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Assessment of Renal and Urinary Tract Function

1. ASSESSMENT OF RENAL AND URINARY
TRACT FUNCTION
Objectives

Identify the assessment parameters used for
determining the status of upper and lower urinary
tract function

Describe the diagnostic studies used to determine
urinary tract function

Initiate education and preparation for patients
undergoing assessment

2. HEALTH HISTORY
Obtaining a urologic
health history requires
excellent communication
skills because many
patients are embarrassed
or uncomfortable
discussing genitourinary
function or symptoms.

3. THE NURSE SHOULD INQUIRE ABOUT THE FF
Px’s chief concern or reason for seeking health
care, the onset of the problem & it’s effect on
the px’s quality of life

Location, character & duration of pain (if
present) & its relationship t voiding; factors that
precipitate pain and those that relieve it

Hx of UTI, including past tx or hospitalization for
UTI

4. Fever or chills
Previous renal or urinary dx tests or use of
indwelling catheters
Dysuria & when it occurs during voiding (at
initiation or termination of voiding)
Hesitancy, straining, or pain during, after
urination

5. Urinary Incontinence (stress intolerance,
urge incontinence, overflow incontinence or
functional incontinence)
Hematuria or change in color, volume of
urine
Nocturia and its date of onset
Renal calculi (kidney stones), passage of
stones or gravel in urine

6. Female px: number & type (vaginal or
cesarean) of deliveries; use of forceps;
vaginal infxn, discharge or irritation;
contraceptive practices
Presence or history of genital lesions or
STD’s
Habits: use of tobacco, alcohol, or
recreational drugs
Any prescription & over-the-counter
medications (including those prescribed for
renal or urinary problems

7. UNEXPLAINED ANEMIA
Gradual kidney dysfunction can be insidious in
its presentation, although fatigue is a common
symptom. Fatigue, shortness of breath, and
exercise intolerance all result from the condition
known as “anemia of chronic dse”
Hgb / Hct are quantified to detect anemia
however Hgb level is more significant it’s the one
responsible for circulating oxygen

9. Problems Associated with Changes in Voiding
Problem Definition Possible Etiology
Frequency Frequent voiding – more than
every 3 hours
Infection, obstruction of lower urinary tract leading to residual urine and
overflow, anxiety diuretics, BPH, urethral stricture, diabetic neuropathy
Urgency Strong desire to void Infection, chronic prostatitis, urethritis, obstruction of lower urinary tract
leading to residual urine and overflow, anxiety, diuretics, BPH, urethral
stricture, diabetic neuropathy
Dysuria Painful or difficult voiding Lower urinary tract infection, inflammation of bladder or urethra, acute
prostatitis, stones, foreign bodies, tumors in bladder
Hesitancy Delay, difficulty in initiating
voiding
BPH, compression of urethra, outlet obstruction, neurogenic bladder
Nocturia Excessive urination at night Decreased renal concentrating ability, ♥ failure, diabetis mellitus,
incomplete bladder emptying, excessive fluid intake at bedtime,
nephritic syndrome, cirrhosis with ascites
Incontinence Involuntary loss of urine External urinary sphincter injury, obstetric injury, lesions of bladder neck,
detrusor dysfunction, infection, neurogenic bladde, medications
neurologic abnormalities
Enuresis Involuntary voiding during sleep Delay in functional maturation of central NVS (bladder control usually
achieved by 5 years of age) obstructive dse of lower urinary tract, genetic
factors, failure to concentrate urine, UTI, psychological stress
Polyuria Increased volume of urine voided DM, diabetes insipidus, use of of diuretics, excess fluid intake, lithium
toxicity, some forms of kidney dse (hypercalmemic and hypokalemia
nephropathy)
Oliguria Urine output less than
400mL/day
Acute or chronic renal failure, complete obstruction
Anuria Urine output less than 50mL/day Acute or chronic renal failure, complete obstruction
Hematuria Red blood cells in the urine Cancer of genitourinary tract, acute glomerulonephritis, renal stones, renal
tuberculosis, blood dyscrasia, trauma, extreme exercise, rheumatic fever,
hemophilia, leukemia, sickle cell trait or disease
Proteinuria Abnormal amounts of protein in
the urine
Acute and chronic renal disease, mephrotic syndrome, vigorous exercise,
heat stroke, severe ♥ failure, diabetic neuropathy, multiple myeloma

10. GASTROINTESTINAL SYMPTOMS
Gastrointestinal symptoms may occur with
urologic conditions because of shared
autonomic and sensory innervation and
renointestinal reflexes.
Common s/sx: N/V, diarrhea, abdominal
discomfort, abd distention,. Urologic
symptoms can mimic appendicits, PUD,
cholecystitis, thus making diagnosis difficult
especially in elderly because of decreased
neurologic innervation to this area.

