URINARY SYSTEM ASSESSMENT

INTRODUCTION

The renal and urinary system is critical to the function of the entire body. An accurate assessment will
help to ensure that any impact on the renal system is recognized and addressed to prevent damages to
the kidneys or other components of the urinary system. The renal system includes the kidneys, ureters,
bladder, and urethra. The kidneys filter the blood and create urine from waste products and excess
water, which then travels through the ureters into the bladder.

The bladder collects the urine and then excretes it by contracting and pushing it out through the urethra.

Although the renal system is sometimes referred to as the urinary system, the kidneys are the vital
organs that drive system processes. The kidneys have four primary functions:

 Excreting the waste products of metabolism like urea and creatinine

 Maintaining fluid and electrolyte balance
 Regulating blood pressure
 Erythropoietin production (the hormone that stimulates red blood cell synthesis) and vitamin D
metabolism
 ANATOMY OVERVIEW

KIDNEY:

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

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).

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.
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 (Table 69-1). The renal artery separates into progres-
sively 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.

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 juxta medullary nephrons. The cortical
nephrons are short, with all parts located in the renal cortex. The juxta medullary nephrons (about 20%
of all nephrons) are longer, and their tubes and associated blood vessels dip deeply into
the medulla. The purpose of the juxta medullary 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

Blood supply to the nephron is delivered via the afferent arteriole, the smallest, most distal portion of
the renal arterial system. From the afferent arteriole, blood flows into the glomerulus, a series of
specialized capillary loops. It is through these capillaries that water and small particles are filtered from
the blood to make urine. The remaining blood exits the glomerulus via the efferent arteriole. From the
efferent arteriole, blood exits into one of two additional capillary systems:

-The peritubular capillaries around the tubular component of cortical nephrons

-The vasa recta around the tubular component of juxtamedullary nephrons

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
empties into the renal pelvis.

A series of specialized cells located in the afferent arteriole, efferent arteriole, and DCT are collectively
known as the jux-taglomerular complex (Figure 69-4). The specialized cells in this area are the renin-
producing cells, which produce and store renin. Renin is a hormone that helps to regulate blood flow,
glomerular filtration rate (GFR), and systemic blood pressure. Renin is secreted when special cells in the
DCT called the macula densa sense changes in blood volume and pressure. The macula densa lies next
to the renin-producing granular cells of both afferent and efferent arterioles. Renin is secreted when the
macula densa cells sense that blood volume, blood pressure, or blood sodium levels are low. Renin then
converts angiotensinogen into angiotensin I. This leads to a series of reactions that cause secretion of the
hormone aldosterone (Figure 69-5). Aldosterone increases kidney reabsorption of sodium and water,
restoring blood pressure, blood volume, and blood sodium levels. (See Chapter 11 for a more complete
description of the renin-angiotensin-aldosterone pathway).
Microscopically, the glomerular capillary wall has three layers (Figure 69-6): the endothelium, the
basement membrane, and the epithelium. The endothelial and epithelial cells lining the glomerular
capillary are separated by pores that filter water and small particles from the blood into Bowman's
capsule. This fluid is called the filtrate, or early urine.
FUNCTIONS OF KIDNEY:
The kidneys have both regulatory and hormonal functions. The regulatory functions control fluid,
electrolyte, and acid-base balance. The hormonal functions control red blood cell formation, blood
pressure, and vitamin D activation.

 Regulatory Functions:

The physiologic processes responsible for maintaining fluid, electrolyte, and acid-base balance are
glomerular filtration, tubular reabsorption, and tubular secretion These processes occur through
filtration, diffusion, active transport, and osmosis.

 Glomerular Filtration.

