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THE URINARY TRACT Structure and Functions The Urinary Tract • •

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KIDNEY Bean-shaped organ Highly vascular Has exocrine and endocrine functions Weight: 150 g Length: 4.5 inches (11.4 cm) Width: 2.5 inches (6.4 cm) Location: Retroperitoneal Supine: T12-L3 Trendelenburg: 10th-11th ICS Standing: Down the iliac crest 1 contains about million nephrons.

NEPHRON 2 sections: 1. Bowman's capsules - outer cortex region 2. Renal tubules - from the cortex into the darker medulla. Filtration: Blood flows to the glomerulus (from the renal artery) Pressure in the glomerulus forces: water, glucose, urea, salts through the capillary wall and tubule (Protein & blood cells remain) Blood leaves the glomerulus Moves to capillaries that surround the renal tubule. Glomerular filtrate passes along the tubule. (GFR – 125 cc/min) Glucose, most of the water and salts are absorbed back into the blood in the nearby capillaries. (TRR – 124 cc/min) Urea and other wastes stay dissolved in the glomerular filtrate. They pass down the tubule and eventually reach the bladder. (Blood flows out of the kidney to the renal vein.)

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URETERS Length: 10-12 inches (25-30 cm) Diameter: 2-8 mm Major function: Channel urine down to the bladder by peristaltic waves (1-5x/min) Ureterovesical valve – prevents reflux of urine URINARY BLADDER

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Hollow, spherical, muscular organ Anterior and inferior to the pelvic cavity Posterior to Symphysis Pubis Elastic as it stores urine a. First Urge: 200-300 cc b. Moderately full: 500-600 cc c. Maximum capacity: 1000-1800 cc (Rises up to the Symphisis Pubis Lester R. L. Lintao, RN Page 1 of 14

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Effects of: a. Parasympathetic Nerves: Contract b. Sympathetic Nerves: Relax URETHRA Anterior to the vagina (female) – behind symphisis pubis Length a.Female: 3-5 cm b.Male: 20 cm RENAL EXCRETORY FUNCTION STUDIES ROUTINE URINALYSIS

Color : Amber / Straw pH : 4.5-8 (Average – 6) Specific Gravity : 1.010-1.025 Protein : Absent RBC : 0-5 / hpf WBC : 0-5 / hpf Pus : Absent Glucose : Absent Ketones : Absent Casts : 0-4 Creatinine Clearance: • 24 hour urine specimen • Test for renal function • Normal Values (Per 24 hours) a. Male – 20-26 mg/kg b. Female – 14-22 mg/kg Blood Tests: BUN Serum Creatinine Serum Uric Acid Albumin RBC Hematocrit

: 10-20 mg/dL : .4-1.2 mg/dL : 2.5-8 mg/dL : 3.2-5.5 mg/dL : 4.5-5.5 mg/dL : 38-54 vol%

Serum Electrolytes: Potassium Sodium Calcium Magnesium Phosphorus Chloride

: 3.5-5 mEq/L : 135-145 mEq/L : 4.5-5.5 mEq/L : 1.5-2.5 mEq/L : 3.5-5.5 mEq/L : 98-108 mEq/L DIAGNOSTIC STUDIES

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CYSTOSCOPY Provides a means of direct visualization of the urethra, bladder, and urethral orifices The Cystoscope (an instrument with lighted lens) is inserted into the urethra Biopsy specimens, lesions, small stones and small foreign bodies can be removed by this means.

Preparation for Cystoscopy: • Written consent • Force fluids • Done under local / general anesthesia • Inform that desire to void will be felt • Position: Lithotomy Lester R. L. Lintao, RN Page 2 of 14

After Cystoscopy: • BR until VS are stable • Blood-tinged (pink) witihin 24-48 hours is normal • Due to irritation: a. Dysuria c. Hematuria b. Frequency • Assess for: a. Urinary retention c. Prolonged / excessive hematuria b. Signs of infection • Monitor VS and I&O • Force fluids • • • • • •

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KUB (Abdominal x-ray film) KUB (Kidney, Ureters, Bladder) Used to determine the size, shape and position of the kidneys. Used to note any stones that may be present in the kidney, bladder or ureters Procedure for KUB A flat plate x-ray film is placed over the abdomen Non-invasive Assure patient it is painless Bowel preparation as feces / gas may interfere with the visualization EXCRETORY UROGRAM / INTRAVENOUS PYELOGRAPHY An x-ray photograph of the renal pelvis and ureter. A radiopaque material is given IV and excreted through the kidneys making the radiographic visualization possible.

