REVIEW OF THE RENAL AND

UROLOGICAL SYSTEM

VALERIE SUGE – MICHIEKA

KABARAK UNIVERSITY
 Assessment of renal and urinary tract
function
Learning Objectives

 Review anatomy and physiology of the renal- urologic

system
 Identify the assessment parameters used for determining
the status of upper and lower urinary tract function

 Describe the diagnostic studies used to determine urinary

tract function

 Initiate education and preparation for patients undergoing

assessment
 Specific Learning Objectives
• Review of Anatomy and physiology
• History taking List the data to be collected when
assessing a patient who has a urologic disorder.
• Describe the diagnostic tests and procedures for
patients
with urologic disorders.
• Explain the nursing responsibilities for patients
having
tests and procedures to diagnose urologic disorders.
• Describe the nursing responsibilities for common
therapeutic
measures used to treat urologic disorders.
 Components – REVIEW FROM
PREVIOUS CLASS NOTES
• The urinary system consists of
– Two kidneys
– Two ureters
– The bladder
– The urethra
 Location of the Kidneys

 Against the dorsal body wall

 At the level of T12 to L3
 The right kidney is slightly lower than
the left
 Attached to ureters, renal blood vessels,
and nerves at renal hilus
 Atop each kidney is an adrenal gland
The kidneys, ureters, and bladder. (Source: Dorling Kindersley Media Library)

6
Figure 40-1
The Renal System
 Kidneys and Ureters
• Kidneys are bean-shaped organs located just
under and below the 12th rib near the waist
in the body trunk
• The entire blood supply circulates through
the kidneys every 4 to 5 minutes.
Figure 40-2
 The kidneys are essentially regulatory organs
which maintain the volume and composition of
body fluid by filtration of the blood and
selective reabsorption or secretion of filtered
solutes.

 The kidneys take their blood supply directly

from the aorta via the renal arteries; blood is
returned to the inferior vena cava via the renal
veins.
 On sectioning, the kidney has a pale outer
region- the cortex- and a darker inner region-
the medulla.
 The medulla is divided into 8-18 conical
regions, called the renal pyramids; the base of
each pyramid starts at the corticomedullary
border, and the apex ends in the renal papilla
which merges to form the renal pelvis and
then on to form the ureter.
 Kidneys and Ureters
• Cortex: outer layer; medulla: inner layer
– Cortex receives a large blood supply; very sensitive to changes in
blood pressure and blood volume
– Medulla organized into 8-18 pyramidal structures; concentrate and
collect urine; drain it into the calices
– The calices then drain urine into the renal pelvis
• Renal pelvis forms funnel-shaped proximal end of ureter
• Ureter carries urine from renal pelvis to bladder
 In humans, the renal pelvis is divided into two or
three spaces -the major calyces- which in turn divide
into further minor calyces.
 The walls of the calyces, pelvis and ureters are lined
with smooth muscle that can contract to force urine
towards the bladder by peristalsis.
 The cortex and the medulla are made up of nephrons;
these are the functional units of the kidney, and each
kidney contains about 1.3 million of them.
 The Nephron
• The nephron is the functional unit of the kidney
– 1 to 1.25 million nephrons in each kidney
– Vascular tubular system: glomerulus, Bowman’s capsule, and tubule
– Glomerulus: mass of blood vessels tucked into the cuplike Bowman’s
capsule
– Each tubule consists of a proximal tubule, the loop of Henle, a distal
tubule, and a collecting duct
– Nephron located mostly in the cortex of the kidney; loop of Henle
dips into the medulla; and the collecting ducts travel through the
medulla to the calices
Anatomy of the Kidney

http://www.venofer.com/VenoferHCP/Venofer_kidneyFunction.html
Figure 40-3
An illustration of the internal structures of the kidney.

18
 Nephron

http://www.venofer.com/VenoferHCP/Venofer_kidneyFunction.h
tml
Figure 40-4
 Structure of the Nephron
 The nephron is the unit of the kidney responsible for ultrafiltration of the
blood and reabsorption or excretion of products in the subsequent filtrate.
Each nephron is made up of:
 A filtering unit- the glomerulus. 125ml/min of filtrate is formed by the
kidneys as blood is filtered through this sieve-like structure. This filtration is
uncontrolled.
 The proximal convoluted tubule. Controlled absorption of glucose, sodium, and
other solutes goes on in this region.
 The loop of Henle. This region is responsible for concentration and dilution of urine
by utilising a counter-current multiplying mechanism- basically, it is water-
impermeable but can pump sodium out, which in turn affects the osmolarity of the
surrounding tissues and will affect the subsequent movement of water in or out of
the water-permeable collecting duct.
 The distal convoluted tubule. This region is responsible, along with
the collecting duct that it joins, for absorbing water back into the
body- simple maths will tell you that the kidney doesn't produce
125ml of urine every minute. 99% of the water is normally
reabsorbed, leaving highly concentrated urine to flow into the
collecting duct and then into the renal pelvis.
 Bladder and Urethra
• Bladder: muscular sac; stretches to store urine
• On floor of pelvic cavity behind the peritoneum
• In front of the rectum in men; in front of the vagina and
uterus in women
• Trigone: triangular-shaped area on posterior wall
• Control possible by sensory and motor nerves
• Urethra: muscular tube lined with mucous membranes;
carries urine from bladder out of the body
Figure 40-5
 Urine (the filtered product containing waste materials
and water) excreted from the kidneys passes down the
fibromuscular ureters and collects in the bladder. The
bladder muscle (the detrusor muscle) is capable of
distending to accept urine without increasing the
pressure inside; this means that large volumes can be
collected (700-1000ml) without high-pressure damage
to the renal system occurring.
 When urine is passed, the urethral sphincter at the base
of the bladder relaxes, the detrusor contracts, and urine
is voided via the urethra.
 Functions of the Kidney
• Regulation of water excretion
• Regulation of electrolyte function
• Regulation of acid-base balance—retain
HCO3- and excrete acid in urine
• Regulation of blood pressure--RAAS
• Regulation of RBCs
• Vitamin D synthesis
 Functions of Kidney cont.
• Secretion of prostaglandin E and prostacyclin
which cause vasodilation, important in
maintaining renal blood flow
• Excretion of waste products-body’s main
excretory organ. Urea, creatinine, phosphates,
uric acid and sulfates. Drug metabolites.
 Physiology of the Urinary System
• Regulation and excretion
– Urine production
• Glomerular filtration, tubular reabsorption, and
tubular secretion
– Urine elimination
– Regulation of serum calcium and phosphate
– Regulation of blood pressure
– Hormonal stimulation of red blood cell
production
 Urine Formation Processes