Glomerular filtration is the first process in urine formation. As blood passes from the afferent arteriole into
the glomerulus, water, electrolytes, and other particles (e.g., creatinine, urea nitrogen, and glucose)
are filtered across the glomerular membrane into Bowman's capsule to form glomerular filtrate. As the
filtrate enters the proximal convoluted tubule (PCT), it is called tubular filtrate.
Large-molecular weight substances (>69,000 daltons), such as albumin and globulin, are too large
to filter through the glomerular capillary walls. Red blood cells (RBCs) also are too large to pass from
the arterioles into the filtrate. Therefore these substances are not normally present in the filtrate or in the
final urine.
Approximately 180 L of glomerular filtrate is formed from the blood each day. The rate of filtration is
often expressed in milliliters per minute. A normal glomerular filtration rate (GFR) averages 125
mL/min. If all filtrate were to be excreted as urine, death would occur quickly from massive
dehydration. Actually, only about 1 to 3 L are excreted each day as urine.
The GFR is related to blood pressure and blood flow. The ability of the kidneys to self-regulate renal
blood pressure and renal blood flow keeps GFR constant. GFR is controlled by selectively constricting
and dilating the afferent and efferent arterioles. When the afferent arteriole is constricted and/or
the efferent arteriole is dilated, pressure in the glomerular capillaries falls and filtration decreases. When
the afferent arteriole is dilated and/or the efferent arteriole is constricted, pressure in the glomerular
capillaries rises and filtration increases. Through this self-regulation the kidney can maintain a constant
GFR, even when systemic blood pressure changes. When systolic blood pressure drops below about
70 mm Hg, these mechanisms are unable to compensate, and GFR stops.
  Tubular Reabsorption:

Tubular reabsorption is the second process involved in urine formation. It is the tubular reabsorption of
most of the filtrate that keeps normal urine output at 1 to 3 L/day and prevents dehydration. As the filtrate
passes through the tubular component of the nephron, the kidney reabsorbs variable amounts of water and
electrolytes. Reabsorption returns particles (solutes) and water to the blood.
Reabsorption occurs from the filtrate across the tubular lumen of the nephron and into the blood of the
peritubular capillaries. The PCT reabsorbs approximately 65% of the total glomerular filtrate.

 Water Reabsorption:
The tubules reabsorb more than 99% of all filtered water back into the body. Most water reabsorption from
the filtrate into the plasma occurs as the filtrate passes through the PCT. Water reabsorption continues as
the filtrate flows down the descending loop of Henle. The thin segment of the ascending loop of Henle
is not permeable to water.

The distal convoluted tubule (DCT) is potentially permeable to water, and therefore water reabsorption
can occur as the filtrate continues to flow through the tubule. The membrane of the DCT may be made
more permeable to water through the influence of the hormones antidiuretic hormone (ADH) and
aldosterone. ADH increases the permeability of the membrane to water and enhances water
reabsorption. Aldosterone promotes the reabsorption of sodium in the DCT; water reabsorption occurs
as a result of the movement of sodium (where sodium goes, water follows).

The ability of the kidneys to vary the volume or concentration of urine helps regulate total water balance
regardless of water intake. In this way, the healthy kidney can prevent dehydration when fluid intake is
low and prevent circulatory overload when fluid intake is excessive.

 Solute Reabsorption:

Some particles in the tubular filtrate are returned to the blood. This process is called tubular
reabsorption. About 50% of all urea present in the glomerular filtrate is reabsorbed, but virtually no
creatinine is reabsorbed.
Most sodium, chloride, and water reabsorption occurs in the PCT. The collecting ducts are the other
major site of sodium, chloride, and water reabsorption, which usually occurs under the stimulation of
aldosterone. Potassium is also primarily reabsorbed in the PCT, with 20% to 40% of potassium
reabsorption occurring in the thick segment of the ascending loop of Henle.
Bicarbonate, calcium, and phosphate are reabsorbed in the PCT, with a little additional reabsorption
occurring in the ascending loop of Henle and the DCT. The reabsorption of bicarbonate helps neutralize
acids and maintain a normal blood pH. Calcium reabsorption and excretion is controlled by circulating
calcitonin and parathyroid hormone (PTH) levels’

