SECTION 9_Problems of Urinary Function Scars eC Urinary System Finding ours Busing on urnaton Dysuria enuresis Frequency Hostaney Ireontnence Nootura Ogura Pain Preumatuia Palyura Retention ress incontinence Description, Teennally no wination Drv wine ovtowt ‘100 mt ‘Stnging pan in uretival oven Pein o cut uinaion Involunary nocturnal uration herent incidence af urnaton hood inthe urns Delay or afew in intatng urnaton Inst 1 volunarly conte lacharge of wine Frequency of urination at ight Diminished amount of nein given tone [Ran une auto of 100-400 mL Suprepune pein lees o oda, uretval pen Iirtaton a Seder neck, tank (CVA pan Possoge of urine cons ning gs Large volume of urine in a gvan tine Ihab 2 unste even though bladder contains ‘excessive amount of ine Involuntary urination sith ineoased oressure Isneezng e* coughing! Possi le Etiology and Significance ‘cute Kidney injury, endstage Kdnoy disease, olstra wreteral oosiracton retaliation, tina tact infection Sign of unity eet infection, inertial eysiis, and wide varity of Pathologie condiions Syrmptomstie of lower urinary act aserser Aeutely nfiamed Header, retention with aver, excess fi intake ine of tle rants ‘censor of genitourinary trae, blood ayserasies, kidney dsease, urinary Tract ivecion, stones in kiey or ureter, meceatons lamlesagulan's) Paral wethal obs:rseson, benign prosaic hyperaasia Newrogeni albaser, bladaes infection, nlury 7 external sphincter Kidney cisease with imeared concenvating city, bladder obstuction, hear nro, dabetes malits, ino ng alter real ranepan, excess ve evening and nig ful ake Severe denyeraton, shack, renstuson rection, kdney disease, fne-stage Kaney seease Infection, urinary teteton, fren Body in winery eet, urethis prelonephvts renal cole or stones Fistula connections between hovel and bheder,gos“orming wrinary Trae iveetions Diabetes melius, dlabetes insipidus, hone kidney disease, diuretics, excess fui intake, obstructive sleep pres Fring ater nele surgery, enleich, caterer removal, anesthe Uretial stitute or obstucion; neuregenie Hadaer Weakness of sanneter conta, eee of e2togen, winery tention (VA, Cavoverebel rah eae Creatinine clearance Composite urine ‘collection oF provide dita to establish a tentative agnosis and need [see Tole Getermine whether further studies « 459), Creatinine is» waste oroauet of protein breskaow iis nee of creatinine by Kidney bbosy muselo mass. cl epproxneces the GFR. Creatinine clarence is calculated os folows: Urinary System ‘Study Description and Purpose Nursing Responsibility Urine Studies Urinalysis General examination of urine te establish beselne information Try fo obtain fst urnated maming specimen. Ensure Specimen is examined wihin T hrf urnsting. Before calecing, wash perinecl cee f sea with menses fecal materal Collect 2441 urine specimen, Discs rst urnaton when Testis sae. Save une for al subsequent Uenstins or 24h Instuet pies to urnate st end ot 2a hr and ade specimen to colection. Ensure that ‘serum cratnine is deverminee curing 24th sein. Creatinine _ Ure ereasnine ingle xUiine volume imine lesrance Seram ereatnine Feast] ference infers. 7015 mlimi.73 mforecte for body Surface ere Messures specie components, such as electobtes, glucose, protein I/-ketoserods, eatecholarnes, eatin, and minerals, Composite Line soee mens are colected over 3 Petes ringing om 2 '0 28 m Instuet the patent to vinate ane cscard this fst urine {peemen, Note ths tre asthe sat of the test, Save siluene trom supseauen: Urnstons a cantare for esgnsied neraa. At end of period, sek ps! en fo neta, ard ths urine [seid to eantaner. Remind puerto seve al uine during study perod. Specimens ‘ay have tobe relzgertea, or preservatives mey nave {2 be added to container used fr ealecing ure GFR, Gera FostCHAPTER 45 _Urinary System. Urine cute (elean eaten, "midstream" Residual urine Protein determination + Dipstek (busts, coms) > Guartetrs pret Urine evtolegie study Blood Studies Blood ures nitrogen un) Creatinine BUNJereatinine ratio Unie aid Sodium Description and Purpose CConfrms suspected urnary tact infection ana entfee ‘causotve orgenisms. Normal ladce is strle, but urethra contains bacteria ane afew WAC, Reference interval perl coleced, stores, ond harales <10erganismslni. Usualy neeates ro infeion. 