Genito-Urinary System Assessment

• Genito-Urinary system assessment and common diagnostic tests to determine renal disorders

GU System Health History

• First determine the chief complaint.
• Inquire about urine color, amount, and clarity.
• Assess voiding patterns by asking about frequency, urgency, dysuria, hesitancy, retention of urine, and incontinence.
• Evaluate pain through intensity, duration and location.
• Review any past health history including investigations and results, medications taken, and operations like lithotripsy or open surgery.
• Inquire about family health history, such as polycystic kidney disease.

GU System Physical Assessment

• Inspection
• Auscultation
• Percussion
• Palpation

Physical Assessment: Inspection for Females

• Assess the female external genitalia, including labia majora, labia minora, clitoris, and urethral orifice.
• Check for any deformities, discharge, or infection.

Physical Assessment: Inspection for Males

• Assess the male external genitalia, including foreskin of penis, glans, urethral orifice, scrotum, and inguinal ring.
• Check for any deformity, discharge, or infection.
• Hydrocele is fluid inside the scrotum from injury or inflammation and transillumination via a torch can confirm diagnosis

Physical Assessment: Auscultation

• Use the bell to auscultate for bruit in the renal arteries.
• Vascular sounds should not be present over renal arteries, Bruit indicate an aneurysm or narrowing of vessel

Physical Assessment: Percussion of Kidney

• Assess pain during percussion of the Kidneys
• The client should be in a sitting position while standing behind them.
• Place the palm of the non-dominant hand over the costovertebral angle (CVA) and curl the dominant hand into a fist
• Strike the area over the CVA with the ulnar surface of the dominant hand.
• No pain or tenderness should be felt with pressure, CVA pain is often a sign of kidney problems like kidney stones or infection.

Physical Assessment: Percussion of Bladder

• Assess for bladder distension.
• Begin at the midline just above the umbilicus and proceed downward.
• If distended, the sound changes from tympanic to dull when percussing over the bladder.
• Dullness indicates incomplete bladder emptying and evaluate for residual urine.

Physical Assessment: Palpation of Kidney

• Kidney size is difficult to palpate unless there is a gross enlargement.
• Client lies in a supine position.
• Stand on the right side, placing the left hand under the client's right flank with the palm upward.
• Elevate the right flank with the fingers to displace the kidney upward.
• The right palmer surface should palpate the kidney while asking the patient to take a deep breath.
• The flank with your left hand rises as the patient inhales, and deep palpation is used to feel the lower pole of the kidney.
• Repeat the technique for the left kidney.

Physical Assessment: Palpation of Bladder

• Assess bladder distension.
• A bladder cant be palpated unless very distended
• Check for a smooth, firm, round organ between the symphysis pubis and umbilicus.

Common Diagnostic Tests

• Urinalysis involves assessing color, clarity, odor, and amount.
• Acidity (pH) should be between 4.5-8.
• Specific gravity range is 1.002-1.030.
• Use Dipstick to test for protein, glucose, and red blood cells.
• Microscopic examination identifies RBCs, WBCs, casts, crystals, pus, & bacteria.
• Measure 24-hour urine for protein and creatinine clearance.
• Mid-stream urine (MSU) is used for culture and sensitivity tests.
• Calculation of estimated Glomerular Filtration Rate (GFR) accounts for age, gender, blood Cr, +/- 24-h urine Cr, and weight.
• GFR (ml/min) = (140-age) x weight (kg) x 0.85 if female / 7.2 x Serum Cr (mg/dL)
• Normal GFR range is GFR of 60 or higher, kidney disease is below 60 and kidney failure is GFR of 15 or lower

Common Diagnostic Tests

• Blood tests for Renal Function include tests for sodium(Na), potassium(K), urea, and creatinine.
• Normal range for Na is 134 - 145 mmol/l.
• Normal range for K is 3.5 - 5.1 mmol/l.
• Normal range for Urea is 3.4 - 8.9 mmol/l.
• Normal range for Creatinine is 57 - 126 umol/l.
• Radiologic studies or imaging, including X-ray abdomen (KUB), Ultrasound (USG), and Computed tomography (CT scan).
• Intravenous urogram (IVU) or Intravenous pyelogram (IVP).
• Renal biopsy (needle biopsy)
• Cystoscopy

Renal Calculi (Nephrolithiasis)

• Mineral crystallization occurs around an organ matrix, leading to stone growth.
• Consists of calcium salts (oxalate or phosphate) or magnesium-ammonium phosphate.
• Location is usually in the renal pelvis of the kidneys or bladder, but may lodge in the ureters or urethra.

Types of Kidney Stones

• Calcium stones are the most common (80%).
• High doses of Vit D increase calcium concentration in urine, which can cause kidney stones..
• Struvite/infected Stones make up 10% of kidney stones and form in response to an UTI.
• Struvite/infected stones grow quickly and become quite large.
• Uric acid stones comprise 7% of kidney stones, and can form if one loses too much fluid.
• Chronis diarrhea, high protein diets, or DM/metabolic syndrome can cause excess fluid loss and and lead to kidney stones.
• Cystine stones are caused by a hereditary disorder and lead to too much amino acid excretion from the kidneys.

