Gut Part 1- Physio Assessment, Labs

THE URINARY SYSTEM

ANATOMY

THE URINARY SYTEM The excretory (GUT) system includes the kidney, ureters, urinary bladder, urethra and the male and female genitalia

Kidneys, Ureters, and Bladder

Ma le Anatomy

Female Anatomy

The Kidney • Two bean-shaped organs that lie in the retroperitoneal space on either side of the vertebral column at the level of T12 to L3 • Adrenal glands located on top of each kidney surrounded by capsule and fats • Right is lower than the left • Each kidney is composed of: - Renal parenchyma, Renal sinus and pelvis and Nephrons

Kidney: Major Functions C-ontrols electrolyte and fluid balance R-egulates homeostasis of blood and acid-base balance R-egulates RBC production E-liminates end products of metabolism, S-ecretes renin, parathyroid hormones and Vitamin D

The Kidney: Nephron Functional unit of the kidney that produces urine by filtration

The Kidney:

Blood Supply of the Kidney • Renal artery- branch of the abdominal aorta • Renal vein- drains into the inferior vena cava

Kidney Circulation

The Ureters • 2 long slender tubes 25-35cms long that extends from the renal pelvis to pelvic cavity where they enter the bladder and propels urine from the kidneys to the urinary bladder • Has smooth muscles and transitional epithelium and a uterovesical valve that prevents backflow of urine into ureters • Has innervations from the sympathetic and parasympathetic

The Urinary Bladder • Hollow pyramid shaped organ located in the pelvis behind the symphysis pubis • Composed of muscular, elastic tissue that makes it distensible • Serves as reservoir of urine (1 to 1.8L; moderately full bladder=500ml) • Lined with transitional epithelium • Internal and external urethral sphincters control the flow of urine

Fig. 18.17

The Urethra • Tube extending from the urinary bladder to the external urethral orifice 3-5cms (1-2 inches) in females 20 cms (8 inches) in males

3 Parts in Males 1. Prostatic urethra- most dilatable 2. Membranous urethra- least dilatable and shortest 3. Penile urethra- longest

Ana of Male

Ana of Female

PHYSIOLOGY

Renal Physiology Urine formation 1. Urinary blood flow 2. Glomerular filtration 3. Tubular reabsorption 4. Tubular secretion

Renal Physiology Ur in e formatio n Glomerular Filtration • Ultrafiltration of blood by the glomerulus; beginning of urine formation • Requires hydrostatic pressure supplied by the heart and assisted by vascular resistance (glomerular hydrostatic pressure) and sufficient circulating volume

Renal Physiology Ur in e formatio n Glomerular Filtration • Pressure in Bowman’s capsule opposes hydrostatic pressure and filtration • If glomerular pressure insufficient to force substances out of the blood into the tubules filtrate formation stops

Renal Physiology Ur in e formatio n Glomerular Filtration • Glomerular Filtration Rate (GFR): amount of blood filtered by the glomeruli in a given time; normal is 125ml/min • Filtrate formed has essentially same composition as blood plasma without the proteins; blood cells and proteins are usually too large to pass the glomerular membrane

Formation of Urine

Renal Physiology Ur in e formatio n Tubular Function • The tubules and collecting ducts carry out the functions of reabsorption, secretion, and excretion • Reabsorption of water and electrolytes is controlled by antidiuretic hormone (ADH), released by the pituitary, and aldosterone, secreted by the adrenal glands

Renal Physiology Ur in e formatio n Tubular Function Proximal Convoluted Tubule - reabsorption of certain constituents of the glomerular filtrate: 80% electrolytes and H2O, all glucose and amino acids, and bicarbonate; - secretes organic substances and wastes

Renal Physiology Ur in e formatio n Tubular Function Loop of Henle - reabsorption of water in the descending limb - reabsorption of sodium and chloride in the ascending limb > descending limb - concentrates and then dilutes urine