Before IVP . . . • Secure written consent • NPO 6-8 hours • Bowel preparation • Check for hypersensitivity to iodine (sea foods) • Emergency drug: Epinephrine (for possible anaphylactic shock) • Inform: warm flushing sensation on IV injection site is normal After the IVP . . . • Monitor VS • Increase fluid intake  flush the dye • Inform: Burning sensation during urination may be experienced • Assess: Late allergic reactions •

RETROGRADE PYELOGRAM (RPG) Outlines renal pelvis and ureters by injecting a dye into each ureter with use of catheter through cystoscope

Before RPG: • Written consent • Check for iodine / dye allergy • Inform: discomfort of the procedure • Emergency drug: Epinephrine (for possible anaphylactic shock) After RPG: • Monitor VS • Increase fluid intake  flush the dye • Inform: Burning sensation during urination may be experienced • Assess: Late allergic reactions Lester R. L. Lintao, RN Page 3 of 14

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VOIDING CYSTOURETHROGRAM FILM Provides visualization in 3 phases: Before voiding: Outlines bladder wall During voiding: Outlines urethra and reflux of urine into ureters After voiding: demonstrates if bladder is emptied completely Contrast medium as instilled into the bladder by the use of cystoscope Nursing responsibilities: Same as of RPG

RENAL ARTERIOGRAM Provides x-ray pictures of the blood vessels supplying the kidney. Introduction of a radiopaque dye directly into the renal artery. Most common site is the femoral artery Used in evaluating persons suspected of having renal artery stenosis, abnormalities on the renal blood vessels or vascular damages.

Before RA • Cleanse bowel(Laxative) • Shave catheter insertion site • After RA • VS until stable • Cold puncture on the puncture site • Check for swelling / edema • Assess peripheral pulses • Check for color and temperature of the skin • Bedrest for 24 hours, no sitting • Measure I and O •

ULTRASOUND Detects tumors, cyst obstructions and abscesses

Nursing Interventions: • Cleanse the bowel • Force fluids • Withhold voiding • •

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RENAL BIOPSY To determine malignancies Nursing Interventions NPO 6-8 hours Check PTT, PT (Bleeding is usual) Mild Sedation Local anesthesia Hold breath during insertion of needle UTZ to locate kidneys

Care after biopsy… • Bedrest – 24 hours • Monitor V/S • Assess for pain, N/V • HCT and HGB to detect bleeding • No heavy activity – 2 weeks ALTERATIONS IN THE GENITO-URINARY SYSTEM Lester R. L. Lintao, RN Page 4 of 14

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A reversible condition characterized by a sudden reduction or cessation of renal function  retention of waste compounds  increase in urea and creatinine

Other names of ARF: • Acute Tubular Necrosis • Renal Parenchymal Failure • Vasomotor Nephropathy • Reversible Instrinsic Renal Failure • Acute Tubulointerstitial Nephritis Phases of ARF: 1. Onset • Initial phase of insult or injury 2. Oliguric Phase • Oliguria (less than 400 cc/24hr) • For older (600-700 cc/24 hours) • Lasts 8-14 days 3. Diuretic Phase • Lasts 10 days • Diuresis of 3-5 L / day • BUN and Creatinine elevated • Dangers: FVD, hyponatremia, hypotension, shock 4. Recovery Phase • Lasts from 6 to 12 months • Avoid nephrotoxic drugs

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CHRONIC RENAL FAILURE Is an irreversible condition of progressive damage to the nephrons and glomeruli  retention of waste compounds  increase urea and creatinine

a. Etiology: Prerenal • Prolonged deficit in renal blood (renal artery disease , hypovolemia, aortic stenosis, hypotension) Intrarenal • Damage to the renal parenchyma (glomerulonephritis, acute tubular necrosis [ATN], diabetic nephropathy, pyelonephritis, drug induced). • Diagnostic tests requiring the use of dye (nephrotoxic.) Postrenal • Obstruction to urine outflow (renal stones, tumors, ureteral kinks, instrumentation). First stage (Diminished Renal reserve) • Renal function is reduced • No metabolic wastes accumulate. • The healthier kidney compensates for the diseased one. • Asymptomatic Second stage (Renal Insufficiency) • Metabolic wastes accumulate • Decreasing GFR, classified as mild, moderate, or severe. (25% nephrons are damaged)  symptoms of renal failure (increasing BUN, fatigue) Final stage (End-stage Renal failure) • Excessive amounts of metabolic wastes, • Kidneys are unable to maintain homeostasis - a life-threatening condition. Lester R. L. Lintao, RN Page 5 of 14