 Filtration
 Reabsorption
 Secretion

Figure 15.4

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide

 Filtration

 Nonselective passive process

 Water and solutes smaller than proteins
are forced through capillary walls
 Blood cells cannot pass out to the
capillaries
 Filtrate is collected in the glomerular
capsule and leaves via the renal tubule
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide
 Reabsorption
 The peritubular capillaries reabsorb several
materials
 Some water
 Glucose
 Amino acids
 Ions
 Some reabsorption is passive, most is active
 Most reabsorption occurs in the proximal
convoluted tubule
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide
 Materials Not Reabsorbed

 Nitrogenous waste products

 Urea
 Uric acid
 Creatinine
 Excess water

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide

 Secretion – Reabsorption in
Reverse
 Some materials move from the
peritubular capillaries into the renal
tubules
 Hydrogen and potassium ions
 Creatinine
 Materials left in the renal tubule move
toward the ureter
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide
 Formation of Urine

Figure 15.5
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide
Figure 40-6
Physiology/Pathophysiology
Renin-angiotensin system
Stimuli for Renin Excretion

Angiotensinogen in liver

Renin release

Angiotensin I

Converting enzyme in lungs

Angiotensin II

Renal autoregulation

Increased BP, increased circulating volume

 Hormones influencing renal function
• Renin—raises BP
• Bradykinins—increase blood flow and vascular
permeability
• Erythropoietin
• ADH
• Aldosterone—promotes sodium reabsorption
and potassium excretion
• Natriuretic hormones—released from the cardiac
atria and brain.
 Risk factors for renal or urologic
disorders
1. Hypertension
2. Diabetes mellitus
3. Immobilization
4. Parkinson’s disease
5. SLE
6. Gout
7. Sickle cell anemia, multiple myeloma
8. BPH
9. Pregnancy
10. SCI
 Developmental Aspects of the
Urinary System

 Functional kidneys are developed by

the third month
 Urinary system of a newborn
 Bladder is small
 Urine cannot be concentrated

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide

 Gerontologic Considerations
• GFR decreases following 40 years with a yearly
decline of about 1 mL/min
• Renal reserve declines
• Multiple medications can result in toxic
metabolites
• Diminished osmotic stimulation of thirst
• Incomplete emptying of bladder
• Urinary incontinence
 Gerontologic considerations
• Aging affects the way the body absorbs,
metabolizes, and excretes drugs thus
placing the elderly patient at risk for
adverse reactions, including compromised
renal function
• Structural or functional abnormalities that
occur with aging may prevent complete
emptying of the bladder. This may be due
to decrease bladder wall contractility due
to myogenic or neurogenic causes or
structurally related to bladder outlet
obstrcution as in BPH.
 Age-Related Changes in the
Urinary System
• Loss of nephrons, thickening of membranes in nephrons,
and sclerosis of renal blood vessels
• Creatinine clearance decreases with age
• Nocturia: awaken from sleep to void
• Bladder muscles weaken; connective tissue increases
• Incontinence not normal consequence of age, but it is
common
• In men, urethral obstruction often a problem
NURSING ASSESSMENT OF A
PATIENT WITH RENAL AND
URINARYTRACT DISORDERS
VALERIE SUGE – MICHIEKA
KABARAK UNIVERSITY
 Health History
• Obtaining a urologic health
history requires excellent
communication skills
because many patients are
embarrassed or
uncomfortable discussing
genitourinary function or
symptoms.
 Health History
• Chief complaint
– Changes in urine quality or quantity, pain
• History of present illness
– Patient’s normal or usual pattern of urination
– Pain or discomfort
– Problem initiating or controlling urination
• Document circumstances under which these
problems occur
Chief Complaint and Present Illness
• The chief complaint is a constant reminder as
to why the patient initially sought care.
• This issue must be addressed even if
subsequent evaluation reveals a more serious
or significant condition that requires
• Duration
• Severity
• Chronicity
• Periodicity
• Degree of disability
 Pain

• Can be severe
– urinary tract obstruction
– inflammation
• Inflammation of the GU tract is most severe when it involves
the parenchyma of a GU organ
– Pyelonephritis
– Prostatitis
– Epididymitis
• Inflammation of the mucosa of a hollow viscus usually
produces discomfort
– Cystitis
– Urethritis
 Pain

• Tumors:
– No pain unless
• obstruction
• extend beyond the primary organ to involve adjacent
nerves
 Pain

• Renal Pain
– Site: ipsilateral
costovertebral angle just
lateral to the
sacrospinalis muscle and
beneath the 12th rib

