Assessing Clients with Urinary Elimination Disorders

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Assessing Clients with Urinary Elimination
Disorders

• Chapter 28

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Structures of the Urinary System

• Kidneys - Function
• 1. Balance electrolyte and water
• 2. Excrete waste
• 3. Regulate acid-base balance
• 4. Secrete hormones
• 5. Form urine
• 6. Regulate blood pressure
• Will affect the entire body.

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Structures of the Urinary System

• Ureters
• transport urine from the kidneys to the bladder
• Bladder
• storage site for urine
• holds 300-500cc
• Urethra
• channels urine to the outside of the body

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Kidneys

• Each kidney has 3 regions
• Cortex- (Outer region) Contains glomeruli which
  are small clusters of capillaries. Glomeruli are
  part of the nephrons which are the functional
  units of the kidney
• Each kidney contains 1 million nephrons which
  process blood to make urine!!
• Medulla- (inner region) nephrons form the renal
  pyramids. They channel urine into branches of the
  innermost region or the renal pelvis.
• Pelvis- Urine is channeled from the pelvis
  through the ureter and into the bladder for
  storage.

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Formation of Urine

• Glomerular Filtration
• fluids and electrolytes go through a membrane
• Tubular Reabsorption
• nutrients are reabsorbed
• Tubular Secretion
• waste is secreted
• Nephron is functioning unit which functions in
  glomerular filtration.

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Process of urine formation

• Glomerular Filtration- Blood from the renal
  artery is filtered in the glomerulus. The
  filtered product which contains water, salts,
  nutrients and waste products is called the
  glomerular filtrate.
• Tubular Reabsorption- Nutrients and salts are
  actively reabsorbed and transported to the
  peritubular capillary network and some water is
  passively reabsorbed into the peritubular
  capillaries
• Tubular Secretion- Some substances are actively
  secreted from the peritubular capillaries into
  the distal tubule for removal from the body.

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Glomerular Filtration

• Passive process where fluids and solutes move
  from the blood in the glomerulus into the
  Bowmans capsule
• The amount of fluid filtered from the blood into
  the capsule per minute is called glomerular
  filtration rate or GFR.
• GFR is the most accurate indicator of kidney
  function. What lab test tells us what GFR is?
• Normal GFR is in adults 120/125 mL per minute.
• What controls GFR?
• -Blood pressure and blood volume.
• A drop in blood pressure and or blood volume will
  cause the GFR and urine output to fall. / Renal
  failure in high risk patients trauma/ severe
  blood loss.

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Reabsorption and Secretion

• Tubular reabsorption- Healthy kidneys all organic
  nutrients such as glucose, and amino acids are
  reabsorbed.
• Water and electrolyte reabsorption is
  continuously regulated and adjusted to maintain
  homeostasis.
• This all happens in the proximal tubules.
• Tubular Secretion- Excess potassium and waste
  products such as hydrogen ion, creatinine and
  ammonia are eliminate from the body. This
  process regulates the acid-base balance in the
  body.

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Urine Concentration

• Loop of Henle urine is concentrated. And further
  wastes are excreted through reabsorption and
  secretion..
• Antidiuretic hormone- Determines the final
  concentration or dilution of the urine.
• When ADH is secreted water is reabsorbed in the
  distal tubule and collecting duct and urine is
  more concentrated.
• When ADH is not secreted, water cannot be
  reabsorbed and the urine is more dilute. What
  substances cause ADH to be secreted or not
  secreted?
• Receptors in the hypothalamus detect changes in
  osmolality and blood volume, thus stimulating ADH
  production and release as needed.
• Urine is about 95 water and 5 solutes.

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Urine Concentration and Endocrine Function

• Solutes normally excreted in the urine- Urea,
  sodium, potassium, phosphate, sulfate,
  creatinine, uric acid, calcium, magnesium, and
  bicarbonate.
• The kidney also produces renin and erythropoietin
  and they activate Vitamin D.
• Renin- Is an enzyme made by the juxtaglomerular
  apparatus in the kidney. It converts the plasma
  protein angiotensin to angiotensin 1. A1 is
  converted to A2 in the lungs.
• Angiotension 2- is a potent vasoconstrictor that
  raises blood pressure, it also stimulates the
  adrenal glands to release aldosterone which
  promotes sodium and water retention. Drugs such
  as ACE inhibitors work on the Angiotension system
  to reduce blood pressure.
• The effect of the Angiotensin system is to raise
  the BP and BV.