Assessment of CRF: 1. Inability of the kidneys to excrete metabolic waste products of protein through urine formation • Oliguria • Increased BUN, s. creatinine (AZOTEMIA) • Uriniferous odor of breath • Stomatitis and G.I. Bleeding – urea is converted back into ammonia which • irritates mucous membrane • Destruction of rbc, wbc, platelets • Renal encepalopathy • Uremic frost (pruritis and dryness of skin) • Decreased libido, impotence, infertility (hormonal imbalances) 2. Inability of the kidneys to maintain fluid – electrolyte, acid – base balance. • Edema • Hyperkalemia • Hypo / hypernatremia • Hypermagnesemia • Metabolic acidosis 3. Inability of the kidneys to secrete Erythropoietin (Renal Erythropoetic Factor)  Anemia 4. Inability of the kidneys to metabolize Vitamin D. • Hypocalcemima • Hyperphosphatemia • Renal osteodystrophy 5. Altered biochemical environment • Glucose intolerance Medical management for renal failure: 1. Conservative Management • Fluid Control • Electrolyte Control • Hyperkalemia • Metabolic acidosis • Hypocalcemia / hyperphosphatemia • Dietary Control 2. Treatment of intercurrent Disorders • Anemia • Gastrointestinal Disturbance • Hypertension, CHF, pulmonary edema, hypocalcemia, hyperphosphatemia, etc. Guidelines for the Care of the Person with Chronic Renal Failure 1. Maintain Fluids and Electrolytes Balance (Monitor fluid and electrolyte balance) • Assess I and O q 8 hours • Weigh patient everyday • Assess presence and extent of edema • Auscultate breath sounds • Monitor cardiac rhythm and BP q 8 hours • Encourage patient to remain within prescribed fluid restrictions. • Provide small quantities of fluid (spaced) • High CHO and prescribed sodium, potassium, phosphorus and protein. • Phosphate – binding agents with meals as prescribed (Amphogel/ AL – OH) 2. Prevent infection and injury • Meticulous skin care. • ctivity within prescribed limits but avoid fatigue. Lester R. L. Lintao, RN Page 6 of 14

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Protect person from exposure to infectious agents. • Maintain good medical / surgical asepsis during treatments and procedures. • Avoid aspirin products. • Encourage use of soft toothbrush. 3. Promote comfort • Medicate patient as needed for pain. • Antipruritics, control environmental temperature to relieve pruritis. • Use of damp cloth to keep lips moist; give good oral hygiene. • Rest for fatigue; however, encourage self – care as tolerated. 4. Assist with coping in life-style and self-concept • Promote hope • Opportunity for Verbalization • Identify available community resources. MEDICAL MANAGEMENT: Hemodialysis • Alternates to the excretory but not on the endocrine function of the kidneys • Practice ARM PRECAUTION • Assess for patency: auscultate for bruit, palpate for thrill • Tourniquet be always available if A – V shunts is present. •A – V shunt may be used immediately •

•A – V fistula may be used after 4-6 weeks wait for healing. It can be used for 3-4 years. Vascular access: •Arteriovenous fistula. •Arteriovenous graft. •External arteriovenous shunt. •Femoral vein catheterization. •Subclavian vein catheterization.

Nursing Interventions in Hemodialysis: 1. Facilitating fluid in electrolyte balance. • Preventing hypovolemia and shock. • Administer blood transfusion as ordered • Omit dose of hypertensive drug 2. Preventing disequilibrium phenomenon. • Initial hemodialysis done for 30 mins. only • Disequilibrium syndrome is caused by more rapid removal of waste products from blood brain barrier, cerebral edema causes signs and symptoms of increased ICP, e.g. restlessness, headache, dizziness, nausea and vomiting, hypertension, etc. 3. Preventing blood loss. 4. Promoting comfort 5. Maintaining activity and nutrition 6. Facilitate learning. Peritoneal Dialysis Advantages: • Steady state of blood chemistries. • Patient can dialyze alone in any location without need for machinery. • Patient can readily be taught the process. • Patient has few dietary restrictions; because of loss of CHON in daily dialysate, the patient is usually placed on a high CHON diet. • Patient has much more control over daily life. Lester R. L. Lintao, RN Page 7 of 14

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Peritoneal dialysis can be used for patients that are hemodynamically unstable.

