1. Genitourinary Assessment
2012

2. Renal System Regulation of body fluids
Maintains homeostasis of the blood
Filtration of metabolic wastes from bloodstream excreting end products
Reabsorption of needed substances and water
Elimination of metabolic wastes and water as urine
Regulation of Acid-Base Balance
Secretes hormones (Renin) to help regulate BP, erythrocyte production and calcium metabolism

3. Renal System
Any alteration in structure or function of urinary system quickly affects the whole body
Health of other body systems, especially the circulatory, endocrine, and nervous systems

4. Review of A&P Organs of Urinary System Paired kidneys Paired ureters
Urinary bladder
Urethra

5. Kidneys Outside peritoneal cavity Either side of vertebral column
At levels T12 through L3
Highly vascular
Bean-shaped
About 11.4cm long X 6.4 cm wide

6. Kidneys Lateral surface – convex Medial surface – concave
Forms a vertical cleft- Hilum

7. Kidneys Ureter Renal artery Renal vein Lymphatic vessels and nerves
Enter and exit at level of Hilum

8. Kidneys Supported by 3 layers of connective tissue Outer Renal Fascia
Dense connective tissue
Also surrounds Adrenal glands
Middle Adipose Capsule
Fatty mass
Holds in place cushions against trauma
Inner Renal Capsule
Provides barrier against infection
Helps protect from trauma

9. Kidneys - Internally Cortex Medulla Pelvis
Contains Glomeruli (capillaries)
Medulla
Cone-shaped pyramids
Formed of bundles of collecting tubules
Channels urine into innermost region
Pelvis
Continuous with ureter leaving the hilum
Major and minor calyces extend toward Medulla
Serve to collect urine and empty into Pelvis

10. Ureters Bilateral tubes 10-12ins (25-30cms) long
Peristaltic waves originate at renal pelvis
3 layered wall
Inner epithelial mucosa
Middle layer of smooth muscle
Outer layer of fibrous connective tissue

11. Urinary Bladder Posterior to Symphysis Pubis Storage of urine Males
Lies immediately in front of rectum
Females
Next to vagina and uterus
Openings for ureters and urethra located inside bladder at the Trigone

12. Urinary Bladder Layers Epithelial Mucosa Connective Tissue
Smooth Muscle Layer
Longitudinal and Circular
Fibrous Outer Layer

13. Urinary Bladder Size varies with amount of urine it contains
mls without “signaling”
Capable of holding up to cc! If need be

14. Urethra Females Males Thin-walled tube Channels urine to outside
Extends from base of bladder to external orifice
Females
3-5cms
Males
20cms
Serves as channel for semen as well
Prostate gland encircles urethra at base of bladder

15. Assessment of Urinary System Function
Health Assessment Interview
Collect subjective data
Assess problems with urinary elimination as part of the total health assessment
Conduct a focused interview for specific problems of urinary system
Interviewing techniques should consist of leading statements and open-ended questions

16. Assessment of Urinary System Function
Overview
Identify a problem with urinary elimination
Its onset
Characteristics
Course
Severity
Precipitating factors
Relieving factors
Any associated symptoms
Note timing and Circumstances

17. Assessment of Urinary System Function
Examples
Do you experience any burning when you urinate?
Do you have difficulty starting to urinate?
When did you first notice that you were unable to control the loss of urine from your bladder?

18. Assessment of Urinary System Function
Current urinary status should include:
Color, odor, amount of urine
Difficulty initiating a stream of urine
Frequency of urination
Painful urination (dysruria)
Excessive urination at night (nocturia)
Blood in the urine (hematuria)
Voiding scant amounts of urine (oliguria)
Voiding excessive amounts of urine (polyuria)
Discharge
Flank pain

19. Assessment of Urinary System Function
How many times a day do you urinate?
Do you fell you are emptying your bladder each time?
How many times do you get up at night to urinate?
Do you experience a very strong desire to urinate and feel that you just can’t?