11. Identifying Characteristics of Genitourinary Pain
TYPE LOCATION CHARACTER ASSOCIATED S/SX POSSIBLE ETIOLOGY
KIDNEY Costovertebral angle, may
extend to umbilicus
Dull constant ache; if
sudden distention of
capsule, pain is severe,
sharp, stabbing and colicky
in nature
n/v, diaphoresis, pallor,
signs of shock
Acute obstruction, kidney
stone, blood clot, acute
pyelonepritis, trauma
BLADDER Suprapubic area Dull, continous pain, may
be intense with voiding,
may be severe if bladder is
full
Urgency, pain at the end of
voiding, painful straining
Overdistended bladder,
infection, interstitial
cystitis; tumor
URETERAL Costovertebral angle,
flank, lower abdominal
area, testis or labium
Severe, sharp, stabbing
pain, colicky in nature
n/v, paralytic ileus Ureteral stone, edema or
stricture, blood clot
PROSTATIC Perineum and rectum Vague discomfort, feeling
of fullness in perineum,
vague back pain
Suprapubic tenderness,
obstruction to urine flow,
frequency, urgency,
dysuria, nocturia
Prostatic cancer, acute or
chronic prsotatitis
URETHRAL Male: along penis to
meatus; female: urethra to
meatus
Pain variable, most severe
during and immediately
after voiding
Frequency, urgency,
dysuria, nocturia, urethral
discharge
Irritation of bladder neck,
infection of urethra,
trauma, foreign body in
lower urinary tract

12. GERONTOLOGIC CONSIDERATIONS
Aging affects the way the body
absorbs, metabolizes, and excretes
drugs thus placing the elderly patient
at risk for adverse reactions, including
compromised renal function
Structural or functional abnormalities
that occur with aging may prevent
complete emptying of the bladder. This
may be due to decrease bladder wall
contractility due to myogenic or
neurogenic causes or structurally
related to bladder outlet obstrcution as
in BPH.

13. DIAGNOSTIC EVALUATION
URINALYSIS – a urine test for evaluation of
the renal system and for determining renal
disease

14. Changes in Urine Color and possible Causes
Urine Color Possible Cause
Colorless to pale yellow Dilute urine due to diuretics, alcohol consumption,
diabetes insipidus, glycosuria, excess fluid intake,
renal dse
Yellow to milky white Pyuria, infection, vaginal cream
Bright yellow Multiple vitamin preparation
Pink to red Hgb breakdown, RBC, gross blood, menses, bladder or
prostate surgery, beets, blackberries, medications
(phenyton, rifampicin, phenothiazine, cascara, senna
products)
Blue, blue green Dyes, methylene blue, pseudmona species organisms,
medications
Orange to amber Concentrated urine due to dehydration, fever, bile,
excess bilirubin or carotene, medications
Brown to black Old RBC, urobilirogen, bilirubin, melanin, porphyrin,
extremely concentrated urine due to dehydration,
medications

15. SPECIFIC GRAVITY DETERMINATION
A urine test that measures the ability of the
kidneys to concentrate urine
NV: 1.016 to 1.022 (may vary depending on
the lab)
An increase in the result may indicate
insufficient fluid intake, decreased renal
perfusion or increased ADH
A decrease in result (less concentrated urine)
occurs with increased fluid intake or DI.

16. URINE CULTURE AND SENSITIVITY TESTING
Urine test that identifies the presence of
microorganisms and determines the specific
antibiotics to treat the existing
microorganisms appropriately.

17. CREATININE CLEARANCE TEST
Evaluates how well the kidneys remove
creatinine from the blood
The urine specimen for the creatinine
clearance is usually collected for 24 hours,
but shorter periods such as 8 to 12 hours
could be prescribed.

18. URIC ACID TEST
A 24 hour urine collection sample is tested to
diagnose gout and kidney dse

19. VANILLYLMANDELIC ACID TEST
The test is a 24 hour urine collection to
diagnose pheocromocytoma, a tumor of the
adrenal gland
The test determines urinary catecholamine
levels in the urine

20. BLADDER UTZ
May be performed for evaluating urinary
frequency, inability to urinate or amount of
residual urine (the amount of urine remaining
in the bladder after voiding)

21. KIDNEYS, URETERS, AND BLADDER (KUB)
RADIOGRAPHY
Performed to delienate
the size, shape and
position of the kidneys
and to reveal any
abnormalities such as
calculi in the kidneys or
urinary tract,
hydronephrosis
(distention of the pelvis of
the kidney) cysts, tumors,
or kidney displacement
by abnormalities in
surrounding tissues

22. CT SCAN / MRI
Used in evaluating
genitourinary
masses,
neprhrolithiasis,
chronic renal infxn,
renal or urinary tract
trauma, metastatic
disease and soft
tissue abnormalities

23. NUCLEAR SCANS
Requires injection of
isotope into the
circulatory system.
Hypersensitivity to the
isotope is rare
Nuclear scans are used
to evaluate acute and
chronic renal failure,
renal masses and blood
flow before and after
kidney transplantation.

