chapter 45 nursing assessment urinary system s. buckley, rn, ms ( adapted from mosby pp) copyright...

Chapter 45Chapter 45

Nursing AssessmentNursing AssessmentUrinary SystemUrinary System

S. Buckley, RN, MSS. Buckley, RN, MS

( adapted from Mosby pp)( adapted from Mosby pp)

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.


Renal A & Pwebsites

1. A & P http://www.youtube.com/watch?v=cc8sUv2SuaY&feature=related another animated a&p http://www.youtube.com/watch?v=aQZaNXNroVY&feature=related 1. urine formation http://health.howstuffworks.com/human-body/systems/kidney-urinary/

adam-200032.htm 2. kidney anatomy http://www.youtube.com/watch?v=SVl81H7H5J4&feature=related http://www.youtube.com/watch?v=vEXx5YLcGmQ&feature=related


Structures and FunctionsStructures and Functionsof the Urinary Systemof the Urinary System

KidneysKidneys MacrostructureMacrostructure MicrostructureMicrostructure Blood supplyBlood supply Primary function of kidneys: Primary function of kidneys:

1. regulate volume and composition of extracellular fluid 1. regulate volume and composition of extracellular fluid (ECF) (ECF)

2. excrete waste products from body.2. excrete waste products from body. Physiology of urine formationPhysiology of urine formation

• Glomerular functionGlomerular function

• Tubular functionTubular function Other functions of the kidney; control blood pressure, Other functions of the kidney; control blood pressure,

produce erythropoietin, activate vitamin D, regulate produce erythropoietin, activate vitamin D, regulate acid-base balance.acid-base balance.


Fig. 45-1


Fig. 45-2


Nephron

Basic function is to clean or clear blood plasma of unnecessary substances


Fig. 45-3


Physiology of urine formationPhysiology of urine formation

* Primary function of kidneys: filter blood, * Primary function of kidneys: filter blood, maintain body’s internal homeostasis. maintain body’s internal homeostasis.

* Multistep process of: * Multistep process of: filtration, reabsorption, filtration, reabsorption, secretions, excretion of water, electrolytes and secretions, excretion of water, electrolytes and metabolic waste.metabolic waste.

* Urine formation begins at glomerulus (blood * Urine formation begins at glomerulus (blood filtered)filtered)

* Glomerular filtration rate (GFR)-* Glomerular filtration rate (GFR)-amount of blood amount of blood filtered by the glomeruli in a given time,filtered by the glomeruli in a given time,

normal is ~ 125ml/min.normal is ~ 125ml/min.


Water balance, acid-base balance

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


Antidiuretic hormone (ADH)-required for Antidiuretic hormone (ADH)-required for water reabsorption in the kidney , important in water reabsorption in the kidney , important in fluid balance. fluid balance.

makes tubules and collecting ducts makes tubules and collecting ducts permeable to water, allowing water to be permeable to water, allowing water to be reabsorbed into the peritubular capillaries and reabsorbed into the peritubular capillaries and returned to the circulation. returned to the circulation.

Functions in concert with hypothalamus and Functions in concert with hypothalamus and neural input as loop mechanismneural input as loop mechanism

decreases urine outputdecreases urine output


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.


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 7.35-7.45.

Metabolic response to ph along with respiratory acid/base balance.


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


Fig. 45-4


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.


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.


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


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.


Structures and FunctionsStructures and Functionsof the Urinary System (cont’d)of the Urinary System (cont’d)

Ureters-Ureters-~~12 inches, carry urine from renal 12 inches, carry urine from renal pelvis to bladder, can become obstructed with pelvis to bladder, can become obstructed with calculi (resulting in calculi (resulting in renal colicrenal colic).).

BladdeBladderr UrethraUrethra-conduit for urine from bladder neck -conduit for urine from bladder neck

to outside body, external sphincter; to outside body, external sphincter; rhabdosphincterrhabdosphincter

Female-1-2 in. , male-8-10in. Female-1-2 in. , male-8-10in. Urethrovesical Urethrovesical unit-consists of bladder, unit-consists of bladder,

urethra, pelvic floor muscles, normal voluntary urethra, pelvic floor muscles, normal voluntary control is defied as control is defied as continence.continence.


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.


Fig. 45-5


Female/Male anatomy


Gerontologic ConsiderationsGerontologic ConsiderationsEffects of Aging on the Urinary SystemEffects 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).


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;1. Obstructive symptoms-decrease in caliber and

force of urinary stream, difficulty initiating voiding, intermittency, dribbling

2. Irritative symptoms- (associated with inflammation or infection)- frequency, urgency, dysuria, nocturia, incontinence


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.


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. 2001 July; 51(468): 548–552. PMCID: PMC1314046Copyright notice Urinary incontinence in older people in the community: a neglected problem? H Stoddart, J Donovan, E Whitley, D Sharp, and I Harvey


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)


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.


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.


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.


Assessment ofAssessment ofthe Urinary Systemthe Urinary System

Subjective dataSubjective data Important health informationImportant health information

• Past health history-related diseases, Past health history-related diseases, surgeries, include family hx, surgeries, include family hx, occupation/environment, diet, water intake, occupation/environment, diet, water intake, exercise, elimination patternexercise, elimination pattern

• Smoking hx; major factor in risk for bladder Smoking hx; major factor in risk for bladder ca. tumors occur 4x more frequently .ca. tumors occur 4x more frequently .

• MedicationsMedications

• Surgery or other treatmentsSurgery or other treatments


Assessment terms(p.1145)


Assessment ofAssessment ofthe Urinary System (cont’d)the Urinary System (cont’d)

Functional health patternsFunctional health patterns• Health Perception–Health Management PatternHealth Perception–Health Management Pattern

• Nutritional-Metabolic PatternNutritional-Metabolic Pattern

• Elimination PatternElimination Pattern

• Activity-Exercise PatternActivity-Exercise Pattern

• Sleep-Rest PatternSleep-Rest Pattern

• Cognitive-Perceptual PatternCognitive-Perceptual Pattern

• Self-Perception–Self-Concept PatternSelf-Perception–Self-Concept Pattern

• Role-Relationship PatternRole-Relationship Pattern

• Sexuality-Reproductive PatternSexuality-Reproductive Pattern


Assessment ofAssessment ofthe Urinary System (cont’d)the Urinary System (cont’d)

Objective dataObjective data Physical examinationPhysical examination

• InspectionInspection

• PalpationPalpation

• PercussionPercussion

• Auscultation Auscultation


Fig. 45-6


Diagnostic StudiesDiagnostic Studiesof the Urinary Systemof the Urinary System

Urine studies- accuracy of results Urine studies- accuracy of results influenced by: influenced by: proper procedure, pt. proper procedure, pt. cooperation, often require bowel prep (KUB, IVP).cooperation, often require bowel prep (KUB, IVP). Urinalysis; 1Urinalysis; 1stst test done, best obtained in am, test done, best obtained in am, Creatinine clearance- Creatinine clearance- Creatinine: waste product Creatinine: waste product

produced by muscle breakdown, produced by muscle breakdown, most accurate indicator of renal function

Normal value: 85-135 ml/min Serum creatinine: 0.5-1.5mg/dl BUN-10-30gm/dlBUN-10-30gm/dl Urodynamics; Urodynamics; measures urinary tract functionmeasures urinary tract function Specific gravity; 1.003-1.030Specific gravity; 1.003-1.030


Fig. 45-7


Fig. 45-8


Fig. 45-9

chapter 45 nursing assessment urinary system s. buckley, rn, ms ( adapted from mosby pp) copyright...

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