10-10%hmL s usualy not dagnaste and test may heve tobe repestee >1DtimL naestes infection, Evalustes cera concentration abily Measure oy specie arvity readings Foforence iter 1.002.020 Determines amount of urine left in blir after urinating Frding may be abnormal n aroblers wih sledder innervation, shiner mpetmest, BPH, 0” uretval stetures. Fotorence interie 250 mm. vine inereases with age Tost detects proten iprmarlyeloums) n wine. Reference interval: O-raee. ‘A 2th colection gves a more accurate inition of smount of Protein n unre, Persistent protenura usually nates Shmerhe kney dsesso, Feference interval 150 mgi2 he (mei elu) Ieomtiies abnormal ell svetures thet acer ith easlr ‘cancer. Also use 10 fllw the progress 0! shader eancer ser restment Used to detect renal problems. Concerti of urea in blood is tegultea by rate at wren Key exeretes urea, Reference interes 6-20 mall. (2.17.1 mmol More relaole than BUN a6 determinant of renal function, Creatinine send product of muscle and protein “eabolsmn and released st » constant rte Foference interes! 0.61.3 mala 53-115 mol [An inereased rato may be due to conditions that decrecse blood fow to kidneys (e.g. heat fare, denyeraion), bleeding, or increased sitary orate. A decreased rio may occur ih Iver saesse ive (9 decreased ures formation) tnd maltiton, Reference interval: 12:1 10 201 Usec as ssreening test rma for esorders of purine Tretabelsm du.can also ndestekney osease, Values Genend an rersl function, ale of purse matenalism, ora etary intake of food chin purines Female! 2.3.6 mala. (137-388 mall. Mala: 4.4.7 8 malo. 262-452 ural) Main extracel elecrobie determining blood vole, Ususlly lis say shin ermal ange unl ate sages of renal faire Feferonce interve:125-145 mE (125-145 rrrol. Nursing Responsibility Use sterle container for coleston of urine. Tauen only uted of container. For women, sepatte Ibis with ne han and elem mestus wih other hand, vsng a Ines tres sponges laturated wit clesnsing solitonl in fonsterbece mation. Fot ren, rete! foreskin if presen ane cleanse glans with s leat ree cleansing sponges. After cleaning, nstuct patient to tert Unnating ane shen contnue veding stele container {ne inal voles urine fushes out most contarsnents In the vretnra and permeal aren) Cathetezavon may be ‘needed f patents anole to eooper'e wih procecue Inscuet pation 0 fast after given time evening (in Usual procedure), Colect thee urine specimens ct hourly intervals in ning, Iromectely ater patient urnstes, catheterize natent or Use older uveseuna eaulpment Ifa large emount of resoul tine sobtenes, ean care provider may ‘want eathetr Its Bsr Dip end of stick in urine end read result by comearson ih cole enor on heel as Srectes. Grading = from 0 to 4s Interoret yh caution, Posve rau mey rot Indieste significant preterura, Some meaestions may Ove false-positive reesings Perform 2étr wine collection as above brain specimens by voiding, catheterization, oF older iregston, Do not use morning ‘rst voided oeemen because eotheta cals may change ” appearance in Une hele i sacdr overnight, As itn urinals, the stecimen should be fresh or brought laboretry Within the nour. A sleohorbesed fiative s then added ‘a preserve *e collar suctre, When interpreting BUN, beware thet norrenl‘etors may esase nerose i.g, "904 eel cestueton om infectons, fever, Gl sleding raume, athlete ativy snd excessive muscle eresksiown, corieosierod tterspy Exphin tas and waten for aostpuneture blessing Exphin tes and waten for postpunetre blessing Exphin test and wateh for postpuneturebleesing PH, Bevan sore ypeoha