A guide to help the students review themselves about the A & P of the urinary system. it also helps in collecting history and appraise the client suffering from various urinary tract disorders or diseases.

1. ASSESSMENT OF
THE RENAL/URINARY SYSTEM
By
Mrs. Babitha K Devu, Asst. Professor, SMVDCoN

2. LEARNING OBJECTIVES
After studying this chapter, you
should be able to:
Compare and contrast kidney
anatomy and function.
Demonstrate the physical
assessment of urinary system.
Use laboratory data to distinguish
between dehydration and renal
impairment.

3. INTRODUCTION
The renal system includes the kidneys and the entire uri-
nary tract. The ureters, bladder, and urethra provide
a drainage route for the excretion of urine. Structural or
functional problems in the kidney or urinary tract
usually alter fluid, electrolyte, and acid-base balance.
Assessment of the client at risk for or with actual
problems of the renal system begins with a history and
physical assessment. A clear understanding of the
anatomy, physiology, and diagnostic tests of the renal
system will help the nurse in problem solving about
renal function in the clinical setting. It also assist the
nurse in teaching the client about the purpose of tests
and in preparing the client for assessment.

4. ANATOMY OVERVIEW
GROSS ANATOMY
 Normally, two kidneys are located in
the retroperitoneal space (behind the
peritoneum, not really in the abdominal
cavity), one on either side of the vertebral
column.

6. KIDNEYS
 The adult kidney is 4 to 5 inches (11 to 13 cm) long, 2 to
3 inches (5 to 7 cm) wide, and about 1 inch (2.5 to 3 cm)
thick. It weighs about 8 ounces (250 g). The left kidney is
slightly longer and narrower than the right kidney. Kidney
size is usually determined via ultrasound. Larger-than-
usual kidneys may indicate renal obstruction or polycystic
disease, whereas smaller-than-usual kidneys may indicate
chronic renal disease.
 Several layers of protective, supportive tissue surround
the kidney. On the outer surface of the kidney is a layer of
fibrous tissue called the renal capsule. This capsule covers
most of the kidney except the hilum, the area in which the
renal artery enters and the renal vein and ureter exit.
The renal capsule is surrounded by layers of fat and
connective tissue (Gerota's fascia).

7. KIDNEYS
 Lying beneath the renal capsule is functional renal
tissue composed of two distinct sections: the cortex and the
medulla. The renal cortex, or outer tissue layer, is in direct
contact with the renal capsule. The medulla, or medullary
tissue, lies below the cortex in the shape of many fans. Each
"fan" is called a pyramid, and there are 12 to 18 pyramids
per kidney. The renal columns (columns of Bertin) are
cortical tissue that dip down into the interior of the kidney
and separate the pyramids.
 The tip, or end, of each pyramid is called
the papilla. The papillae drain urine into the collecting
system. A cuplike structure called a calyx collects the urine
at the end of each papilla. The calices merge together to
form the renal pelvis, which narrows to become the ureter.

8. KIDNEYS
 The kidneys receive 20% to 25% of the total cardiac
output. Renal blood flow per minute varies from about
600 to 1300 mL/min. The blood supply to each kidney
is usually delivered by a single renal artery, which
branches from the abdominal aorta. The renal artery
separates into progressively smaller arteries, supplying
all areas of the renal tissue (parenchyma) and the
nephrons. The smallest arteries, the afferent arterioles,
feed the nephrons directly to form urine. Venous blood
from the kidneys starts with the capillaries surrounding
each nephron. These capillaries drain into progressively
larger veins, with blood eventually returned to the
inferior vena cava through the renal vein.

10. MICROSCOPIC ANATOMY
 The nephron is the functional unit of the kidney, and
it is here that urine is actually formed from blood.
There are about 1 million nephrons per kidney, and
each nephron separately makes urine from blood.
 There are two types of nephrons: cortical nephrons
and juxtamedullary nephrons. The cortical nephrons
are short, with all parts located in the renal cortex. The
juxtamedullary nephrons (about 20% of all nephrons)
are longer, and their tubes and associated blood
vessels dip deeply into the medulla. The purpose of the
juxtamedullary nephrons is to concentrate urine during
times of low fluid intake. The ability to concentrate
urine allows for the maximum excretion of waste
products with less fluid loss.

