1. Chapter 45 Nursing Assessment Urinary System S. Buckley, RN, MS
( adapted from Mosby pp)
Adequate functioning of the kidneys is essential to the maintenance of a healthy body. If there is complete kidney failure and treatment is not given, death is inevitable.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

2. Renal A & P websites
1. A & P
another animated a&p
1. urine formation
2. kidney anatomy

3. Structures and Functions of the Urinary System
Kidneys
Macrostructure
Microstructure
Blood supply
Primary function of kidneys:
1. regulate volume and composition of extracellular fluid (ECF)
2. excrete waste products from body.
Physiology of urine formation
Glomerular function
Tubular function
Other functions of the kidney; control blood pressure, produce erythropoietin, activate vitamin D, regulate acid-base balance.
Macro structure: 2 kidneys, 2 ureters, a urinary bladder, a urethra.
Micro: nephron: functional unit of the kidney.
Blood supply: 1200ml/min, which is ~25% of cardiac output

4. Fig. 45-1
System consists of 2 kidneys, two ureters (drainage channels), a urinary bladder (storage) and a urethra
Macrostructure: bean-shaped organs that are retroperitoneal (behind the peritoneum) on either side of vertebral column at T12-L3.
5 inches long. R lover than left. Adrenal gland lies on top of each kidney (adrenal gland, p consists of medulla and cortex; adrenal inner part secretes catecholamines epinephrine (major hormone ~75%), norepinephrine (25%), and dopamine. Catecholamines are usually neurotransmitters but are hormones when secreted by the adrenal medulla because they are released into the circulation and transported to their target organs. Catecholamines have widespread effects on all body systems, especially in response to stress.
Adrenal cortex-outer part of adrenal gland. Secretes more than 50 steroid hormones such as glucocorticoids, mineralcocorticoids and androgens. Corticosteroid refers to any of the hormones synthesized by the adrenal cortex (excluding androgens) cortisol is most abundant and potent glucocorticoid and is involved in the regulation of blood glucose concentration.
Each kidney is covered in fat and a sheath (capsule) which protect the kidney and act a shock absorber.
Blood supply: blood reaches kidneys via renal artery which arises from the aorta and enters the kidney through the hilus. Renal artery divides into secondary branches and into smaller branches each of which eventually forms an “afferent arteriole.” Afferent arteriole divides into a capillary network termed the glomerulus, which is a tuft of up to 50 capillaries, which unite to form the efferent arteriole.
Rhabdomyolysis=serious disease characterized by breakdown of skeletal muscle, leads to myoglobinuria, which places the kidneys at risk for acute failure. Rhabdosphincter-muscle sphincter surrounding urethra at prostate.
Rhabdomylosis-an acute, sometimes fatal disease in which the byproducts of skeletal muscle destruction accumulate in the ranal tubules and produce acute renal failure. Rhabodmylosis may result from crush injuries, the toxic effect of drugs or chemicals on skeletal muscle, extremes of exertion, septic, shock and severe hyponatremia. May result in life-threatening hyperkalemia and metabolic acidosis may result. Management may include the infusion of bicarbonate-containing fluids (to enhance urinary secretion of myoglobin and iron, or hemodialyis.

5. Fig. 45-2
Hilus is on the medial side of kidney and serves as entry site for renal artery and nerves and exit site for the renal vein and ureter
Actual kidney tissue is called “parenchyma”, outer layer is cortex, inner layer is medulla. Medulla consists of a number of pyramids, the apices of these pyramids are papillae, through which urine passes to enter the calyses. Calyses widen and merge to form a sac called renal pelvis. Calyces transport urine to the renal pelvis, from which it drains via the ureter to the bladder. The pelvis of the kidney can store a small volume of urine (3-5ml).

6. Nephron
Basic function is to clean or clear blood plasma of unnecessary substances
After the glomerulus has filtered the blood, the tubules select the unwanted from the wanted portion of tubular fluid. The necessary portions are returned to the blood, and the unnecessary portions pass into urine.