• Acute distention of the

renal capsule
 Pain
• Associated symptoms
– Gastrointestinal symptoms
• Nausea
• Vomiting
• Ileus
 Pain

• Renal pain may also be confused with pain

resulting from irritation of the costal nerves,
most commonly T10–T12 which is:
– not colicky in nature.
– Severity of radicular pain may be altered by
changing position
 Ureteral pain
• Usually acute and secondary to obstruction

– Midureter ( Rt side): referred to the right lower quadrant

(McBurney's point) and simulate appendicitis
– Midureter (Lt side) :referred over the left lower quadrant
and resembles diverticulitis.
– Scrotum in the male or the labium in the female.
– Lower ureteral obstruction frequently produces symptoms
of bladder irritability( frequency, urgency, and suprapubic
discomfort)
 Vesical Pain
• Vesical pain is due

– Overdistention

– inflammation
 Prostatic Pain
• Inflammation with secondary edema and distention
of the prostatic capsule
• poorly localized
– lower abdominal
– Inguinal
– Perineal
– Lumbosacral
– rectal pain.
– irritative urinary symptoms ( frequency and dysuria)
– acute urinary retention.
 Penile Pain
• Pain in the erect penis is usually due to
Peyronie's disease or priapism
• Pain in the flaccid penis
– usually secondary to inflammation in the bladder
or urethra
– referred pain that is maximally at the urethral
meatus
• paraphimosis
 Testicular Pain
• Acute pain
– epididymitis
– torsion of the testicle
• Chronic scrotal pain
– hydrocele
– varicocele,
– dull, heavy sensation that does not radiate
– Referred pain: kidneys or retroperitoneum
 Hematuria
• Hematuria : the presence of blood in the urine

• In adults, should be regarded as a symptom of

urologic malignancy until proved otherwise
– Is the hematuria gross or microscopic?
– Timing: (beginning or end of stream or during entire
stream)?
– Is it associated with pain?
– Is the patient passing clots?
– If the patient is passing clots, do the clots have a specific
shape?
 Hematuria
• Initial hematuria:
– usually arises from the urethra
– least common
– usually secondary to inflammation.
• Total hematuria
– most common
– bladder or upper urinary tracts.
• Terminal hematuria
– the end of micturition
– secondary to inflammation bladder neck or prostatic
urethra.
 Lower Urinary Tract Symptoms
• Irritative Symptoms
– Urinary frequency
– Nocturia
– Frequency
– Dysuria: painful urination
– Incontinence
• Stress
• Urge
 Obstructive Symptoms
• Decreased force of urination
• Urinary hesitancy
• Intermittency
• Post void dribbling
• Straining
 Enuresis
• Urinary incontinence that occurs during sleep
• Mostly in children up to 5 years
 Urethral Discharge

• Urethral discharge is the most common

symptom of venereal infection.
 Fever and Chills
• Usually in
– Pyelonephritis
– Prostatitis
– Epididymitis
 Health History
• Past medical history
– A history of streptococcal infections, recurrent
urinary tract infections (UTIs), renal calculi
(“stones”), gout, or hypercalcemia
• Family history
– Congenital kidney problems, such as polycystic
kidneys or urinary tract malformations, diabetes
mellitus, and hypertension
 Past Medical History
• Systemic diseases that may affect the GU
system
– diabetes mellitus.
– multiple sclerosis
– TB
– Schistosomiasis
 Family History
• prostate cancer
• Stones( cystine)
• Renal tumors (some types)
 Smoking and Alcohol Use
• Cigarette smoking
– urothelial carcinoma, mostly bladder cancer
– Erectile dysfunction.
• Chronic alcoholism
– impaired urinary function
– Sexual dysfunction.
– testicular atrophy, and decreased libido.
 Health History
• Review of systems
– Changes in skin color, respiratory distress,
edema, fatigue, nausea, vomiting, chills, and
fever
• Functional assessment
– Daily fluid intake
– Effects of the chief complaint on daily life
The nurse should inquire about……
Px’s chief concern or reason for seeking health
care, the onset of the problem & it’s effect on the
px’s quality of life

Location, character & duration of pain (if present)

& its relationship t voiding; factors that
precipitate pain and those that relieve it