ContinSECTION 9 Problems of Urinary Function ices Urinary System PEs ‘Study Description and Purpose Nursing Responsibility Blood Studies—cont’d otassivm Klneys are responsible fr excreting maiorty af body's Because Ks ene a he frat eletaltes to become normal Fleets klvels >6 maf ean less to muscle Weakness and eariae dysrhythies, ference inter: 3.65.9 meal (2.55.0 melt. Clefum (ota) Main minerlin bone an ass m muscle contacton, Feassertion of Ca" loses to feel osteodysthy. Reference interval 8610.2 mala. 2152.55 mmol Phosphorus Prosphorus babes is inversely rested Yo Ca bales, In Karey s the emery exerery organ Reference interval 2.644 mgld [0.78142 mall Bicarbonate serum HCOy levels, Feference infers! 2226 meal. (27-26 mmol Radiologie Procedures Kidneys, ureters, X+ay exerinton of ssdornen end pelv delinestes size, ‘ladder (KUB) Shape, and poston of hisneys. Aadioscaue stones and foreign bodies can be seen sualzessrnary tae aftr IV jection of canvas mast Intravenous ‘pyelegram (VP) baser ean be evslistes, Cysts, tumors, lesions, ond ‘should not have VP becouse contrast m rephatene ana warsen real function jean be Renal artriogram langogram! \Vsualzes renal blood vessels. Con assist n dlagnesing renal vessel, ane renovesculat hypertension. Can ass st included in workup ofa porerval ena vanselent donor. catheter ie nserteg into the ‘sora {othe level of tne renal areres (9. 45). Contest ‘dia is jects to outing the rena logs sop.” polessium,Inkidrey disease, determinations are erie! ewrvansmission, ena elting. In key sseose,decreosec Karey siaeese, prospnorus levels ate elevated becouse the Most patios in renal ‘sire nave metabole aedosis 2nd tw Presence, positon, si, and anapo of ceneys, ureters, ane Stuerwes, Patient with sgniesrly aeereased reel function Srery stenons (F250), addons! or isang venel slood Gtferertting between a reel cyst onde eral ter. Also ral eery and passed us the Exphin test and waten for postpunetre blessing Exphin test and waten for postpunetre blessing Lxphin test and waten for postpuneture blessing Exphin test and waten for postpunetre blessing Perform bowel preperation ff erdere Evening before procedure, ave eatharte oF enema 9 ‘empry colon of fees and gas. Before procecue, fzsess pair for odine sensitiv to sve uphylele rection, Inform aatent that procedure involes lying on table and having aerial x-ays taken ‘abise patens rt dung injection of eonvast rate warmth fushed face, an a salty taste may be oxperonces. Aer pracecut, fore fui if permites) fo flush out contrast mess Before pracedure Prosar navn ne pit evening By {Gung ealrarie or enema. Before rection 9! contrast hate astess for odie senstivty. The patient may ‘aperience a ransiant warm feling along the course of ‘a bloas vessel wnen contrat messi ieee, ‘Aor eracedure: Place a assure ess ng over femoral artery jection site. Observe ste fer aleesing, Have ptort marian bea rest vith affecten leg S097 Take per anerlaulies nthe inelie leg every 30-60 min a detec! aeelison of blood Vow eaused by 8 thrombus. Osserve for eomaleatons ineusing ‘trombus, embolus, lol ilarmation, erator, FIG, 45-6 Renal arteriogram snowing stenosis of te rght renal aery fro FIG, 45-9 Catheter insertion forCHAPTER 45 _Urinary System. Pee eed Urinary System ‘Study Description and Purpose Nursing Responsibility ra prela = eo e Exphin orocedure and prepare patent as for NP. (nephrostogram) contrast meus, cecreased renal freon, or aonormalties _Waten fr signs of commalestins e.g, hematua, Renal ultrasound Computed ‘tomography (7) ‘sean (CT urosrem) imaging (MRD Urethrogram Veiding {ystourethrogram weve) {na event sassige of 9 Uetera etnete, Conrast res ray be nectea peeuteneoushy nf renal pels or un & reshrestomy (ube Ina is aeeay = place winen cetermnng {be ‘uneton o ureteral egy aller eure or surgery.” ay of urnary tat taken aor nection of eantrast material inte ksneys I ray be done isn IVP does not visualize