7. Fig. 45-3
NEPHRON-functional unit of the kidney, each kidney contains ~800, million nephrons. Composed of: glomerulus, Bowman’s capsule and tubular system.
Tubular system consists of proximal convoluted tubule, loop of Henle, distal convoluted tubule and collecting tubule..
The glomeruli, Bowman’s capsule, proximal tubule, and distal tubule are located in the cortex of kidney. Loop of Henle and collecting tubules are located in the medulla. Several collecting tubules join to form a single collecting duct. Collecting ducts merge into a pyramid that empties via the papilla into a minor calyx.
Blood supply: aorta-renal artery-afferent arteriole-capillaries (glomerulus). Capillaries of glomerulus unite in the efferent arteriole-splits to form capillary network called the peritubular capillaries-these drain into the venous system, the renal vein empties into the inferior vena cava.
Glomerulus-selective filtration
Proximal tubule-reabsorption of 80% of electrolytes and water: reabsorption of all glucose and amino acids; reabsorption of HCO3-; secretion of H+ and creatinine.
Loop of Henle-reabsorption of NA and CL in ascending limb; reabsorption of water in descending loop; concentration of filtrate
Distal tubule-secretion of K, H, ammonia: reabsorption of water (regulated by ADH); reabsorption of HCO3; regulation of CA and PO4 by parathyroid hormone, regulation of Na and K and aldosterone
Collecting duct-reabsorption of water (ADH required)

9. Physiology of urine formation
* Primary function of kidneys: filter blood, maintain body’s internal homeostasis.
* Multistep process of: filtration, reabsorption, secretions, excretion of water, electrolytes and metabolic waste.
* Urine formation begins at glomerulus (blood filtered)
* Glomerular filtration rate (GFR)-amount of blood filtered by the glomeruli in a given time,
normal is ~ 125ml/min.
Primary function accomplished via complex system of urine formation
Begins at glomerulus, where blood is filtered. Glomerulus is semipermeable membrane that allows filtration. Hydrostatic pressure of the blood within the glomerular capillaries causes a portion of the blood to be filtered across the semipermeable membrane into Bowmans capsule, where the filtered portion of the blood, the glomerular filtrate begins to pass down the tubule. The ultrafiltrate is similar to blood except the it lacks blood cells, platelets, and large plasma proteins. Under normal conditions, the capillary pores are too small to allow the loss of these large blood components, Capillary permeability is increased in many renal diseases, permitting plasma proteins and blood cells to pass into the urine.
The amount of blood filtered by the glomeruli in a given time is termed the glomerular filtration rate (GFR). Normal GFR is 125ml/min. However, on average only 1ml/min is excreted as urine because most glomerular filtrate is reabsorbed by the peritubublar capillary network before it reaches the end of the collecting duct.

10. Water balance, acid-base balance
Function of:
1. ADH
2. Aldosterone
3. HCO3 and H+ (acid/base balance)
4. ANP

11. decreases urine output
Antidiuretic hormone (ADH)-required for water reabsorption in the kidney , important in fluid balance.
makes tubules and collecting ducts permeable to water, allowing water to be reabsorbed into the peritubular capillaries and returned to the circulation.
Functions in concert with hypothalamus and neural input as loop mechanism
decreases urine output
ADH-antidiuretic, (against diuresis, decreases urine output, holds onto fluid (water) causing edema, hypervolemia)
In absence of ADH, the tubules are practically impermeable to water and any water in the tubules leaves the body as urine (diluted urine, diuresis). Explain p review ADH

12. aldosterone
Released from adrenal cortex, acts on distal tubule to cause reabsorption of Na+ and water.
Influenced by blood concentrations of Na+ and K+
In exchange for Na+ reabsorption, potassium ions (K+) are excreted.
p. 1138, lewis.

13. Acid base regulation
Reabsorbing and conserving bicarbonate (HCO3) and secreting Hydrogen (H+) in response ph of ECF
Distal tubule functions to maintain the ph of ECF within range of
Metabolic response to ph along with respiratory acid/base balance.

14. Atrial Natriuretic peptide (ANP)
Hormone secreted from cells in R atrium in response to atrial distention due to an increase in plasma volume.
Acts on kidneys to increase Na+ excretion.
Inhibits renin, ADH and action of angiotensinII on the adrenal glands, thus suppresses aldosterone secretion.
ANP causes relaxation of afferent arteriole, thus increasing the GFR
Combined effects of ANP=production of large volume of dilute urine

15. Fig. 45-4

16. Other Kidney functions (continued)
Erythropoietin-stimulates the production of red blood cells (RBCs) in bone marrow
produced and released in response to hypoxia and decreased renal blood flow.
In renal failure, a deficiency of erythropoietin occurs leading to anemia
Vitamin D-hormone obtained in diet and sun.
requires metabolism in liver and kidney to be “activated”, essential for absorption of Ca+ from GI tract.
In renal failure manifestation of problems of altered Ca+ and PO2 balance.
Erthropoietin-type of cytokine (soluble factors secreted by WBCs and other cells that act as messengers between the cell types. Cytokines instruct cells to alter their proliferation, differentiation, secretion or activity. There are abut 100 different cytokines, p they have a beneficial role in hematopoiesis, thus the cytokine, erthropoietin stimulates erythroid progenitor cells in bone marrow to produce red blood cells.
Vitamin D-needs metabolism by liver and kidney. In renal failure, altered calcium and phosphate balance.