The kidney reabsorbs some of the glucose filtered from the blood. However, there is a limit to how much
glucose the kidney can reabsorb. This limit is called the renal threshold for glucose reabsorption or the
transport maximum for glucose reabsorption. The usual renal threshold for glucose is about 220
mg/dL. This means that at a blood glucose level of 220 mg/dL, all glucose is reabsorbed from the filtrate
and returned to the blood. When blood glucose levels are greater than 220 mg/dL, some glucose stays in
the filtrate and is present in the urine. Normally, almost all glucose and any filtered amino acids or
proteins are reabsorbed.

 Tubular Secretion:

Tubular secretion is a third process involved in urine formation. Like glomerular filtration, it is a process
by which substances may move from the blood into the tubular filtrate. During tubular secretion, mole-
cules pass from the peritubular capillaries, across capillary membranes, and into the cells that line the
tubules. From the cells these substances are moved into the urine to be excreted from the body.
Potassium (K+) and hydrogen ions (H+) are some of the substances moved in this way to maintain homeo-
stasis of electrolytes and pH.

 К Hormonal Functions:
The kidneys produce renin, prostaglandins, bradykinin, erythropoietin, and activated vitamin D. Other
secretions, such as the kinins, influence renal blood flow and capillary permeability. The kidneys also have
a role in the breakdown and excretion of insulin.

 Renin Production:

As discussed earlier under Microscopic Anatomy, renin assists in the regulation of blood pressure. Renin
is formed and released when there is a decrease in blood flow, volume, or pressure through the renal
arterioles or when a decrease in the sodium ion concentration of the tubular filtrate is detected through
the receptors of the juxtaglomerular complex.
The release of renin stimulates the production of angiotensin II through a series of metabolic steps (see
Figure 69-5). Angiotensin II increases systemic blood pressure through powerful vasoconstrictive
effects and stimulates the release of aldosterone from the adrenal cortex. Aldosterone increases the
reabsorption of sodium in the distal tubule of the nephron. Therefore more water is reabsorbed and blood
pressure is increased because of increases in blood volume expansion. When renal blood flow is
diminished, this renin-angiotensin-aldosterone system of blood pressure regulation influences the
autoregulatory blood pressure processes within the nephron as well as systemic blood pressure

 Prostaglandin Production:

Prostaglandins are produced in a variety of tissues, including the kidney. Specific prostaglandins
produced in the kidney are prostaglandin E2 (PGE2) and prostacyclin (PGI2). These prostaglandins
help regulate glomerular filtration, kidney vascular resistance, and renin production. PGE2 acts on the
distal tubule and collecting duct to inhibit ADH secretion, decrease membrane permeability, and
promote sodium and water excretion.

 Bradykinin Production:

The presence of angiotensin II, prostaglandins, and ADH stimulates the release of bradykinin in the
renal system. Bradykinin dilates the afferent arteriole and increases capillary membrane permeability to
some solutes. These actions maintain kidney blood flow and tubular function even when other conditions
cause systemic vasoconstriction.

 Erythropoietin Production:

Erythropoietin is produced and released in response to decreased oxygen tension in the renal blood supply.
Erythropoietin stimulates red blood cell (RBC) production in the bone marrow. When kidney tissue is
destroyed or nonfunctional, erythropoietin production decreases and the person becomes anemic.