the Unnary tact of puent is alerge to contest media 0” haa Gecreases ronal funcion. A eystoscane inserted ana Ureterl catheters are naerted trough fe int renal pelvis Contrast mesa is injected shrough eateters.” Uses t0 setect renal or penal masses, slifrental diagras's of renleysis, sold masses, and dent eatin af obstuel ons, Srl ecerel ultrasound probe is places! on aavens stn Conductive gli eaaea to ke. Noninvasive procedure involves oass'ng sound waves into boay stuctues ane recording mages a ney ar rofected back. Computer interprets tesue densi based on sound waves ans depays itimpietire form. I ean be used sate m patents with renal ‘aie, Provides excellent euslzeton of kidneys. Kisney ze can be ovalaied, Tomers,abseosses, suprareral masses (og. acreral timers, preoctomecytoras, ana obstructions fan be detected, Advantage of CT over ulasourd iss bly to dstinguisn sualle siffeerees m denaiy. Use of Iesmateresconvast media dung CT secentustes density of Yenl tissue ane helps aferentate messes." Usefl for vsusiestion of kaneys, Not proven sofa for electing winary eal a elias turers, Compute. {generates (Ins rely on fedarequency wives ane aeration in ogres fel. Allows wsuslznton of renal vaseulture, Gadolinum-ennaneed ‘tudes slow vaushenion 9 te renal srry \Viauazes olcder ana evaluates vesicouteeralrefux. Also ovalistes peterts with neurogenic slaseer era recurrent Unary vaet nections. Can eso delineate conorralies of he bheser (eg. everseubs, cake, tomers). Convast mesa s insblea into blsder va eystoscope or eather Siler oa eystogtem. Contes messi inject retrograde inte the seta to entity stetures, dverteua, or eter Urethral pathologic canditans. When uetral vaume uspectes, a uetnrograr:s done before exinetenznton, \Voding sty ofthe tld opening (ladder nee) ora urethra “The Hldae’ i ile wth eonvast media. Flueroseosie films ae taken fo veualze the blader ana urethra, Atter urnaton, Snotner Sify is token to assess fr residual urne, Can detect shnormolies ofthe lower urinary at, urethral sero, hover neck onsen, and prostatic enkrgorent Detects obstuctons, anastomotic leaks, stones, rel, ane ‘other uropathologe features when patent nas 2 urinary pouch {Teal eondut Because urinary diversions are created wih bowie, heres F860! soaorntion of contrast mes, infecton, hematoma Prepare pation as for NP. Inform pation that pain may be eiperenced frm sstention of pelvis and scamiont ‘rom eystoscope, Inform patient that anesthesia be ven for procedure CComelicatons are similar Yo those for eystoscony (see ceystescony lc in “abl Exphin otoceaure ta patent, Because rsstion exposure Is voideo,» numer of images ean be obianee ond repest studies ean be done over brief period, mages can be tein Hom born pone ana supine 20stions 2 bowel aeperatin snot reared Exphinorocedue to patent. Ask aatent about fone Sonstivy. Inset the patent toe sill uring ime Procedure wie the maenine “aes precise vanssxal Images, Seaton maybe requires fratien is unable Exphin oroceaure to stent Have patent remove al ‘etal objects, Patents with a history of ehustrograbia thay need to be sedated. Conrandcaions: presence of implores megnete elas o° prosthesis and pacemakers Some 2s above. Does not require femoral atory Faphinotecesure co saent. I done via eytoscope, ‘low nursing eae elatea to cystoscopy Explin orocedure to patent. Explain orocedce to patent Explin oroceduce to patent. Closely mentor patent for reactions to the contest medi, *Haceyepene Moers eval vse nd anions sometimes wise oduct incidence of canverindved vetropaty ean be given by eater ContinueSECTION 9_Problems of Urinary Function Cee eee) Urinary System ‘Study Description and Purpose Nursing Responsibility Endoscopy Cystoscopy Inspects interior of blaaer with a suburHghted scone Before procedure: Force thids or give IV Fuds f general {eystoscope (9. 