12. MICROSCOPIC ANATOMY
 Each nephron is a tubular structure with distinct parts . The
tubular component of the nephron begins with Bowman's
capsule, a saclike structure that surrounds the glomerulus.
The tubular tissue of Bowman's capsule narrows into
the proximal convoluted tubule (PCT). The PCT twists and
turns, finally straightening into the descending limb of
the loop of Henle. The descending loop of Henle dips in the
direction of the medulla but forms a hairpin loop and
comes back up into the cortex.
 As the loop of Henle changes direction, two segments
are identified in the ascending limb of the loop of Henle: the
thin and thick segments. The distal convoluted tubule
(DCT) is formed from the thick segment of the ascending
limb of the loop of Henle. The DCT ends in one of
many collecting ducts located in the kidney tissue. The urine
in the collecting ducts passes through the papillae and

13. URETERS
 Each kidney has a single ureter, a hollow tube like
structure that connects the renal pelvis with the urinary
bladder. The ureter is about 1/2 inch (1.25 cm) in diameter
and about 12 to 18 inches (30 to 45 cm) in length.
 The ureter tunnels through bladder tissue for a few cen-
timeters before opening into the bladder in an area
referred to as the trigone.
 The ureter is composed of three layers: an inner lining
of mucous membrane (urothelium), a middle layer of
smooth muscle fibers, and an outer layer of fibrous
tissue. The outer layer of the ureter contains the blood
supply. The middle layer of ureteral tissue contains
longitudinal and circular muscle fibers. These muscle
fibers are under the control of a variety of nerve pathways
from the lower spinal cord.

15. URINARY BLADDER
 The urinary bladder is a muscular sac. The upper surface
lies next to the peritoneal cavity. In men, the bladder is in
front of the rectum. In women, the bladder is in front of the
vagina. The bladder lies directly behind the pubic
symphysis, the connecting point for pelvic bone structures.
 The bladder is composed of the body (the rounded sac por-
tion) and the bladder neck (posterior urethra), which con-
nects to the bladder body. The bladder has three linings, an
inner lining of epithelial cells (urothelium), middle layers
of smooth muscle (detrusor muscle), and an outer lining.
The trigone is an area on the inner aspect of the posterior
bladder wall between the points of ureteral entry
(ureterovesical junctions [UVJs]) and the urethra.

16. URINARY BLADDER
 The internal urethral sphincter is composed
of the smooth detrusor muscle of the bladder
neck and elastic tissue. The external urethral
sphincter is composed of skeletal muscle that
surrounds the urethra. In men, the external
sphincter surrounds the urethra at the base of
the prostate gland. In women, the external
sphincter is at the base of the bladder. The
pudendal nerve from the spinal cord controls
the external sphincter.

17. URETHRA
 The urethra is a narrow, tube like structure lined with
mucous membranes and epithelial cells. The urethral
meatus, or opening, is the terminal point of the urethra. In
men, the urethra is about 6 to 8 inches (15 to 20 cm) long,
with the urethral meatus is located at the tip of the penis.
Three sections make up the male urethra:
 The prostatic urethra, which traverses the prostate
gland from the urinary bladder
 The membranous urethra, which traverses the wall of
the pelvic floor
 The cavernous urethra, which is external and
extends through the length of the penis
 In women, the urethra is about 1 to 1.5 inches (2.5 to
3.75 cm) long and exits the urinary bladder through the
pelvic floor. The urethral meatus lies slightly below the
clitoris and directly in front of the vagina and rectum.

