Nursing Assessment: Urinary System

1. Nursing Assessment: Urinary System NURS 1228 Spring 2003 By Nina Green, RN, Instructor

2. Structures and Functions of the Urinary System Please review your A & P textbook Look closely at the Macrostructure and Microstructure of the Kidneys

3. Normal Glomerular Filtrate (Review) Normally the capillary pores are to small to allow loss of large blood components. With many renal diseases, capillary permeability is increased allowing plasma proteins to enter urine. It is like blood, except it doesn�t have the large blood components (plasma proteins, blood cells, and platelets)

4. Normal Glomerular Filtration Rate Normal GFR is 125 ml/minute However, because much is reabsorbed by the peritubular capillary network as the filtrate travels toward the collecting duct, usually only 1 ml/minute is excreted as urine

5. Antidiuretic Hormone (ADH) Released from the posterior pituitary gland Stimulated by increased serum osmolality and decreased blood volume Acts on the distal convoluted tubules and collecting ducts increasing wall permeability to water, allowing water reabsorption back into the capillaries.

6. Aldosterone Released from the adrenal cortex Release is stimulated by the circulating blood volume and plasma concentrations of sodium ion (Na+) and potassium ion (K+) Acts on the distal tubule Causes the reabsorption of (Na+) and water. In exchange for Na+, K+ is excreted.

7. Acid-base regulation The conservation of bicarbonate (HCO3-) and the excreting of excess hydrogen ion (H-). The distal tubule functions to maintain the pH of the ECF between 7.35 and 7.45

8. Atrial Natriuretic Factor (ANF) Hormone released from the right atrium of heart Stimulated by elevated right atrial blood pressures Inhibits secretion of ADH and its effect on reabsorption of water into blood system Causes dilute urine in large amounts

9. Parathyroid Hormone Released from the parathyroid gland Stimulated by low serum calcium (Ca++) levels in blood Causes the reabsorption of calcium ions increasing serum calcium

10. Other Renal Functions Production of erythropoietin Released in response to decreased oxygen tension in the renal blood supply (usually due to loss of RBC�s) Stimulates the production of RBC�s in bone marrow A deficiency of erythropoietin causes anemia in renal failure

11. Other Renal Functions Assists in the activation of Vitamin D Ingested Vitamin D and Vitamin D from the sun via the skin are inactive until they are acted upon by the liver and kidney. Vitamin D is essential for the uptake of calcium from the GI tract. The patient with renal failure has a deficiency of the active metabolite Vitamin D and so has problems with calcium and phosphate balance.

12. Other Renal Functions Renin Assists in the regulation of blood pressure Is released in response to decreased arterial blood pressure,renal ischemia, ECF depletion, increased norepinephrine, and increased levels of Na+ in urine Catalyzes the splitting of the plasma protein angiotensinogen into angiotensin 1

13. Other Renal Functions Angiotension 2 Is converted from angiotension 1 Stimulates the release of aldosterone. (Na+ and water retention and yields greater ECF volume) Causes increased peripheral vasoconstriction which combined with the increased ECF volume causes increased blood pressure. This inhibits the release of renin.

14. Prostaglandin's Synthesized by most body tissues In kidney, produced mainly in Medulla Causes vasodilation, increased blood flow, and Na+ excretion, lowers blood pressure Counteracts angiotensin and norepinephrine Loss of Prostaglandin tissue in the kidney due to renal failure ? Cause of HTN in renal patients.

15. Organs of Urinary System Kidneys Ureters Urethra Female 1-2 inches long Male 8-10 inches long Meatus* Bladder Urethrovesical Unit Bladder Bladder neck Urethra Pelvic floor muscles Meatus is not mentioned in text, but it is included because it is included when discussing cancers.Meatus is not mentioned in text, but it is included because it is included when discussing cancers.

16. Effects of aging on Urinary System Decreased Renal tissue Number of nephrons Renal vascular supply Function of loop of Henle and tubules Elasticity of muscle tone in bladder/urethra Decreased Bladder capacity and sensory receptors Weakened Urinary sphincter Estrogen deficiency causing thin, dry vaginal tissues Prostatic enlargement Between ages 30-90 there is a 20-30% decrease in the size and weight of the kidneys By age 70 about 30-50% of glomeruli have lost their function. Blood flow to the kidney decreases. This causes a decreased glomerular filtration rate (GFR) and a reduced ability of the glomeruli and tubules to conserve Na+, dilute or concentrate urine, and excrete acid load, and etc�. Decreased estrogen levels in older women causes urethral irritation, urethral and bladder infections, and urinary incontinence. In men, the prostate enlarges with age and can affect urination. May cause a partial obstruction. Constipation can affect urination also.Between ages 30-90 there is a 20-30% decrease in the size and weight of the kidneys By age 70 about 30-50% of glomeruli have lost their function. Blood flow to the kidney decreases. This causes a decreased glomerular filtration rate (GFR) and a reduced ability of the glomeruli and tubules to conserve Na+, dilute or concentrate urine, and excrete acid load, and etc�. Decreased estrogen levels in older women causes urethral irritation, urethral and bladder infections, and urinary incontinence. In men, the prostate enlarges with age and can affect urination. May cause a partial obstruction. Constipation can affect urination also.

