Week 13: Chp 61: Assessment of Renal and Urinary Function Flashcards
History Collection Includes what?
- demographics and personal data
- personal and family health history
- medication use
- renal and urinary assessment
When the renal and urinary systems are evaluated, essential demographic data includes?
gender, age, race, socioeconomic status, occupational history, and dietary and personal habits
What is a critical component when assessing the function of any body system?
collecting a subjective patient history
Why is each gender predisposed to unique complications that should be considered and assessed?
because of the variations in the anatomy of the male and female urinary systems
- ex: females are more susceptible to develop UTIs than males because of the short length of the female urethra
- ex: the presence of the prostate gland in males introduces the potential for complications including prostatitis, benign prostate hypertrophy (BPH) or nonmalignant enlargement of the prostate gland, or prostate cancer
History: Socioeconomic status
low socioeconomic status, low levels of education, and lack of access to healthcare and the development of chronic conditions that increase the risk of renal complications
-low socioeconomic status has been linked with higher incidence of bladder cancer; due in part with occupational exposure to specific chemicals and to an increased rate of smoking
History: Chemical exposure
-exposure to chemicals such as aromatic amines and hydrocarbons is known to increase risk of bladder cancer
History: Occupation
employed as textile workers, hairdressers, painters, and manufacturers of rubber and leather products have a high incidence of bladder cancer
History: Dietary intake
consumption of foods high in protein, dairy products, and salt may lead to increased development of renal calculi
-inadequate fluid intake also increases the risk of developing UTIs, renal calculi, and even renal failure
History: Smoking
primary risk for bladder cancer
History: Family history
diabetes and hypertension have a hereditary component and the patient should be assessed for these conditions; these conditions can compromise blood flow to and through the kidneys, resulting in renal complications
-as well as assess a family history of kidney disease, urological failure, and frequent UTIs
History: Personal history
- changes in weight, excessive thirst, fatigue, and signs of fluid retention are symptoms that warrant further investigation of the functioning of the renal and urinary systems
- personal history of neurological deficits, urological cancers, frequent UTIs, and trauma to the urinary tract should be assessed
History: Medication use
history of patients current and past use of over-the-counter (OTC) medications, prescription medications, vitamins and herbal supplements
-many classes of medications are known to affect the normal functioning of the urinary system
>Diuretics: increase the quantity and frequency of urine output
>Some chemotherapeutic agents, phenazopyridine (Pyridium), and nitrofurantoin (Macrodantin), are known to alter the color of urine
>Classes of medications used to treat neurological and musculoskeletal disorders can affect the normal functioning of the muscles and nerves controlling the bladder contraction and relaxation; may lead to urinary incontinence, retention, and other difficulties in voiding
>some medications can be toxic to the kidneys (nephrotoxic)
Classes of Medication that are known to affect the normal functioning of the urinary system
- diuretics: increase the quantity and frequency of urine output
- chemotherapeutic agents, phenazopyridine (Pyridium), and nitrofurantoin (Macrodantin), are known to alter the color of urine
- classes of medications used to treat neurological and musculoskeletal disorders can affect the normal functioning of the muscles and nerves controlling the bladder contraction and relaxation; may lead to urinary incontinence, retention, and other difficulties in voiding
- some can be toxic to the kidneys (nephrotoxic) (analgesics like aspirin and ibuprofen)
Renal and Urinary Assessment
ask questions regarding any changes in appearance (clarity and color), or odor of urine, the pattern of urination, and the ability to voluntarily control voiding
>a change in the color of urine may be a result of medications, overhydration, dehydration, or the presence of blood in the urine (hematuria)
>urine typically smells like ammonia
>changes in the odor of urine may be caused by medications, hydration status, or the presence of infectious organisms
Hematuria
presence of blood in the urine
-due to cystitis or other inflammation in the urinary tract, calculi, cancers of the urinary tract, renal disease, bleeding disorders, medications such as anticoagulants
A change in the color of urine may be due to what?