18. FUNCTION OF THE URINARY SYSTEM
 KIDNEY – regulate blood
volume and composition,
regulate pH, produce 2
hormones and excrete waste
 URETERS- transport urine
from kidney to urinary
bladder
 URINARY BLADDER- store
urine and expels through
urethra
 URETHRA- discharge urine
from the body

19. ASSESSMENT TECHNIQUES
History
 One way to assess renal and urologic function
is to use Gordon's Functional Health Patterns
(Gordon, 2000). The patterns most pertinent
to the renal system are Nutritional/ Metabolic
and Elimination (Chart in next slide).

21. ASSESSMENT TECHNIQUES
History
 DEMOGRAPHIC DATA
 Age, gender, race, and ethnicity are important in the
overall history of the client with suspected renal or urinary
dysfunction. A sudden onset of hypertension in clients older
than 50 years of age suggests possible kidney disease. Clinical
evidence of adult polycystic kidney disease typically occurs
in clients in their 40s or 50s. In men older than 50 years,
altered urine patterns suggest prostatic disease.
 Anatomic gender differences make some disorders worse or
more common. For example, men rarely have urinary
tract infections unless there are abnormalities, such as
ureteral reflux or prostatic enlargement. Women have a
shorter urethra and therefore more commonly
experience cystitis (bladder infection) because bacteria pass
more readily into the bladder.

22. ASSESSMENT TECHNIQUES
History
 PERSONAL AND FAMILY HISTORY
 The family history of the client with a suspected
kidney or urologic problem is significant because
some disorders have a familial inheritance
pattern.
 The client is asked about any previous renal or
urologic disorders, including tumors, infections,
stones, or urologic surgery. A history of any
chronic health problems, such as diabetes
mellitus or hypertension, may contribute to the
development of renal disease.

23. ASSESSMENT TECHNIQUES
History
 PERSONAL AND FAMILY HISTORY
 The use of over-the-counter (OTC) drugs or
agents, including vitamin and mineral
supplements and replacements, laxatives,
analgesics, and nonsteroidal anti-
inflammatory drugs (NS AIDs) is explored. Many
of these drugs affect renal function. The long-
term use of NSAIDs, especially combination
agents, can seriously reduce renal function.
 The client is specifically asked whether he or she
has ever been told about the presence of protein
or albumin in the urine.

24. ASSESSMENT TECHNIQUES
History
 PERSONAL AND FAMILY HISTORY
 Additional information is obtained about the
following:
 Chemical or environmental toxin exposure in occupa-
tional or other settings
 Recent travel to geographic regions that pose
infectious disease risks
 Recent physical injuries
 Trauma
 Sexual contacts
 A history of altered patterns of urinary elimination

25. DIET
 The excessive intake or omission of certain categories
of foods is noted.
 Information about food and fluid intake is obtained.
 If the client has followed a diet for weight reduction,
the details of the diet plan are pertinent.
 Changes in appetite, alterations in taste acuity, and an
inability to discriminate tastes are important. These
symptoms are associated with the accumulation of
nitrogenous waste products from renal failure.
 Changes in thirst or fluid intake may also produce
changes in urine output or other evidence of urologic
disorders. Endocrine disorders may also produce
changes in thirst, fluid intake, and urine output

26. SOCIOECONOMIC STATUS
 People with limited income or no health
insurance often ignore physical ailments or
delay seeking health care.
 The information that a client has about the
disease and its symptoms may relate to
educational level.
 The client's health beliefs affect the approach
to health and illness. Cultural background or
religious affiliation may influence the belief
system.

27. CURRENT HEALTH PROBLEMS
 The effects of renal failure result in changes in all
body systems. Therefore all of the client's current
health problems are documented.
 The client is asked about any changes in the
appearance (color, odor, clarity) of the urine,
pattern of urination, ability to initiate or control
voiding, and other unusual symptoms.
 The client is asked about changes in urination
patterns, such as nocturia, frequency, or an
increase or decrease in the amount of urine. The
normal urine output for adults is 1 mL/kg/hr, or
approximately 1500 to 2000 mL/day.