17. Other Kidney functions
Calcium balance -parathyroid hormone (PTH) is released from parathyroid gland in response to low serum ca+ levels. PTH works by causing increased tubular reabsorption of CA2+ and decreased tubular reabsorption of phosphate ions (PO4 2-)
In renal disease, the effects of PTH may have major effect on bone metabolism.

18. Other Kidney functions (continued)
Renin-regulates BP, involved in splitting of angiotensin cascade (p. 1138). Angiotensin II stimulates release of aldosterone (causes Na+ and water retention leading to increased ECF volume) Also causes peripheral vasoconstriction. (both increase BP)
Produced and secreted by cells in kidneys, released into blood in response to decreased; renal perfusion, arterial BP, ECF, Na+
Released into blood in response to increased urinary Na+ concentration
the elevation of blood pressure brought abut by the increase in ECF and vasoconstriction and the increase in plasma sodium inhibit further renin release. Excessive renin production caused by impaired renal perfusion may be a contributing factor in the etiology of hypertension. Feedback loop does not function properly due to poor kidney perfusion. P.1139.

19. Other kidney functions (continued)
Prostaglandins (PGs)- involved in the regulation of cell function and host defenses
PG synthesis occurs in the medullla of the kidney. PGs increase renal blood flow and promote Na+ excretion.
Counteract the vasoconstrictor effect of angiotensin and norepinephrine =decreased systemic vascular resistance= decreased BP.
PGs-exert their influence primarily on cells or tissues that are close to the site where they are synthesized. P.195-prostaglandins are potent vasodilator and inhibit platelet and neutrophil aggregation. Also pyrogen, usually considered proinflammator, contributing to increased blood flow, edema and pain. Inhibited by NSAIDs
PGs therefore may have a system effect in lowering blood pressure by decreasing systemic vascular resistance. The significance of PGs is related to the role of kidneys in causing hypertension. In kidney failure, with loss of function tissue, renal vasodilator factors are also lost, which may be one factor that contributes to hypertension in renal failure.

20. Structures and Functions of the Urinary System (cont’d)
Ureters-~12 inches, carry urine from renal pelvis to bladder, can become obstructed with calculi (resulting in renal colic).
Bladder
Urethra-conduit for urine from bladder neck to outside body, external sphincter; rhabdosphincter
Female-1-2 in. , male-8-10in.
Urethrovesical unit-consists of bladder, urethra, pelvic floor muscles, normal voluntary control is defied as continence.
Ureters-can become obstructed by urinary stone calculi (internal) or occluded by external factors ,e.g., tumors, adhesions, inflammation. Sympathetic and parasympathetic nerves, circular smooth fibers that contract to promote the peristaltic one-way flow of urine. Contraction s can be impacted by distention, neurologic endocrine and pharmacologic factors,. Stimulation of the nerves during passage of a stone or clot may cause acute, severe pain, termed renal colic.
Renal pelvis holds only 3-5 ml of urine, kidney damage can result form a backflow of more than the amount of urine. The UVJ (ureterovesical junction) relies on the angle of bladder penetration and muscle fiber attachments with the bladder to prevent the backflow of urine (reflux) and ascending infection. When bladder pressure rises, during voiding or coughing, muscle fibers in ureter and bladder base contract first to help promote ureteral lumen closure. The bladder than contracts against its base to further close the UVJ and prevent urine from moving back through the junction.
Urethra; females are shorter and therefore more prone to infection (ascending)
Urethrovesical unit-stimulating and inhibiting impulses are sent from the brain to the thoracolumbar (T11-L2) and sacral (S2-S4) area of the spinal cord to control voiding. Distention of bladder stimulates stretch receptors within the bladder wall. Impulses are transmitted to sacral spinal cord and to brain causing desire to urinate. If the time to void is not appropriate, inhibitor impulses in the brain are stimulated and transmitted to sacral nerves innervating the bladder. In a coordinated fashion, the detrusor accommodates to the pressure (does not contract) while sphincter and pelvic floor muscles tighten to resist bladder pressure. If voiding is appropriate, cerebral inhibition is voluntarily suppressed and impulses are transmitted via spinal cord. The sphincter closes and the detrusor muscle relaxes when the bladder is empty. Any diseases or trauma that affects function of the brain, spinal cord, or nerves that directly innervate the bladder, neck, external sphincter or pelvic floor can affect bladder functions.
Hypospadias
One of the most common birth defects among boys, hypospadias is caused by the incomplete development of the urethra, the canal that carries urine from the bladder out of the body and also serves as the passageway for semen. The defect results in a urethra that opens on the underside of the penis. In the most serious cases, boys can't urinate normally unless they're treated.
Hypospadias has become much more common in the United States and Europe over the past 30 years, and occurs in one out of every 250 to 300 boys born in the U.S. It's second only to undescended testicles among birth abnormalities affecting a boy's genitalia.
Read More
There is a family tendency towards hypospadias, with an increased rate noted in boys whose father or brothers have hypospadias. Other than inherited cases, the cause is usually unknown. Researchers speculate that the increase may be related to exposure to environmental toxins. Some believe that the increase may be due to a greater interest in detecting and reporting the condition.
Fortunately, most boys born with this condition have mild cases that can be repaired relatively easily, with a single outpatient operation performed between the ages of 6 to 18 months.
UCSF experts are skilled at correcting hypospadias, including severe deformities, and over the years we have successfully treated thousands of children born with this condition.
Read Less
Signs and Symptoms
Diagnosis
Treatment
Hypospadias can occur in many different ways, including:
Opening of the urethra below the tip on the bottom side of the penis
Abnormal appearance of the glans penis (the tip)
Incomplete foreskin in which the foreskin extends only around the top of the penis
Curvature of the penis during an erection (called chordee)
Buried penis
Abnormal position of scrotum with respect to penis
Problems resulting from hypospadias include deviation of the urinary stream, cosmetic and psychological considerations and potential adverse effects on sexual functioning.
Hypospadias is typically diagnosed during a newborn examination. The opening of the urethra is below the tip of the penis. The penis may be curved and the foreskin not completely formed around the entire tip of the penis. Occasionally a specific type of hypospadias, known as megameatus intact prepuce variant of hypospadias, isn't noted until a circumcision has been performed.