Fig. 18.12

Fig. 18.13

Renal Physiology Ur in e formatio n

Tubular Function

Distal Convoluted Tubule - secretes potassium, hydrogen ions, and ammonia - reabsorbs H2O (regulated by ADH and aldosterone) back into the tubule - reabsorbs bicarbonate - regulates calcium and phosphate concentrations

Renal Physiology Ur in e formatio n Tubular Function Collecting Ducts - receives urine from distal convoluted tubules - reabsorbs water (regulated by ADH) back in vessels

Fig. 18.14

Renal Physiology Ur in e formatio n

• As fluid flows through the proximal tubules, water and solutes reabsorption starts • Normal adult produces 1 to 1.5 liter/day of urine • The process of selective reabsorption determines the amount of water and solutes to be secreted

Renin-Angiotensin System

ASS ES SME NT

GU T Asse ssm ent Nursing History Reason for seeking care Current illness Previous illness Family History Social History Sexual history

GU T Asse ssm ent Health History • Presenting Problem: symptoms may include 1. Pain in flank, groin; dysuria 2. Changes in urination patterns: frequency, nocturia, hesitancy of stream, urgency, dribbling, incontinence, retention

GU T Asse ssm ent Health History • Presenting Problem: symptoms may include 3. Changes in urinary output: polyuria, oliguria, anuria 4. Changes in color/consistency of urine: dilute, concentrated, malodorous; hematuria, pyuria

GU T Asse ssm ent Health History Lifestyle: - Occupation (type of employment, exposure to chemicals such as carbon tetrachloride, ethylene glycol) - Level of activity - Exercise • Nutrition/Diet: water, calcium, dairy product intake

GU T Asse ssm ent Health History Past Medical History - Hypertension, diabetes mellitus, gout, cystitis, kidney infections, connective tissue diseases (SLE), infectious diseases, drug use (prescribed/OTC); previous catheterizations, hospitalizations, or surgery for renal problems

GU T Asse ssm ent Health History Family History - Hypertension, diabetes mellitus, renal disease, gout, connective tissue disorders, urinary tract infections (UTIs), renal calculi

GU T Asse ssm ent Physical Examination Inspect skin for color, turgor, and mobility; purpuric lesions, integrity Inspect mouth for color, moisture, odor, ulcerations Inspect abdomen, and palpate bladder for distension; percuss bladder for tympany or dullness (if full)

GU T Asse ssm ent Physical Examination Inspect face for edema, particularly periorbital edema Inspect extremities for edema Determine rate, rhythm, and depth of respirations Inspect muscles for tremors, atrophy

GU T Asse ssm ent Physical Examination Palpate right and left kidneys for tenderness, pain, enlargement; percuss costovertebral angles for tenderness/pain; first percuss kidneys for tenderness/pain Palpate flank area for pain Auscultate aorta and renal arteries for bruits

GUT Assessment PHYSICAL EXAMINATION Inspection Auscultation Percussion Palpation

GUT Assessment Key Signs and Symptoms of Urological Problems EDEMA associated with fluid retention renal dysfunctions usually produce ANASARCA check for weight daily ( weight increase of 1 Kg = 1 Liter of fluid retained)

GUT Assessment Key Signs and Symptoms of Urological Problems PAIN Suprapubic pain= bladder Colicky pain on the flank= kidney

GUT Assessment Key Signs and Symptoms of Urological Problems HEMATURIA Painless hematuria may indicate URINARY CANCER! Early-stream hematuria= urethral lesion Late-stream hematuria= bladder lesion

GUT Assessment Key Signs and Symptoms of Urological Problems DYSURIA Pain with urination= lower urinary tract infection

GUT Assessment Key Signs and Symptoms of Urological Problems POLYURIA More than 2 Liters urine per day

OLIGURIA Less than 400 mL per day

ANURIA Less than 50 mL per day

GUT Assessment Key Signs and Symptoms of Urological Problems Urinary Urgency Urinary Retention Urinary Frequency