28. CURRENT HEALTH PROBLEMS
 Urinary incontience or retention
 Flank region pain
 Uremia
 Fatigue
 Itching
 Symptoms of dehydration

29. TERMINOLOGIES

30. PHYSICAL ASSESSMENT
 The physical assessment of the client with a
known or suspected renal or urologic disorder
includes an assessment of general appearance,
a general review of body systems, and specific
structure and functions of the renal/urinary
systems.

31. PHYSICAL ASSESSMENT
GENERAL APPEARANCE
 Checks for a yellowish skin colour and the presence of
any rashes, bruising, or other discoloration. The skin and
tissues may show edema, which with renal disorders may be
detected in the pedal (foot), pretibial (shin), sacral tissues,
and around the eyes.
 The lungs are auscultated to determine whether fluid is
present.
 Weight and blood pressure measurements are obtained for
comparison purposes.
 The nurse assesses the client's general level of consciousness
and level of alertness, noting deficits in concentration,
thought processes, or memory. Family members may
report subtle changes. Such cognitive changes may be the
result of an insufficient clearance of waste products.

32. PHYSICAL ASSESSMENT
ASSESSMENT OF THE KIDNEYS, URETERS, AND BLADDER
 Inspection
 The nurse inspects the abdomen and the flank regions
with the client in both the supine and the sitting position. The
client is observed for asymmetry (e.g., swelling) or
discoloration (e.g., bruising or redness) in the flank region,
especially in the area of the costovertebral angle (CVA). The
CVA is located between the lower portion of the twelveth rib
and the vertebral column.

33. PHYSICAL ASSESSMENT
ASSESSMENT OF THE
KIDNEYS, URETERS, AND
BLADDER
 Auscultation
 The nurse listens for a bruit over
each renal artery on the mid-
clavicular line. A bruit is an
audible swishing sound produced
when the volume of blood or the
diameter of the blood vessel
changes. A bruit is usually
associated with blood
flow through a narrowed vessel, as
in renal artery stenosis.

34. PHYSICAL ASSESSMENT
ASSESSMENT OF THE KIDNEYS, URETERS, AND BLADDER
 Palpation
 Renal palpation identifies masses and areas of tenderness
in or around the kidney. The abdomen is lightly palpated in all
quadrants. The nurse asks about areas of tenderness or
discomfort and examines non-tender areas first. The outline
of the bladder may be seen as high as the umbilicus in clients
with severe bladder distention. Special training and practice
under the guidance of a qualified practitioner are necessary;
therefore appropriate education is essential before attempting
the procedure. If tumor or aneurysm is suspected, palpation
may harm the client.

36. PHYSICAL ASSESSMENT
ASSESSMENT OF THE KIDNEYS, URETERS, AND BLADDER
 Palpation
 Because the kidneys are deep, posterior structures, palpation
is easier in thin clients who have little abdominal
musculature. For palpation of the right kidney, the client
assumes a supine position while the nurse places one hand
under the right flank and the other hand over the abdomen
below the lower right part of the rib cage. The lower hand
raises the flank, and the upper hand depresses the anterior
abdomen as the client takes a deep breath. The left kidney is
deeper and rarely palpable. A transplanted kidney is readily
palpable in either the lower right or left abdominal quadrant.
The kidney should feel smooth, firm, and nontender.

37. PHYSICAL ASSESSMENT
ASSESSMENT OF THE KIDNEYS, URETERS, AND BLADDER
 Percussion
 A distended bladder sounds dull when percussed. After gently
palpating to determine the general outline of the distended
bladder, the nurse begins percussion on the skin of the lower
abdomen and continues in the direction of the umbilicus
until dull sounds are no longer produced.

38. PHYSICAL ASSESSMENT
ASSESSMENT OF THE URETHRA
Using a good light source and wearing gloves, the nurse
inspects the urethra by examining the meatus and
surrounding tissues. Any unusual discharge such as
blood, mucus, and purulent drainage is noted. The
skin and mucous membranes of surrounding tissues
are inspected, and the presence of lesions, rashes, or
other abnormalities of the penis or scrotum or of
the labia or vaginal orifice is documented. Urethral
irritation is suspected when the client reports
discomfort with urination.