17. Causing Kidneys to be less palpable Decrease in creatinine clearance, increase in BUN Alterations in drug excretion Nocturia, frequency, urgency, incontinence Decreased ability to concentrate urine, diluted urine Loss of usual pattern with urination Urine retention Stress incontinence, dysuria, dribbling Increased infections

18. Functional Health Patterns Health Perception-Health Management Pattern How is energy level? Vision changes? Smoker? How long? Nutritional-Metabolic Pattern: How is appetite? Weight changes? Vitamin or mineral supplements? Kinds of fluids drink? How much? Caffeine? Caffeine or spicy foods? How much?

19. Functional Health Patterns Elimination Pattern Urination, how often? Nocturia? Color? Blood? Urgency? Frequency? Incontinence? Dribbling? Pain? Use special devices for elimination or control? Bowels regular? Activity-Exercise Pattern Changes in ADL�s? Activities aggravate urinary problem? Urinary problem caused you to alter or stop activities or exercise? Require assistance moving? To bathroom?

20. Functional Health Patterns Cognitive-Perceptual Pattern Pain with urination? Self-Perception-Self-Concept Pattern How does urinary problem make you feel about yourself? Different body perception since urinary problem?

21. Functional Health Patterns Role-Relationship Pattern Problems with relationships due to urinary problem? Change in job status or ability to do job related responsibilities due to urinary problem? Sexuality-Reproductive Pattern Change in sexual pleasure or performance due to urinary problem? Hygiene problems r/t sexual activities causing concerns?

22. Functional Health Patterns Coping-Stress Tolerance Pattern Able to manage urinary problem? Strategies using to cope with urinary problem? Values-Beliefs Pattern Present illness affecting belief system? Treatment decisions r/t urinary problem in conflict with value system?

23. Common Abnormalities of Urinary System Dysuria Frequency Enuresis Hesitancy Urgency Hematuria Burning on urination Pneumaturia Retention Pain Incontinence Stress incontinence Nocturia Polyuria Anuria Oliguria See text pg 1250 Table 42-7See text pg 1250 Table 42-7

24. Diagnostic Studies of the Urinary System Urine Studies Urinalysis Creatinine clearance Urine culture (clean catch midstream) Concentration test Residual urine Protein determination Urine cytology Blood Chemistries BUN Creatinine Uric acid Sodium Potassium Calcium Phosphorus bicarbonate BUN Blood urea nitrogen is a by product of the breakdown of amino acids used for energy production. It is a rough indicator of decreased kidney function. It is elevated in kidney failure, shock, GI bleeding, diabetes and some tumors. Normal range is 10-30mg/dl. Increase may mean renal problems. Creatinine The decomposition product of the metabolism of phosphocreatine, a source of energy for muscle contraction. Increased quantities of it are found in advanced stages of renal disease. It is a normal alkaline constituent of urine and blood. Normal serum range is 0.5-1.5mg/dl. BUN/Creatinine ratio normal finding is 10:1 Uric acid normal finding is 2.5-5.5mg/dl for women and 4.5-6.5mg/dl for men Sodium normal range is 135-145mEq/l Potassium normal range is 3.5-5.5mEq/l Calcium normal range is 9-11mg/dl Phosphorus normal range is 2.8-4.5 mg/dl Bicarbonate normal range 20-30mEq/l. Most patients in renal failure have metabolic acidosis and low serum HCO3- levels.BUN Blood urea nitrogen is a by product of the breakdown of amino acids used for energy production. It is a rough indicator of decreased kidney function. It is elevated in kidney failure, shock, GI bleeding, diabetes and some tumors. Normal range is 10-30mg/dl. Increase may mean renal problems. Creatinine The decomposition product of the metabolism of phosphocreatine, a source of energy for muscle contraction. Increased quantities of it are found in advanced stages of renal disease. It is a normal alkaline constituent of urine and blood. Normal serum range is 0.5-1.5mg/dl. BUN/Creatinine ratio normal finding is 10:1 Uric acid normal finding is 2.5-5.5mg/dl for women and 4.5-6.5mg/dl for men Sodium normal range is 135-145mEq/l Potassium normal range is 3.5-5.5mEq/l Calcium normal range is 9-11mg/dl Phosphorus normal range is 2.8-4.5 mg/dl Bicarbonate normal range 20-30mEq/l. Most patients in renal failure have metabolic acidosis and low serum HCO3- levels.

