Chapter 45: Nursing Assessment: Urinary System

STRUCTURES AND FUNCTIONS • The urinary system consists of two kidneys, two ureters, a urinary bladder, and a urethra. • The bladder provides storage, and the ureters and urethra are the drainage channels for the urine after it is formed by the kidneys. Kidneys • The primary functions of the kidneys are (1) to regulate the volume and composition of extracellular fluid (ECF), and (2) to excrete waste products from the body. • • • • The kidneys function to control blood pressure, produce erythropoietin, activate vitamin D, and regulate acid-base balance. The outer layer of the kidney is termed the cortex, and the inner layer is called the medulla. The nephron is the functional unit of the kidney. Each kidney contains 800,000 to 1.2 million nephrons. A nephron is composed of a glomerulus, Bowman’s capsule, and a tubular system. The tubular system consists of the proximal convoluted tubule, the loop of Henle, the distal convoluted tubule, and a collecting tubule. The kidneys receive 20% to 25% of cardiac output. The primary function of the kidneys is to filter the blood and maintain the body’s internal homeostasis. Urine formation is the result of a multistep process of filtration, reabsorption, secretion, and excretion of water, electrolytes, and metabolic waste products.

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Glomerular Function • Blood is filtered in the glomerulus. • • • The hydrostatic pressure of the blood within the glomerular capillaries causes a portion of blood to be filtered across the semipermeable membrane into Bowman’s capsule. The ultrafiltrate is similar in composition to blood except that it lacks blood cells, platelets, and large plasma proteins. The amount of blood filtered by the glomeruli in a given time is termed the glomerular filtration rate (GFR). The normal GFR is about 125 ml/min.

Tubular Function • The functions of the tubules and collecting ducts include reabsorption and secretion. Reabsorption is the passage of a substance from the lumen of the tubules through the tubule cells and into the capillaries. Tubular secretion is the passage of a substance from the capillaries through the tubular cells into the lumen of the tubule. o The loop of Henle is important in conserving water and thus concentrating the filtrate. In the loop of Henle, reabsorption continues.

o Two important functions of the distal convoluted tubules are final regulation of water balance and acid-base balance.  Antidiuretic hormone (ADH) is required for water reabsorption in the kidney.  Aldosterone acts on the distal tubule to cause reabsorption of sodium ions (Na+) and water. In exchange for Na+, potassium ions (K+) are excreted. o Acid-base regulation involves reabsorbing and conserving most of the bicarbonate − (HCO3 ) and secreting excess H+. o Atrial natriuretic peptide (ANP) acts on the kidneys to increase sodium excretion. o Parathyroid hormone (PTH) acts on renal tubules to increase reabsorption of calcium. Other Functions of the Kidney • The kidneys produce erythropoietin in response to hypoxia and decreased renal blood flow. Erythropoietin stimulates the production of red blood cells (RBCs) in the bone marrow. • • • Vitamin D is activated in kidneys. Vitamin D is important for calcium balance and bone health. Renin, which is produced and secreted by juxtaglomerular cells, is important in the regulation of blood pressure. Prostaglandin (PG) synthesis (primarily PGE2 and PGI2) occurs in the kidney, primarily in the medulla. These PGs have a vasodilating action, thus increasing renal blood flow and promoting Na+ excretion.

Ureters • The ureters are tubes that carry urine from the renal pelvis to the bladder. • Circular and longitudinal smooth muscle fibers, arranged in a meshlike outer layer, contract to promote the peristaltic one-way flow of urine.

Bladder • The urinary bladder is a distensible organ positioned behind the symphysis pubis and anterior to the vagina and rectum. • • • Its primary functions are to serve as a reservoir for urine and to help the body eliminate waste products. Normal adult urine output is approximately 1500 ml/day, which varies with food and fluid intake. On the average, 200 to 250 ml of urine in the bladder causes moderate distention and the urge to urinate.

Urethra • The urethra is a small muscular tube that leads from the bladder neck to the external meatus. • • The primary function of the urethra is to serve as a conduit for urine from the bladder neck to outside the body during voiding. The female urethra is significantly shorter than that of the male.

Urethrovesical Unit • Together, the bladder, urethra, and pelvic floor muscles form the urethrovesical unit. It receives neuronal input from the autonomic nervous system. • • Normal voluntary control of this unit is defined as continence. Any disease or trauma that affects function of the brain, spinal cord, or nerves that directly innervate the bladder, bladder neck, external sphincter, or pelvic floor can affect bladder function.

Effects of Aging on the Urinary System • By the seventh decade of life, 30% to 50% of glomeruli have lost their function. • • Atherosclerosis has been found to accelerate the decrease of renal size with age. Older individuals maintain body fluid homeostasis unless they encounter diseases or other physiologic stressors.