24. INTRAVENOUS UROGRAPHY
Intravenous urography
includes test includes
tests such as excretory
urography, intravenous
pyelography (IVP) and
infusion drip pyelography.
Used as the initial
assessment of any
suspected urologic
problem, especially
lesions in the kidneys and
ureters. It also provide a
rough estimate of renal
function.

25. RETROGRADE PYELOGRAPHY
Catheters are advanced into renal pelvis by
means of cystoscopy. It is usually performed
if Intravenous urography provides inadequate
visualization of the collecting systems.
It may also be used before extracorporeal
shock wave lithotripsy or in px with urologic
cancer who need to follow up and are allergic
to intravenous contrast.

26. CYSTOGRAPHY
Aids in evaluating vesicoureteral reflux
(backflow of urine from the bladder into one
or both ureters) and assessing the px for
bladder injury

27. VOIDING CYSTOURETHROGRAPHY
Uses fluoroscopy to visualize the lower
urinary tract and assess urine storage in the
bladder.
A urethral catheter is inserted and a contrast
agent in instilled into the bladder. When the
bladder is full and the patient feels the urge
to void, the catheter is removed and the px
voids.

28. RENAL ANGIOGRHAPHY
Renal angiogram/renal arteriogram provides
an image of the renal arteries.
The femoral or axillary are the preferred
sites.
Use to evaluate renal blood flow in
suspected renal trauma, to differentiate renal
cysts from tumors and to evaluate
hypertension.
It is used for preoperatively for
tyransplantaion.

29. UROLOGIC ENDOSCOPIC PROCEDURES
Endourology or urologic endoscopic
procedures can be performed in one of two
ways; using a cystoscope inserted into the
urethra, or percutaneously through an
incision.
Used to directly visualize the urethra and
bladder.
The cystoscope also permits the urologist to
obtain a urine specimen from each kidney to
evaluate its function.

30. Cup forceps can be inserted through the
cystoscope for biopsy.
Calculi may be removed from the urethra,
bladder and ureter using cystoscopy.

31. BIOPSY (RENAL & URETERAL BRUSH BIOPSY)
Brush biopsy techniques provide specific
information when abnormal x-ray findings of
the ureter or renal pelvis raise questions
about whether the defect is a tumor, a stone,
a blood clot, or an artifact.
First a cystoscopic exam, then a ureteral
catheter is introduced, follwed bya biopsy
brush that is passed through the catheter.

32. KIDNEY BIOPSY
Used in diagnosing and evaluating the extent
of kidney dse. Indications for biopsy include
unexplained acute renal failure, persistent
proteinuria or hematruria, transplant rejection
and glomerulonephritis .
Obtained either percutaneously (needle
biopsy) or by open incision through a small
flank incision.

33. URODYNAMIC TESTS
Uroflowmetry – is the record of the volume of
urine passing through the urethra per time
unit (milliliter per second).
The px is advised to arrive for the test with a
strong urge to void but not have an overly full
bladder.
It is combined with electromyographic
measurement of the external urethral
sphincter via surface wire or needle
electrodes placed at th level of the sphincter,
on eother side of the urethra.

34. Cystometrography – graphic recording of the
pressures in the bladder filling and emptying.
It is the major dx portion of urodynamic
testing.

35. ELECTROMYOGRAPHY
Involves placement of
electrodes in the pelvic
floor musculature or over
the area of the anal
sphincter to evaluate the
neuromuscular function of
the lower tract.
It is performed
simultaneously with CMG

36. VIDEOFLUOROURODYNAMIC STUDY
Consideres optimal urodynamic evaluation.
This test combines a study of the filling and
voiding phases of the CMG and EMG with a
simultaneous visualization of the lower
urinary tract via a radiopaque filling and
detailed assessment of the voiding
dysfunction which may be due in part to
anatomic dysfunction.

38. PATIENT CARE DURING UROLOGIC TESTING
WITH CONTRAST AGENTS
For some patients, contrast agents are
neprhotoxic and allergenic. The following
guidelines can help the nurse and other care
givers respond quickly in the event of a
problem.

39. Have emergency equipment and medications
available in case of the patient has an
anaphylactic reaction to the contrast agent.
Emergency supplies include epinephrine,
corticosteroids, and vasopressors, oxygen
and airway and suction equipment

40. Thank you 