Care during Peritoneal Dialysis: • Regulating fluid volume and drainage • Promoting comfort. • Preventing complications. a. Monitor urine / blood glucose levels • Teaching Plan a. The process of dialysis and how the dialysis relates to the patient’s own body needs. b. Signs and symptoms of infection (peritonitis) c. Appropriate care of the permanent peritoneal catheter. • Common side effects of treatment, means of controlling mild symptoms. • Changes in medication schedule required before and after dialysis. • Activity schedule as physical capabilities permit, with animal inference from scheduled dialysis time.

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URINARY TRACT INFECTION Infections of the kidney (pyelonephritis), bladder (cystitis) and urethra (urethritis). Classified as upper (kidney) or lower (bladder, urethra).

a. Etiology • Bacteria, usually E. Coli. • Pyelonephritis  spread of bacteria into the bloodstream, urinary reflux, obstruction or ascending UTI. • Cystitis: a. BPH b. Occurs more commonly in women c. Uretheritis - bacterial and viral infections • Other factors include: a. Stasis b. Urinary retention and bladder distention. c. Instrumentation d. Poor hygiene e. Fecal incontinence f. Sexual transmission of bacteria b. Pathophysiology and manifestations: • Bacterial and viral transmission at the lower urinary tract  transmission to the upper tract. • Manifestations related to pyelonephritis. • Manifestations of cystitis and urethritis are similar: a. Urinary frequency, urgency and dysuria from bacterial irritation. b. Suprapubic pain (inflammation and edema.) c. Hematuria and pyuria (irritation and elimination of bacteria) • Cystitis and urethritis may be asymptomatic; diagnosis results urine specimen analysis. c. Nursing interventions: • C AND S before antibiotic therapy • Fluid intake (3 – 5 L/day) • Acidity • Hot Sitz bath • 3 W’s: wash, wear, wipe • Empty bladder every 2-3hours • Empty bladder immediately after sexual intercourse • Analgesic: PYRIDIUM (Phenazopyridine) - Causes red – orange discoloration of body secretions • Urinary Antiseptic Cinoxacin (Cinobac) Nalidixic (Noroxin) Lester R. L. Lintao, RN Page 8 of 14

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Nitrofurantoin (Macrodatin) Metheranime Mandelate (mandelamine) Sulfonamides Co-trimoxazole (Bactrim) Sulfisoxazole (Gantrisin) Cholinergics (to relieve urinary retention) Bethanechol chloride (Urecholine) Anticholinergics (to decrease bladder muscle spasms) Propantheline Bromide (Pro-Banthine) Antibiotics Ciprofloxacin (Cipro) Cephalexin (Keflex)

UROLITHIASIS (Renal Calculi)

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The formation of stones in the urinary tract secondary to precipitates.

a. Etiology • Urinary pH influences stone formation • Low  calcium and phosphate stone formation • High  uric acid stone formation • Other factors are: • Excessive calcium and protein intake • Urinary stasis • Dehydration b. Pathophysiology and manifestations: • Manifestations can include: a. Costovertbral Pain b. Infection and fever c. Decreased urinary output with complaints of urgency, burning and frequency. d. If obstruction causes kidney damage, impaired renal function leads to hydronephrosis. c. Nursing Interventions • Increase fluid intake 1 to 3 L daily • Strain urine to determine type of stone • Encourage patient to ambulate to facilitate passage of stones. • Administer analgesics for pain • Provide dietary counseling to prevent recurrent stone formation: a. Acid-ash diet for calcium and phosphate stones b. Alkaline ash and low purine diet for uric acid stones • Prepare for surgery for stone removal: a. Nephrolithotomy – kidney stone b. Pyelolithotomy – renal pelvis c. Ureterolithotomy – ureters d. Cystostomy – bladder calculi • Institute postop care.

