Urinary System Assessment PDF

Urinary System Assessment Dr. Mohamed Elsayed Allawy Dr. Ghonem Elsayed Ghonem Outlines  Introduction  Anatomy of urinary system  Physiology of urinary system  Assessment of urinary system 1. History taking 2. Physical examination introduction  The renal system, from the kidneys to the bl...

Urinary System Assessment Dr. Mohamed Elsayed Allawy Dr. Ghonem Elsayed Ghonem Outlines  Introduction  Anatomy of urinary system  Physiology of urinary system  Assessment of urinary system 1. History taking 2. Physical examination introduction  The renal system, from the kidneys to the bladder to the urinary meatus, functions to filter and excrete waste products and contribute to fluid and electrolyte balance.  Assessment of the urinary system involves determining how well the kidneys perform their many functions. It also includes gathering information about other systems. A careful assessment of the history and physical findings, with interpretation of laboratory and diagnostic test results, provides early clues to the diagnosis of disorders of water and volume imbalance and other complications of renal dysfunction. An Over View About Anatomy and Physiology of Kidney  The kidneys are bean shaped organ about the size of a fist they are located at the bottom of the rib cage at the back of the body "retroperitoneally".  Represent about 0-5 of total weight of the body.  Most people have two kidneys, but some people have only one it is possible to lead totally normal healthy life with just one kidney.  Kidney receive 20-25% of total arterial blood pumped by heart.  Each kidney is enclosed as fibrous capsule and is embedded in fatty tissue. It consist approximately 1-3millions nephrons. The kidney is anatomically divide into outer dark red portion called the cortex and inner height coloured section lying between cortex and pelvic. The medullary tissue is arranged in conical or pyramidal masses.  The nephron ❖ The nephron: The nephron is a tube closed at one end, open at the other it consist of:  Glomerulus: A capillary net work within the Bowman's capsule blood the glomerulus passes into second capillary network.  Bowman's capsule: located at the closed end the wall of the nephron is pushed forming a double walled chamber.  Proximal convoluted tubule: Coiled and lined with microvilli and staffed with mitochondria.  Loop of Henle: It makes a hair pin and returns to DCT.  Distal convoluted tubule: Which is also highly coiled and surrounded by capillaries.  Collecting tubule: It leads to the pelvic of the kidney from where urine flows to the bladder and periodically on to outside the body. Renal pelvis:  When the ureter joins the kidney it expands to form a funnel shaped receiving basin for urine delivered by collecting tubules, it has projecting pouches "calyces". Blood supply:  Renal artery to each kidney arises from the abdominal aorta. When the artery enter the kidney it progressively subdivides to become afferent arterioles. Each afferent arteriole enters nephron to form glomerulus.  The glomerular capillaries unite to form the efferent arterioles the blood is then collected into venules and eventually into renal veins that carries to inferior vena cava.  Large volume of blood continuously circulated through the kidneys it is estimated that renal blood flow average about 1000-1200 L per minutes about 23% from cardiac output. Function of the kidney 1. Control of body fluid osmolarity to maintain the normal intra cellular fluid "ICF" and extracellular fluid volume "ECF including the blood volume. 2. Regulation of electrolyte balance K+ and Na+. 3. Regulation of acid base balance and blood PH. 4. Excretion of waste products, urea, uric acid and creatinine. 5. Excretion of drugs, chemicals. Toxins. 6. Secretion of hormones.  Erythropoietin  Renin  Vitamin D3  Prostaglandins Ureters  The ureters are two slender tubes that run from the sides of the kidneys to the bladder. Their function is to transport urine from the kidneys to the bladder.  Peristalsis movement in ureters to propel urine from kidneys to bladder. Bladder  The bladder is a muscular organ and serves as a reservoir for urine. Located just behind the pubic bone, it can extend well up into the abdominal cavity when full. Near the outlet of the bladder is a small muscle called the internal sphincter, which contract involuntarily to prevent the emptying of the bladder Urethra The urethra differs in the two sexes: A-The male urethra:  Conveys urine and reproductive secretion to the exterior. It extends from the internal urinary meatus to the external meatus at the tip of the glans penis and is about 20cm long. B-The female urethra:  A short channel about 4cm long, passing down wards from the internal