Hx of UTI, including past tx or hospitalization for

UTI
• Fever or chills
• Previous renal or urinary dx tests or use of
indwelling catheters
• Dysuria & when it occurs during voiding (at
initiation or termination of voiding)
• Hesitancy, straining, or pain during, after
urination
• Urinary Incontinence (stress intolerance, urge
incontinence, overflow incontinence or
functional incontinence)
• Hematuria or change in color, volume of urine
• Nocturia and its date of onset
• Renal calculi (kidney stones), passage of
stones or gravel in urine
• Female px: number & type (vaginal or cesarean)
of deliveries; use of forceps; vaginal infxn,
discharge or irritation; contraceptive practices
• Presence or history of genital lesions or STD’s
• Habits: use of tobacco, alcohol, or recreational
drugs
• Any prescription & over-the-counter medications
(including those prescribed for renal or urinary
problems
 Unexplained anemia
• Gradual kidney dysfunction can be insidious in its
presentation, although fatigue is a common
symptom. Fatigue, shortness of breath, and exercise
intolerance all result from the condition known as
“anemia of chronic dse”
• Hgb / Hct are quantified to detect anemia however
Hgb level is more significant it’s the one responsible
for circulating oxygen
Problems Associated with Changes in Voiding
Problem Definition Possible Etiology
Frequency Frequent voiding – more than Infection, obstruction of lower urinary tract leading to residual urine and
every 3 hours overflow, anxiety diuretics, BPH, urethral stricture, diabetic neuropathy
Urgency Strong desire to void Infection, chronic prostatitis, urethritis, obstruction of lower urinary tract
leading to residual urine and overflow, anxiety, diuretics, BPH, urethral
stricture, diabetic neuropathy
Dysuria Painful or difficult voiding Lower urinary tract infection, inflammation of bladder or urethra, acute
prostatitis, stones, foreign bodies, tumors in bladder
Hesitancy Delay, difficulty in initiating BPH, compression of urethra, outlet obstruction, neurogenic bladder
voiding
Nocturia Excessive urination at night Decreased renal concentrating ability, ♥ failure, diabetis mellitus,
incomplete bladder emptying, excessive fluid intake at bedtime,
nephritic syndrome, cirrhosis with ascites
Incontinence Involuntary loss of urine External urinary sphincter injury, obstetric injury, lesions of bladder neck,
detrusor dysfunction, infection, neurogenic bladde, medications
neurologic abnormalities
Enuresis Involuntary voiding during sleep Delay in functional maturation of central NVS (bladder control usually
achieved by 5 years of age) obstructive dse of lower urinary tract, genetic
factors, failure to concentrate urine, UTI, psychological stress
Polyuria Increased volume of urine voided DM, diabetes insipidus, use of of diuretics, excess fluid intake, lithium
toxicity, some forms of kidney dse (hypercalmemic and hypokalemia
nephropathy)
Oliguria Urine output less than Acute or chronic renal failure, complete obstruction
400mL/day
Anuria Urine output less than 50mL/day Acute or chronic renal failure, complete obstruction
Hematuria Red blood cells in the urine Cancer of genitourinary tract, acute glomerulonephritis, renal stones, renal
tuberculosis, blood dyscrasia, trauma, extreme exercise, rheumatic fever,
hemophilia, leukemia, sickle cell trait or disease
Proteinuria Abnormal amounts of protein in Acute and chronic renal disease, mephrotic syndrome, vigorous exercise,
the urine heat stroke, severe ♥ failure, diabetic neuropathy, multiple myeloma
 Gastrointestinal symptoms
• Gastrointestinal symptoms may occur with
urologic conditions because of shared autonomic
and sensory innervation and renointestinal
reflexes.
• Common s/sx: N/V, diarrhea, abdominal
discomfort, abd distention,. Urologic symptoms
can mimic appendicits, PUD, cholecystitis, thus
making diagnosis difficult especially in elderly
because of decreased neurologic innervation to
this area.
Identifying Characteristics of Genitourinary Pain

TYPE LOCATION CHARACTER ASSOCIATED S/SX POSSIBLE ETIOLOGY

KIDNEY Costovertebral angle, may Dull constant ache; if
extend to umbilicus sudden distention of
capsule, pain is severe,
sharp, stabbing and colicky
in nature
n/v, diaphoresis, pallor, Acute obstruction, kidney
signs of shock stone, blood clot, acute
pyelonepritis, trauma

BLADDER Suprapubic area Dull, continous pain, may Urgency, pain at the end of Overdistended bladder,
be intense with voiding, voiding, painful straining infection, interstitial
may be severe if bladder is cystitis; tumor
full

URETERAL Costovertebral angle, Severe, sharp, stabbing n/v, paralytic ileus Ureteral stone, edema or
flank, lower abdominal pain, colicky in nature stricture, blood clot
area, testis or labium

PROSTATIC Perineum and rectum Vague discomfort, feeling Suprapubic tenderness, Prostatic cancer, acute or
of fullness in perineum, obstruction to urine flow, chronic prsotatitis
vague back pain frequency, urgency,
dysuria, nocturia

URETHRAL Male: along penis to Pain variable, most severe Frequency, urgency, Irritation of bladder neck,
meatus; female: urethra to during and immediately dysuria, nocturia, urethral infection of urethra,
meatus after voiding discharge trauma, foreign body in
lower urinary tract
 Entry Points to Physical Examination
• Properly taken medical history
• Aim at performing a thorough and complete
physical examination
• Aim- to evaluate patients who present with
medical problems
• Why?
• Physical examination (P/E) remains to be the key
component of diagnostic evaluation along with
properly taken history
• What is expected?
• To perform conscientiously – “Take time”
 Diagnostic Evaluation
Diagnostic evaluation will point to the nature
of the disease:
• Congenital
• Infections and infestations
• Metabolic problems
• Traumatic
• Neoplastic
 Diagnostic Evaluation Cont’d
• Diagnostic evaluation begins as the patient
comes in or the physician/medical trainee
comes in to evaluate the patient
• General assessment of severity of the
illness/medical condition – “visual inspection”
• Evidence of pain
• Nutritional status: weight loss/obesity
• Gait
• Abnormal body movements
• Wetting
• Fever
• Edema
 Diagnostic Evaluation Cont’d
• Pick features that draws attention to disorders
in another system and examine that system:
• Edema – cardiac disease, renal failure etc.
• Gynacomastia – alcoholism, endocrinologic diseases,
post chemotherapy (for example, for prostatic cancer)
• Lymphadenopathy – metastatic genitourinary (GU)
neoplasms
 Diagnostic Evaluation Cont’d
• During examination of the GU tract look for:
• Enlargement of the kidneys
• Enlargement of the bladder
• Disorders of the inguinal region
• Disorders of the genitalia
• Pelvic disease detectable by internal examination
(Digital Rectal Examination-DRE and per vaginal
examination - PV)
• Neurological examination
 Physical Examination
• Skin color (ashen, yellow); crystals on skin (uremic frost)
• Tissue turgor: to detect dehydration or edema
• Periorbital edema: suggests fluid retention. Inspect the mouth for
moisture and odor
• Observe respiratory rate, pattern, and effort
• Auscultate the lungs for crackles or rhonchi
• Inspect the abdomen for scars and contours, and palpate for tenderness
and bladder distention
• Auscultate the kidney area over costovertebral angle (Figure 40-2) to
detect renal bruits
• Edema
• Inspect the genitalia
Figure 40-2
 PHYSICAL EXAMINATION
• General Observations
– visual inspection of the patient
– Cachexia
• Malignancy, TB
– Jaundice or pallor
– Gynecomastia
• endocrinologic disease
• alcoholism
• hormonal therapy for prostate cancer
Physical Assessment of Urinary System
• Inspection
• Inspection including examination of abdomen and urethral
meatus
• Auscultation including renal arteries
• Percussion includes the kidneys to detect tenderness
• Palpation to detect any mass, lumps, tenderness
Percussion of the kidney
• To detect areas of tenderness by costovertebral test, normally
will feel a thudding sensation or pressure but not tenderness
Palpation of kidney
• Contour, size, tenderness, and lump.
• In adult normal the kidneys not be palpable because of their
location deep with abnormal.
• Elderly the right kidney is slightly lower than the left, it may be
easier to palpate.

