Renal Assessment Flashcards
Where do you elicit for kidney tenderness?
- Costovertebral angle
- formed by the lower border of the 12th rib & the transverse processes of the upper lumbar vertebrae
What is contained within the Pelvic cavity
- Terminal ureters
- Bladder
- Pelvic genital organs
- At times small & large intestine
What type of muscle is the bladder composed of ?
- Strong smooth muscle chiefly detrusor muscle
How much urine can the bladder hold
400 - 500 mL
What does bladder expansion stimulate?l
- Parasympathetic innervation at relatively low pressures = detrusor contraction & inhibition (relaxation) internal urethral sphincter
- Also requires relaxation of the external urethral sphincter
Relaxation of the external urethral sphincter is controlled via:
- Voluntary control as it is composed of striated muscle
When can you palpate the bladder?
- A distended bladder may be palpable above the symphysis pubis
= nearly full ~400 - 500 mL
In infants how is the bladder emptied?
- By reflex mechanisms in the sacral spinal cord
How does one have voluntary control of the bladder?
- Voluntary control of the bladder depends on HIGHER centers in the brain & the reflex arcs of the SACRAL spinal cord
- When voiding is inconvenient - the brains higher centers can inhibit the detrusor contractions
How can the integrity of the sacral nerves be tested?
- By assessing perirectal & perineal sensation in the
S2, S3, & S4 dermatomes
5 Common or concerning urinary symptoms
- Suprapubic pain
- Dysuria, urgency or frequency
- Nocturnal & polyuria
- Incontinence
- Hematuria
Dysuria
- Pain on urination, usually felt as a burning sensation
Burning can be a common complaint of Dysuria, but for women you really want to distinguish the pain between what other diagnosis?
- For women distinguish from burning of inflamed labia (vulvovaginitis)
Men typically feel a burning sensation proximal to the glans penis in what condition?
- Infection
Men typically feel a burning sensation in the perineum and occasionally in the rectum in what condition?
- Prostatic pain
Painful urination accompanies what 6 other conditions?
- Cystitis
- Urethritis
- UTI
- Bladder stones
- Tumors
- In men - Acute Prostatitis
Urinary Urgency
- An unusually intense & immediate desire to void
- sometimes w/ urge incontinence & frequency (abnormally frequent voiding)
Urinary Frequency
- Can be either High volume (polyuria) or low volume (oliguria)
If your patient is having urinary urgency what might it suggest?
- UTI or irritation from possible urinary calculi
If your patient is having urinary frequency what might it suggest?
- Suggest UTI & bladder neck obstruction
If your patient is having urinary urgency or frequency with flank or back pain what might it suggest?
- Pyelonephritis
Polyuria
- A significant increase in 24-hr urine volume
- roughly defined as exceeding 3 L
Nocturia
- Urinary frequency at night (awakening the patient more than once) w/ small or large volumes
- need to clarify the daily total fluid intake & how much they are consuming in the evening
What are 4 causes of Polyuria ?
- High fluid intake of psychogenic polydipsia
- Poorly controlled diabetes
- Decreased secretion of antidiuretic hormone (ADH) of central diabetes insipidus
- Decreased renal sensitivity to ADH of Nephrogenic diabetes insipidus
Why is incontinence a big concern in older adults?
- Socially restricting
- Increase risk of infection
- Increase risk of falls
Central or peripheral nerve lesions affecting where can affect normal voiding ?
- S2, S3, & S4 = Sacral spinal reflex
What are the 5 types of incontinence?
- Stress incontinence
- Urge incontinence
- Overflow incontinence
- Functional incontinence
- Incontinence secondary to medications
Stress incontinence
- Urethral sphincter is weakened so that transient increases in intraabdominal pressure raises the bladder pressure to levels that exceed urethral resistance
Causes of stress incontinence in women
- Pelvic floor weakness & inadequate muscular & ligamentous support
- Childbirth
- Surgery
- Postmenopausal atrophy of the mucosa
- Urethral infection
Causes of stress incontinence in men
- Prostate surgery
What are symptoms of stress incontinence
- Momentary leakage of small amounts of urine with coughing, laughing, & sneezing while the person is in an upright position
- Urine loss is unrelated to a conscious urge to urinate
What are signs of stress incontinence
- May be demonstrable, especially if bladder is full
- Atrophic vaginitis may be present
- Bladder distention is absent
Urge incontinence
- Detrusor contractions are stronger than normal & overcome the normal urethral resistance
- Several causes
Decreased cortical inhibition of the detrusor contractions causing urge incontinence may be caused from ?