ASSESSMENT • Subjective data: • Past health history • The patient is asked about the presence or history of diseases that are related to renal or urologic problems. Diseases include hypertension, diabetes mellitus, gout and other metabolic problems, connective tissue disorders (e.g., systemic lupus erythematosus), skin or upper respiratory infections of streptococcal origin, tuberculosis, hepatitis, congenital disorders, neurologic conditions (e.g., stroke), or trauma. • Medications: an assessment of the patient’s current and past use of medications is important. This should include over-the-counter drugs, prescription medications, and herbs. Many drugs are known to be nephrotoxic. • Surgery or other treatments: the patient is asked about any previous hospitalizations related to renal or urologic diseases and all urinary problems during past pregnancies. Past surgeries, particularly pelvic surgeries, or urinary tract instrumentation is documented. • Objective data: • Physical examination

• Inspection: the nurse should assess for changes in the following:

 Skin: pallor, yellow-gray cast, excoriations, changes in turgor, bruises, texture (e.g., rough, dry skin)  Mouth: stomatitis, ammonia breath odor  Face and extremities: generalized edema, peripheral edema, bladder distention, masses, enlarged kidneys  Abdomen: striae, abdominal contour for midline mass in lower abdomen (may indicate urinary retention) or unilateral mass (occasionally seen in adult, indicating enlargement of one or both kidneys from large tumor or polycystic kidney)  Weight: weight gain secondary to edema; weight loss and muscle wasting in renal failure  General state of health: fatigue, lethargy, and diminished alertness

• Palpation: A landmark useful in locating the kidneys is the costovertebral angle

(CVA) formed by the rib cage and the vertebral column.  The normal-size kidney is usually not palpable.  If the kidney is palpable, its size, contour, and tenderness should be noted. Kidney enlargement is suggestive of neoplasm or other serious renal pathologic condition.  The urinary bladder is normally not palpable unless it is distended with urine.

• Percussion: Tenderness in the flank area may be detected by fist percussion (kidney

punch).  Normally a firm blow in the flank area should not elicit pain.  Normally a bladder is not percussible until it contains 150 ml of urine. If the bladder is full, dullness is heard above the symphysis pubis. A distended bladder may be percussed as high as the umbilicus. Auscultation: With a stethoscope the abdominal aorta and renal arteries are auscultated for a bruit (an abnormal murmur), which indicates impaired blood flow to the kidneys.

DIAGNOSTIC STUDIES • Urine studies: o Urinalysis. This test may provide information about possible abnormalities, indicate what further studies need to be done, and supply information on the progression of a diagnosed disorder. o Creatinine clearance. Because almost all creatinine in the blood is normally excreted by the kidneys, creatinine clearance is the most accurate indicator of renal function. The result of a creatinine clearance test closely approximates that of the GFR. o Urodynamic tests study the storage of urine within the bladder and the flow of urine through the urinary tract to the outside of the body.

****Chapter 46: Nursing Management: Renal and Urologic Problems
URINARY TRACT INFECTIONS • Urinary tract infections (UTIs) are the second most common bacterial disease, and the most common bacterial infection in women. • UTIs include cystitis, pyelonephritis, and urethritis.

• Risk factors for UTIs include pregnancy, menopause, instrumentation, and sexual intercourse. Escherichia coli (E. coli) is the most common pathogen causing a UTI. • UTIs that are hospital-acquired are called nosocomial infections.

• UTI symptoms include dysuria, frequent urination (more than every 2 hours), urgency, and suprapubic discomfort or pressure. Flank pain, chills, and the presence of a fever indicate an infection involving the upper urinary tract (pyelonephritis). • UTIs are diagnosed by dipstick urinalysis to identify the presence of nitrites