urinary meatus to open just in front of the vaginal orifice in the vaginal vestibule. Prostate gland:  Is a male reproductive gland  Numerous prostatic ducts empty into urethra Functions of the urinary system  The function of the urinary system is to: (1) removes waste products from the blood (2) eliminate them from the body. The principal waste products being eliminated are water, carbon dioxide and nitrogenous wastes including urea, uric acid and creatinine (3) regulation of the volume of body fluids (4) balance of pH and the electrolyte composition of these fluids Steps of urine formation  Filtration occurs in Bowman's capsule  Resorption occurs in the tubules and collecting duct  Secretion occurs in the tubules and collecting duct Ultrafiltration:  Is the process by which the fluid part of the urine is formed.  Blood passes through the capillary bed of the glomerulus, the pressure of plasma forces fluid across the semi permeable membrane (basement membrane) of the glomerulus into Bowman's capsule.  Water and small molecules begins to be filtered out into Bowman's capsule through tiny pres in the capillary wall  Blood cells and proteins are too large but urea is the correct size to be filtered  The volume of this glomerular filtrate approximates 180 L/Day.  99% Of This Total Volume Is Reabsorbed And Only 1% Is Secreted  Clinically GFR is the amount of glomerular filtrate formed in 1 minute approximately(125ml/min) ( 7.5 L/ hr)  Urine formation begins when blood enters the afferent arteriole of the nephron. it is in Bowman's capsule and the tubules that the ulrafilterate begins to be transformed into urine Resorption and secretion:  The proximal convoluted tubules resorb 85% to 90% of the water in the ultrafilterate up to 80% of filtered sodium and most of the filtered potassium , bicarbonate , chloride, phosphate, glucose, and amino acids  The distal convoluted tubules and collecting tubule produce the final urine  Another mechanism that prevents water and electrolyte depletion is endocrine or hormonal response ADH or vasopressin is produced by the hypothalamus and stored and released by the pituitary glad in response to changes in plasma osmolarity  In both descending and ascending loops of the Henle the ultrafilterate is further refined as more sodium , and water is desorbed, and magnesium is reclaimed from the tubules  Final urine composition is made in the distal nephron which include distal convoluted tubules and collecting ducts  The final urine becomes concentrated and acidic as it moves from the proximal to the distal tubules and finally into the collecting duct  The average urine output in adult is 1-2 L/Day Urinary assessment  History taking  Physical examination  Diagnostic tests Common terminology related urinary system ▪ Uremia: is a syndrome of kidney failure characterized by elevated blood urea nitrogen (BUN) and creatinine levels ▪ Azotemia: is defined as increase in serum urea and creatinine levels ▪ Frequency : voiding more frequently than every 3 hours ▪ Urgency: The need to void immediately ▪ Hesistancy : Difficulty initiating voiding ▪ Oliguria: Urine output < 400ml/24hr ▪ Anuria: Urine output < 100ml/24hr ▪ urethrovesical reflux: backward flow of urine from the urethra into the bladder ▪ Nephrotic syndrome: Is a set of clinical manifestations caused by protein wasting secondary to diffuse glomerular damage manifestation include (proteinuria , hypoalbunemia, and edema) ▪ Nephritic syndrome: refers to set of clinical manifestations that include hematuria and at least one of the following: oliguria, hypertension, elevated BUN or decreased GFR. ▪ urinary casts: protein plugs secreted by damaged kidney tubules  specific gravity: reflects the weight of particles dissolved in the urine; expression of the degree of concentration of the urine History taking  Health history focus on  Assessment of predisposing factors of disorders  Signs and symptoms of disorder  Family history and surgical history Chief complain  Patient’s description of the problem History of the Present Illness Complete analysis of the following signs and symptoms (using the NOPQRST format Frequency,Urgency,Hesitancy Burning, Dysuria Hematuria Incontinence Lower back pain Pain with urination Change in color, odor, or amount of urine Thirst,Change in weight Edema The following signs and symptoms are those most commonly associated with urinary tract infection (UTI) in children:  -Fever  – Enuresis (bed-wetting)  – Incontinence (new onset)  –Dysuria – Hematuria  – Frequency – Urgency  – Change in colour or cloudy, foul-smelling urine  – Abdominal, suprapubic, flank or back pain or tenderness  – Scrotal or groin pain  – Genital sores, swelling, discoloration  – Lack of circumcision  – Toilet-training problems  – Irritability  – Poor feeding The following symptoms are associated with nephrotic syndrome and glomerulonephritis:  – Swelling (for example, ankles, around eyes)  – Headaches  – Nosebleeds (an occasional symptom of hypertension, but nosebleeds also occur frequently in normal children)  – Hematuria  – Smoky or coffee-coloured urine  – Decreased urinary output  – Pallor  – Weight gain A complete history of the GU system should include questions related to:  – Sexual activity (for adolescents)  – Problems related to inappropriate touching by others (that is, sexual abuse) Past Health History  Relevant antenatal history and immunizations: prematurity; antenatal use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, or nonsteroidal anti inflammatory drugs (NSAIDs; eg, ibuprofen); ensuring antenatal vaccination against rubella; screening for cytomegalovirus or toxoplasmosis  Past surgeries: kidney transplantation, placement of dialysis fistula  Past diagnostic tests and interventions: urinalysis, cystoscopy, intravenous pyelography, ultrasound of kidneys, renal biopsy  Past acute and chronic medical problems: including treatments and hospitalizations: renal failure; renal calculi; renal cancer; glomerulonephritis; Wegener’s granulomatosis; polycystic kidney disease; dialysis, including type, frequency, and duration; urinary tract infections; systemic lupus erythematous; sickle cell anemia; cancer; AIDS; hepatitis C; heart failure; diabetes; hypertension  Risk factors: age; trauma; heavy use of ibuprofen, naproxen, or acetaminophen; use of heroin or cocaine  Medications: diuretics, aminoglycosides, antibiotics, NSAIDs  Allergies and reactions: radiographic contrast media  Transfusions Family History Health status or cause of death of parents and siblings: hereditary nephritis, polycystic kidney disease, diabetes, high blood pressure. Personal and Social History  Tobacco, alcohol, and substance use  Family composition  Occupation and work environment: exposure to nephrotoxic  substances such as organic acids, pesticides, lead, and mercury  Living environment: exposure to nephrotoxic substances such as  organic acids, pesticides, lead, mercury  Diet, Sleep patterns, Exercise  Cultural beliefs, Spiritual and religious beliefs  Coping patterns and social support systems  Leisure activities  Physical examination General assessment  the patient’s overall appearance, including facial expression, height and weight, position in bed, grooming, personal hygiene, and signs of distress.  The nurse observes the patient’s level of responsiveness, cognition, and interaction with people, including positive, negative, or unusual responses.  kidney  The nurse can assess kidney tenderness. To do this, the nurse places one hand over the posterior costovertebral angle (CVA). Then, using the fist of the second hand, the nurse gently percusses the CVA and notes whether the patient has discomfort ,which is known as CVA tenderness (CVAT). Palpate right kidney palpate left kidney Urethra:-  Urethra examination primarily in valves inspecting the external meatus and perineal for signs of discharge or abnormal tissue growth.  Palpate perineal area for tenderness, in female, the posterior urethera is examined vaginally for masses, tenderness or expressed discharge from urethra.  **Assessment of urine:  The assessment of urine involves measuring the client's fluid intake and urine out put and observing the characteristics of urine.  Cont; *Intake and out put:-  The nurse assess the client's average daily fluid intake includes all sources of fluid intake. Change in urine volumes of urine voided is a significant indicator of fluid imbalances or kidney disease.  Volume assesses by measuring (with bedpans or catheter bag).  Fluid chart Intake Output Kind Amount Kind Amount Total: Total: Review of Systems 1. Skin: dryness, itching 2. HEENT: periorbital edema 3. Cardiovascular: hypertension, heart failure, vascular disease 4. Respiratory: Good pasture’s syndrome 5. Gastrointestinal (GI): hepatitis, cirrhosis 6. Endocrine: diabetes mellitus 7. Neurological: numbness, tingling, burning, tremors, memory loss 8. Hematological: sickle cell anemia 9. Immune: systemic lupus erythematous 10. Musculoskeletal: rhabdomyolysis, muscle weakness Diagnostic Evaluation 1. Blood tests  Blood urea nitrogen(BUN)  Serum creatinine  BUN-to- creatinine ratio  Uric acid  Na,K,Mg,Cl, albumin Urine tests  Urinalysis  Urine culture  Urine specific gravity  Residual urine  Urine cytology  creatinine clearance Imaging studies  Renal ,bladder ultrasonography  MRI,CT  Kidney-ureter-bladder x-ray study  Intravenous pyelography  Renal angiography or arteriogram  Nephrotomogram  Renal scan  Cystoscopy  Renal biopsy