Assessment of Renal and Urinary Tract Function

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Renal and Urinary Systems

Function: - to maintain the bodys state of homeostasis by regulating fluid and electrolytes, - removing wastes, and providing hormones involved in red blood cell production, bone metabolism, and - control of blood pressure Structures Kidneys Ureters Bladder Urethra
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Kidneys, Ureters, and Bladder

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Internal Structure of the Kidney

-Pair of bean shaped, brownishred structures located retroperitoneally (behind and outside the peritoneal cavity on the posterior wall of the abdomen from the 12th thoracic vertebra to the third lumbar vertebra in the adult -Weigh approximately 113 to 170 g ( about 4.5 oz) and 10 to 12 cm long, 6 cm wide and 2.5 cm thick -Right kidney is slightly lower than the left due to the location of the liver. -Divided into two parts: Renal cortex and the renal medulla; renal medulla is approximately 5cm wide, is in the inner portion of the kidney; renal cortex is approximately 1 cm wide, located farthest from the center of the kidney and around outermost edges. Contains the NEPHRONS (the functional units of the kidney)
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Nephron
-Each kidney has 1 million nephrons -Two types of nephron: cortical nephron 80% - 85% of the total number located in the outermost Part of the cortex; juxtamedullary nephron located deeper in the cortex which is 15% - 20%. -Two basic components of the nephron; filtering element composed of an enclosed capillary network (the glomerulus) and the attached tubule.

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URETER,
Ureter are long fibromuscular tubes that connects each kidney to the bladder. These narrow tubes, each 24 cm to 30 cm long, originate at the lower portion of the renal pelvis and terminate in the trigone of the bladder wall. The left ureter is slightly shorter than the right ureter. Lining of the ureters is made up of transitional cell epithelium called urothelium. Urothelium prevents reabsorption of the urine. Movement of the urine from each renal pelvis through the ureter is facilitated by peristaltic contraction of the muscles in the ureter wall. Three narrowed areas of each ureter: ureteroplevic junction, ureteral segment near the sacroiliac junction and the ureterovesical junction.

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Bladder
-Is a muscular hollow sac located just behind the pubic bone. -400 to 500 ml is the cappacity of the adult bladder -It is characterized by its central, hollow area, called the vesicle, which has two inlets (the ureters) and one outlet (the urethra). -Angling of the ureterovesical junction is the primary means of providing antegrade, or downward, movement of urine, also referred as efflux of urine.

The trigone is a smooth triangular region of the internal urinary bladder formed by the two ureteral orifices and the internal urethral orifice. The area is very sensitive to expansion and once stretched to a certain degree, the urinary bladder signals the brain of its need to empty. The signals become stronger as the bladder continues to fill.

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Four layers of the bladder wall

Adventitia outermost layer which is made up of connective tissue. Smooth musle (detrusor) Submucosal layer (lamina propria) serves as an interface between the detrusor and the innermost layer. Transitional cell epithelium innermost layer a membrane that is impermeable to water and prevents reabsorption of urine stored in the the bladder

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Formation of Urine
Urine is formed in the nephrons in a three step process: -Filtration -Reabsorption -Excretion

Various substances normally Filtered by the glomerulus, reAbsorbed by the tubules, and Excreted in the urine. Amino acids and glucose are Usually filtered at the level of Glomerulus and reabsorbed so That neither is excreted in the Urine. Renal glycosuria occurs if the Amount of glucose in the blood and Glomerular filtrate exceeds the Amount that the tubules are able to Reabsorb. Protein molecules are not usually foun in The urine; however low-molecular-weight Proteins (globulins and albumin) may Periodically be excreted in small amounts.