45-1). Can be used to insert ureteral catheters, remove eakt, obtes biopsy specimens 9 Bacaer lesions, and rt pleasing fs.ons, Lthotomy postin = sed, Procedure may be done wing lel or general anesthesis, siepending on patient's needs and condition. Completions inelude unary retention, utnery taet hemorthage, blade! infection, end peroraton of the bleader Urodynamie Studies Urine flow study (ureflow! Messures atine volume in single voiding expelled in peice of tine. Used tI) assess she segree of outlaw abstueton caused by such conations ws APH or svitue, (2) assess baader or sahnete aystunetion eects on voising, ne (3 ovalate effects of eatment fr lover uinary tect problems. GGraohe daphys can iustate sraning and ncermttert flow patterns of cine sbrotml viding svorders Normal moumum flow rate ren, 20-25 ml/see, waren 12530 msec, Volume voided and ihe patents age con alee! the tow rate Evaluates bladders capacity to contact and expel urn. Involves iserion a cotheter sna nsliation a water o° sale allan ino bledee, Measurements af pressure exered paint blader wad sre recor. sbsomielaressure essured, a second tbe is inserted int the rectum or ‘opin. This tube s artachod toe smal ica alaan sllow pressure recorang Recarsng of electesl sity crested when nervous system ‘mlstes muscle tissve. By pleing neesles,pereutaneous Wites oF patches nea the uttiva, the elnican cen esses ‘he pebic ler muscle activity. During the eystometrogram, sphincter EMG is used to isenity voluntary pele fact ‘scle conrectons andthe response ofthese muscles to badser fling, coughing, ang other provocative maneuvers lee ee linravesiea,sedornnal, nd sero" pressutes. and 2 "phineter EMG for aetaled evalaton of mictunton. Kis comoletes by sensing in patient to # specilzed tole to Uurnate while the yorous pressure tubes and EMG apparatus Comeinatin of eystometegram, sphincter EMG, anafer wrinry ‘low study wth enatomie maging of the ower urinary ac, ‘ypesly wa fuoroscopy, Used n select cases to iserity on Costruive lesion and sharelerize avatomie ehonges in Ine blser ona lower urinary at Ccystometrogrem Sphincter ‘lectromyography (ema) Veiding pressure flow study Videourodynamics Ssnesthesa is tobe ures, Ensure consent forse Signed. Exsan procedure to patent. Give preoperative redeston ‘Aor erocede: Explain tna burnng on uration Prkeinged ure, end winay equency of exsecied fects. Caserve for bright re lewsing, which nat armel Do net et patent wal alone immediately ater Procedire because erthesatic ypotens on may occur Dffer warm siz oath, heat ml analgesics to relieve escomior. Explain otocodure to patent. Ask the patient to stat the test with e comfortably ful blader, write into © specil contin, ene try to ematy eamletaly Measure rescual uine volume rmmediey ater unary flow sty because *is wil help ident he {ogree of ehrone urnery recenton tats often Sesodistea wth sonermal flow patina Exphinorocedure to patent During the infuson, ask Dont ebaut sensations of blogoe ing, usualy Ireluing ne ‘ra! oes (urge) owns,» song esie 0 unas, ard perception of Hadder fulness. (Observe patent for rantesttons of urnry tact infection ae’ proceaure Exphin otecesure to patent Exphinorecesive co patent. Exphinorecesure co patent. FIG, 45-10 Cystoseopic examination ofthe bad eer “ In aman. A, Flexible eystonephrascape. B, Scoze inserted intoCHAPTER 45 _Urinary System. Pee ‘Study Description and Purpose Nursing Responsibitity Radioncli ‘ystography (RNC) Whitaker study Renal Sean Renal Biopsy Detects and gtades vesicoureveralrefux. Similar t0 VCUG wih ' small dose of radiesotone acer nailed int the older ‘a urethral ennater, More sensive ttn VCUS, and ranaion ose i 1/1000 tat ofthe VEUG, opstucton cn Oe Percuteneous access is quired fo tre renal pois by plaena 8 catheter in he renal pels. A catheter [sao oloced inthe bhaser, Flue nerluses trough ‘ne ereuteneous ube oF needle vate af 10 m/min. Pressure aaa we ten Colected. Pressure meaturemerts are comained wih ‘orosconic imaging to dently the lvel of