(indicating bacteriuria), WBCs, and leukocyte esterase (an enzyme present in WBCs indicating pyuria). A voided midstream technique yielding a clean-catch urine sample is preferred. • Trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin (Macrodantin) is often used to empirically treat uncomplicated or initial UTIs. Additional drugs may be used to relieve discomfort. • Health promotion activities include teaching preventive measures such as (1) emptying the bladder regularly and completely, (2) evacuating the bowel regularly, (3) wiping the perineal area from front to back after urination and defecation, and (4) drinking an adequate amount of liquid each day. PYELONEPHRITIS • Pyelonephritis is an inflammation of the renal parenchyma and collecting system (including the renal pelvis). The most common cause is bacterial infection which begins in the lower urinary tract. Recurring infection can result in chronic pyelonephritis. • Clinical manifestations vary from mild fatigue to the sudden onset of chills, fever, vomiting, malaise, flank pain, and the lower UTI characteristics. • Interventions include teaching about the disease process with emphasis on (1) the need to continue drugs as prescribed, (2) the need for a follow-up urine culture to ensure proper management, and (3) identification of risk for recurrence or relapse. INTERSTITIAL CYSTITIS • Interstitial cystitis (IC) is a chronic, painful inflammatory disease of the bladder characterized by symptoms of urgency/frequency and pain in the bladder and/or pelvis. IMMUNOLOGIC DISORDERS OF THE KIDNEY Glomerulonephritis • Immunologic processes involving the urinary tract predominantly affect the renal glomerulus (glomerulonephritis). • Clinical manifestations of glomerulonephritis include varying degrees of hematuria (ranging from microscopic to gross) and urinary excretion of various formed elements, including RBCs, WBCs, proteins, and casts. • Acute poststreptococcal glomerulonephritis (APSGN) develops 5 to 21 days after an infection of the tonsils, pharynx, or skin (e.g., streptococcal sore throat, impetigo) by nephrotoxic strains of group A β -hemolytic streptococci. Manifestations include generalized body edema, hypertension, oliguria, hematuria with a smoky or rusty appearance, and proteinuria. • APSGN management focuses on symptomatic relief. This includes rest, edema and hypertension management, and dietary protein restriction when an increase in nitrogenous wastes (e.g., elevated BUN value) is present. • One of the most important ways to prevent the development of APSGN is to encourage early diagnosis and treatment of sore throats and skin lesions.

• Goodpasture syndrome is a rare autoimmune disease characterized by the presence of circulating antibodies against glomerular and alveolar basement membrane. • Rapidly progressive glomerulonephritis (RPGN) is glomerular disease associated with acute renal failure where there is rapid, progressive loss of renal function over days to weeks. • Chronic glomerulonephritis is a syndrome that reflects the end stage of glomerular inflammatory disease. It is characterized by proteinuria, hematuria, and development of uremia. Treatment is supportive and symptomatic. • Nephrotic syndrome results when the glomerulus is excessively permeable to plasma protein, causing proteinuria that leads to low plasma albumin and tissue edema. o Nephrotic syndrome is associated with systemic illness such as diabetes or systemic lupus erythematosus. o Treatment is focused on symptom management. o The major nursing interventions for a patient with nephrotic syndrome are related to edema. Edema is assessed by weighing the patient daily, accurately recording intake and output, and measuring abdominal girth or extremity size. OBSTRUCTIVE UROPATHIES Urinary Stones • Factors involved in the development of urinary stones include metabolic, dietary, genetic, climatic, lifestyle, and occupational influences. Other factors are obstruction with urinary stasis and urinary tract infection. • The five major categories of stones (lithiasis) are (1) calcium phosphate, (2) calcium oxalate, (3) uric acid, (4) cystine, and (5) struvite. • Urinary stones cause clinical manifestations when they obstruct urinary flow. Common sites of complete obstruction are at the UPJ (the point where the ureter crosses the iliac vessels) and at the ureterovesical junction (UVJ). • Management of a patient with renal lithiasis consists of treating the symptoms of pain, infection, or obstruction. • Lithotripsy is used to eliminate calculi from the urinary tract. Outcome for lithotripsy is based on stone size, stone location, and stone composition. • The goals are that the patient with urinary tract calculi will have (1) relief of pain, (2) no urinary tract obstruction, and (3) an understanding of measures to prevent further recurrence of stones. • To prevent stone recurrence, the patient should consume an adequate fluid intake to produce a urine output of approximately 2 L/day. Additional preventive measures focus on reducing metabolic or secondary risk factors. Urethral Stricture • A stricture is a narrowing of the lumen of the ureter or urethra. Ureteral strictures can affect the entire length of the ureter.

A urethral stricture is the result of fibrosis or inflammation of the urethral lumen. o Causes of urethral strictures include trauma, urethritis, iatrogenic, or a congenital defect. o Clinical manifestations associated with a urethral stricture include a diminished force of the urinary stream, straining to void, sprayed stream, postvoid dribbling, or a split urine stream.

