by the PPG in response to changes in osmolality of the blood With decreased water intake, blood osmolality tends to rise and stimulate ADH release. It then acts on the kidney, increasing reabsorption of water and thereby returning the osmolality of the blood to normal. With excess water intake, the secretion of ADH by the pituitary is suppressed; therefore, less water is reabsorbed by the kidney tubule. 6.)Autoregulation of Blood Pressure
-When the blood pressure drops, a hormone known as renin is secreted by specialized juxtaglomerular cells near the afferent arteriole, distal tubule, and efferent arteriole. An enzyme converts renin to angiotensin I, which is then converted to angiotensin II, a potent vasoconstrictor. The vasoconstriction causes the blood pressure to increase. Aldosterone is secreted by the adrenal cortex in response to stimulation by the pituitary gland, which in turn is in response to poor perfusion or increasing serum osmolality. The result is an increase in blood pressure 7.)Renal Clearance
– the ability of the kidneys to clear solutes from the plasma 8.)Regulation of Red Blood Cell Production
-When the kidneys sense a decrease in the oxygen tension in renal blood flow, they release erthyropoietin. Erythropoietin stimulates the bone marrow to produce red blood cells, thereby increasing the amount of haemoglobin available to carry oxygen. 9.)Synthesis of Vitamin D to active form
-The kidney is responsible for the final conversion of inactive vitamin D to its active form, 1,25-dihydroxycholecalciferol. It is necessary for maintaining normal calcium balance in the body 10.)Secretion of Prostaglandin
-The kidneys also produce prostaglandin E2 (PGE2) and prostacylin (PGI2), which have a vasodilatory effect and are important in maintaining renal blood flow.
It is a long fibromuscular tube that connects each kidney to the bladder. It carries urine from the kidneys to the urinary bladder. The ureters are muscular tubes that can propel urine along by the motions of peristalsis. The ureters enter the bladder through the back, running within the wall of the bladder for a few centimetres. There are no valves in the ureters, backflow is being prevented by pressure from the filling of the bladder, as well as the tone of the muscle in the bladder wall.
The Urinary Bladder
It is a muscular, hollow sac located just behind the pubic bone and can hold about 300-500 mL of urine. Normally, the pressure in the bladder is low, even as the urine accumulates, because the bladder’s smooth muscle adapts to the increased stretch. The first sensations of bladder filling ordinarily occur when about 100-150 mL of urine is present in the bladder. There is a desire to void when the bladder contains about 200-300 mL or urine and a
marked sense of fullness when the bladder contains about 400 mL of urine.
It arises from the bladder; in the male, it passes through the penis, and in the female, it opens just anterior to the vagina. In the male, the prostate gland, which lies just below the bladder neck, surrounds the urethra posteriorly and laterally. The external urinary sphincter is a round, voluntary muscle that controls the initiation of urination. Functions of the ureters, urinary bladder, and urethra
-Urine formed by the kidney flows from the renal pelvis through the ureter and into the bladder, which is facilitated by peristaltic waves from contraction of the smooth muscle in the ureter wall. 1.)Storage of urine
-The bladder is the reservoir of urine. Reflux of urine from the bladder is normally prevented by the unidirectional nature of the peristaltic waves and because each ureter enters the bladder at an oblique angle. 2.)Voiding
-Muscle Control. Voiding of urine is controlled by contraction of the external urethral sphincter. This muscle is under voluntary control and is innervated by the nerves from the sacral area of the spinal cord. When a person wants to urinate, the external urethral sphincter relaxes, and the detrusor muscle contracts and expels the urine from the bladder throught the urethra. Urine remaining in the urethra drains by gravity in females and is expelled by voluntary muscle contractions in the male. -Neural Control. Contraction of the detrusor muscle is regulated by a reflex involving the parasympathetic nervous system, specifically in the sacral portion of the spinal tract. The sympathetic nervous system plays no essential part in micturition but does not prevent semen from entering the bladder during ejaculation