BLADDER CANCER • •

More common in males Cause: unknown

a. Risks Factors • Exposure to cigarette smoke • Pelvic radiation • Use of cyclophosphamide • Chronic cystitis Lester R. L. Lintao, RN Page 9 of 14

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Bladder calculi Schistosomiasis

b. Assessment • Painless hematuria (first sign) • Dysuria • Gross hematuria • Obstruction to urine flow • Development of fistula (urine from the vagina, fecal material in the urine) c. Collaborative Management • Chemotherapy Thiotepa Mitomycin C Doxorubicin (Adriamycin) Cyclophosphamide (cytoxan) Cisplatin (Platinol) Methotrexate • Radiation • Surgery - Urinary Diversion Surgeries

Types of Urinary Diversion: a. Ileal Conduit • For CA Bladder • Adult Neurogenic Bladder • Insterstitial Cystitis • Irreparable Trauma Important! • External collection device needed • Proper fitting to prevent urine leak to the skin • Skin care with warm water and mild soap Complications: • Obstruction to the urine flow via small intestines secondary to edema • Infection • Stoma prolapse • Calculi • Electrolyte imbalances b. Ureterostomy • Either or both ureters are out to the abdominal wall • Ureteral stoma is created • External collection device is needed • Infection is a potential hazard • Increase fluid intake c. Nephrostomy • To drain the urine while ureteral inflammation from trauma or calculus is present Complications: • Infection (Pyelonephritis) • Blockage of the catheter Important! • DO NOT IRRIGATE!!!

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d. Ureterosigmoidostomy • No external collection device • Passage of flatus includes leak of urine • Infection is possible

BENIGN PROSTATIC HYPERPLASIA a. Cause: unknown b. Predisposing Factor Aging process  hormonal imbalance  estrogen > androgen  hyperplasia  urinary obstruction  renal insufficiency c. Assessment • Rectal Examination (Digital Examination) • Cystoscopy • Nocturia • Hesitancy • Residual urine • Hematuria • UTI d. Management 1. TURP (Transurethral Resection of the Prostate) • No incision • Continuous bladder irrigation (CBI) or dystoclysis I done postpop • This is to irrigate the bladder and remove blood clots • No incontenence, no impotence postop. 2. Suprapublic Prostatectomy • Incision over lower abdomen and bladder • With cystostomy tube and 2-way foley chatter postop • No incontenence, no impotence post 3. Retropublic Prostatectomy • Incision over the abdomen • No incontenence, no impotence postop Postoperative Care Care of the patient with CBI (post – TURP) • Maintain patency of catheter • If drainage: Reddish – increase flow rate Clear – decrease flow rate • Practice asepsis • Use sterile NSS to prevent water intoxication • Prevent thrombophlebitis • Monitor for hemorrhage • Red to light pine urine – 1st 24 hours; amber – 3 days postop • Advice not to void around catheter  bladder spasm • Increase fluid intake • Relieve pain-analgesic - spasm ↓ after 24-48 hours Client Teaching • After removal of catheter: observe for urinary retention/dribbling • Dribbling: KEGEL’s exercise to strengthen pubococcygeal muscle and help regain control voiding • Avoid the following 1. Vigorous exercise Lester R. L. Lintao, RN Page 11 of 14

2. Having lifting sexual intercourse 3 weeks after the discharge 3. 4. 5. 6. 7.

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Driving 2 weeks after discharge Straining with defection Prolonged sitting / standing Crossing the legs Long trips

PROSTATE CANCER Most common male cancer Androgen – dependent adenocarcinomas

a. Predisposing Factors • 50 years of age • Genetic tendency • Hormonal factors • Late puberty • High frequency of sexual experience • History of multiple sexual partners • High fertility • Diet • ↑fat (alters cholesterol and steroid metabolism) • Chemical carcinogens • Air pollution • Occupation-related; industries – fertilizer, rubber, textile; batteries containing Cadmium • Viruses b. Assessment • Hesistancy • Hematuria • Urinary retention • Stool changes • Pain radiating down hips and legs • Cytitis • Dribbling • Nocturia • Hard, enlarged prostate • Pain on defaction • High level of acid phospatase • Pain on defection • Elevated PSA (Prostatic Specific Antigen) c. Nursing Interventions • Early detection of tumor • Ultrasound • MRI • X-ray • CT Scan • Radiation therapy • Endocrine therapy - DES (diethylstilbestrol) decreases testosterome level) • Surgery: Prostatectomy

