 Non - modifiable:  Modifiable:

1. Body fats 1. Age

2. Diseases 2. Gender
3. Injury (Burn) 3. Family history of
4. Drugs disease (DM, HPN)
1. Biographical Data
• Age
• dehydration (older adults)
• Electrolyte imbalances (older adults and infants)

• Gender
• Females are prone to UTI, hormonal changes,
Detrusor muscle atrophy

• Occupation (usual & present)

• Ex. Occupation - Athletes, Out-door labourers
2. Source of History
 Patient (reliable), (w/o mental deterioration,
severe DHN)
 interpreter if needed

3. Reason for seeking care

 S/Sx of Fluid Volume, Electrolyte and Acid-
Base Imbalances.

 Ex. Tented skin turgor, Headache, Acetone

breath, Dizziness.
4. Present Health
 Ex. vomiting –loss of several
electrolytes, ingestion of excess
sodium bicarbonate can alter both
sodium level and acid-base
balance.
Renal failure – fluid, electrolyte
imbalances

5. Past History
Ex. Childhood illness (whooping
cough)
Accidents(burns), chronic
illnesses(cushing syndrome)
6. Hospitalizations
Pt. with dysphagia, with NGT,
disturbances in voiding.

7. Operations
Urinary instrumentation and Dx
tests (cystoscopy, cystoclysis,
resection of the pituitary glad,
thyroidectomy)
8. Current Medications
Diuretics, Steroid, Cardiac Drugs
Urine color
Phenytoin – pink to red
Rifampicin – reddish orange
Nitrofurantoin – orange to amber
Iron preparation – brown to black

 Family History (Genogram)

diseases that maybe genetic in
origin, communicable, or possibly
environmental .
 Functional assessment/ADL’s
Activity / Exercise - Is the
person able to ambulate and use
both arms and hands to reach
fluids and foods?

Sleep / rest

Nutrition / elimination
Is the patient able to
swallow?
Chronic malnutrition- F&E
imbalances
Personal habits - Smoking, use
of drugs, alcohol, and caffeine,
Personal hygiene, toileting
habits, sexual practices,
tight fitting underwears.
 INSPECTION
◦ masses in the upper abdomen and flank pain.
◦ external meatus for signs of discharge, cleanliness,
location, and size.

 PALPATION
◦ lower poles of the right and left kidney, noting
enlargement.

 PERCUSSION
◦ above the symphysis pubis for a distended bladder.

 AUSCULTATION
◦ bruits over the renal arteries.
◦ ***A bruit may be heard over an artery or vascular
channel, reflecting turbulence of flow.
 Urine Color Possible Causes
Colorless to Dilute urine d/t Diuretics, Alcohol, DI,
pale yellow excess fluid intake, renal disease
Yellow to Milky Pyuria, Infections, Vaginal Creams,
white increased WBC
Bright Yellow Multivitamins preparation ( esp. Vit.
C)
Pink to Red RBC, Gross menses, bladder /
prostate surgery, medications such
as Phenytoin, Rifampicin,
Phenothiazine

F&E/Urinary Team
 Urine Color Possible Causes
Blue to Blue Dyes, pseudomonas orgamisms
green medications such as Amitriptylene,
Triamterene, phenylsalycilate
Orange to Concentrated urine d/t DHN, excess
Amber bilirubin, medications such as
Phenazopyridium, Nitrofurantoin
Brown to Black Extremely concentrated urine d/t
DHN, medications such as Iron
Preparations, Metronidazole,
Quinine, Methyldopa

F&E/Urinary Team