39. DIAGNOSTIC ASSESSMENT
LABORATORY TESTS
Blood Tests
 SERUM CREATININE
Normal levels of creatinine in the blood are approximately
 0.6 to 1.2 milligrams (mg) per decilitre (dL) in
adult males
 0.5 to 1.1 milligrams per decilitre in adult females.
Serum creatinine is a measurement of the end product
of muscle and protein metabolism. No common
pathologic condition other than renal disease results
in an increase in serum creatinine level. The
serum creatinine level does not increase until at least
50% of the renal function is lost.

40. DIAGNOSTIC ASSESSMENT
LABORATORY TESTS
Blood Tests
 BLOOD UREA NITROGEN
 Blood urea nitrogen (BUN) measures the renal excretion
of urea nitrogen, a by-product of protein metabolism. When
liver and kidney dysfunction are both present, urea nitrogen
levels are actually decreased; this decrease reflects the liver
failure but not the kidney failure. The BUN level is not always
elevated with kidney disease and is not the most reliable
indicator of kidney function. However, an elevated BUN level
is highly suggestive of kidney dysfunction.
 7 to 20 mg/dL (2.5 to 7.1 mmol/L)

41. DIAGNOSTIC ASSESSMENT
LABORATORY TESTS
Urine Tests
 URINALYSIS
 COLOR, ODOR, AND TURBIDITY.
 SPECIFIC GRAVITY. 1.000 (the specific gravity of water) to
greater than 1.035.
 pH. A pH value less than 7 is considered acidic, and a value
greater than 7 is considered alkaline.
 GLUCOSE. < 0.5g/day
 KETONE BODIES. Three types of ketone bodies are acetone,
acetoacetic acid, and beta-hydroxybutyric acid. Ketone
bodies are by-products of the incomplete metabolism of fatty
acids. Normally there are no ketones in urine.

42. DIAGNOSTIC ASSESSMENT
LABORATORY TESTS
Urine Tests
 URINALYSIS
 PROTEIN. Protein, such as albumin, is not normally present
in the urine. 8 – 18 mg/dl is normal.
 SEDIMENT. Urine sediment refers to particles in the urine.
These particles include cells, casts, crystals, and bacteria.
o CELLS. Types of cells abnormally present in the urine may
include tubular cells (from the tubule of the
nephron), epithelial cells (from the lining of the urinary
tract), red blood cells (RBCs), and white blood cells (WBCs).
o CASTS. Casts are structures formed around other particles.
There may be casts of cells, bacteria, or protein.

43. DIAGNOSTIC ASSESSMENT
LABORATORY TESTS
Urine Tests
 URINALYSIS
 SEDIMENT.
o CRYSTALS. Crystals in the urine come from various
salts. These particles may be a result of diet, drugs, or disease.
The salts may be composed of calcium, oxalate, urea,
phosphate, magnesium, or other substances. Certain drugs,
such as the sulfates, can also produce crystals.
o BACTERIA. Bacteria in a urine sample multiply quickly, so the
specimen must be analyzed promptly. Normally urine is
sterile

44. DIAGNOSTIC ASSESSMENT
LABORATORY TESTS
Urine Tests
 URINE FOR CULTURE AND SENSITIVITY
 CREATININE CLEARANCE TEST. Creatinine clearance is a
calculation of glomerular filtration rate.
The range for normal creatinine clearance is 90 to 139 mL/min
for adult males and 80 to 125 mL/min for females.
 URINE ELECTROLYTES. analysis of urine electrolyte levels
(e.g., sodium and chloride).
 OSMOLALITY

45. DIAGNOSTIC ASSESSMENT
LABORATORY TESTS
RADIOGRAPHIC EXAMINATIONS
 Kidney, Ureter, and Bladder X-Ray Examination
 Intravenous Urography
 CT
 Cystography and cystoscopy
 USG
 Renal scan
 Renal arteriography
 Voiding cystourethrography