Transcript Chapter 45 Nursing Assessment Urinary System S. Buckley, RN, MS ( adapted from Mosby pp) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of.

Chapter 45
Nursing Assessment
Urinary System
S. Buckley, RN, MS
( adapted from Mosby pp)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Renal A & P
websites
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1. A & P
http://www.youtube.com/watch?v=cc8sUv2SuaY&feature=related
another animated a&p
http://www.youtube.com/watch?v=aQZaNXNroVY&feature=related
1. urine formation
http://health.howstuffworks.com/human-body/systems/kidneyurinary/adam-200032.htm
2. kidney anatomy
http://www.youtube.com/watch?v=SVl81H7H5J4&feature=related
http://www.youtube.com/watch?v=vEXx5YLcGmQ&feature=related
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Structures and Functions
of the Urinary System
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Kidneys
Macrostructure
 Microstructure
 Blood supply
 Primary function of kidneys:
1. regulate volume and composition of extracellular fluid
(ECF)
2. excrete waste products from body.
 Physiology of urine formation
• Glomerular function
• Tubular function
 Other functions of the kidney; control blood pressure,
produce erythropoietin, activate vitamin D, regulate
acid-base balance.
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Fig. 45-1
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Fig. 45-2
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Nephron
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Basic function is to clean or clear blood
plasma of unnecessary substances
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Fig. 45-3
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Physiology of urine formation
* Primary function of kidneys: filter blood,
maintain body’s internal homeostasis.
* Multistep process of: filtration, reabsorption,
secretions, excretion of water, electrolytes and
metabolic waste.
* Urine formation begins at glomerulus (blood
filtered)
* Glomerular filtration rate (GFR)-amount of blood
filtered by the glomeruli in a given time,
normal is ~ 125ml/min.
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Water balance, acid-base balance
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Function of:
1. ADH
2. Aldosterone
3. HCO3 and H+ (acid/base balance)
4. ANP
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Antidiuretic hormone (ADH)-required for
water reabsorption in the kidney , important in
fluid balance.
makes tubules and collecting ducts
permeable to water, allowing water to be
reabsorbed into the peritubular capillaries and
returned to the circulation.
Functions in concert with hypothalamus and
neural input as loop mechanism
decreases urine output
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aldosterone
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Released from adrenal cortex, acts on distal
tubule to cause reabsorption of Na+ and
water.
Influenced by blood concentrations of Na+
and K+
In exchange for Na+ reabsorption, potassium
ions (K+) are excreted.
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Acid base regulation
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Reabsorbing and conserving bicarbonate
(HCO3) and secreting Hydrogen (H+) in
response ph of ECF
Distal tubule functions to maintain the ph of
ECF within range of 7.35-7.45.
Metabolic response to ph along with
respiratory acid/base balance.
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Atrial Natriuretic peptide (ANP)
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Hormone secreted from cells in R atrium in response
to atrial distention due to an increase in plasma
volume.
Acts on kidneys to increase Na+ excretion.
Inhibits renin, ADH and action of angiotensinII on the
adrenal glands, thus suppresses aldosterone
secretion.
ANP causes relaxation of afferent arteriole, thus
increasing the GFR
Combined effects of ANP=production of large volume
of dilute urine
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Fig. 45-4
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Other Kidney functions
(continued)
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Erythropoietin-stimulates the production of red blood cells
(RBCs) in bone marrow
produced and released in response to hypoxia and decreased
renal blood flow.
In renal failure, a deficiency of erythropoietin occurs leading to
anemia
Vitamin D-hormone obtained in diet and sun.
requires metabolism in liver and kidney to be “activated”,
essential for absorption of Ca+ from GI tract.
In renal failure manifestation of problems of altered Ca+ and PO2
balance.
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Other Kidney functions
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Calcium balance -parathyroid hormone
(PTH) is released from parathyroid gland in
response to low serum ca+ levels. PTH works
by causing increased tubular reabsorption of
CA2+ and decreased tubular reabsorption of
phosphate ions (PO4 2-)
In renal disease, the effects of PTH may have
major effect on bone metabolism.
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Other Kidney functions
(continued)
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Renin-regulates BP, involved in splitting of
angiotensin cascade (p. 1138). Angiotensin II
stimulates release of aldosterone (causes Na+ and
water retention leading to increased ECF volume)
Also causes peripheral vasoconstriction. (both
increase BP)
Produced and secreted by cells in kidneys, released
into blood in response to decreased; renal perfusion,
arterial BP, ECF, Na+
Released into blood in response to increased urinary
Na+ concentration
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Other kidney functions
(continued)
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Prostaglandins (PGs)- involved in the
regulation of cell function and host defenses
PG synthesis occurs in the medullla of the
kidney. PGs increase renal blood flow and
promote Na+ excretion.
Counteract the vasoconstrictor effect of
angiotensin and norepinephrine =decreased
systemic vascular resistance= decreased BP.
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Structures and Functions
of the Urinary System (cont’d)
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Ureters-~12 inches, carry urine from renal
pelvis to bladder, can become obstructed with
calculi (resulting in renal colic).
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Bladder
Urethra-conduit for urine from bladder neck
to outside body, external sphincter;
rhabdosphincter
Female-1-2 in. , male-8-10in.
Urethrovesical unit-consists of bladder,
urethra, pelvic floor muscles, normal voluntary
control is defied as continence.
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Urinary Bladder
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Serves as reservoir for urine
Bladder muscle-detrusor muscle
Normal urine output, ~1500ml/day, varies
with intake of food and water, diurnal pattern.