21. Urinary Bladder Serves as reservoir for urine
Bladder muscle-detrusor muscle
Normal urine output, ~1500ml/day, varies with intake of food and water, diurnal pattern.
~250ml of urine in bladder cause moderate distention and urge to urinate.
Volume of urine at night is ½ of formed in day because of hormonal influences (ADH), p This diurnal pattern is normal, most people urinate 5-6 times during the day and occasionally at night. Diurnal=daytime, happening in the day (as opposed to nocturnal, or circadian.)
Bladder affixed to pelvis by umbilical ligament called urachus. Does not change shape during bladder filling or emptying. Bladder muscle (detrusor) is composed of layers of intertwined smooth muscle fibers capable of distention and contraction. ~250 to feel urge to urinate, ml., the person feels uncomfortable. Bladder capacity varies with the individual ranging from m.
Evacuation of urine is termed urination, micturition, or voiding.
Bladder has same mucosal lining throughout urethrovesical unit, lining called transitional cell epithelium or urothelium and is unique to the urinary tract. Transitional cell epithelium is resistant to absorption of urine, and has phagocytic properties. However, if there are cellular changes in the epithelium, it can migrate easily to all areas. Transitional cell tumors (bladder ca) cam easily metastasize to other urinary tract areas and tumor recurrence within the bladder is common

22. Fig. 45-5

23. Female/Male anatomy
Difference in anatomy is generally related to the length of the urethra.
Female: urethra is 1-2 inches (3-5cm) the rabdosphincter, or external sphincter surround a portion or the urethra and voluntarily contracts to prevent leaking when bladder pressure increases. The short urethra is a contributing factor in the increased incidence of UTI in women.
Male –urethra is ~ 8-10 inches (20-25 cm).

24. Gerontologic Considerations Effects of Aging on the Urinary System
20-30% decrease in size with aging, by 70 yrs old, 30-50% of glomeruli have lost function.
Decreased renal blood flow, decreased GFR, alterations in hormone levels (ADH, aldosterone, ANP=decreased urinary concentration, limitations in excretion of water, Na+, K+ and acid).
20-30% decrease in size between ages of yrs., atheroscelosis increases demise of glomeruli and decreases kidney size.
What happens to specific gravity? Specific gravity=the weight of a substance compared with the weight of an equal volume of water. For solid and liquid materials, water is used as a standard and has a specific gravity of p. 1154, sp. Gravity of urine is
low specific gravity=dilute urine and possibly excessive diuresis, high specific gravity indicates dehydration. If sp. Gravity becomes fixed at ~1.010 this indicates renal inability to concentrate urine, suggesting that the kidney is progressing to end-stage renal disease.