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NEPHROTIC SYNDROME A group of symptoms associated with the protein loss that occurs with various renal disorders. a. Etiology:

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Presence of other primary diseases, such as diabetes, and systemic lupus erythematosus (SLE).

b. Pathophysiology and manifestations: 1. Injury to the glomerular membrane results in plasma protein loss by way of leakage from the blood through the glomerulus into the urine. Protein loss often exceeds 3.0 to 3.5 g/day. 2. Because albumin is plentiful and of a low molecular weight, it is the primary protein lost. 3. Immunoglobulins, which also are proteins, are lost, lowering resistance to infection. 4. Hypoalbuminemia and hyperlipidemia result from protein loss. 5. Protein loss also facilitates third spacing of fluid because blood vessels become more porous. This leads to soft, pitting edema, which may be noted in the feet, legs, sacrum, or in the periorbital area. 6. Protein loss may also lead to vitamin D deficiency because the hormone required for its activation (25-hydroxycholecalciferol) is usually bound to protein. c. Nursing interventions: 1. Provide the patient with a high-protein, low-salt, diet. 2. Administer diuretics, as ordered. 3. Observe carefully for signs of hypovolemia and hypokalemia. 4. Observe for and treat symptoms of renal failure. • •

GLOMERULONEPHRITIS Glomerulonephritis is an inflammatory disorder involving the glomerulus. Types of glomerulonephritis include: a. Acute poststreptococcal: Onset is abrupt, typically occurring 7 to 10 days after a streptococcal throat or skin infection. b. Chronic glomerulonephritis: Occurs when glomerular disease leads to chronic renal failure c. Glomerular lesions may assume any shape or form; the type of lesions present often determines the course and severity of the disease.

a. Etiology: • Glomerulonephritis is caused by an immune reaction to the presence of an infectious organism, usually group A beta-hemolytic Streptococcus. b. Pathophysiology and manifestations: Entrance of Antigen (usually streptococcus) to the blood ↓ Formation of anti-GBM antibodies ↓ Damage to the glomerulus ↓ Antigen – antibody complex ↓ Inflammation and activation of chemical mediators (complement and leukocytes) ↓ Immune system enzymes migrate to the area and attack the glomerular basement membrane ↓ Membrane permeability is altered permitting red blood cells and protein to pass through ↓ These changes lead to acute or chronic renal failure, which could result in chronic renal failure. Manifestations include: • Acute onset of hematuria • Red blood cell casts • Proteinuria • Decreased (GFR) • Oliguria • Edema • Hypertension

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c. Nursing interventions: 1. Assess and monitor renal functions - serum creatinine (BUN) tests. 2. Observe for signs and symptoms of infection; avoid exposing the patient to persons with infections. 3. Limit sodium, potassium, fluid, and protein intake. 4. Prepare for dialysis, as indicated. •

PYELONEPHRITIS Infection of the kidney tissue and pelvis that occurs from several sources; may be acute or chronic.

a. Etiology: 1. Typically is caused by bacteria, but may result from fungi or viruses. 2. Acute pyelonephritis results • From bacterial contamination by way of the urethra or from instrumentation. • Bacterial hematogenous spread 3. Chronic pyelonephritis may: • Be idiopathic • May occur in association with obstruction or reflux due to kidney stones or neurogenic bladder b. Pathophysiology and manifestations: 1. The onset of symptoms is usually parenchyma and can include: • Fever • Urinary frequency • Chills

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Dysuria Groin or plank pain Costovertebral tenderness

2. Bacteriuria may or may not be associated with these symptoms. 3. Infection of the renal parenchyma  inflammatory response. 4. Disturbance of metabolic function and infection  fatigue. 5. Obstruction  prevention of bacterial elimination  progressive inflammation  fibrosis and scarring. 6. Diagnosis of chronic pyelonephritis is accomplished by IVP and UTZ. c. Nursing interventions: 1. Administer antimicrobial agents, as ordered. 2. Avoid exposing the patient to persons with infections. 3. High normal fluid intake, 2 to 3 L daily 4. CBR to reduce the metabolic rate and rest the kidneys. 5. Analgesics PRN 6. Monitor I & O, weight, temperature, PR, and BP to assess volume status.

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