Risk Factors for Renal Calculi

• Dehydration
• Obstruction and urinary stasis
• Immobility
• Family history of stone formation
• Obesity
• Diet high in protein, sodium, and sugar
• Medical conditions like chronic urinary tract infection, hyperparathyroidism, elevated uric acid level in gout, hypercalcemia

Clinical Manifestations of Renal Calculi

• Symptoms don't present until a kidney stone moves around within the kidney or passes into one of the ureters.
• Kidney stone becomes lodged in the ureters, which blocks the flow of urine and causes the kidney to swell → Severe and intermittent colicky loin/back pain or referred pain
• Other symptoms include: hematuria / cloudy or foul-smelling urine from infection, nausea/vomiting, urinary retention, and S/S of infection.

Diagnosis of Renal Calculi

• Blood tests analyze calcium and uric acid levels.
• Urine testing checks for stone-forming minerals and stone-preventing substances
• Imaging with USG, CT, and AXR.
• Analysis of passed stones can help determine the plan of action and prevention methods.

Management of Renal Calculi

• About 90% of urinary calculi will pass spontaneously.
• Drink/maintain High fluid intake to increase flow of urine.
• Narcotic analgesic for severe pain
• Antispasmodics to relieve ureteral spasms
• Dietary changes to help future stone formation
• Removal of stones occurs when >/= 4mm in diameter: Extracorporeal shock wave lithotripsy (ESWL) and Percutaneous lithotripsy
• For large stones use surgical removal. ie. Pyelolithotomy and Nephrolithotomy

Nursing Interventions for Post ESWL

• Monitor vital signs to assess for complications.
• Monitor intake and output to assess the presence of obstruction.
• Monitor the amount, color, and clarity of urine, as hematuria is anticipated
• Administer analgesics and antispasmodics for pain relief.
• Encourage fluid intake to facilitate the passage of the stone.
• Encourage ambulation to promote passage of the stone.
• Inspect voided urine and save the stone to assess the presence of a stone fragment and save it for analysis.
• Understanding of ESWL and possible complications.
• Factors that increase the risk of recurrence of renal calculi and strategies to reduce those risks.
• Educate on signs and symptoms of stone formation, obstruction, and infection.

Nursing Management for Surgical Removal of Stones

1. Monitor urine output hourly to assess the presence of obstruction.
2. Each ureteric & urethral catheter should drain into its own collection bag.
3. Ensure catheter's patency and never clamp the catheter.
4. Provide general post-operative care.

Bladder Stones

• Bladder stones are a common cause of urinary tract obstruction.
• Occurs when there is a development when minerals in concentrated urine crystallize and form stones.
• This happens when having trouble emptying bladder.
• Risk factors include: Age >50 male, obstruction from bladder to urethra like in BPH, and nerve damage interfering with bladder function like in those with a stroke, spinal cord injuries, DM, Parkinsons
• Bladder can produce manifestations: asymptomatic if no obstruction/irritation on bladder wall.
• Other bladder stone symptoms include obstructed urine flow with bladder distention, dull suprapubic pain possibly associated with exercise or after voiding, microscopic hematuria, dysuria, frequency in urination, difficulty urinating or interrupted urine flow and cloudy/unusually dark-colored urine.
• Diagnosis involves: Urine test for RBC, culturing and kidney, ureters, and bladder x-ray (KUB) – for calcium stones only
• Ultrasonogram for definitive diagnosis.
• Intravenous pyelography or IVP, and CT scan of the pelvis also offer diagnosis
• Treatment: hydration and healthy balanced diet, analgesia and medication (alpha1-adrenergic blocker) and Ureteroscopy (basket) and Litholapaxy (jaws) and insertion of Ureteric stent

Take Home Message: Assessment of GU System

• Inspection of external genitalia
• Auscultation by bell, listening for renal arteries bruit which an indication of aneursym or vessel narrowing
• Percussion is used to assess the Kidneys for no CVA tenderness or pain, in suspect kidney stones
• Palpation is used to assess kidney size- and for if the the bladder is distended

Take Home Messages

• Kidney stones: calcium stone (most common), struvite stones, uric acid stones, cystine stones
• Risk factors include: dehydration, obstruction and urinary stasis, immobility, family history, obesity, diet, medical condition.
• Signs and Symptoms: asymptomatic until a stone moves around and causes loinback pain with heamturia
• Diagnosis is blood test, urine test, USG, CT, AXR, analysis of passed stones and Treatment: spontaneous passing through high fluid intake, dietary changes and possible ESWL/surgery.
• Bladder stones produce asymptomatic if no obstruction/ irradiation on bladder wall, requires hydration, analgesia, medication, ureteric stent, ureteroscopy, litholapaxy