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Endocrine Function- Kidney

• Erythropoietin- a substance produced by the
  kidney in response to cellular hypoxia. It
  stimulates the bone marrow to produce red blood
  cells.
• Vitamin D- Is inactive when it enters the body
  either through the diet or by exposure to
  ultraviolet light. It is activated in two steps
  by the liver and then the kidney.
• Age Related Changes in the Kidney
• Nephrons are lost with aging, thus kidney mass
  and GFR are reduced.
• By age 80 GFR may be less than half of what it
  was at 30.
• The kidneys are less able to concentrate urine.
• Increased risk for dehydration. Potassium
  excretion may be decreased in older, thus
  electrolyte imbalances are a risk!

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Formation of Urine
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Assessment of Urinary Function

• Health Assessment Interview
• Any burning on urination?
• Any difficulty in starting a stream?
• Bladder control?
• Ask about
• Pregnancy
• Family history of kidney disease
• Alcohol and caffeine
• dysuria, nocturia, hematuria, oliguria, polyuria

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Physical Assessment

• Inspection
• Skin
• Abdomen
• Urine
• Percussion
• for CVA tenderness, suprapubic pain, bladder.
• Palpation- Kidneys?

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Physical Assessment

• Palpation
• bladder
• palpate over the symphysis pubis for distension

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Urinalysis - how collected, why collected?
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Characteristics of Normal Urine

• Color - pale to deep yellow, clear
• Odor - aromatic
• Specific Gravity - 1.001-1.030
• pH - 4.5-8.0
• Protein - negative to trace
• Glucose - negative
• Ketones - negative
• WBCs 0-5
• RBCs 0-5
• Casts - negative to occasional

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Laboratory Tests

• UA- Urinalysis is a key part of the diagnostic
  evaluation of the urinary system.
• Urea- is formed in the metabolism of dietary and
  body proteins.
• Creatinine is produced by muscle cell metabolism.
• Both substances are eliminated from the body by
  the kidneys by filtration and secretion neither
  is reabsorbed, thus BUN and Serum creatinine
  levels in the blood are effective indicators of
  renal function.
• Creatinine Clearance test requires 24 hour urine
  sample- Another indicator of GFR./ Blood at the
  same time.
• KUB- Abdominal X-ray evaluate the size, shape and
  position of organs in the urinary tract.
• IVP-Intravenous pyelography- contrast medium and
  x-ray to evaluate the urinary tract.

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NCLEX

• Digoxin 0.25mg daily has been prescribed for an
  80 yo client.
• The nurse observes closely for
• A. Evidence of drug excretion without the desired
  effect
• B. Excretion of the drug unchanged in the urine
• C. Impaired urination due to the effects of the
  drug
• D. Manifestations of drug toxicity due to
  impaired excretion

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NCLEX

• During the assessment of a clients renal system,
  the nurse is unable to palpate the kidneys. This
  finding is indicative of
• A. inflammation
• B. chronic renal disease
• C. nothing
• D. polycystic kidney disease

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NCLEX

• A client is admitted with an infection of the
  ureters. The nurse realizes that this infection
  could include which of the following structures
  of the kidney?
• A. cortex
• B. Medulla
• C. Pelvis
• D. Adrenal glands

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NCLEX

• During the assessment of a client with multiple
  injuries, the nurse notices a large hematoma
  located at the left costovertebral angle. Which
  additional body system should this nurse assess?
• A. gastrointestinal
• B. renal
• C. spinal
• D. respiratory

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NCLEX

• A client is experiencing a sudden decrease in
  systemic blood pressure. Which of the following
  will occur within the kidney to help control this
  blood pressure drop?
• A. Juxtaglomerular cells will release renin
• B. GFR will increase
• C. Renal vessels will dilate
• D. Hydrostatic pressure will increase

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NCLEX

• A client is voiding large amounts of highly
  diluted urine. The nurse realized the dilution
  or concentration of urine is determined by which
  of the following?
• A. Presence of urea
• B. Quantity of chloride
• C. Patency of the ureters
• D. Action of antidiuretic hormone

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NCLEX

• A client experienced a temporary reduction of
  oxygen due to an asthma attack. The nurse
  realized that this drop in oxygen level will have
  which impact on the clients renal functioning?
• A. nothing
• B. stimulate the absorption of calcium and
  phosphate
• C. stimulate bone marrow to produce more red
  blood cells
• D. produce large amounts of dilute urine