~250ml of urine in bladder cause moderate
distention and urge to urinate.
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Fig. 45-5
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Female/Male anatomy
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Gerontologic Considerations
Effects of Aging on the Urinary System
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20-30% decrease in size with aging, by 70
yrs old, 30-50% of glomeruli have lost
function.
Decreased renal blood flow, decreased GFR,
alterations in hormone levels (ADH,
aldosterone, ANP=decreased urinary
concentration, limitations in excretion of
water, Na+, K+ and acid).
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Benign prostatic hyperplasia
(BPH)
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1.
Enlargement of prostate
Prevalence-50% of men over 50 yrs, 90% of
men over 80 yrs.
Symptoms result from urinary obstruction;
Obstructive symptoms-decrease in caliber and
force of urinary stream, difficulty initiating voiding,
intermittency, dribbling
2.
Irritative symptoms- (associated with
inflammation or infection)- frequency, urgency,
dysuria, nocturia, incontinence
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BPH
(continued)
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Complications-urinary retention, UTI; potential
sepsis, urinary calculi, hydronephrosis leading to
renal failure, pyelonephritis, bladder damage.
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Diagnostic-DRE (digital rectal exam), PSA ( prostatespecific antigen-blood level associated with ca and BPH)
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Collaborative care-drug therapy, diet,
catheterization, surgery (TURP), laser prostatectomy,
stent placement, monitor for infection, hemorrhage,
education, emotional support.
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Incontinence in elderly
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DESIGN OF STUDY:
Cross-sectional survey to measure
prevalence of urinary incontinence, the impact on
people's lives, use of protection, and health services.
SETTING: Stratified random sample of 2000
community-living elderly (equal numbers of men and
women, aged 65 to 74 years and over 75 years) in 11
general practices in a British city. RESULTS: The
response rate was 79%. The overall prevalence of
incontinence in the previous month was 31% for
women and 23% for men. Women generally had
more severe frequency of incontinence and a greater
degree of wetness than men. Protection use was
greater in women than in men.
Br J Gen Pract. 2001 July; 51(468): 548–552. PMCID: PMC1314046Copyright notice
Urinary incontinence in older people in the community: a neglected problem?
H Stoddart, J Donovan, E Whitley, D Sharp, and I Harvey
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Women’s gerontological urinary
issues
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Urethrovesical unit undergoes loss of
elasticity, vascularity and structure, may
result in incontinence (stress), irritation,
bladder infections, prolapse
Hormonal changes result in decrease in
estrogen, mucosal dryness and irritation
(cystitis)
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Women’s gerontological issues
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Research: Incidence of urinary
incontinence in postmenopausal women
treated with raloxifene or estrogen
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Goldstein, Steven R. MD; Johnson, Susan MD;
Abstract
Objective: Determine the effect of raloxifene or estrogen, as compared
with placebo, on the reporting of urinary incontinence in
postmenopausal women participating in an osteoporosis prevention
trial.
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Conclusion: During 3 years of follow-up, conjugated equine
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estrogen was associated with an increased incidence of reports of
urinary incontinence in women with a prior hysterectomy and this
was significantly greater than both placebo and raloxifene.
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Incidence of uti
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Most common bacterial infection, not reportable (US)
7 million office visits, 1million ER visits, 100,000
hospitalizations.
1in 3 women will have 1 episode requiring antibiotics
by age 24, ½ of all women in lifetime
Increased in pts with; infants, pregnancy, aids, ms,
dm, BPH
Catheter associated uti: most common nosocomial,
>1million cases a year. Costs: 1.6 billion.
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Conditions impacting voiding
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Any disease or trauma that affects function of
the brain, spinal cord, nerves that innervate
bladder, sphincter or pelvic floor can affect
bladder function. These include:
DM, MS, paraplegia, quadriplegia, spinal
problems, drugs affecting nerve transmission.
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Assessment of
the Urinary System
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Subjective data
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Important health information
• Past health history-related diseases,
surgeries, include family hx,
occupation/environment, diet, water intake,
exercise, elimination pattern
• Smoking hx; major factor in risk for bladder
ca. tumors occur 4x more frequently .
• Medications
• Surgery or other treatments
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Assessment terms
(p.1145)
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Assessment of
the Urinary System (cont’d)
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Functional health patterns
• Health Perception–Health Management Pattern
• Nutritional-Metabolic Pattern
• Elimination Pattern
• Activity-Exercise Pattern
• Sleep-Rest Pattern
• Cognitive-Perceptual Pattern
• Self-Perception–Self-Concept Pattern
• Role-Relationship Pattern
• Sexuality-Reproductive Pattern
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Assessment of
the Urinary System (cont’d)
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Objective data
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Physical examination
• Inspection
• Palpation
• Percussion
• Auscultation
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Fig. 45-6
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Diagnostic Studies
of the Urinary System
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Urine studies- accuracy of results
influenced by: proper procedure, pt.
cooperation, often require bowel prep (KUB, IVP).
 Urinalysis; 1st test done, best obtained in am,
 Creatinine clearance- Creatinine: waste product
produced by muscle breakdown, most accurate
indicator of renal function
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Normal value: 85-135 ml/min
Serum creatinine: 0.5-1.5mg/dl
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BUN-10-30gm/dl
 Urodynamics; measures urinary tract function
 Specific gravity; 1.003-1.030
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Fig. 45-7
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Fig. 45-8
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Fig. 45-9
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