may be a result of medications, overhydration, dehydration, or the presence of blood (hematuria) in the urine
A change in the odor of urine may be due to what?
caused by medications, hydration status, or the presence of infectious organisms
-urine typically smells like ammonia
A patients pattern of urination
should be assessed in regard to frequency, flow, and amount
-average adult voids 5 to 6 times per day and does not regularly need to void overnight
Urinary Frequency
refers to the sensation of needing to void more than normal but voiding only small amounts of urine each time
-due to bladder inflammation, excessive fluid intake, urinary retention
Nocturia
describes the increased need to urinate at night
-due to heart failure, renal disease, bladder obstruction, consumption of fluids late at night
Dysuria
pain or discomfort with urination
- may indicate an obstruction or infection
- UTI, cystitis (bladder infection)
Hesitancy
difficulty starting the flow of urine despite the sensation to void
- may be indicative of age-related changes in the male prostate gland
- urethral obstruction, enlargement of the prostate gland (benign or malignant)
Anuria
total urine output of less than 100 mL in 24 hours
-in end-stage renal disease, acute renal failure, urinary tract obstruction
Oliguria
decreased urine output; less than 400 mL in 24 hours
- 100 to 400 mL in 24 hours
- in shock, end-stage renal disease, acute kidney injury, severe dehydration, blood transfusion reaction
Polyuria
excess quantities of urine output
- greater than 2000 mL urine output/ 24 hr
- due to excessive fluid intake, diabetes insipidus, diabetes mellitus, diuretic medications, diuresis phase of chronic renal failure
Enuresis
involuntary urination at night
-due to lower urinary tract disorder
Incontinence
inability to voluntarily control micturition
-due to bladder infections, trauma to the external sphincter, neurogenic bladder, trauma to the nerve innervating the urinary tract structure
Renal Colic
pain radiating to the perineal or groin area
-due to ureter spasm during passage of calculi, ureter obstruction
Retention
inability to completely empty the bladder of urine
- normal finding briefly after childbirth, pelvic surgery, and removal of indwelling catheter
- due to prolonged/abnormal related to neurogenic bladder, obstruction or stricture to the urethra
Urgency
sudden onset of the urge to void immediately
-due to medications, pelvic organ prolapse, cystitis, or UTI
Renal and Urinary System Assessment Abnormalities
- anuria
- dysuria
- enuresis
- frequency
- hematuria
- hesitancy
- incontinence
- nocturia
- oliguria
- polyuria
- renal colic
- retention
- urgency
Physical Examination should include
- vital signs and weight (valuable baseline on overall health status)
- mental status and level of consciousness
- auscultation of the lungs (for fluid status)
- inspection, auscultation, palpation, and percussion
When the renal system is assessed, the location of the kidneys can be estimated by using what as a landmark?
using the costovertebral angle (CVA)
-formed by the lower border of the 12th rib and the spine (on the patients back, below the 12th rib next to the spine; pg 1428 in hoffman)
Proper way to assess the renal system
start with inspection, auscultation and then palpation and percussion
-because these palpation and percussion amplify bowel sounds and diminish abdominal vascular sounds
Inspection: What to look for
inspection of the skin, oral mucosa, abdomen, and extremities
-inspection of urethral meatus may be necessary
>skin: poor skin turgor, rough texture, pallor, yellow-gray color, flank bruising
>mouth: ammonia breath odor, stomatitis (inflammation and ulceration of oral mucosa)
>abdomen: uneven contour, unilateral abdominal mass, striae (stretch marks)
>extremities: edema
>urethral meatus: bloody or purulent discharge, skin lesions or rashes, obvious tissue trauma
Inspection of the skin: assess for abnormal changes
poor skin turgor, rough texture, pallor, yellow-gray color, flank bruising
Inspection of the mouth: assess for abnormal changes
ammonia breath odor, stomatitis (inflammation and ulceration of oral mucosa)
Inspection of the abdomen: assess for abnormal changes
uneven contour, unilateral abdominal mass, striae (stretch marks)
Inspection of extremities: assess for abnormal changes
edema
Inspection of urethral meatus: assess for abnormal changes
bloody or purulent discharge, skin lesions or rashes, obvious tissue trauma
Auscultation: what position and where to listen
with the patient supine, auscultate over the abdominal aorta, and each renal artery with the bell of the stethoscope
Auscultation: what to listen for
listen for a bruit (a turbulent or whooshing sound produced by an increase in the volume of blood traveling through a vessel or a decrease in the diameter of a blood vessel)
-presence of a bruit indicates altered blood flow to the kidneys and warrants further investigation
What does the presence of a bruit indicate if heard on auscultation?