20. Assessment of Urinary System Function
Do you have any burning or pain while you urinate?
Explore its location, duration, and intensity
Kidney pain is experienced in the back and costovertebral angle, may spread toward umbilicus
Renal colic is severe, sharp, stabbing, and excruciating, often felt in the flank, bladder, urethra, testes, or ovaries

21. Assessment of Urinary System Function
Bladder and urethral pain is usually dull and continuous and may be experienced with spasms
Patient with distended bladder experiences constant pain increased by any pressure over the bladder

22. Assessment of Urinary System Function
Have you noticed that you urinate small amounts of strong-smelling urine?
Cloudy, foul-smelling urine? (pyuria)
Temperature elevations?, chills?, general malaise?
Strange color?
Explore for any medications
Blood? (hematuria)
Explore if on any medications

23. Assessment of Urinary System Function
Surgeries and other treatments in the past?
Family history of altered structure or function?
ESRD
Renal calculi
Frequent infections
HTN DM

24. Assessment of Urinary System Function
Life-style
Diet
Work history
Sexual history
Cigarette smoking
Exposure to toxic chemicals
Usual fluid intake
Self-care measures to replace fluids lost during day’s activity

25. Interview Questions Health Perception-Health Management
Have you ever had a bladder or kidney disease, injury, or surgery?
How was the problem treated?
Describe your usual intake of fluids and food for a 24-hour period
What type of fluids do you drink?
Describe the current problem you are having with urinary elimination?

26. Interview Questions Health Perception-Health Management
Are you taking any medications for this problem?
If so, what are you taking and how often?
Are you taking medications for any other health problem? Explain.
For Women: Describe how you care for yourself in terms of urinary elimination
What do you do to care for yourself if you believe you have a urinary infection?

27. Interview Questions Health Perception-Health Management
If you have had a surgical alteration of urine flow (ileal conduit), describe how you care for yourself
(what skin and appliance care do you provide, how often do you empty the bag?)
Have you ever been taught to begin the flow of your urine by the Credé Maneuver or any other method? Explain.

28. Interview Questions Health Perception-Health Management
Have you ever worn or do you now wear an incontinence pad, external catheter, or indwelling catheter? Explain
Have you ever done self-catheterization? Explain.

29. Interview Questions Nutritional-Metabolic
Do you limit the amount of salt in your diet? Explain.
How much coffee, tea, or alcohol do you drink in a 24-hour period?
Do you ever have swelling of any part of your body? Describe.

30. Interview Questions Elimination How many times a day do you urinate?
Do you have to get up at night?
Has there been a change in your usual pattern of urination?
Do you experience a sudden urge to urinate?
Has there been recent increase or decrease in amount of urine you eliminate with each voiding?

31. Interview Questions Elimination
Has there been a recent change in the color or odor of your urine?
Have you ever had problems controlling urination when you laugh, sneeze, or cough?
Is it difficult for you to start or maintain the flow of urine?
Have you ever had difficulty controlling urination when you are sleeping?
Do you have any discharge from your urethra?

32. Interview Questions Activity-Exercise
Do your urinary problems interfere with your usual activities of daily living? Explain.
Have you ever been taught to do Kegel Exercises to tone bladder muscles?
If so, how often do you practice these?
Describe your energy level. Has there been a recent change? Explain.

33. Interview Questions Seep-Rest
Does a problem with urinary elimination interfere with your ability to rest or sleep? Explain.
Has there been a recent change in the number of times you wake up to urinate during the night? Explain

34. Interview Questions Cognitive-Perceptual
Do you have any pain or burning with urination? Explain.
Have you experienced any tenderness or pain over the lower sides of your back or severe pain that spreads to your lower abdomen? If so, describe the location, intensity, aggravating factors, and duration.

35. Interview Questions Self-Perception - Self-Concept
How has this problem with your urinary elimination affected how you feel about yourself?
How has this problem with your urinary elimination affected how you feel about your normal life?
If appropriate: How do you feel about wearing incontinence pads?, using external devices?, having an indwelling catheter?, having a urinary diversion?
If so, how?

36. Interview Questions Role- Relationship
Is there a history of bladder or kidney problems in your family?
Has your urinary elimination problem affected your role in the family?
Has your problem with urinary elimination affected your interactions with your family?, with friends?, at work?, in social activities?
Has your urinary elimination problem affected your ability to work?

37. Interview Questions Sexuality- Reproductive
Has your urinary elimination affected your usual sexual activities?
Describe how having this health problem has made you feel about yourself as a man or woman.

