ASSESSMENT OF RENAL AND URINARY TRACT FUNCTION

Objectives

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

HEALTH HISTORY

Obtaining a urologic health history requires excellent communication skills because many patients are embarrassed or uncomfortable discussing genitourinary function or symptoms.

THE NURSE SHOULD INQUIRE ABOUT THE FF

Pxs chief concern or reason for seeking health care, the onset of the problem & its effect on the pxs 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 STDs Habits: use of tobacco, alcohol, or recreational drugs Any prescription & over-the-counter medications (including those prescribed for

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 its the one responsible for circulating oxygen

Problems Associated with Changes in Voiding Problem Definition Frequency Frequent voiding more than every 3 hours Urgency Strong desire to void

Possible Etiology Infection, obstruction of lower urinary tract leading to residual urine and overflow, anxiety diuretics, BPH, urethral stricture, diabetic neuropathy Infection, chronic prostatitis, urethritis, obstruction of lower urinary tract leading to residual urine and overflow, anxiety, diuretics, BPH, urethral stricture, diabetic neuropathy Lower urinary tract infection, inflammation of bladder or urethra, acute prostatitis, stones, foreign bodies, tumors in bladder BPH, compression of urethra, outlet obstruction, neurogenic bladder Decreased renal concentrating ability, failure, diabetis mellitus, incomplete bladder emptying, excessive fluid intake at bedtime, nephritic syndrome, cirrhosis with ascites

Dysuria Hesitancy Nocturia

Painful or difficult voiding Delay, difficulty in initiating voiding Excessive urination at night

Incontinence

Involuntary loss of urine

External urinary sphincter injury, obstetric injury, lesions of bladder neck, detrusor dysfunction, infection, neurogenic bladde, medications neurologic abnormalities
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

Enuresis

Involuntary voiding during sleep

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) Urine output less than 400mL/day Urine output less than 50mL/day Red blood cells in the urine Acute or chronic renal failure, complete obstruction Acute or chronic renal failure, complete obstruction Cancer of genitourinary tract, acute glomerulonephritis, renal stones, renal tuberculosis, blood dyscrasia, trauma, extreme exercise, rheumatic fever, hemophilia, leukemia, sickle cell trait or disease Acute and chronic renal disease, mephrotic syndrome, vigorous exercise, heat stroke, severe failure, diabetic neuropathy, multiple myeloma

Oliguria Anuria Hematuria

Proteinuria

Abnormal amounts of protein in the urine

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 KIDNEY LOCATION Costovertebral angle, may extend to umbilicus CHARACTER Dull constant ache; if sudden distention of capsule, pain is severe, sharp, stabbing and colicky in nature ASSOCIATED S/SX n/v, diaphoresis, pallor, signs of shock POSSIBLE ETIOLOGY 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 Perineum and rectum

Severe, sharp, stabbing pain, colicky in nature

n/v, paralytic ileus

Ureteral stone, edema or stricture, blood clot

PROSTATIC

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

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.

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 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, medications

Yellow to milky white Bright yellow Pink to red

Blue, blue green Orange to amber

Brown to black

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) 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 UTZ

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

Thank you