indicates altered blood flow to the kidneys
Palpation: what position and where to palpate
with the patient in a supine position, lightly palpate in all four abdominal quadrants
Palpation: what to palpate for
instruct the patient to report any discomfort or tenderness upon palpation
-the bladder is typically not palpable unless distended with urine; if filled with urine, the bladder is sensitive to palpation and feels round and firm
Palpation: how to palpate the kidneys
position one hand under the patient’s flank between the rib cage and the iliac crest; position the other hand over the abdomen, just below the rib cage; ask the patient to take a deep breath , and use your lower hand to raise the flank while the upper hand palpates
-the lower pole of the right kidney is occasionally palpable in some patients; the left kidney is positioned deeper than the right and is typically not palpable
Percussion: position and where to percuss
patient remains supine, percuss over the symphysis pubis upward toward the umbilicus
Percussion: what to assess for
dullness is the sound elicited over a distended bladder
-a bladder containing little to no urine produces no sound upon percussion
Percussion: how to assess for flank tenderness
utilizing fist percussion over each kidney at the CVA (on the patients back below the 12th rib next to the spine)
- have the patient in a sitting position and position yourself behind the patient
- place one hand flat over the CVA; form a first with the other hand and strike it against the dorsal surface of the flattened hand; this blow to the flank area should not elicit pain or tenderness; if reports pain or tenderness it is suggestive of kidney inflammation or infection
The nurse is assessing a patient for a routine physical examination. Which of the following are normal findings when assessing the renal and urinary systems?
A. inability to palpate the kidneys
B. CVA tenderness upon percussion
C. Absence of renal artery bruit
D. Purulent drainage from the urinary meatus
E. Tympanic sounds over an empty bladder upon percussion
A. Inability to palpate the kidneys
C. absence of renal artery bruit
Laboratory Studies Include
- blood tests (serum creatinine, BUN, BUN/creatinine ratio, Uric Acid, Bicarbonate, Electrolytes)
- urine tests (bedside urine dipsticks, urinalysis, culture and sensitivity, composite urine collection, creatinine clearance, and urine cytology)
Imaging Studies Include
- bedside sonography
- x-ray
- intravenous urography
- renal ultrasound
- computed tomography
- MRI
- cystography and urethrography
- arteriography
- renography (kidney scan)
- renal biopsy
- cystoscopy
Age-related changes and assessment findings
- kidneys decrease in size–> kidneys less palpable on examination (not really palpable anyway)
- number of nephrons decreases, nephrons lose functioning, glomerular membrane thickens–> decreased glomerular filtration rate (GFR), increased BUN and creatinine
- changes in loop of Henle–> decreased ability to concentrate urine, decreased effect of ADH and aldosterone, urinary frequency, risk for dehydration
- loss of muscle tone and elasticity–> risk for urinary incontinence
- decreased bladder capacity–> urinary urgency, frequency, and incontinence
- enlargement of prostate gland–> urinary hesitancy, frequency, straining, slow urine stream, urinary retention
The nurse caring for an 85y/o female patient who presents with nocturnal polyuria incorporates which priority nursing diagnosis into the plan of care? A. risk for deficient fluid volume B. risk for sleep deprivation C. risk for excess fluid volume D. risk for urge urinary incontinence
A. risk for deficient fluid volume