88
Percussion of the bladder
• Percuss the area over the bladder (5cm) above the symphysis pubis.
• To detect difference in sound, percuss toward the base of the bladder.
• Percussion normally produces a tympanic sound.
Palpation of bladder
• Normally feel firm and smooth.
• In adult bladder may not be palpable
Inspection of the urethral meatus
• Look for swelling, discharge and inflammation
Assessment of Urine
• Urine assessment includes:
• Measure volume of urine
• Inspect color, clarity, and volume
• Test the specific gravity, glucose, ketone bodies and blood and pH
• Normal urine volume 1-2 litter per 24 hours (normal adult)

89
• Color: typically yellow-straw but varies according to recent diet
and concentration of the urine. Drinking more water generally
tends to reduce the concentration of the urine and therefore
cause it to have a lighter color. (The converse is also true.)
• Smell: Generally fresh urine has a mild smell but aged urine has
a stronger odor, similar to that of ammonia.
• The smell urine may provide health information. For example,
urine of diabetics may have a sweet or fruity odor due to the
presence of ketones.
• Acidity: PH is a measure of the acidity (or alkalinity of a
solution). PH is a measure of the activity of hydrogen ions (H+)
in a solution.
• 95% Water, 5% chemical solutes. Urea from breakdown of
amino acids (protein) to give ammonia + C02 giving urea and
creatinine from breakdown of creatine phosphate in muscle

90
Collection of urine samples
• All urine tests are ideally performed on fresh specimens:
• Urine container has been adequate protection agonist bacterial
contamination and chemical deterioration
• Identification or labeled should be provided.
• The patient should then be gowned for the physical examination
• Bring it into the dry room
• Urine specimens should collect from the patient means of the clean–
catch midstream technique.
• All specimens should be refrigerated as soon as possible they are
obtained to avoid shifting of the PH of urine to alkaline because
contamination of urea- splitting bacteria from the environment.
Consider the Developmental Stages
• Pediatric: difficulties, crying, change in urinary in childhood.
• Pregnant: Pain during urination, normal increase urine in volume and
frequency and decrease urine specific gravity.
• Elderly: how much and how type of liquid do you drink in the evening?
do you ever lose of control of your bladder?

91
DETAILED PHYSICAL EXAMINATION
• Read and practice in the skills Lab
 Examination

 Pallor, Jaundice
 Loss of weigh, over weight
 Cervical Lymph nodes
 Kidneys
• Palpation of the kidneys
– supine position
– The kidney is lifted from behind with one hand in
the costovertebral angle
– In neonates, palpating of the flank between the
thumb anteriorly and the fingers over the
costovertebral angle posteriorly
Abdominal Examination
 Kidneys
• Auscultation : epigastrium for bruit
– renal artery stenosis
– aneurysm.
– renal arteriovenous fistula.
Abnormal Physical Examination Findings—
Kidneys
• The most common abnormality detected on
examination of the kidneys is a mass
• In neonates and younger children, the
transillumination helps to distinction between
cystic and solid
 Abdominal Examination of the GU Tract

• Physical examination for signs of enlarged

kidneys by bimanual palpation
Kidneys
 Abdominal Examination of the GU Tract
Cont’d:
• Normal sized kidneys may not be palpable
– May be palpable in thin patients and in children
• Enlarged kidney is a classical sign of a palpable
mass
– Benign cysts/ hydronephrosis benign or malignant
renal tumors
• Absence of colonic resonance
• Costovertebral angle tenderness (CVAT)
Urinary Bladder
 Bladder
• at least 150 ml of urine in it to be felt.
• Percussion is better than palpation
• A bimanual examination, best done under
anesthesia, is very valuable to asses bladder
tumor extension
Bladder
 Abdominal Examination Cont’d:
Physical Signs of an Enlarged Bladder
• Normal bladder can not be palpated or
percussed
• Distended bladder becomes visible in patients
• It is a palpable subumblical midline
abdominal mass
Medical Terms related to urinary system
• Dysuria: painful or difficult voiding
• Hematuria: red blood cells in the urine
• Urgency: strong desired to urinate due to
inflammation in bladder , prostate , urethra
• Polyuria: abnormal large volume of urine voided in
given time = 2500ml
• Oliguria: small volume of urine between 100-500 ml
• Anuria: absence of urine in bladder less than 50 ml
• Enuresis: involuntary voiding during sleeping