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ANTIDIURETIC HORMONE

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Renin Angiotensin System

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ASSESSMENT OF THE RENAL AND URINARY TRACT SYSTEMS

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Important points in assessment

Excellent communication skills Correct usage of language Review of risk factors ( table 43-1)

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Information a nurse should inquire:

The patients chief concern or reason for seeking health care, the onset of the problem, and its effect on the patients quality of life. The location, character , and duration of pain, if peristent and its relationship to voiding; factors that precipitate pain, and those that relieve it History of UTI, including past treatment or hospitalization for UTI Fever and chills Previous renal or urinary diagnostic tests or use of indwelling urinary catheters Dysuria and when during voiding (ie, at initiation or at termination of voiding) it occurs Hesitancy, straining, or pain during or after urination Urinary incontinence (stress incontinence, urge incontinence, overflow incontinence, or functional incontinence) Hematuria or change in color or volume of urine Nocturia and its date of onset Renal calculi (kidney stones), passage of stones or gravel in urine Female patient: number and type (vaginal or cesarean deliveries); use of forceps, vaginal infection, discharge or irritation, contraceptive practices
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 History of anuria (decreased urine production) or other renal problem Presence of history of genital lesions or sexually transmitted diseases Use of tobacco, alcohol, or recreational drugs Any prescription and over the counter medications (including those prescribed for renal or urinary problems)

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Common Symptoms
Genitourinary pain Changes in Voiding Gastrointestinal Symptoms Unexplained Anemia

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Genitourinary Pain
Usually caused by distention of some portion of the urinary tract as a result of obstructed urine flow or inflammation and swelling of tissues. Severity of the pain is related to sudden onset rather than the extent of distention Various types of genitourinary pain (refer to table 43-2 p. 1300)

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Changes in Voiding
Micturition is normally a painless function that occurs approximately eight times in a 24-hour period. Average person voids 1 to 2 L of urine in 24 hours. Common problems associated with changes in voiding (refer to table 43-3)

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Gastrointestinal Symptoms
Often associated with urologic conditions because of shared autonomic and sensory innervation and renointestinal reflexes Most common signs and symptoms: nausea, vomiting, diarrhea, abdominal discomfort, abdominal distention.

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Unexplaines Anemia

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Physical Examination Percussion of the kidney

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Diagnostic Studies
Urinalysis and urine culture Renal function tests See Table 43-5 Ultrasonography CT and MRI Nuclear scans Intravenous urography, retrograde pyelography, cystography, renal angiography See Chart 43-2 Endoscopic procedures Biopsies
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Urinalysis and urine culture

Urinalysis provides improtant clinical information about kidney function and helps diagnose other diseases. Urine culture determines whether bacteria are present in the urine, as well as their strains and concentrations. It also identify antimicrobial therapy that is best suited for the particular strains, taking into considerations the antibiotics that have the best rate of resolution Components need for examination: Urine color ( table 43-4) Urine clarity and odor Urine pH and specific gravity Tests to detect protein, glucose, and ketone bodies in the urine) Microscopic examination of the urine sediment after centrifugartion

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Cystoscopic Examination

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Nursing Care of the Patient Undergoing Diagnostic Testing of the Renal-Urologic System: Assessment
Patient knowledge Psychosocial and emotional factors; fear, anxiety Urologic function; include voiding habits/pattern Fluid intake Hygiene Presence of pain or discomfort Allergies

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Nursing Care of the Patient Undergoing Diagnostic Testing of the Renal-Urologic System: Diagnosis
Knowledge deficiency Pain Fear

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Nursing Care of the Patient Undergoing Diagnostic Testing of the Renal-Urologic System: Planning
Patient goals may include understanding of procedures, tests, and expected behaviors; decreased pain or absence of discomfort; and decreased apprehension and fear.

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Interventions
Patient teaching: provide a description of the tests and procedures in language the patient can understand Use appropriate, correct terminology. Encourage fluid intake unless contraindicated. Instruct patient in methods to reduce discomfort: sitz baths, relaxation techniques. Administer analgesics and antispasmodics as prescribed. Assess voiding and provide instruction related to voiding practices and hygiene. Provide privacy and respect.
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Copyright 2008 Lippincott Williams & Wilkins.