25. Physiologic changes: women; aging bladder, vagina, pelvic floor muscles undergo a loss of elasticity, vascularity and structure. Periurethral striated muscle fibers and muscles supporting the bladder relax, consequently, older women are more prone to urethral irritation and urethral and bladder infections. Urinary incontinence in older women has long been associated with diminished estrogen levels, recent research has found that the incidence of incontinence is higher in menopausal women who use hormone replacement therapy.
Prostate surrounds the urethra, thus increasing size may affect urinary patterns in men, causing hesitancy, retention, slow stream and bladder infections.
Constipation- can affect urination. partial urethral obstruction may occur because of the rectum’s close proximity to urethra.
Terms:
Nocturia-night urination, diurnal-daytime urination, sp. Gravity, dysuria-painful urination,
Test question:know terms on this page and interventions: increase fluids,

27. Benign prostatic hyperplasia (BPH)
Enlargement of prostate
Prevalence-50% of men over 50 yrs, 90% of men over 80 yrs.
Symptoms result from urinary obstruction;
Obstructive symptoms-decrease in caliber and force of urinary stream, difficulty initiating voiding, intermittency, dribbling
Irritative symptoms- (associated with inflammation or infection)- frequency, urgency, dysuria, nocturia, incontinence
gland-resulting from increase in number of epithelial cells and stromal tissue
Results from increase in number epithelial cells and stromal tissue. Most common urologic problem in males. Results from endocrine changes associated with aging process, usually develops in inner part of prostate, (ca is usually outer part), enlargement compresses urethra, leading to partial or complete obstruction. The compression of the urethra ultimately leads to the development of clinical symptoms. Intermittency-stopping and starting stream several times while voiding.
Incidence( frequency of new cases of a disease or condition. Prevalence-number of cases of a disease in a specific population at a given time.

28. BPH (continued)
Complications-urinary retention, UTI; potential sepsis, urinary calculi, hydronephrosis leading to renal failure, pyelonephritis, bladder damage.
Diagnostic-DRE (digital rectal exam), PSA ( prostate-specific antigen-blood level associated with ca and BPH)
Collaborative care-drug therapy, diet, catheterization, surgery (TURP), laser prostatectomy, stent placement, monitor for infection, hemorrhage, education, emotional support.
Backup residual urine may result in alkalinization of residual urine creating stones (8x more common in men with BPH). DRE- should be symmetrical, enlarged, firm. Irregularity associated with ca. TURP-transurethral resection of prostate, may result in indwelling catheter, requires 24 hour irrigation, results in blood clotted urine and dilutional hyponatremia. May result in sexual dysfunction of :
Retrograde ejaculation because of trauma to the internal urethral sphincter. Semen is discharged into the bladder at orgasm and may produce cloudy urine when the patient urinates after orgasm. ED –erectile dysfunction may occur if the nerves are cut or damaged. , bladder may take up to 2 months to return to normal capacity.

30. Incontinence in elderly
DESIGN OF STUDY: Cross-sectional survey to measure prevalence of urinary incontinence, the impact on people's lives, use of protection, and health services. SETTING: Stratified random sample of 2000 community-living elderly (equal numbers of men and women, aged 65 to 74 years and over 75 years) in 11 general practices in a British city. RESULTS: The response rate was 79%. The overall prevalence of incontinence in the previous month was 31% for women and 23% for men. Women generally had more severe frequency of incontinence and a greater degree of wetness than men. Protection use was greater in women than in men.
Br J Gen Pract July; 51(468): 548–552. PMCID: PMC Copyright notice
Urinary incontinence in older people in the community: a neglected problem?
H Stoddart, J Donovan, E Whitley, D Sharp, and I Harvey

32. Women’s gerontological urinary issues
Urethrovesical unit undergoes loss of elasticity, vascularity and structure, may result in incontinence (stress), irritation, bladder infections, prolapse
Hormonal changes result in decrease in estrogen, mucosal dryness and irritation (cystitis)
Cystitis-bladder inflammation as a result of UTI, or irritation, may be acute or chronic, symptoms of urinary urgency, frequency, pain. Most common disease seen in women yrs old, often idiopathic ( ) vaginal organ prolapse may cause suprapubic pressure, frequency, urgency and incontinence secondary to urinary retention.
Cystocele-bladder hernia that protrudes into the vagina, may occur during delivery or from aging.
“cysto- refers to urinary bladder. Irritation may be from sex after menopause, or without foreplay or lubrication.

33. Women’s gerontological issues
Research: Incidence of urinary incontinence in postmenopausal women treated with raloxifene or estrogen
Goldstein, Steven R. MD; Johnson, Susan MD;
Abstract
Objective: Determine the effect of raloxifene or estrogen, as compared with placebo, on the reporting of urinary incontinence in postmenopausal women participating in an osteoporosis prevention trial.
Conclusion: During 3 years of follow-up, conjugated equine estrogen was associated with an increased incidence of reports of urinary incontinence in women with a prior hysterectomy and this was significantly greater than both placebo and raloxifene.
Conclusion

34. Incidence of uti Most common bacterial infection, not reportable (US)
7 million office visits, 1million ER visits, 100,000 hospitalizations.
1in 3 women will have 1 episode requiring antibiotics by age 24, ½ of all women in lifetime
Increased in pts with; infants, pregnancy, aids, ms, dm, BPH
Catheter associated uti: most common nosocomial, >1million cases a year. Costs: 1.6 billion.