107
Physical Signs of an Enlarged Bladder
Cont’d:
 Physical Signs of an Enlarged Bladder
Cont’d:
• Floppy bladder
• Cystic mass
• May be more to one side
• Bladder moves from side to side only
• Gravid uterus moves from side to side and up
and down
• Bimanual Examination (BME)
• Suprapubic fluid filled bladder
• Irregular mass
• Cystic mass
• BME under anesthesia (for better assessment
of a bladder mass)
• Bladder palpated between the abdomen and the rectum in males
and between the abdomen and the vagina in females
 Physical Signs of an Enlarged Bladder
Cont’d
• Abnormal findings are:
• Over distended bladder noticeable and palpable
– Bladder outlet obstruction (BOO)
– Neurogenic conditions
• Large bladder tumors or calculi
• Tenderness - cystitis
 Penis
• The position of the urethral meatus
• Priapism: sickle cell disease
Hypospadias
 Scrotal masses
Inspection Palpation
• Site • Temp.
• Size • Tenderness
• Shape
• Consistency
• Skin
• Others according
• Cough impulse
to diagnosis
 Scrotum and Contents
• Painful
– Torsion
– Epididymitis firm or hard area within the testis should be considered a
malignant tumor until proved otherwise
• Painless
– Spermatocele
– Hydrocele
– Varicocele

• Transillumination : Cystic vs. solid

• Painless solid testicular mass is tumor until proven otherwise
Genital Examination
Transillumination
 Rectal and Prostate Examination in the
Male
• Digital rectal
examination (DRE) :
– every male after age 40
years
– Men of any age who
present for urologic
evaluation
Per- rectal Examination
 Prostate Examination
• Acute Prostatitis
• Benign Prostatic Hyperplasia
• Carcinoma of the Prostate
 Diagnostic Tests and Procedures
• Urine tests
– Urinalysis
– Urine culture and sensitivity
– Creatinine clearance
• Blood tests
– Blood urea nitrogen
– Serum creatinine
– Serum electrolytes
 Diagnostic Tests and Procedures
• Radiographic tests and procedures
– Kidneys, ureters, bladder (KUB)
– Intravenous pyelogram
– Arteriogram
– Cystogram
– Renal scan
– CT scan and MRI
 Diagnostic Tests and Procedures
• Ultrasonography
• Invasive procedures
– Renal biopsy
– Cystoscopy
• Urodynamic studies
– Cystogram and voiding cystourethrogram
– Cystometrogram
 Diagnostic evaluation
• URINALYSIS – a urine test for evaluation of the
renal system and for determining renal disease
Changes in Urine Color and possible Causes

Urine Color Possible Cause

Colorless to pale yellow Dilute urine due to diuretics, alcohol consumption,

diabetes insipidus, glycosuria, excess fluid intake,
renal dse

Yellow to milky white Pyuria, infection, vaginal cream

Bright yellow Multiple vitamin preparation

Pink to red Hgb breakdown, RBC, gross blood, menses, bladder or

prostate surgery, beets, blackberries, medications
(phenyton, rifampicin, phenothiazine, cascara, senna
products)

Blue, blue green Dyes, methylene blue, pseudmona species organisms,

medications
Orange to amber Concentrated urine due to dehydration, fever, bile,
excess bilirubin or carotene, medications