 Vitamin D Activation:

A series of metabolic changes are necessary for vitamin D, a hormone, to become active. Metabolic
conversions take place in the skin through exposure to ultraviolet light and then in the liver. From
there, vitamin D is converted to its active form (1,25-dihydroxy-cholecalciferol) in the kidney. Activated
vitamin D is necessary to absorb calcium in the gastrointestinal tract and is critical in the regulation of
calcium balance.
URETER:

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 diameter of the ureter narrows in three areas:

 In the upper third of the ureter, at the point at which the renal pelvis becomes the ureter, is a narrowing
known as the ureteropelvic junction (UPJ).
 The ureter also narrows as it arches toward the abdominal wall (aortoiliac bend).
 Each ureter then narrows upon entering the posterior wall of the urinary bladder at an oblique
angle; this point is referred to as the ureterovesical junction (UVJ).
The ureter tunnels through bladder tissue for a few centimeters 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.

FUNCTION OF URETER:
Rapid peristaltic contractions of the smooth muscle in the ureter move urine from the renal pelvis of
the kidney to the bladder. Stretch receptors in the renal pelvis regulate ureteral peristalsis. For example,
a large volume of urine in the renal pelvis stimulates the stretch receptors, which respond by causing
an increase in ureteral peristalsis.

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 portion) and the bladder neck (posterior urethra),
which connects 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.
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.

FUNCTION OF URINARY BLADDER

The urinary bladder is a site for the temporary storage of urine. The bladder also provides continence and
enables micturition (voiding). The secretions of the bladder lining resist bacteria.
Bladder continence is achieved during filling through the combination of detrusor muscle relaxation,
internal sphincter muscle tone, and external sphincter contraction. As the bladder fills with urine, stretch
sensations are transmitted to segments of spinal sacral nerves S2 and S3.
 Maintaining Continence

Continence is maintained by the interaction of the nerves that control the muscles of the bladder,
bladder neck, urethra, the pelvic floor, as well as by factors that close the urethra. During bladder
filling, the sympathetic nervous system fibers prevent detrusor muscle contraction. These
control centers are located in the cerebral cortex, the brainstem, and the sacral part of the spinal cord.
For urethral closure to be adequate for continence, the mucosal surfaces must be in contact and must
be adhesive. Contact depends on the structural and functional integrity of the involved nerves and
muscles. Adhesion depends on the adequate secretion of mucus-like substances.
  Micturition
Micturition (voiding) is a reflex of parasympathetic control that stimulates contraction of the
detrusor muscle at the same time as relaxation of the external sphincter and the muscles of the pelvic
floor. With detrusor muscle contraction, the UVJ of the ureter closes, and the normally round bladder
assumes the shape of a funnel. Voiding is a voluntary act as the result of a learned response and is
controlled by the cerebral cortex and the brainstem. Contraction of the external sphincter inhibits the
micturition reflex and prevents voiding.

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.
FUNCTION OF URETHRA
The urethra is a tube for eliminating urine from the body. The passing of urine normally removes
bacteria from the urethra.

RENAL/URINARY SYSTEM CHANGES ASSOCIATED WITH AGING

Renal Changes:
Structural and functional changes occur in the kidney as a result of the aging process. These changes
often have clinical significance. The kidney loses cortical mass and gets smaller by 80 years of age. This
cortical loss is caused by reduced renal blood flow. The medulla appears not to be affected by aging, and
the juxtamedullary nephrons are generally preserved. However, the glomerular and tubular basement
membranes thicken, reducing filtrating ability. Both the number of glomerali and their surface area
decrease with aging. The length of the tubules also decreases.
Kidney function also changes with ageing. Blood flow the kidney decreases by about 10% per decade as
blood vessels thicken and become more rigid. Glomerular filtration rate (GFR) decreases with
advancing age and more rapidly after 45 years of age. By age 65 years, the GFR decreases to
approximately 65 mL/min (roughly half the rate in a young adult). This decline is more rapid in clients
with diabetes or hypertension. Tubular changes with aging are shown by a decreased ability to
concentrate urine, resulting in nocturia (increased need to urinate at night). The excretion and
regulation of sodium, acids, and bicarbonate remain effective but are less efficient because
homeostasis is slower. Along with an age-related impairment in the thirst mechanism, these changes
may be associated with an increased incidence of dehydration and hypernatremia (increased blood
sodium levels) in the older adult (Brenner, 2000). Hormonal changes include a decrease in renin
secretion, aldosterone levels, and activation of vitamin D.
Urinary Changes:

Changes in the elasticity of the detrusor muscle may cause decreased bladder capacity and a decreased
ability to retain urine. The sensation of the urge to void may cause immediate bladder emptying
because the urinary sphincters lose muscle tone and often become weaker with age. In
women, weakening muscles shorten the urethra, which contributes to incontinence. In men, an
enlarged prostate gland causes difficulty in starting the urine stream and may cause urinary retention

A S S E S S M E N T T E C H N I Q UE S

As with all system assessments, there are two types of data that can be collects. Subjective data includes
reports from the patient. Objective data includes data from physical examinations and medical tests.
Together the data creates a picture of how the renal system is functioning. It is important to note that
the absence of signs or symptoms does not always mean the system is normal. Sometimes even
advanced renal disease has few or vague symptoms.

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.

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.

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 whether his or her siblings, parents,
parents' siblings, or grandparents have had renal problems. Past terms used for kidney disease include
Bright's disease, nephritis, and nephrosis. Clients may use these terms to describe kidney disease as it
was known by their parents or grandparents in the earlier part of the twentieth century. Adult polycystic
kidney disease can occur in clients of either gender.
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.
The nurse identifies all of the client's prescription medications. The client is asked about their duration
of use and whether any recent changes in medications have been prescribed. Drugs prescribed for
diabetes mellitus, hypertension, cardiac disorders, hormonal disorders, cancer, arthritis, and psychiatric
disorders are potential causes of renal dysfunction. Antibiotics taken for infections, such as
gentamicin (Garamycin, Cidomycin), may also produce sudden renal dysfunction.
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. The question "Have you ever been told that your blood pressure is high?" may
prompt a vastly different response than "Do you have high blood pressure?" The nurse also asks female
clients about health problems associated with pregnancy (e.g., proteinuria, high blood pressure,
gestational diabetes, and urinary tract infections). Additional information is obtained about the
following:
 Chemical or environmental toxin exposure in occupational 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

DIET HISTORY
The client with known or suspected renal or urologic disorders is asked about his or her usual diet and
any recent changes in the 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. A high-protein intake can result in temporary renal
problems. Clients susceptible to calculi (stone) formation who ingest large amounts of calcium-
containing products or have an insufficient fluid intake may form new stones.
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.

SOCIOECONOMIC STATUS
The socioeconomic status of the client may influence health care practices. People with limited income
or no health insurance often ignore physical ailments or delay seeking health care because they lack the
funds to pay for diagnostic tests or treatment. They may also have difficulty following medical advice,
having prescriptions filled, and keeping follow-up appointments.
The information that a client has about the disease and its symptoms may relate to educational level.
Educational level may also affect health-seeking practices. Recurring urinary tract infections often
result from inadequate or incomplete treatment, including lack of follow-up to ensure eradication. The
lack of money to pay for antibiotics or nutritious foods or the lack of knowledge or motivation to select
healthful foods may inhibit full recovery.
The client's health beliefs affect the approach to health and illness. Cultural background or religious
affiliation may influence the belief system.
The language used by clients may be different from that used by the health care professional. Anatomic
or medical terms may have no meaning for the client (Table 69-4). When obtaining a history, the nurse
listens to and explores the terms used by the client. By using the client's own terms, the nurse may help
him or her to provide a more complete and thorough description of the problem. This technique may
increase the amount of information communicated and decrease the client's discomfort when
discussing bodily functions.

