Assessment of Urinary System

• Obtaining a comprehensive health history, which includes an

assessment of risk factors, is the first step in assessing a patient
with upper or lower urinary tract dysfunction.

• Data collection about previous health problems or diseases

provides the health care team with useful information for
evaluating the patient’s current urinary status.
 Health History
• Obtaining a urologic health history requires excellent
communication skills because many patients are uncomfortable
discussing genitourinary function or symptoms.
• It is also important to review risk factors, particularly with those
at risk.
• For example, the nurse needs to be aware that multiparous
women delivering their children vaginally are at high risk for
stress urinary incontinence.
 Health History
• Elderly women and persons with neurologic disorders such as
diabetic neuropathy (damage of nerve fibres in people with
diabetes), multiple sclerosis (MS) (affects nerves in the brain and
spinal cord, causing a wide range of symptoms including problems
with muscle movement), or Parkinson’s disease (is a progressive
disorder of the nervous system that affects movement) often have
incomplete emptying of the bladder with urinary stasis, which
may result in urinary tract infection or increasing bladder pressure
leading to overflow incontinence, hydronephrosis (is a condition
that typically occurs when one kidney becomes swollen due to the
failure of normal drainage of urine), pyelonephritis ( is a specific
type of urinary tract infection (UTI) that generally begins in your
urethra or bladder and travels up into your kidneys), or renal
insufficiency.
 Health History

• Persons with a family history of urinary tract problems are at

increased risk for renal disorders. Persons with diabetes who have
consistent hypertension are at risk for renal dysfunction.
• Older men are at risk for prostatic enlargement, which causes
urethral obstruction and which can result in urinary tract
infections and renal failure
 Health History
• When obtaining the health history, the nurse should inquire
about the following:
• The patient’s chief concern or reason for seeking health care, the
onset of the problem, and its effect on the patient’s quality of life.
• The location, character, and duration of pain, if present, and its
relationship to voiding; factors that precipitate pain, and those
that relieve it.
• History of urinary tract infections, including past treatment or
hospitalization for urinary tract infection.
• Fever or chills.
 Health History
• Previous renal or urinary diagnostic tests or use of indwelling urinary
catheters.
• Dysuria and when difficult urination occurs during voiding (at initiation or
termination of voiding).
• Hesitancy, straining, or pain during or after urination.
• Urinary incontinence (stress incontinence: occurs when the muscles that
control your ability to hold get weak or do not work & happens when
physical movement or activity — such as coughing, sneezing, running, urge
incontinence: a sudden involuntary contraction of the muscular wall of the
bladder causing urinary urgency, overflow incontinence characterized by
the involuntary release of urine from an overly full urinary bladder).
• Hematuria or change in color or volume of urine.
• Nocturia the need to wake and pass urine at night.
 Health History

• Renal calculi (kidney stones), passage of stones or gravel in the

urine.
• Female patients: number and type (vaginal or cesarean) of
deliveries; use of forceps; vaginal infection, discharge, or
irritation; contraceptive practices
• Presence or history of genital lesions or sexually transmitted
diseases
• Habits: use of tobacco, alcohol, or recreational drugs. Any
prescription and over-the-counter medications ‫ب دونوصفة طبية‬
(including those prescribed for renal or urinary problems).
 Health History

• Other key information to obtain while gathering the health

history includes an assessment of the patient’s psychosocial
status, level of anxiety, perceived threats to body image, available
support systems, and sociocultural patterns.
 Health History

• Pain
• Genitourinary pain is usually caused by distention of some
portion of the urinary tract because of obstructed urine flow or
inflammation and swelling of tissues.
• Severity of pain is related to the sudden onset rather than the
extent of distention.
 Health History

• Changes in Voiding
• Voiding (micturition) is normally a function occurring
approximately eight times in a 24 hour period.
• The average person voids 1,200 to 1,500 mL of urine in 24 hours,
although this amount varies depending on fluid intake, sweating,
environmental temperature, vomiting, or diarrhea.
 Health History

• Common problems associated with voiding include frequency,

urgency, dysuria, hesitancy, incontinence, enuresis refers to a
repeated inability to control urination, polyuria, oliguria, and
hematuria.
• Increased urinary urgency and frequency coupled with or beside
to decreasing urine volumes strongly suggest urine retention.
• Depending on the onset of these symptoms, immediate bladder
emptying via catheterization and evaluation are necessary to
prevent kidney dysfunction.
 Health History

• Gastrointestinal Symptoms:
• Gastrointestinal symptoms may occur with urologic conditions
because of shared autonomic (involuntary) and sensory
innervation (stretching) and renointestinal reflexes. The anatomic
relation of the right kidney to the colon, duodenum, head of the
pancreas, common bile duct, liver, and gallbladder may cause
gastrointestinal disturbances.
 Health History

• The proximity of the left kidney to the colon, stomach, pancreas,

and spleen may also result in intestinal symptoms.
• The most common signs and symptoms include nausea, vomiting,
diarrhea, abdominal discomfort, and abdominal distention.
• Urologic symptoms can mimic ‫ متشابهه‬such disorders as
appendicitis, peptic ulcer disease, or cholecystitis, thus making
difficult diagnosis.
 Physical Examination
• Direct palpation of the kidneys may help determine their size and
mobility.
• It may be possible to feel the smooth, rounded lower pole of the
kidney between the hands, although the right kidney is easier to
feel because it is somewhat lower than the left one.
• In obese patients, palpation of the kidneys is generally more
difficult.
Renal dysfunction may produce
tenderness over the costovertebral
angle, which is the angle formed by the
lower border of the 12th, or bottom, rib
and the spine.
 Physical Examination
• The abdomen (just slightly to the right and left of midline in both
upper quadrants) is auscultated to assess for bruits (low-pitched
murmurs that indicate renal artery stenosis or an aortic
aneurysm).
• The abdomen is also assessed for the presence of peritoneal
fluid, which may occur with kidney dysfunction.
 Physical Examination
• The bladder should be percussed after the patient voids to check
for residual urine.
• Percussion of the bladder begins at the midline just above the
umbilicus and proceeds downward.
• The sound changes from tympanic to dull when percussing over
the bladder.
 Physical Examination
• The bladder, which can be palpated only if it is moderately
distended, feels like a smooth, firm, round mass rising out of the
abdomen, usually at midline.
• Dullness to percussion of the bladder following voiding indicates
incomplete bladder emptying.
 Physical Examination
• The patient is assessed for edema and changes in body weight.
• Edema may be observed, particularly in the face and dependent
parts of the body, such as the ankles and sacral areas, and
suggests fluid retention.
• An increase in body weight commonly accompanies edema.
• 1 kg weight gain equals approximately 1,000 mL of fluid.
 Physical Examination
• The deep tendon reflexes of the knee are assessed for quality and
symmetry.
• This is an important part of testing for neurological causes of
bladder dysfunction because the sacral area, which innervates
(stretch) the lower extremities, is the same peripheral nerve area
responsible for urinary continence.
 Physical Examination
• The gait pattern of the individual with bladder dysfunction is also
noted, as well as the patient’s ability to walk toe-to-heel.
• These tests evaluate possible supraspinal causes for urinary
incontinence