Brown to black Old RBC, urobilirogen, bilirubin, melanin, porphyrin,

extremely concentrated urine due to dehydration,
 Specific gravity determination
• A urine test that measures the ability of the
kidneys to concentrate urine
• NV: 1.016 to 1.022 (may vary depending on
the lab – 1.010- 1.020)
• An increase in the result may indicate
insufficient fluid intake, decreased renal
perfusion or increased ADH
• A decrease in result (less concentrated urine)
occurs with increased fluid intake or DI.
Urine culture and sensitivity testing
• Urine test that identifies the presence of
microorganisms and determines the specific
antibiotics to treat the existing
microorganisms appropriately.
 Creatinine clearance test
• Evaluates how well the kidneys remove
creatinine from the blood
• The urine specimen for the creatinine
clearance is usually collected for 24 hours, but
shorter periods such as 8 to 12 hours could be
prescribed.
 Uric acid test
• A 24 hour urine collection sample is tested to
diagnose gout and kidney dse
 Vanillylmandelic acid test
• The test is a 24 hour urine collection to
diagnose pheocromocytoma, a tumor of the
adrenal gland
• The test determines urinary catecholamine
levels in the urine
 Bladder ultrasound
• May be performed for evaluating urinary
frequency, inability to urinate or amount of
residual urine (the amount of urine remaining
in the bladder after voiding)
 Kidneys, ureters, and bladder (Kub)
radiography
• Performed to delienate the
size, shape and position of
the kidneys and to reveal
any abnormalities such as
calculi in the kidneys or
urinary tract,
hydronephrosis (distention
of the pelvis of the kidney)
cysts, tumors, or kidney
displacement by
abnormalities in
surrounding tissues
 Ct scan / mri
• Used in evaluating
genitourinary masses,
neprhrolithiasis,
chronic renal infxn,
renal or urinary tract
trauma, metastatic
disease and soft tissue
abnormalities
 Nuclear scans
• Requires injection of
isotope into the circulatory
system.
• Hypersensitivity to the
isotope is rare
• Nuclear scans are used to
evaluate acute and chronic
renal failure, renal masses
and blood flow before and
after kidney
transplantation.
 Intravenous urography
• Intravenous urography
includes test includes tests
such as excretory urography,
intravenous pyelography
(IVP) and infusion drip
pyelography.
• Used as the initial
assessment of any
suspected urologic problem,
especially lesions in the
kidneys and ureters. It also
provide a rough estimate of
renal function.
 Retrograde pyelography
• Catheters are advanced into renal pelvis by
means of cystoscopy. It is usually performed if
Intravenous urography provides inadequate
visualization of the collecting systems.
• It may also be used before extracorporeal
shock wave lithotripsy or in px with urologic
cancer who need to follow up and are allergic
to intravenous contrast.
 cystography
• Aids in evaluating vesicoureteral reflux
(backflow of urine from the bladder into one
or both ureters) and assessing the px for
bladder injury
 Voiding cystourethrography
• Uses fluoroscopy to visualize the lower urinary
tract and assess urine storage in the bladder.
• A urethral catheter is inserted and a contrast
agent in instilled into the bladder. When the
bladder is full and the patient feels the urge to
void, the catheter is removed and the px
voids.
 Renal angiogrhaphy
• Renal angiogram/renal arteriogram provides
an image of the renal arteries.
• The femoral or axillary are the preferred sites.
• Use to evaluate renal blood flow in suspected
renal trauma, to differentiate renal cysts from
tumors and to evaluate hypertension.
• It is used for preoperatively for
tyransplantaion.
 Urologic endoscopic procedures
• Endourology or urologic endoscopic procedures
can be performed in one of two ways; using a
cystoscope inserted into the urethra, or
percutaneously through an incision.
• Used to directly visualize the urethra and bladder.
• The cystoscope also permits the urologist to
obtain a urine specimen from each kidney to
evaluate its function.
• Cup forceps can be inserted through the
cystoscope for biopsy.
• Calculi may be removed from the urethra,
bladder and ureter using cystoscopy.
Biopsy (renal & ureteral brush biopsy)
• Brush biopsy techniques provide specific
information when abnormal x-ray findings of
the ureter or renal pelvis raise questions
about whether the defect is a tumor, a stone,
a blood clot, or an artifact.
• First a cystoscopic exam, then a ureteral
catheter is introduced, follwed bya biopsy
brush that is passed through the catheter.
 Kidney biopsy
• Used in diagnosing and evaluating the extent
of kidney dse. Indications for biopsy include
unexplained acute renal failure, persistent
proteinuria or hematruria, transplant rejection
and glomerulonephritis .
• Obtained either percutaneously (needle
biopsy) or by open incision through a small
flank incision.
 Urodynamic tests
Uroflowmetry – is the record of the volume of urine
passing through the urethra per time unit (milliliter
per second).
• The px is advised to arrive for the test with a strong
urge to void but not have an overly full bladder.
• It is combined with electromyographic measurement
of the external urethral sphincter via surface wire or
needle electrodes placed at th level of the sphincter,
on eother side of the urethra.
• Cystometrography – graphic recording of the
pressures in the bladder filling and emptying.
• It is the major dx portion of urodynamic
testing.
 electromyography
• Involves placement of
electrodes in the pelvic
floor musculature or over
the area of the anal
sphincter to evaluate the
neuromuscular function of
the lower tract.
• It is performed
simultaneously with CMG
 Videofluorourodynamic study
• Consideres optimal urodynamic evaluation.
• This test combines a study of the filling and
voiding phases of the CMG and EMG with a
simultaneous visualization of the lower
urinary tract via a radiopaque filling and
detailed assessment of the voiding
dysfunction which may be due in part to
anatomic dysfunction.
Patient care during urologic testing with
contrast agents
• For some patients, contrast agents are
neprhotoxic and allergenic. The following
guidelines can help the nurse and other care
givers respond quickly in the event of a
problem.
• Have emergency equipment and medications
available in case of the patient has an
anaphylactic reaction to the contrast agent.
Emergency supplies include epinephrine,
corticosteroids, and vasopressors, oxygen and
airway and suction equipment
 SUMMARY: Nursing History
• The nurse determines:
– Normal voiding pattern and frequency
– Appearance of the urine and any recent changes
– Any past or current problems with urination
– The presence of an ostomy
– Factors influencing the elimination pattern
 Physical Assessment
• Percussion of the kidneys
– To detect areas of tenderness and palpation for
contour, size, tenderness, and lumps.
• Percussion and palpation of the bladder
• Examination of the urethral meatus
– Look for swelling, discharge, and inflammation.
 Assessment of Urine
• Measure volume
• Inspect color, clarity, and volume
• Test for specific gravity, glucose, ketone
bodies, blood, and pH
 Diagnostic Tests
• To determine urinary tract disease or
disorders of other body systems influencing
the production of urine
– Urinalysis
– Urine culture
– Radiographic examinations (KUB and IVP)
– Cystoscopy
– Blood tests
 Therapeutic Measures
• Catheterization • Urologic surgery
• Ureteral catheter – Nephrectomy
• Nephrostomy tube – Removal of calculi
• Urinary stent – Lithotripsy
• Drug therapy – Cystectomy
– Cystotomy
– Urinary diversions
– Cystostomy
 Nursing Dx R/T Urinary Elimination

Impaired urinary elimination Functional urinary incontinence

Urinary retention
Risk for infection r/t urinary retention
and/or urinary catheterization
Overflow urinary incontinence
Stress urinary incontinence
Reflex urinary incontinence
Urge urinary incontinence