RENAL VASCULAR PROBLEMS •Vascular problems involving the kidney include (1) nephrosclerosis, (2) renal artery stenosis, and (3) renal vein thrombosis. •Renal artery stenosis is a partial occlusion of one or both renal arteries and their major branches due to atherosclerotic narrowing. The goals of therapy are control of BP and restoration of perfusion to the kidney. HEREDITARY RENAL DISEASES • Polycystic kidney disease (PKD) is the most common life-threatening genetic disease. It is characterized by cysts that enlarge and destroy surrounding tissue by compression. • Diagnosis is based on clinical manifestations, family history, IVP, ultrasound (best screening measure), or CT scan. RENAL INVOLVEMENT IN METABOLIC AND CONNECTIVE TISSUE DISEASES • Diabetic nephropathy is the primary cause of end-stage renal failure in the United States. Diabetes mellitus affects the kidneys by causing microangiopathic changes. • Systemic sclerosis (scleroderma) is a disease of unknown etiology characterized by widespread alterations of connective tissue and by vascular lesions in many organs. • Gout, a syndrome of acute attacks of arthritis caused by hyperuricemia, can also result in significant renal disease. • Systemic lupus erythematosus is a connective tissue disorder characterized by the involvement of several tissues and organs, particularly the joints, skin, and kidneys. It results in clinical manifestations similar to glomerulonephritis. URINARY TRACT TUMORS • Kidney cancer: o There are no early symptoms of kidney cancer. Many patients with kidney cancer go undetected. o Diagnostic tests include IVP with nephrotomography, ultrasound, percutaneous needle aspiration, CT, and MRI. • Bladder cancer: o Risk factors for bladder cancer include cigarette smoking, exposure to dyes used in the rubber and cable industries, chronic abuse of phenacetin-containing analgesics, and chronic, recurrent renal calculi o Microscopic or gross, painless hematuria (chronic or intermittent) is the most common clinical finding with bladder cancer.

o Surgical therapies for bladder cancer include transurethral resection with fulguration, laser photocoagulation, and open loop resection. o Postoperative management following bladder cancer surgery includes instructions to drink a large volume of fluid each day for the first week following the procedure and to avoid intake of alcoholic beverages. o Intravesical therapy is chemotherapy that is locally instilled. Chemotherapeutic or immune-stimulating agents can be delivered directly into the bladder by a urethral catheter. BCG is the treatment of choice for carcinoma in situ. URINARY INCONTINENCE AND RETENTION • Urinary incontinence (UI) is an uncontrolled leakage of urine. The prevalence of incontinence is higher among older women and older men, but it is not a natural consequence of aging. • Causes of UI include confusion or depression, infection, atrophic vaginitis, urinary retention, restricted mobility, fecal impaction, or drugs. • Urinary retention is the inability to empty the bladder despite micturition or the accumulation of urine in the bladder because of an inability to urinate. • Urinary retention is caused by two different dysfunctions of the urinary system: bladder outlet obstruction and deficient detrusor (bladder muscle) contraction strength. • Evaluation for UI and urinary retention includes a focused history, physical assessment, and a bladder log or voiding record whenever possible. • Management strategies for UI include lifestyle interventions such as an adequate volume of fluids and reduction or elimination of bladder irritants from the diet. Behavioral treatments include scheduled voiding regimens (timed voiding, habit training, and prompted voiding), bladder retraining, and pelvic floor muscle training. • Acute urinary retention is a medical emergency that requires prompt recognition and bladder drainage. • Short-term urinary catheterization may be performed to obtain a urine specimen for laboratory analysis. Complications from long-term use (>30 days) of indwelling catheters include bladder spasms, periurethral abscess, pain, and urosepsis. • While the patient has a catheter in place, nursing actions should include maintaining patency of the catheter, managing fluid intake, providing for the comfort and safety of the patient, and preventing infection. • The ureteral catheter is placed through the ureters into the renal pelvis. The catheter is inserted either (1) by being threaded up the urethra and bladder to the ureters under cystoscopic observation, or (2) by surgical insertion through the abdominal wall into the ureters. • The suprapubic catheter is used in temporary situations such as bladder, prostate, and urethral surgery. The suprapubic catheter is also used long term in selected patients. SURGERY OF THE URINARY TRACT

• Common indications for nephrectomy include a renal tumor, polycystic kidney disease (PKD) that is bleeding or severely infected, massive traumatic injury to the kidney, and the elective removal of a kidney from a donor. A kidney can be removed by laparoscopic nephrectomy. • In the immediate postoperative period following renal surgery, urine output should be determined at least every 1 to 2 hours. • Numerous urinary diversion techniques and bladder substitutes are possible, including an incontinent urinary diversion, a continent urinary diversion catheterized by the patient, or an orthotopic bladder so that the patient voids urethrally. • Common peristomal skin problems associated with an ileal conduit include dermatitis, yeast infections, product allergies, and shearing-effect excoriations. • Discharge planning after an ileal conduit includes teaching the patient symptoms of obstruction or infection and care of the ostomy.