Chapter 43: Assessment of renal and urinary tract function

Vocabulary

Aldosterone: hormone synthesized and secreted by the adrenal cortex, causes the kidneys to reabsorb
sodium.

Antidiuretic hormone: Hormone secreted by the posterior pituitary gland, causes the kidneys to
reabsorb more water---also known as vasopressin.

Anuria: total urine output less than 50 ml in 24hr

Bacteriuria: bacteria in the urine

Creatinine: Endogenous waste product of muscle energy metabolism

Diuresis: Increased formation and secretion of urine

Dysuria: Painful or difficult urination

Frequency: Voiding more frequently than every 3 hours

Glomerular filtration: Plasma filtered at the glomerulus into the kidney tubules

Hematuria: Red blood cells in the urine

Micturition: urination or voiding

Nephron structural and functional unit of the kidney responsible for urine formation

Nocturia: Awakening at night to urinate

Oliguria: total urine output less than 500ml/24hrs

Proteinuria: protein in the urine

Pyuria: white blood cells in the urine

Renal clearance: volume of plasma that the kidneys can clear of a specific solute

renal glycosuria: recurring or persistent excretion of glucose in the urine

specific gravity: Reflects the weight of particles dissolved in the urine; degree of concentration of the
urine

tubular reabsorption: movement of a substance from the kidney tubule into the blood in the
peritubular capillaries or vasa recta

Tubular secretion: movement of a substance from the blood in the peritubular capillaries or vasa recta
into the kidney tubule

Urea nitrogen: nitrogenous end product of protein metabolism

Chart 43-1 • Functions of the Kidney

 Urine formation

 Excretion of waste products

 Regulation of electrolytes

 Regulation of acid–base balance

 Control of water balance

 Control of blood pressure

 Renal clearance

 Regulation of red blood cell production

 Synthesis of vitamin D to active form

 Secretion of prostaglandins

 Regulates calcium and phosphorus balance

Anatomic and Physiologic Overview

 The renal and urinary systems include the kidneys, ureters, bladder, and urethra.

 The kidneys receive 20% to 25% of the total cardiac output, which means that all of the body's blood
circulates through the kidneys approximately 12 times per hour
 Each kidney has 1 million nephrons , responsible for the initial formation of urine.
 The large number of nephrons allows for adequate renal function even if the opposite kidney is
damaged or becomes nonfunctional. If the total number of functioning nephrons is less then 20% of
normal, renal replacement therapy needs to be considered.

Assessment of the Renal and Urinary Tract Systems

Health History

 The patient's chief concern or reason for seeking health care, the onset of the problem, and its effect on
the patient's quality of life
 The location, character, and duration of pain, if present, and its relationship to voiding; factors that
precipitate pain, and those that relieve it
 History of urinary tract infections, including past treatment or hospitalization for urinary tract infection
 Fever or 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 patients: number and type (vaginal or cesarean) of deliveries; use of forceps; vaginal infection,
discharge, or irritation; contraceptive practices
 History of anuria (decreased urine production) or other renal problem
 Presence or 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

Common symptoms to observe for with health history

Pain- Pain caused by distention of some portion of the urinary tract as a result of obstructed urine flow
or inflammation and swelling of tissues

Changes in voiding- Micturition- normally occurs 8 x's/24hr

 average person voids 1 to 2 L of urine in 24 hours
 Common problems associated with voiding include frequency, urgency, dysuria, hesitancy, incontinence,
enuresis, polyuria, oliguria, and hematuria

Gastrointestinal symptoms
The most common signs and symptoms are nausea, vomiting, diarrhea, abdominal discomfort, and abdominal
distention

Physical Assessment
 Areas of emphasis include the abdomen, suprapubic region, genitalia, lower back, and lower extremities
 patient is assessed for edema and changes in body weight.
 Edema may be observed, particularly in the face and dependent parts of the body, such as the ankles and
sacral areas, and suggests fluid retention.

 An increase in body weight commonly accompanies edema. A 1-kg weight gain equals approximately 1000
mL of fluid (1 lb is approximately 500 mL).

Diagnostic Evaluation
Urinalysis and Urine Culture
 urinalysis provides important clinical information about kidney function and helps diagnose other diseases,
such as diabetes.

 The urine culture determines whether bacteria are present in the urine, as well as their strains and
concentration

Specific Gravity
 Specific gravity measures the density of a solution compared to the density of water, which is
1.000. Specific gravity is altered by the presence of blood, protein, and casts in the urine.

 The normal range of urine specific gravity is 1.010 to 1.025

Osmolality
 Osmolality is the most accurate measurement of the kidney's ability to dilute and concentrate
urine.
 normal urine osmolality is 20 0 t o 80 0 mO sm /k g
Rena l function tes t

Table 43-5 Renal Function Tests

Test Purpose Normal Values
Renal Concentration Tests

Specif Evaluate 1.010–1.025

ic s ability
gravit of
y kidneys
to
concentr
ate
solutes in
urine.