Risk for impaired skin integrity r/t urinary Total urinary incontinence
incontinence
Situational low self esteem r/t
incontinence
 INCONTINENCE
• Functional = d/t inability to get to toilet as in
altered mobility, or altered cognition
• Overflow = loss of urine d/t over distention of
bladder (urinary retention)
• Stress = leakage with increased intra-
abdominal pressure
• Reflex = d/t neuro deficits ie spinal cord injury
• Urge = leakage accompanied by sudden
urgency
• Total = continuous loss of urine d/t ex fistula
 Outcome Criteria
Patient will:
• Empty bladder completely at regular
intervals
• Decrease episodes of incontinence
• Maintain regular urinary elimination
pattern
• Develop adequate Intake/Output
• Have decreased dysuria
 Nursing Interventions
• Maintain voiding habits
• Promote fluid intake
• Strengthen muscle tone
Kegels 30-80/day
• Stimulate urination
Auditory
Tactile
 Implementation…..
• Maintain habits by promoting, scheduling,
positioning, hygiene.
• Privacy & Comfort
• Allow adequate time to void
• Promote relaxation - breathing, imagery etc.
• Fluid intake 2000cc/day
• Kegel exercises to strengthen pelvic muscles30-80
times/day for 6 wks
 Implementation Cont….
• Stimulate urination…privacy, position,running water,
warm water over perineum Auditory- sound of
running water
• Tactile- feel of water, place hands in warm water,
pour warm water over perineum
• Application heat/cold, apply warm soaks over pubic
area may decrease muscle tension. Sitz bath
• Apply cold packs over abd. may increase muscle
contraction…
• Avoid increasing Anxiety by over emphasizing the
problem
 Interventions: Toileting
• Toilet
• Commode • Safety Concerns
• Bedpan
• Urinal • Female Hygiene
• Disposable“ Hat”
• Fx pan
 Interventions for Urinary
Incontinence
• Bladder training/ Habit training
• Bladder training- postpone voiding according
to timetable rather than urge…gradually
lengthen intervals stabilize bladder decrease
urgency
• Habit training- timed voiding to keep dry…no
motivation to delay voiding if urge occurs
• External urinary device
- Condom Catheter
• Indwelling catheter-LAST resort
 Condom Catheter (Texas Cath)
• Rubber condom placed on penis of
incontinent males
• Connects to drainage bag to collect
urine
• Easy to apply and observe
• Comfortable
• Doesn’t require intubation
• Prevents skin irritation from
incontinence
 Condom Catheter
• Check every 2-4 hrs.
• Remove and replace every 24 hrs.
• Maintain free urinary drainage
• Never tape to skin
• Leave 1-2 inch space at tip of penis
• Secure snuggly but not too tight
• Follow manufacturer instructions
 Urinary Catheterization
Used to:
• Keep bladder deflated during surgery
• Measure residual urine
PVR (post void residual) should be < 50 ml
• Relieve retention
• Obtain sterile urine specimen
May use either:
• Straight catheter or indwelling catheter
 Indwelling catheter
• Catheter inserted into urinary meatus through urethra
into bladder to drain urine
• Last resort as it introduces microbes into bladder…leading
to UTI (urinary tract infection)
• Performed using sterile technique...MD order needed
• Remains in place via inflated balloon
ALSO
Suprapubic Catheter – diverts urethra
Urologic Stents- temporary in ureters
permanent in urethra
Ileal Conduit – diversion of ureters to
ileum and stoma; requires appliance
 Medications Affecting Urinary
Elimination

• Antibiotics …work against infection

Bactrim, Levaquin, Cipro
• Urinary antispasmotics …relieve spasms with
UTI
Ditropan, Pro-Banthine
• Diuretics….increase urinary output
Lasix, Diuril
• Cholinergics…increase muscle tone & function
Used for urinary retention, neurogenic bladder
Urecholine
 Urinary Specimen Collection

• Routine urinalysis
• Clean-catch/midstream urine
• Sterile specimen ( catheterization or
from indwelling catheter)
• 24 hr. urine
Evaluating Urinary Elimination

• Frequency
• Amount
• Ease/Difficulty
• Color
• Appearance
• Odor
 Diseases & Disorders
Congenital
 Congenital hydronephrosis
 Congenital obstruction of urinary tract
 Duplicated ureter
 Horseshoe kidney
 Polycystic kidney disease
 Renal dysplasia
 Unilateral small kidney
 Multicystic dysplastic kidney
 Big Kidney
Acquired
 Diabetic nephropathy
 Glomerulonephritis
 Hydronephrosis is the enlargement of one or both
of the kidneys caused by obstruction of the flow of
urine.
 Interstitial nephritis
 Kidney stones are a relatively common and
particularly painful disorder.
 Kidney tumors – Wilms tumor, Renal cell
carcinoma
 Acquired cont..
 Lupus nephritis
 Minimal change disease
 In nephrotic syndrome, the glomerulus has been
damaged so that a large amount of protein in the
blood enters the urine. Other frequent features of
the nephrotic syndrome include swelling, low serum
albumin, and high cholesterol.
 Pyelonephritis is infection of the kidneys and is
frequently caused by complication of a urinary tract
infection.
 Renal failure – Acute renal failure, Stage 5 Chronic
Kidney Disease
 COMMON DISEASES IN RENAL
 Acute renal failure, a sudden loss of renal
function
 Chronic kidney disease, declining renal
function, usually with an inexorable rise in
creatinine.
 Hematuria, blood loss in the urine
 Proteinuria, the loss of protein especially
albumin in the urine
 Microalbuminuria, slight increase in urinary
albumin excretion
 Cont…..
 Electrolyte disorders or acid/base imbalance
 Kidney stones, usually only recurrent stone
formers.
 Nephrosis, degeneration of renal tubular
epithelium.
 Nephritis, inflammation of the kidneys
 Chronic or recurrent urinary tract infections
 Hypertension that has failed to respond to
multiple forms of anti-hypertensive medication
or could have a secondary cause
• Thank you
• Questions……