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 encouraged to describe all health concerns, because some renal and
urologic disorders are associated with symptoms that are related to other body systems or that occur
as generalized problems. Recent upper respiratory problems, generalized musculoskeletal discomfort, or
gastrointestinal (GI) problems may be related to problems of kidney function.
The kidney and urologic system are assessed specifically. 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. Urine that is reddish, dark brown or black, greenish, or otherwise different
from the usual yellowish, straw color usually prompts the client to seek health care assistance. Urine
typically has a mild but distinct odor of ammonia. An increase in the intensity of color, a change in odor
quality, or a decrease in urine clarity may suggest infection.
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. The client usually does not know the exact amount of urine produced; a bladder
diary may provide useful data (see the Evidence Based Practice for Nursing box above). The nurse
also asks the following:
 If the client has difficulty initiating urine flow
 If a burning sensation or other discomfort is present on urination
 If the force of the urine stream is decreased (in men)
The nurse asks about any loss of urinary continence. Situations that increase intra-abdominal pressure
(e.g., coughing and sneezing) may result in the involuntary passage of urine. Clients may also report a
persistent dribbling of urine. The onset of pain in the flank, in the lower abdomen or pelvic region, or
in the perineal area is often of great concern and usually prompts the client to seek assistance. The
nurse inquires about the onset, intensity, and duration of the pain, its location, and its association with
any activity or event.
Pain associated with renal or ureteral irritation is often severe and spasmodic. Pain that radiates into the
perineal area, groin, scrotum, or labia is described as renal colic. Renal colic pain is usually associated
with distention or spasm of the ureter, such as in an obstruction or the passing of a stone. Renal colic pain
may be intermittent or continuous and may even be systemic with pallor, diaphoresis, and hypotension.
These general symptoms occur because of the location of the nerve tracts associated with the kidneys
and ureters.
Because the kidneys are close to the GI organs and the nerve pathways are similar, GI symptoms may
be part of the client's presenting history. These reno-intestinal reflexes often complicate the detailed
description of the renal problem.
Uremia results from the accumulation of nitrogenous waste products in the blood, a result of renal
failure. Symptoms include anorexia, nausea and vomiting, muscle cramps, pruritus (itching), fatigue,
and lethargy.

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.
 The nurse assesses the general appearance of the client and checks for a yellowish skin color 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 when renal disease is
present.

General
• Apparent state of health
• Appearance of comfort or distress
• Color (e.g., flushed, pale)
• Nutritional status (emaciated or obese)
• Match between appearance and stated age

Vital Signs
• Temperature
• Heart rate
• Respiratory rate
• Blood pressure

ASSESSMENT OF THE KIDNEYS, URETERS, AND BLADDER

Assessment of the kidneys, ureters, and bladder is performed in conjunction with an abdominal
assessment. Auscultation is performed before percussion and palpation because these activities can
enhance bowel sounds and obscure abdominal vascular sounds.

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 twelfth rib and the vertebral column.
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.

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.

The kidneys lie rather high under the diaphragm and lower ribs and are therefore well protected from
injury. Because of the position of the liver, the right kidney is lower than the left. The kidneys are
difficult to palpate in men because of

(1) resistance from abdominal muscle tone and

(2) more fixed position than in women, moving only slightly with change of posture or respiration. The
lower part of the right kidney can sometimes be felt, particularly in thin patients, but the left kidney
usually cannot be felt unless it is enlarged or displaced.

The most successful method of renal palpation is carried out with the patient lying in the supine position
on a hard surface. The kidney is lifted by one hand in the costovertebral angle (CVA). On deep
inspiration, the kidney moves downward; the other hand is pushed firmly and deeply beneath the costal
margin in an effort to trap the kidney. When successful, the anterior hand can palpate the size, shape,
and consistency of the organ as it slips back into its normal position.

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 non-tender.

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.
If the client identifies flank pain or tenderness, the non-tender flank is percussed first. The client assumes a
sitting, side-lying, or supine position, and the nurse forms one hand into a clenched fist. The heel of
the other hand and the little finger form a flat area with which a firm thump to the CVA area can be
quickly administered. Costovertebral tenderness is highly suggestive of kidney infection or inflammation.
Clients with inflammation or infection in the kidney or adjacent structures may describe their pain as
severe or as a constant, dull ache.