Urine Concentr 300–900

osmol ating mOsm/kg/24 h,
ality ability is 50–1200
lost early mOsm/kg
in kidney random sample
disease;
hence,
these test
findings
may
disclose
early
defects
in renal
function.

24-Hour Urine Test

Creati Detects Measured in

nine and mL/min/1.73 m2
cleara evaluates Mal Fem
nce progressi Age e ale
on of
renal Un 8 8
disease. der 8 1
Test
 measures
volume 30 – –
of blood 1 1
cleared 4 3
of 6 4
endogen
ous 30 8 7
creatinin – 2 5
e in 1 40 – –
min, 1 1
which 4 2
provides 0 8
an
approxim 40 7 6
ation of – 5 9
the 50 – –
glomerul 1 1
ar 3 2
filtration 3 2
rate.
Sensitive
50 6 6
indicator
– 8 4
of renal
60 – –
disease
1 1
used to
2 1
follow
6 6
progressi
on of
renal 60 6 5
disease. – 1 8
70 – –
1 1
2 1
0 0

70 5 5
– 5 2
80 – –
1 1
1 0
3 5

Serum Tests
Creati Measures 0.6–1.2 mg/dL
nine effective (50–110
level ness of mmol/L)
renal
function.
Creatinin
e is end
product
of
muscle
energy
metaboli
sm. In
normal
function,
level of
creatinin
e, which
is
regulated
and
excreted
by the
kidneys,
remains
fairly
constant
in body.

Urea Serves as 7–18 mg/dL

nitrog index of Patients >60 yrs:
en renal 8–20 mg/dL
(blood function.
urea Urea is
nitrog nitrogeno
en us end
[BUN product
]) of
protein
metaboli
sm. Test
values
are
affected
 by
protein
intake,
tissue
breakdo
wn, and
fluid
volume
changes.

BUN- Evaluate
to- s
creati hydration
nine status.
ratio An
elevated
ratio is
seen in
hypovole
mia; a
normal
ratio
with an
elevated
BUN and
creatinin
e is seen
with
intrinsic
renal
disease.

Diagnostic Imaging
Kidney, Ureter, and Bla dder Studies
An x-ray study of the abdomen or kidneys, ureters, and bladder (KUB) may be performed to delineate the size,
shape, and position of the kidneys and to reveal urinary system abnormalities

Ge nera l Ultras onogra phy

 detect abnormalities of internal tissues and organs.
 Abnormalities such as fluid accumulation , masses, congenital malformations , changes in organ size ,
and obstructions can be identified.
 . Ultrasonography requires a full bladder ; therefore, fluid intake should be encouraged before the
procedure
Bladde r Ultras onogra phy
 noninvasive method for measuring urine in the bladder

Compute d Tomography and Magnetic Res ona nce Ima gi ng

 Computed tomography (CT) scans and magnetic resonance imaging (MRI) are noninvasive techniques that
provide excellent cross-sectional views of the anatomy of the kidney and urinary tract (
 used to evaluate genitourinary masses, nephrolithiasis, chronic renal infections, renal or urinary tract
trauma, metastatic disease, and soft tissue abnormalities.
 , an oral or intravenous (IV) radiopaque contrast agent is used in CT scanning to enhance visualization

Nucl ear Scans

 Nuclear scans are used to evaluate acute and chronic renal failure, renal masses, and blood flow before
and after kidney transplantation
 uses a radioisotope to monitor circulation through the kidneys

Rena l Angiography
 P rovide s image of renal a rte ries
 Evalua tes re nal blood f lo w in suspe cted re nal t rauma, dif ferentiate cyst s
f rom tumo rs, evaluate hype rten sion
 befo re pro cedu re, sha ve area of inse rt ion , laxa tive given fo r unobst ru cted
x ra ys, and periphe ra l pulses a re marked fo r comp arison after p roced ure

Urologic endos copic proce dure

 cytoscopic evaluation done to directly visualize bladder and urethra
 small catheters may be used through cytoscope for evaluation of the ureters and pelvis of each
kidney
 biopsy may be performed
 calculi may be removed
 pt will be npo several hours prior to test
 pts who experience urinary retention may be administered URISPAS to relieve urinary retention

Biopsy
Renal and Ureteral brush biopsy

 provide specific information when abnormal x-ray findings of the ureter or renal pelvis raise questions
about whether a defect is a tumor, a stone, a blood clot, or an artifact

Kidney Bi opsy
 Biopsy of the kidney is used to help diagnose and evaluate the extent of kidney disease
 fasting regimen 6 to 8 hours before the test.
 An IV line is established.
 A urine specimen is obtained and saved for comparison with the postbiopsy specimen.
 If a needle biopsy is to be performed, the patient is instructed to breathe in and hold that breath
(to prevent the kidney from moving) while the needle is being inserted. The sedated patient is
placed in a prone position with a sandbag under the abdomen