- Stroke
- Brain tumor
- Dementia
- Lesions of the spinal cord above the sacral level
- Symptoms: involuntary urine loss preceded by an urge to void - moderate volume
- Signs: small bladder
Hyper-excitability of sensory pathways causing urge incontinence can be caused from what? What might you see clinically?
- Bladder infections
- Tumors
- Fecal impactions
- Symptoms: urgency, frequency, & nocturia with small- moderate volumes
- Signs: possible mental deficits or motor signs of central nervous system disease
Deconditioning of voiding reflexes that cause urge incontinence can be caused by what? What might you see clinically?
- Frequent voluntary voiding at low bladder volumes
- Symptoms: poss. “Pseudo-stress incontinence” = voiding 10 -20 sec after stresses such as a change of position, going up-or- down stairs, coughing, laughing, or sneezing
- Signs: local pelvic problems or a fecal impact ion may be present
Overflow incontinence
- Detrusor contractions are insufficient to overcome urethral resistance, causing urinary retention
Mechanisms of overflow incontinence
- Obstruction of the bladder outlet = BPH or tumor
- Weakness of the detrusor muscle with peripheral nerve disease at S2-S4 level
- Impaired bladder sensation that interrupts the reflex arc = diabetic neuropathy
What symptoms might you see clinically with overflow incontinence ?
- Continuous dripping or dribbling incontinence
- Decreased force of the urinary stream
- Prior symptoms of partial urinary obstruction
What signs might you see clinically with overflow incontinence ?
- Examination often reveals an enlarged, sometimes tender bladder
- Prostatic enlargement
- Motor signs of peripheral nerve disease
- A decrease sensation (including perineal sensation)
- Diminished to absent reflexes
Functional incontinence
- The patient is functionally unable to reach the toilet in time because of impaired health or environmental conditions
What are some mechanisms behind functional incontinence?
- Problems in mobility: weakness, arthritis, poor vision
- Environmental factors: unfamiliar setting, distant bathroom, bed rails, or physical restraint
What are the symptoms of functional incontinence you might see clinically ?
- Incontinence on the way to the toilet or only in the early morning
What are signs of functional incontinence you might see clinically ?
- Bladder is not detectable on exam (look for physical or environmental clues)
Incontinence secondary to medications
- Drugs may contribute to any type of incontinence
- Sedatives
- Antipsychotics
- Anticholinergics
- Sympathetic blockers
- Potent diuretics
What is major cause of concern in a renal assessment
- Hematuria
- gross Hematuria = visible to the naked eye
- microscopic = detected only during urinalysis
Where is flank/ kidney pain usually located?
- At or below the posterior costal margin near the CVA (costovertebral angle) & may radiate anteriorly toward the umbilicus
What is the mechanism behind flank/ kidney pain? And how is it described?
- Visceral pain produced by distention of the renal capsule
- Typically dull, aching & steady
Where would you assess for urethral colic?
- Pain radiating around the trunk into the lower abdomen & groin or possibly into the upper thigh, testicle or labium
What is the mechanism behind ureteral colic?
- Sudden distention/ obstruction of the ureter & renal pelvis
What is the quality of pain described as with ureteral colic?
- Severe colicky pain (comes & goes)
Your patient presents with flank pain, fever, & chills this would signal what ?
- Acute pyelonephritis
How do you assess the kidneys during a general exam?
- 1st check for CVA tenderness using percussion
- the kidneys are usually not palpable unless markedly enlarged
Which patients might present with CVA tenderness?
- Renal colic or Pyelonephritis
- due to inflammation of the renal capsule
How do you assess the urinary bladder during a general exam?
- Percuss the urinary bladder (distention, tenderness)
- not palpable unless distended above the pubic symphysis
- bladder vol. must be ~ 400 - 600 mL before dullness appears
3 abnormal findings during the general renal exam?
- CVA pain (costovertebral angle)
- Bladder distention: outlet obstruction, meds, neurological (stroke, MS)
- Suprapubic tenderness: bladder infection
Your patient is experiencing dull/ pressure like pain in the lower abdomen, what do you expect to find?
- A bladder infection
Your patient is experiencing agonizing pain, accompanied by acute urinary retention, what do you expect to find?
- Sudden over distention of the bladder - this can be emergent
- This can be due to regional anesthesia & not able to void yet d/t sacral block
Your male patient is experiencing agonizing pain, accompanied by acute urinary retention, plus painful urination. He does not have frequency or urgency, what do you suspect?
- Urethritis
Your patient has chronic bladder distention listed in their medical history you understand the sensation to be…
- Painless