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.
Psychosocial Assessment
Concerns about the urologic system may evoke fear, anger, embarrassment, anxiety, guilt, or sadness in
the client. Childhood learning often includes privacy with regard to urination habits. Urologic disorders
may stimulate previously forgotten memories of difficult toilet training and bedwetting or of childhood
experiences of exploring one's body. The client may ignore symptoms or delay seeking health care
because of emotional responses or culture al taboos about the urogenital area.
DIAGNOSTIC ASSESSMENT
 LABORATORY TESTS
Blood Tests

o Serum Creatinine
Serum creatinine is a measurement of the end product of muscle and protein metabolism. Creatinine is
filtered by the kidneys and excreted in the urine. Because muscle mass and metabolism are usually
constant, the serum creatinine level is an excellent indicator of kidney function. Normal serum creatinine
levels vary with age, gender, and body muscle mass. The normal serum creatinine value is slightly higher
in adult men than in adult women. In general, men have a larger muscle mass than do women, but there
are exceptions. Muscle mass and the amount of creatinine produced diminish with age. Because of
decreased rates of creatinine clearance, however, the serum creatinine level remains relatively constant
in older adults unless renal disease is present.
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, and
therefore any elevation of serum creatinine values is important.

o Blood Urea Nitrogen

Blood urea nitrogen (BUN) measures the renal excretion of urea nitrogen, a by-product of protein
metabolism in the liver. Urea nitrogen is produced primarily from food sources of protein, which undergo
metabolism by the liver. The kidneys filter urea nitrogen from the blood and excrete the nitrogenous
waste in urine. BUN levels indicate the extent of renal clearance of this nitrogenous waste product.
Other factors may influence the BUN level, and therefore an elevation does not always represent renal
disease .For example, rapid cell destruction from infection or steroid therapy may elevate BUN level.
In addition, blood is a protein. If blood is present in body tissues, the re-absorption of the blood protein
is processed by the liver, resulting in an increased BUN level.
The liver must function properly to produce urea nitrogen. 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.
 o Ratio of Blood Urea Nitrogen to Serum Creatinine
The BUN/creatinine ratio determines whether factors such as dehydration or lack of renal perfusion are
causing the elevated BUN level. When a blood volume deficit (dehydration) or hypo perfusion exists, the
BUN level rises more rapidly than the serum creatinine level. As a result, the ratio of BUN to create nine
is increased.
When both the BUN and serum creatinine levels increase at the same rate, the BUN/creatinine ratio
remains normal. However, the elevated serum creatinine and BUN levels suggest renal dysfunction that
is not related to acute volume depletion or hypo perfusion.

Urine Tests

o Urinalysis
Urinalysis is a usual part of any complete physical examination but is particularly useful for clients with
suspected kidney or urologic disorders. Ideally, the urine specimen is collected at the first morning's
voiding; specimens obtained at other times may not be adequately concentrated. The specimen may be
collected by several techniques.

o Color, Odor, And Turbidity.

The color of urine is derived from urochrome pigment. Variations in color may result from increased
levels of urochrome or other pigments, changes in the concentration or dilution of the urine, and the
presence of drug metabolites in the urine. Urine smells faintly like ammonia and is normally clear
without turbidity (cloudiness) or haziness.

o Specific Gravity.