GUT Assessment Irritation Dysuria Frequency Urgency Nocturia Strangury

GUT Assessment Obstruction Weak Stream Hesitancy Terminal Dribbling Incomplete emptying

GUT Assessment Pain Flank or lumbar Inguinal or iliac Initiation of voiding End of voiding

GUT Assessment Uri ne Changes Pneumaturia Proteinuria Ketonuria Glycosuria Hematuria

GUT Assessment Incontinence Stress Urge Overflow Total Mixed Enuresis

LAB OR ATO RY DIA GNO STI CS

GUT: LABORATORY DIAGNOSTICS Urine Studies: • Urinalysis: examination to assess the nature of the urine produced

- evaluates color, pH and specific gravity - determines presence of glucose (glycosuria), protein (proteinuria), blood (hematuria), ketones (ketonuria) - analyzes sediment for cells (presence of WBC called pyuria), casts, bacteria, crystals

Urine Specimen

GUT: LABORATORY DIAGNOSTICS Urine Studies: 1. Urinalysis: Interventions - Wash perineal area & use a clean container - Obtain 10 to 15 mL of the first morning sample - Specimen should be examined within 1 hour of voiding. Note that refrigerated samples may alter the specific gravity - If the client is menstruating, indicate this on

Urine Specimen

Collection of Urine Specimen Clean catch (midstream) urine specimen A. Cleanse perineal area 1. Females: spread labia and cleanse meatus front to back using antiseptic sponges 2. Males: retract foreskin (if uncircumcised) and cleanse glans with antiseptic sponges B. Have client initiate urine stream then stop C. Collect specimen in a sterile container D. Have client complete urination but not in specimen container

Collection of Urine Specimen 24-hour urine specimen - Preferred method for creatinine clearance test INTERVENTIONS: - Have client void and discard specimen; note time - Collect all subsequent urine specimens for 24 hours - If specimen is accidentally discarded, the test must be restarted - Record exact start and finish collection; include date and times

Collection of Urine Specimen Random urine sample Urine straining Double catch Catheter Diversionary Method

Collection of Urine Specimen It involves overall characteristics of urine: Appearance normal urine is clear cloudy = due to pus, blood, bacteria and lymph fluid

Odor normal is faint aromatic odor offensive odor = bacterial action

Collection of Urine Specimen

Color

normal is clear yellow or amber straw colored = diluted highly colored = concentrated urine due to insufficient fluid intake cloudy or smoky = infection, spermatozoa red or red brown = hematuria, bleeding or drugs and food yellow-brown or green-brown = obstructive jaundice or lesion from bile duct dark-brown or black = malignant melanoma or leukemia

Collection of Urine Specimen pH maintain normal hydrogen ion concentration in plasma and ECF must be measured in fresh urine because the breakdown of urine to ammonia causes urine to become alkali normal pH is around 6 (acid) or 4.6-7.5

Check: ketones, glucose and albumin

Collection of Urine Specimen Specific Gravity Determination Reflects ability of the kidneys to concentrate or dilute urine, normal range is from 1.005-1.025 (1.003- 1.030)

INTERVENTIONS: Specific gravity can be measured by multiple dipstick (most common method), refractometer (an instrument used in the laboratory setting) or urinometer (least accurate method)

Collection of Urine Specimen Specific Gravity Determination INTERVENTIONS: Factors that interfere with an accurate reading include radiopaque contrast agents, glucose, and proteins An increase in specific gravity occurs with insufficient fluid intake, decreased renal perfusion, or the presence of SIADH

Collection of Urine Specimen Specific Gravity Determination INTERVENTIONS: A decrease in specific gravity occurs with increased fluid intake, renal failure (diuretic phase) and diabetes insipidus Cold specimens may produce a false high reading

Collection of Urine Specimen Osmolality more precise test than specific gravity 1-2 ml urine are required normal range is from 300-1090 mOsm/kg (number of particles per unit volume of water)

GUT: LABORATORY DIAGNOSTICS Urine Studies: • Urine Culture and Sensitivityexamination for bacterial infections of urinary tract that identifies the presence of microorganisms and determines the specific antibiotics that will treat the existing microorganism appropriately