35. Conditions impacting voiding
Any disease or trauma that affects function of the brain, spinal cord, nerves that innervate bladder, sphincter or pelvic floor can affect bladder function. These include:
DM, MS, paraplegia, quadriplegia, spinal problems, drugs affecting nerve transmission.

39. Assessment of the Urinary System
Subjective data
Important health information
Past health history-related diseases, surgeries, include family hx, occupation/environment, diet, water intake, exercise, elimination pattern
Smoking hx; major factor in risk for bladder ca. tumors occur 4x more frequently .
Medications
Surgery or other treatments
Related diseases-dm, hypertension, gout infections, strep infections, tb, viral hepatitis, stroke, back injury, trauma. Specific to renal: ca, infections, BPH, calculi.
Meds_how drugs affect the urinary tract; alter quantity of output; diuretics, change color of urine Pyridum, hematuria , antidepressants, and calcium channel blockers, antihistamines and drugs used for neurologic and musculoskeletal disorders may affect the ability of the bladder or sphincter to contract or relax normally. P1142
Family hx-may run in families, polycystic renal disease, congenital urinary tract abnormalities
Occupational- certain jobs associated with exposure to chemicals and toxins; phenol and ethylene glycol are nephrotoxic (in plastics), textile workers, painters, hairdressers and industrial workers have a high incidence of bladder tumors.
Environment-certain parts of US have higher then normal incidence of urinary calculi related to mineral content of soil and water (great lakes, southwest, southesast), africa and middle eastern countries can acquire certain parasites that cause cystitis or bladder ca. Women in most areas of world have problems with urinary voiding related to safety, increases retention, also have increased trauma related to primative surgeries at childbirth and female mutilation, rape, no access to bathrooms
Smoking
Diet-decreased h2o intake, dairy may cause calculi, asparagus may cause smelly urine, red by beets, caffeine, alcohol, carbonated beverages, spicy food may aggravate urinary inflammatory diseases. Anorexia, nausea and vomiting can dramatically affect fluid status.
Elimination pattern; bowel function-problem with fecal incontinence may signal neurologic causes for bladder problems related to shared nerve pathways. Questions about urine elimation patterns are important in assessing the history of a pt. with a lower uti. The line of inquiry begins to question how the patient manages urination. The majority of patients eliminate urine by spontaneous voiding, and they should be asked abut daytime (diurnal ) voiding frequency and the frequency of nocturia. . Pelvic organ prolapse may cause suprapubic pressure, frequency, urgency and incontinence secondary to urinary retention. The nurse should determine the patient’s method of handling a urinary problem. A pt. may already be using a catheter or collection device. Sometime a pt. Has to assume a particular position to urinate or perform such maneuvers as pressing on the lower abdomen (Crede’s method), straining (valsalva maneuver) or stretching the rectum to empty the bladder. Test questionBEFORE BEGINNING INTERVENTIONS, the nurse should complete the assessment and determine the patient’s normal bladder pattern and the usual measures used by the pt. oat home. Until the assessment is complete, an individual zied plan of the pt. cannot be developed
Urinary retention: marked accumulation of urine in the bladder as a result of the inability of the bladder to empty. Normally urine production slowly fills the bladder and prevents activation of stretch receptors until it distends to a certain level of stretch. The micturition reflex occurs, and the bladder empties. In restention, the bladder becomes unable to respond to the micturition reflex and thus unable to empty. Urine continues to collect in the bladder, stretching its walls and causing feelings of pressure, discomfort, tenderness over the symphysis pubis, restlessness, and diaphoresis. As retention progresses, retention with overflow may develop. Pressure in the bladder builds to a point where the external urethral sphincter is unable to hold back urine. The sphincter temporarily opens to allow a small volume of urine to escape. As urine exits, the bladder pressure falls enough to allow the sphincter to regain control and close. With retention overflow, the client voids small amounts of urine 2-3 times an hours (25-60ml) with no relief of discomfort. The nurs should be aare of the volume and frequency of voiding to assess this condition in the client. The nurse should asses the abdomen for evidence of bladder distention. Retention occurs as a result of urethral obstrudion, surgical or childbirth trauma, alterations in motor sensory innervation of the bladder, medication side effects or anxiety.
Exercise-stress incontinence may then cause decrease in willingness to exercise
Sleep rest-nocturia may predispose to safety issues, fatigue, skin integrity problems.
1 episode nocturia is normal, 2 for older than 65. self concept is problem. As is role relation and sexuality related to hygiene, fatigue, embarrassment. Counseling advised.
Family hx-