38. Interview Questions Coping – Stress
Have you experienced increased stress because of this problem with urinary elimination?
Have you noticed an increase in urination when you experience stress?
What do you feel is the most stressful time you have had with your urinary problem?
Who or what will be able to help you cope with stress caused by this problem with urinary elimination?

39. Interview Questions Value- Belief
Are there significant others, practices, or activities that help you cope with this health problem?
How do you perceive the future with this problem?
Early sailors getting drained because obstruction caused by STDs (we still do this!)

40. Physical Assessment Inspection auscultation Palpation Percussion
Performed as part of a total health assessment
Performed as part of the abdominal assessment
As part of the back assessment
Inspection
auscultation
Palpation
Percussion

41. Physical Assessment Equipment Specimen cup
*Ask for specimen before inspection
Disposable gloves
Position
Begin by sitting
Lying supine
Gown or drape
Characteristics of Normal Urine Color - pale to deep yellow Odor – aromatic SpGr – pH – 4.5 to 8.0 Protein – Negative to trace Glucose – Negative Ketones – Negative WBCs – 0-5 RBCs – 0-5 Casts – Negative to occasional

42. Physical Assessment Inspection Skin and mucous membranes
Color, turgor, excretions
Pallor may indicate kidney disease with anemia
Decreased turgor may indicate dehydration; Edema may indicate fluid volume excess. Either change may indicate renal insufficiency
Uric acid crystals, called uremic frost, indicates untreated renal failure

43. Physical Assessment Inspection
Abdomen for size, symmetry, masses or lumps, swelling, prominent veins, distention, glistening, or skin tightness
Asymmetry may indicate a hernia or superficial mass
Prominent veins may indicate renal dysfunction
Distention, glistening, or skin tightness may be associated with fluid retention

44. Physical Assessment Inspection Urinary meatus
Increased redness, swelling, or discharge may indicate infection or sexually transmitted disease
Deviation of meatus from midline in males may suggest a congenital defect

45. Physical Assessment Percussion of kidneys
Helps assess pain and/or tenderness
Sitting position
Stand behind client
Strike with ulnar surface of hand, curled in fist
Percuss over costovertebral angle
“Gentle thud”
Tenderness or pain elicited on percussion suggest glomerulonephritis or glomerulonephrosis

46. Physical Assessment Palpation of the kidneys
Best performed by advanced practitioner
Involves deep palpation
Kidneys difficult to palpate
Ask patient to take deep breath
Use palmer surface of hands

47. Physical Assessment Palpation of the kidneys
Mass or lump may indicate a tumor or cyst
Tenderness suggests an inflammatory process
Soft or “spongy” kidney may indicate Chronic Renal Disease
Bilaterally enlarged kidneys may suggest polycystic kidney disease
Unequal kidney size may indicate hydronephrosis

48. Physical Assessment Percussion of Bladder Supine position
Tone and position
Dull percussion tone over bladder of a client who has just urinated may indicate urinary retention

49. Physical Assessment Palpation of Bladder
Gently palpate over Symphysis Pubis and Abdomen
Distended bladder may be palpated at any point from the Symphysis Pubis to the Umbilicus and is felt as a firm, rounded organ

50. Physical Assessment Auscultation of the Renal Arteries
Help client to a supine position
Place bell of stethoscope lightly in areas of renal arteries, located in the left and right upper quadrants
Systolic bruits (whooshing sounds) may indicate renal artery stenosis

51. Physical Assessment Variations in Assessment Findings for the Elderly
Progressive decline in kidney function
Bladder shrinks
Has less than half capacity
Nocturia
Frequency
Urgency
Urinary incontinence is not a normal aspect of aging

52. Physical Assessment By age 70, GFR is half
Desire to urinate is decreased, delayed, bladder doesn’t empty well, leading to retention and increased residual urine
Prostate enlargement
Stress incontinence is often problem with postmenopausal women because urethra loses tone and tends to atrophy along with genital structures
Glucose not well absorbed, contributing to an increased amount of glucose in the urine

53. Normal Renal Function Tests
BUN 8 to 25mg/dL
Serum Creatinine 0.6 to 1.3 mg/dL
Creatinine Clearance 100 to 120mL/min
Serum Uric Acid 2.5 to 8.0 ng/dL
Urine Uric Acid 250 to 750 mg/24 hr