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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 T 12 to L 3

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)

The kidneys, ureters, and bladder. (Source: Dorling Kindersley Media Library) 6
Figure 40-1

The Renal System

The Renal System
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

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

Figure 40-3

Figure 40-3

An illustration of the internal structures of the kidney.

An illustration of the internal structures of the kidney. 18
Figure 40-4

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

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 balanceretain

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
Urine Formation Processes

Filtration

Reabsorption

Secretion

Figure 15.4
Figure 15.4

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

Slide

Filtration
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
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
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
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
Formation of Urine
Formation of Urine Figure 15.5 Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide

Figure 15.5

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

Slide

Figure 40-6
Figure 40-6

Physiology/Pathophysiology

Renin-angiotensin system

Stimuli for Renin Excretion

Stimuli for Renin Excretion

Angiotensinogen in liver

Angiotensinogen in liver

Renin release

Renin release

Angiotensin I

Angiotensin I

Converting enzyme in lungs

Converting enzyme in lungs

Angiotensin II

Angiotensin II

Renal autoregulation

Renal autoregulation

Hormones influencing renal function

Reninraises BP

Bradykininsincrease blood flow and vascular

permeability

Erythropoietin

ADH

Aldosteronepromotes sodium reabsorption and potassium excretion

Natriuretic hormonesreleased 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
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

Can be severe

Pain

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

Tumors:

Pain

No pain unless

obstruction

extend beyond the primary organ to involve adjacent

nerves

Renal Pain

Site: ipsilateral

Pain

costovertebral angle just

lateral to the sacrospinalis muscle and beneath the 12th rib

angle just lateral to the sacrospinalis muscle and beneath the 12th rib • Acute distention of

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 T10T12 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?

Initial hematuria:

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 every 3 hours

Infection, obstruction of lower urinary tract leading to residual urine and 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 voiding

BPH, compression of urethra, outlet obstruction, neurogenic bladder

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 the urine

Acute and chronic renal disease, mephrotic syndrome, vigorous exercise, 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 extend to umbilicus

Dull constant ache; if sudden distention of capsule, pain is severe, sharp, stabbing and colicky in nature

n/v, diaphoresis, pallor, signs of shock

Acute obstruction, kidney stone, blood clot, acute pyelonepritis, trauma

BLADDER

Suprapubic area

Dull, continous pain, may be intense with voiding, may be severe if bladder is full

Urgency, pain at the end of voiding, painful straining

Overdistended bladder, infection, interstitial cystitis; tumor

URETERAL

Costovertebral angle, flank, lower abdominal area, testis or labium

Severe, sharp, stabbing pain, colicky in nature

n/v, paralytic ileus

Ureteral stone, edema or stricture, blood clot

PROSTATIC

Perineum and rectum

Vague discomfort, feeling of fullness in perineum, vague back pain

Suprapubic tenderness, obstruction to urine flow, frequency, urgency, dysuria, nocturia

Prostatic cancer, acute or chronic prsotatitis

URETHRAL

Male: along penis to meatus; female: urethra to meatus

Pain variable, most severe during and immediately after voiding

Frequency, urgency, dysuria, nocturia, urethral discharge

Irritation of bladder neck, infection of urethra, 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

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.

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)

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

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?

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

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

Abdominal Examination of the GU Tract • Physical examination for signs of enlarged kidneys by bimanual

Kidneys

Kidneys
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

Bladder
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

Physical Signs of an Enlarged Bladder

Cont’d:

Physical Signs of an Enlarged Bladder Cont’d:
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

Hypospadias
Hypospadias

Scrotal masses

Inspection

Site

Size

Shape

Skin

Cough impulse

Palpation

Temp.

Tenderness

Consistency

Others according

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

Genital Examination

Transillumination

Rectal and Prostate Examination in the

Male

Digital rectal

and Prostate Examination in the Male • Digital rectal examination (DRE) : – every male after

examination (DRE) :

every male after age 40 years Men of any age who present for urologic evaluation

Per- rectal Examination

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

Colorless to pale yellow

Yellow to milky white

Bright yellow

Pink to red

Blue, blue green

Orange to amber

Brown to black

Possible Cause

Dilute urine due to diuretics, alcohol consumption, diabetes insipidus, glycosuria, excess fluid intake, renal dse

Pyuria, infection, vaginal cream

Multiple vitamin preparation

Hgb breakdown, RBC, gross blood, menses, bladder or prostate surgery, beets, blackberries, medications (phenyton, rifampicin, phenothiazine, cascara, senna products)

Dyes, methylene blue, pseudmona species organisms, medications Concentrated urine due to dehydration, fever, bile, excess bilirubin or carotene, medications

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

(distention of the pelvis of the kidney) cysts, tumors, or kidney displacement by abnormalities in surrounding

Ct scan / mri

Used in evaluating

genitourinary masses,

neprhrolithiasis, chronic renal infxn,

renal or urinary tract

trauma, metastatic disease and soft tissue

abnormalities

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.

are used to evaluate acute and chronic renal failure, renal masses and blood flow before and

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.

urologic problem, especially lesions in the kidneys and ureters. It also provide a rough estimate of

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

the anal sphincter to evaluate the neuromuscular function of the lower tract. • It is performed

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

Ureteral catheter

Nephrostomy tube

Urinary stent

Drug therapy

Urologic surgery

Nephrectomy

Removal of calculi

Lithotripsy

Cystectomy

Cystotomy

Urinary diversions

Cystostomy

Nursing Dx R/T Urinary Elimination

Impaired urinary elimination

Urinary retention

Risk for infection r/t urinary retention and/or urinary catheterization

Risk for impaired skin integrity r/t urinary incontinence

Situational low self esteem r/t

incontinence

Functional urinary incontinence

Overflow urinary incontinence

Stress urinary incontinence

Reflex urinary incontinence

Urge urinary incontinence

Total urinary 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

Bedpan

Urinal

Disposable“ Hat”

Fx pan

Safety Concerns

Female Hygiene

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

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

Remains in place via inflated balloon

MD

ALSO

order needed

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

function

failure,

a

sudden

loss

of

renal

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,

albumin excretion

slight

increase

in

urinary

Cont…

Electrolyte disorders or acid/base imbalance

Kidney

stones,

usually

only

recurrent

stone

formers.

Nephrosis,

epithelium.

degeneration

of

renal

tubular

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……