INTERVENTIONS: - Clean perineal area and urinary meatus with bacteriostatic solution

GUT: LABORATORY DIAGNOSTICS Urine Studies: 1. Urine Culture and SensitivityINTERVENTIONS: - Collect midstream sample in a sterile container - Send the collected specimen to the laboratory immediately - Note that urine from the client who forced fluids may be too diluted to provide a positive

GUT: LABORATORY DIAGNOSTICS Urine Studies: 1. Urine Culture and SensitivityINTERVENTIONS: - Identify any sources of peritoneal contaminants during the collection of the specimen, such as the hands, skin, clothing, hair, or vaginal or rectal secretions

GUT: LABORATORY DIAGNOSTICS Urine Studies: • Residual Urine- amount of urine left in bladder after voiding measured via catheter (permanent or temporary) in bladder

GUT: LABORATORY DIAGNOSTICS Urine Studies:

• Creatinine Clearance- determine amount of creatinine (waste product of protein breakdown) in the urine over 24 hours, measures overall renal function

INTERVENTIONS: - Encourage adequate fluids before and during the test - Instruct the client, as prescribed, to avoid tea, coffee, and medications during

GUT: LABORATORY DIAGNOSTICS

Urine Studies:

1. Creatinine ClearanceINTERVENTIONS: - If the client is taking corticosteroids or thyroid medication, check with the physician regarding the administration of these medications during testing - Maintain the urine specimen on ice or refrigerate and check with the laboratory regarding the addition of a preservative to the

GUT: LABORATORY DIAGNOSTICS Blood Studies: • BUN: measures renal ability to excrete urea nitrogen • Serum creatinine: specific test for renal disorders; reflects ability of kidneys to excrete creatinine • Bicarbonate • Calcium

GUT: LABORATORY DIAGNOSTICS Blood Studies: 1. Phosphorus 2. Potassium 3. Sodium

GUT: LABORATORY DIAGNOSTICS Blood Urea Nitrogen (BUN) • primary end product of protein metabolism and is excreted by the kidneys • an elevation of BUN may indicate chronic renal disease • not specific for the kidney function • normal value= 20-30 mg/dl • assess concentration of urea in the blood • can be reabsorbed by the kidney tubules

GUT: LABORATORY DIAGNOSTICS Serum Creatinine • is more specific for renal function test • is not affected by dietary intake or hydration status • normal value 0.5-1.5 mg/dl • can not be reabsorbed by the kidney tubules • assess GFR • can be elevated in cases of glomerulonephritis Pyelonephritis, acute tubular necrosis nephrotoxicity, renal insufficiency and renal failure.

GUT: LABORATORY DIAGNOSTICS KUB Radiograph  Initial procedure for KUB disorders  An X-ray film of the urinary system and adjacent structures that is used to detect urinary calculuses

INTERVENTIONS:  No specific preparation is necessary

GUT: LABORATORY DIAGNOSTICS KUB Ultrasound  Non-invasive method  NPO for 6 to 8 hours  Is a noninvasive method of determining renal damage, stones in the urinary tract and measuring the volume of urine in the bladder  May be performed for evaluating urinary frequency or inability to urinate

GUT: LABORATORY DIAGNOSTICS Computed Tomography  Imaging methods that provide crosssectional views of the kidney and urinary tract

INTERVENTIONS (CT Scan):  Obtain an informed consent if a dye is used  Assess for allergies to iodine, contrast dyes, or shellfish if a dye is used

Contrast Media

GUT: LABORATORY DIAGNOSTICS Computed Tomography INTERVENTIONS (CT Scan):  Instruct the client in the need to lie still and flat during the test  Instruct the client to hold his or her breath when requested  Initiate an IV line if prescribed

GUT: LABORATORY DIAGNOSTICS Computed Tomography INTERVENTIONS (CT Scan):  Assess for claustrophobia  Inform the client of possible mechanical noises as the scanning occurs  Inform the client that there may be a hot, flushed sensation and a metallic taste in the mouth when the dye is injected