40. Test question-Ibuprofen (motrin) is an NSAID. It is nephrotoxic
Test question-Ibuprofen (motrin) is an NSAID. It is nephrotoxic. Should not be given to pts with possible renal insufficiency.
Other NSAIDS; 8 types; salicylates (aspirin-acetylsalicylic acid), all others: INdocin (indomethacin, Toradol (ketorolac), ibuprofen (motrin, advil), naproxen, (naprosyn)

41. Assessment terms (p.1145)

42. Assessment of the Urinary System (cont’d)
Functional health patterns
Health Perception–Health Management Pattern
Nutritional-Metabolic Pattern
Elimination Pattern
Activity-Exercise Pattern
Sleep-Rest Pattern
Cognitive-Perceptual Pattern
Self-Perception–Self-Concept Pattern
Role-Relationship Pattern
Sexuality-Reproductive Pattern

43. Assessment of the Urinary System (cont’d)
Objective data
Physical examination
Inspection
Palpation
Percussion
Auscultation
See assessment abnormalities charts on p. 1143, 1145, know terms.
Palpation,landmark useful in locating the kidneys is the costovertebral angle (CVA) formed by the rib cage and the vertebral column. If Normal size kidneys, left is not palpabl ebecause the spleen lies over it. The lower lobe of the right kidney is palpable. are rarely palpable

44. Fig. 45-6

45. Diagnostic Studies of the Urinary System
Urine studies- accuracy of results influenced by: proper procedure, pt. cooperation, often require bowel prep (KUB, IVP).
Urinalysis; 1st test done, best obtained in am,
Creatinine clearance- Creatinine: waste product produced by muscle breakdown, most accurate indicator of renal function
Normal value: ml/min
Serum creatinine: mg/dl
BUN-10-30gm/dl
Urodynamics; measures urinary tract function
Specific gravity;
p.1146,
Bowel prep: may radiologic studies requires the use of a bowel prep the evening before the study to care the ower GI tract of feces and flatus. The contents of the colon may obstruct visualization of the urinary tract. If prep not properly done, the study by be unsuccessful and have to b e rescheduled. Commonly used prep: enemas, magnesium citrate, dulcolax. Mag citrate and fleets enema are contraindicated in pt. with renal failure. magnesium can be excreted by pt. with renal failure. note allergies, fluid status, npo status, exposure to xray,potential for dehydration if npo. Test question-must collect 24 hour urine, urine should be rerfrigerated or cooled, so therefore may need ice.
Urinalysis-clean catch, get to lab within one hour as bacteria can multiply giving false results, if not possible, refrigerate.
Creatinine-urinary excretion is a measure of the amount of active muscle tissue in the body, not of body weight. Therefore, people with larger muscle mass have higher values (men, AA). Since all creatinine in the blood is normally excreted by the kidneys, creatinine clearance is the most accurate indicator of renal function. Nursing; hours test, have pt. void 1st, then start test, may be influenced by red meat, tea or coffee, encourage water, no exercise. diet, toilet paper and feces will contaminate sample. Must collect for 24 hrs, keep refrigerated and iced in room (test question) Closely approximates GFR, also get serum creatinine to determine correlation. Formula in book, p creatinine levels remain remarkably constant for people because they are not significantly affected by protein ingestion, muscular exercise, water intake or rate of urine production. Use 24 hours urine collection.
Specific gravity 1152, concentrating ability of kidney, low indicates dilute urine and excessive diuresis, high indicates dehydration.
Cratinine is a by product of muscle catabolism, derived from the breakdown of muscle creatinine phosphate. The amount of creatinine produced is proportional to the muscle mass (higher in men and AA). Creatinine is filtered by the glomeruli and it is excreted in the urine. Serum creatinine is considered a more sensitive and specific indicator of renal disease than blood urea nitrogen (BUN), p. 141, lab tests, kee) it rises later and is not influenced by diet or fluid intake.a slight BUN elevation could be indicative of hypovolemia (fluid volume deficit); however a serum creatinine of 2.5 could indicate renal impairment. BUN and cratinine are frequently compared. IF BUN increases and serum creatinine remains normal, dehydration (hypovolemia) is present, if both increase, then renal disorder is present. Serum creatinine is especially useful in the evaluation of glomerular function. Used to diagnose renal dysfunction.
Decreased in pregnancy and preeclampsia, increased in; acute and chronic renal failure, shock, lupus, cancer, hypertension, mi, chf, diet rich in creatine (beef, poultry, fish).
Drug influences; elevated with; amphotericnin, cephalosporins, gentamicin, vit a, barbituates, glucose,
Nursing implications: related elevated creatinine levels to clinical problems. serum creatinine may be low in clients with small muscle mass, in amputees, and in clients with muscle disease. Older clients may have decreased muscle mass.
Hold meds 24 hours before test, check amount of urine output in 24 hrs. less than 600ml/24 hrs can indicate renal insufficiency. Creatinine is excreted by the kidneys, and a continuous decrease in urine output could result in an increased serum creatinine level.
Compare the BUN and creatinine levels. If both are elevated, the problem is most likely kidney disease.
BUNp.1147-most commonly used to identify presence of renal problems. Concentration of urea in blood is regulated by rate at which kidney excretes urea. Normal 10-30mg/dl ( mlo/l), when interpreting BUN factors may cause increase (eg, rapid cell destruction form infections, fever, GI bleed, trauma, athletic activity, excessive muscle breakdown, corticosteriod therapy).
BUN (kee,p. 83), 5-25 mg/dl, urea formed as end product of protein metabolism and is excreted by the kidneys. An elevated BUN could be an indication of dehydration, prerenal failure, or renal failure. dehydration from vomiting, diarrhea, and or inadequate fluid intake can cause an increase in the BUN. With dehydration, the serum creatinine level would most likely be normal
Once a client is hydrated, the BUN should return to normal, if it does not, prerenal or renal failure would be suspected. Nephrons tend to decrease during the aging process, and so older persons may have a higher BUN. Digested blood from gi bleed is a source of protein and can cause the BUN to elevate. A low BUN usually indicated overhydration (hypervolemia)
The BUN/creatinine ratio:10/1, decreased ratio occurs with malnutrition, liver disease, low protein diet, excessive IV fluids, dialysis or overhydration. An elevated BUN/creatinine ration >15/1 is found in renal disease, inadequate renal perfusion, shock, dehydration, gi bleed, steroids.
Ratio BUN/creatinine normal finding 10:1.