25. Diagnostic Studies of the Urinary System Radiologic Procedures Kidneys, ureters, bladder (KUB) IVP or excretory urogram Nephrotomogram Retrograde pyelogram Radiologic Procedures Cystogram Renal arteriogram (angiogram) Ultrasound CT scan MRI KUB is a flat abdominal x-ray taken without contrast to show the renal outline, surrounding musculature and the bladder if it is full. Stones and foreign bodies (tumors) can be seen with this x-ray. IVP or excretory urogram, is to visualize the urinary tract. Gives clues to renal function. Uses IV contrast material, which circulates in the blood and is excreted in the kidneys and urinary tract. Is possible to detect tumors, cysts, lesions, and obstructions. Nephrotomogram is similar to a CT scan. An IV contrast is given and excreted in the kidneys. Pictures are taken of the kidneys during the procedure in sections. Can see blockages, stenosing and other factors causing urinary problems. Retrograde pyelogram is similar to an IVP. Contrast is inserted directly into the kidney and pictures are taken sequentially. Contrast is inserted via a urinary catheter inserted through a cystoscope. There is a risk of infection and patient undergoes sedation. Is used if patient is allergic to contrast media, has decreased renal function or IVP was inconclusive in findings. Cystogram: contrast media is instilled into bladder via a cystoscope or urinary catheter. Purpose is to visualize the bladder and evaluate for reflux of urine. Renal arteriogram: contrast material is injected into the renal artery via a catheter inserted into the femoral artery. Purpose is to visualize the renal blood vessels. Ultrasound is a noninvasive procedure ulilizing sound waves inserted into body structures and recorded. A computer interprets the tissue density based on sound waves and displays it in a picture form. CT scan provides excellent visualization of kidneys. Advantage over ultrasound is that the CT scan can pick up subtle differences. IV contrast media is given. Tumors and abnormalities can be detected easily. MRI is computer generated films that rely on radio waves and alteration in magnetic field. Not useful in detecting some tumors and foreign bodies. Used to visualize the kidneys.KUB is a flat abdominal x-ray taken without contrast to show the renal outline, surrounding musculature and the bladder if it is full. Stones and foreign bodies (tumors) can be seen with this x-ray. IVP or excretory urogram, is to visualize the urinary tract. Gives clues to renal function. Uses IV contrast material, which circulates in the blood and is excreted in the kidneys and urinary tract. Is possible to detect tumors, cysts, lesions, and obstructions. Nephrotomogram is similar to a CT scan. An IV contrast is given and excreted in the kidneys. Pictures are taken of the kidneys during the procedure in sections. Can see blockages, stenosing and other factors causing urinary problems. Retrograde pyelogram is similar to an IVP. Contrast is inserted directly into the kidney and pictures are taken sequentially. Contrast is inserted via a urinary catheter inserted through a cystoscope. There is a risk of infection and patient undergoes sedation. Is used if patient is allergic to contrast media, has decreased renal function or IVP was inconclusive in findings. Cystogram: contrast media is instilled into bladder via a cystoscope or urinary catheter. Purpose is to visualize the bladder and evaluate for reflux of urine. Renal arteriogram: contrast material is injected into the renal artery via a catheter inserted into the femoral artery. Purpose is to visualize the renal blood vessels. Ultrasound is a noninvasive procedure ulilizing sound waves inserted into body structures and recorded. A computer interprets the tissue density based on sound waves and displays it in a picture form. CT scan provides excellent visualization of kidneys. Advantage over ultrasound is that the CT scan can pick up subtle differences. IV contrast media is given. Tumors and abnormalities can be detected easily. MRI is computer generated films that rely on radio waves and alteration in magnetic field. Not useful in detecting some tumors and foreign bodies. Used to visualize the kidneys.

26. Diagnostic Studies of the Urinary System Renal Radionuclide Imaging Renal Scan Endoscopy Cystoscopy Urodynamics Cystometrogram Invasive Procedure Renal biopsy Renal Scan Radioactive isotopes are injected IV. Radiation detector probes are placed over kidney, and scintillation counter monitors radioactive material in kidney. Purpose is to show blood flow, glomerular filtration, tubular function, and excretion. The radioisotope distribution in the kidney is scanned and mapped. Cystoscopy: study involves use of tubular lited scope to inspect the bladder. Is done under local or general anesthesia. Cystometrogram: is a study where a catheter is inserted and water or saline is instilled into the bladder. Measurements are taken of the pressure this exherts on the bladder wall. Purpose is to evaluate bladder tone, sensations of filling, and bladder stability. Renal Biopsy: is usually done as a skin biopsy through needle insertion into the lower lobe of the kidney. The purpose is obtain renal tissue for examination to determine type of renal disease or to follow the progress of renal disease. Renal Scan Radioactive isotopes are injected IV. Radiation detector probes are placed over kidney, and scintillation counter monitors radioactive material in kidney. Purpose is to show blood flow, glomerular filtration, tubular function, and excretion. The radioisotope distribution in the kidney is scanned and mapped. Cystoscopy: study involves use of tubular lited scope to inspect the bladder. Is done under local or general anesthesia. Cystometrogram: is a study where a catheter is inserted and water or saline is instilled into the bladder. Measurements are taken of the pressure this exherts on the bladder wall. Purpose is to evaluate bladder tone, sensations of filling, and bladder stability. Renal Biopsy: is usually done as a skin biopsy through needle insertion into the lower lobe of the kidney. The purpose is obtain renal tissue for examination to determine type of renal disease or to follow the progress of renal disease.