GUT: LABORATORY DIAGNOSTICS Computed Tomography INTERVENTIONS (CT Scan):  Note some clients may be given the dye even if they report an allergy and are treated with an antihistamine and corticosteroids before the injection to reduce the severity of a reaction

GUT: LABORATORY DIAGNOSTICS Computed Tomography INTERVENTIONS (CT Scan): PostProcedure  Provide replacement fluids because diuresis from the dye is expected  Monitor for an allergic reaction to the dye  Assess dye injection site for bleeding or hematoma, and monitor extremity for color, warmth, and the presence of distal pulses

GUT: LABORATORY DIAGNOSTICS Magnetic Resonance Imaging  Non-invasive imaging methods that provide more detailed cross-sectional views of the kidney and urinary tract that identifies types of tissues, tumors, and vascular abnormalities

INTERVENTIONS (MRI): Pre-Procedure  Remove all metal objects from the client  Remove IV fluid pumps during the test

GUT: LABORATORY DIAGNOSTICS Magnetic Resonance Imaging INTERVENTIONS (MRI): Pre-Procedure  Determine whether the client has a pacemaker, implanted defibrillator, or metal implants such as a hip prosthesis or vascular clips because these clients cannot have this test performed  Provide precautions for the client who is attached to pulse oximeter because it can cause a burn during testing if coiled around the body or a body part

GUT: LABORATORY DIAGNOSTICS Magnetic Resonance Imaging INTERVENTIONS (MRI): Pre-Procedure  Provide an assessment of the client with claustrophobia  Administer medication as prescribed for the client with claustrophobia  Determine whether a contrast agent is to be used, and follow the prescription related to the administration of food, fluids, and medications

GUT: LABORATORY DIAGNOSTICS Magnetic Resonance Imaging INTERVENTIONS (MRI): Pre-Procedure  Instruct the client that he or she will need to remain still during the procedure

INTERVENTIONS: Post-Procedure  Client may resume normal activities  Expect diuresis if a contrast agent was used

GUT: LABORATORY DIAGNOSTICS Intravenous Pyelogram  A radiopaque dye is injected that outlines the renal system to identify abnormalities

INTERVENTIONS: Pre-Procedure  Obtain an informed consent  Assess the client for allergies to iodine, seafood, and radiopaque dyes  Withhold food and fluids after midnight on the night before the test

IVP

GUT: LABORATORY DIAGNOSTICS Intravenous Pyelogram INTERVENTIONS: Pre-Procedure  Administer laxatives as prescribed  Inform the client about possible throat irritation, flushing of the face, warmth, or a salty taste during the test

INTERVENTIONS: Post-Procedure  Monitor vital signs  Assess the venipuncture site for bleeding

GUT: LABORATORY DIAGNOSTICS Intravenous Pyelogram INTERVENTIONS: Post-Procedure  Monitor urinary output  Instruct the client to drink at least 1 L of fluid unless contraindicated  Monitor for signs of a possible allergic reaction to the dye used during the test

GUT: LABORATORY DIAGNOSTICS Renal Angiography  The injection of a radiopaque dye through a catheter for examination of the renal arterial supply

INTERVENTIONS: Pre-Procedure  Obtain an informed consent  Assess the client for allergies to iodine, seafood, and radiopaque dyes  Inform the client about the possible burning feeling along the vessel when the dye is used

GUT: LABORATORY DIAGNOSTICS Renal Angiography INTERVENTIONS: Pre-Procedure  Withhold food and fluids after midnight on the night before the test  Instruct the client to void immediately before the procedure  Administer enemas as prescribed  Shave injection sites as prescribed  Assess and mark the peripheral pulses

GUT: LABORATORY DIAGNOSTICS Renal Angiography INTERVENTIONS: Post-Procedure  Assess vital signs and peripheral pulses  Provide bed rest and use of a sandbag at the insertion site for 4 to 8 hours  Assess the color and temperature of the involved extremity  Inspect the catheter insertion site for bleeding or swelling