46. Test question-normally no or very low wbc in urine, also, no sugar, no protein!, no RBC’s. note color

47. Fig. 45-7
test question;Renal arteriogram (to visualize renal blood flow) remember to ask about allergies, especially wit iodine-based contrast used during IVP and CT scan, pt may be allergic to shellfish and penicillin. Anaphylactic reaction would: increase pulse, increase temp, increase respirations. Test question; if resp. rate high, probably anaphylaxis from dye, nurse should immediately asses the pt’s o2 sat and breath sounds. Normally after an ivp, pt could have u/o<400ml/2hrs, dry mounth.
Radiology:
KUB=kidneys, ureters, bladder xray of abdomen and pelvis to determine size, shape and position of kidneys, stones and foreign bodies can be seen. Perform bowel prep, contrast given.
IVP=intravenous pyelogram=visualizes urinary tract after IV injection f contrast material. Kidneys , ureters, and bladder can be evaluated, cysts, tumors, lesions and obstructions can be detercted. Pats with decreased reanl function should not have IVp because contrast medial can be nephrotoxic and worsen renal function, requires prep;empty colon, npo, advise of warmth, face flushed and saltly taste during injection of contrast material. After procedure, force fluids to flush out contrast. Test question” your dr. will inject a radioactive solution” describes IVP.
Retrograde pylogram=xray of urinary tract taken after injection of contrast material into kidneys. If IVP doesn’t visualize the urinary tradt or pt. allergic to contrast or decreased renal function. A cystocsope is inserted and ureteral catheters are inserted through it into the renal pelvis.
Renal biopsy; type or renal disease, done as skin (percutaneos) thruogh needle insertion into lower lobe of kidney. Can be perfomred with ct . Absolute contraindications are bleeding disorders, single kidney and uncontrolled hyperteension. NURse pres; type and cross for blood, before, ascertain coagulation status, labs, pts should not be taking aspirin or coumadin. (test question), after, app;y pressure dressing and keep on affected side for min, bed rest for 24 hrs, vitals q 10, assess for flank pain, hypotension, decreased hematocrit, temp, frequency dysuria.

48. Fig. 45-8
Catheter insertion for renal arteriogram-test question doctor will place a catheter into an artery in your groin and inject a dye that will visualize the blood supply to the kidneys

49. Fig. 45-9
Cystoscope exam of the bladder in a man, flexible cysto nephroscope
Cystoscopoe and cystogram procedure, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that xrays can be taken. “your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on exay. Pink-tinged urine and urinary frequency are expected after cystoscopry, burning may be common, but not pain that requires medication. Good fluid intake encouraged, bed rest not required.