obstruction. Evalustes anotomic structures, perfusion, sr fuevon of Kereys. Rodoaeive isotopes are njectea IV. Rasiaton etector arabes are ahced over key, and sentilaton ‘Counter monitors redioactive material in Kdhey, Radisctope ‘Sst-buton in Kdroy is scanned end repped. Shows location, Sie, and shape af key andr general assesses loos Sov, glomeruli fhraven, tuulr function, and urinary excretion, Abscesses, cyst, and turers may eppear 35 cold Spots because of nonfuneionng verve Also montors ‘enc ofa warsohniea kane. (Obtain renal tise fo exarination te determine type of Karey ssesse oft alow progtens of ney esease Tecnrique s ussly cone as © skin Iperetaneaus] Biopsy ‘rough neecle inzervon ino lower Ibe of aney. Can be performed with CT or utresound guidance Absolute conrsinasatons ar oleeding dsorsers, single kine, ‘and uncortroled nypertension. Hestve contrandestions Exphin rocedure to patent se m VOUS. Exphin orocesie to patent. eoures no cerry or activity restretion Inform pater: ‘at no pain 0 dscomfort shoul be fe during fst. “ype ane crossmatch patent er bleed. Ersute consent Yermis sine, Before procedure Ascersin cosguletion status trough patent history, meceation hatery, CRC, hemsters, protroméin tme, end bleding sd eating time Patient shoul net be taking asin or warfarin (Cours. possible vaseclr lesions, inelude suspected reno infection, hystonestrosis, ana Alter eroceatre: Apply pressure dressing and keep pen on sffetes side for 3060 min, Be! est fr 2a he. Vitel signs every 5-10 rn, fst hou. Assess {or tank pain, hypotension, decoasing heater, Temperature, nil, urrary Hequency, dysura, end sonal urre specimens gross o” mirescopicherater Unie sostee ean ae use totes or Dleesing i urine Inspec: bonay ste for Bkeding,Insruet pavent 0 voi Hing heey abject for 87 says ant 0 90 Toke Snecoguantatugs unt elentea by eelh exe prover ‘extended time in the x-ray department, is too tired to eat, sleeps the rest of the day, and is NPO after midnight again because of studies scheduled for the next day. Severe dehydration, expe cially in a diabetic, debilitated, or older patient, may lead to acute kidney injury. When a patient is scheduled for diagnostic studies, ensure that the patient is properly hydrated and given, adequate nourishment between studies. Also check with the health care provider regarding insulin dosage for diabetic patients who are placed on NPO status Urine Studies Urinalysis. Urinalysis (see Tables 45-8 and 45.9) is one of, the first studies done to evaluate disorders of the urinary tract, Results from the urinalysis may indicate posible abnormalities, suggest the need for further studies, or provide evidence progression in a previously diagnosed disorder. Although a specimen may be collected at any time of the day. for a routine urinalysis, it is best to obtain the first specimen trinated in the morning. This concentrated specimen is more likely to contain abnormal constituents if they are present the twine. The specimen should be examined within 1 hour of ri nating. Otherwise, bacteria multiply rapidly, RBCs hemolyze, casts (molds of renal tubules) disintegrate, and the urine becomes alkaline as a result of urea-spliting bacteria, itis not possible to send the specimen to the laboratory immediatly, refrigerate it. However, to obtain the best results, coordinate specimen collection with routine laboratory hours. Creatinine Clearance. A common te:t used to analyze inary system disorders is creatinine clearance, Creatinine isa ‘waste product produced by muscle breakdown. Urinary excre tion of creatinine is a measure of the amount of active muscle tissue in the body, not of body weight. Therefore individuals with lager muscle mass have higher values." Because almost all creatinine in the blood is normally excreted by the kidneys, creatinine clearance is the most accurate indicator of renal fune- tion, The result of a creatinine clearance test closely approxi-