GUT: LABORATORY DIAGNOSTICS Renal Angiography INTERVENTIONS: Post-Procedure  Encourage increased fluids unless contraindicated  Monitor urinary output

GUT: LABORATORY DIAGNOSTICS

Renal Scan

 An IV injection of a radioisotope for visual imaging of renal blood flow

INTERVENTIONS: Pre-Procedure  Obtain an informed consent form  Assess for allergies  Assist with administering radioisotope as necessary  Instruct the client that he or she will be required to remain motionless during the test

GUT: LABORATORY DIAGNOSTICS Renal Scan INTERVENTIONS: Pre-Procedure  Instruct the client that imaging may be repeated at various intervals before the test is complete

INTERVENTIONS: Post-Procedure  Encourage fluid intake unless contraindicated  Assess the client for signs of delayed allergic reaction such as itching and hives

GUT: LABORATORY DIAGNOSTICS Renal Scan INTERVENTIONS: Post-Procedure  Note that the radioactivity is eliminated in 24 hours  Follow standard precautions when caring for incontinent clients and double-bag client linens per agency policy

GUT: LABORATORY DIAGNOSTICS Cystometrogram  A graphic recording of the pressures exerted at varying phases of the bladder

INTERVENTIONS: Pre-Procedure  Inform the client of the voiding requirements during the procedure

INTERVENTIONS: Post-Procedure  Monitor the client’s voiding after the procedure

Cystometrogram

GUT: LABORATORY DIAGNOSTICS Cystoscopy and Biopsy  The bladder mucosa, ureteral orifice and urethra is examined for inflammation, calculuses, or tumors by means of cystoscope; a biopsy may be obtained

INTERVENTIONS: Pre-Procedure  Obtain an informed consent  If biopsy is planned, withhold food and fluids after midnight on the night before the test

Cystoscopic Examination

GUT: LABORATORY DIAGNOSTICS Cystoscopy and Biopsy INTERVENTIONS: Pre-Procedure  If a cystoscopy alone is planned, no special preparation is necessary  And the procedure may be performed in the physician’s office  Post-procedure includes increasing fluid intake

GUT: LABORATORY DIAGNOSTICS Cystoscopy and Biopsy INTERVENTIONS: Post-Procedure  Monitor vital signs  Increase fluid intake and output  Encourage deep-breathing exercises to relieve bladder spasms  Administer analgesics as prescribed  Administer sitz baths for back and abdominal pain

GUT: LABORATORY DIAGNOSTICS Renal Biopsy  Ultrasound guided insertion of needle into the kidney to obtain a sample of tissue for examination

INTERVENTIONS: Pre-Procedure    

Assess vital signs Assess baseline clotting studies (Bleeding time) Obtain an informed consent Withhold food and fluids after midnight on the night before the test

GUT: LABORATORY DIAGNOSTICS Renal Biopsy INTERVENTIONS: During the Procedure  Position the client prone with a pillow under the abdomen and shoulders  Hold breath when the kidney is about to puncture

INTERVENTIONS: Post-Procedure  Monitor vital signs  Place the client in the supine position and on bed rest for 8 hours as prescribed

Renal Biopsy

GUT: LABORATORY DIAGNOSTICS Renal Biopsy INTERVENTIONS: Post-Procedure  Monitor hemoglobin and hematocrit  Avoid palpation and manipulation on the area  Monitor complications:

urine

Colicky pain = clot in the ureter/s Flank pain = bleeding in the muscle Evaluate hematuria = collect serial specimen

GUT: LABORATORY DIAGNOSTICS Renal Biopsy INTERVENTIONS: Post-Procedure  Provide pressure to the biopsy site for 30 minutes  Check the biopsy site for bleeding  Encourage fluid intake of 1500 to 2000 mL as prescribed  Instruct the client to avoid heavy lifting and strenuous activity for 2 weeks