The specific gravity of urine measures the concentration or density of urine compared to water. The
specific gravity of urine ranges from 1.000 (the specific gravity of water) to greater than 1.035. In kidney
disease, increases and decreases in specific gravity may not reflect systemic fluid volume. For example,
dilute urine with a decreased specific gravity may occur in a dehydrated client who has a lack of nephron
receptors for antidiuretic hormone. An increase in specific gravity occurs with dehydration, decreased
kidney perfusion, or the presence of antidiuretic hormone (ADH). (ADH production is normally
increased with stress, surgery, anesthetic agents, and certain drugs such as morphine and oral antidiabetic
agents.) In each of these situations the expected kidney response is to reabsorb water and decrease urine
output. As a result, the urine produced is more concentrated.
A decrease in specific gravity occurs with increased fluid intake, diuretic administration, and diabetes
insipidus. In each of these situations, the normal kidney response is to excrete more water; thus urine
output is increased. In kidney disease, the specific gravity decreases because there is less solute, and it
does not vary with changes in plasma osmolality (e.g., it becomes fixed).

o pH

A pH value less than 7 is considered acidic, and a value greater than 7 is considered alkaline. Various
factors influence the acidity or alkalinity of urine. A diet high in certain fruits and vegetables results in a
more alkaline urine, whereas a high-protein diet produces a more acidic urine. The presence
of Escherichia coli in the urine also results in an acidic urine.
Urine specimens become more alkaline when left standing unrefrigerated for more than 1 hour, if urea-
splitting bacteria are present, or if a specimen is left uncovered. Alkaline urine increases cell breakdown;
thus the presence of red blood cells may be missed on analysis. The nurse ensures that urine specimens
are covered and delivered to the laboratory promptly or refrigerated. During metabolic or respiratory
acidosis or alka-losis, the kidneys, along with blood buffers and the lungs, should respond appropriately
to maintain a normal serum pH. discuss acid-base balance and imbalance.

o Glucose.

Glucose is filtered at the glomerulus and is reabsorbed in the proximal tubule of the nephron. When the
blood glucose level rises above 220 mg/dL, the renal threshold for reabsorption is usually exceeded,
and glucose is excreted in the urine. Variations in the renal threshold for glucose occur in many clients,
such as those who experience any infection or those who have had diabetes mellitus for a number of
years. It is possible that their serum glucose level may be high (e.g., greater than 400 mg/dL), and
glucose may still not be present in the urine.

o 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. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular
energy. When ketones are present in the blood, they are partially excreted in the urine.

o Protein.

Protein, such as albumin, is not normally present in the urine. Levels greater than 300 mg/24 hr, or 200
|xg/min, are abnormal. The glomerular membrane is semiper-meable to small molecules; protein
molecules are too large to pass through this semipermeable membrane. When permeability of the
glomerular membrane is increased, protein molecules pass through and are excreted in the urine.
Increased glomerular membrane permeability may be caused by infection, inflammation, or
immunologic problems. Certain systemic processes result in the production of abnormal proteins, such
as globulin. These proteins are not detected with routine urinalysis procedures; urine protein
electrophoresis or other tests are necessary to detect these unusual proteins.

A random finding of proteinuria followed by a series of negative (normal) findings does not imply renal
disease. If infection is suspected to be the cause of the proteinuria, urinal-yses after elimination of the
infection should be negative for protein. Persistent proteinuria needs further investigation.

Microalbuminuria is the presence of albumin in the urine that is not measurable by a urine dipstick or
conventional urinalysis procedures. Specialized immunoassay tests can quickly analyze a freshly
voided urine specimen for microscopic levels of albumin. The normal microalbumin levels in a freshly
voided random specimen should range between 2.0 to 20 mg/mmol for men and 2.8 to 28 mg/mmol for
women. Higher levels indicate microalbuminuria and could mean the presence of very early kidney
disease, especially in clients with diabetes mellitus. For 24-hour urine specimens, levels of 30 to 300
mg/24 hr, or 20 to 200 |xg/min, indicate microalbuminuria.

o 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.
When casts are formed, there is a clumping or agglutination of the element, and gelatinous substances
form the surrounding structure, a cast. Casts are described by the type of element in the structure (e.g.,
RBC cast, WBC cast, tubular epithelial cast) or the stage of degeneration. The degeneration of
casts refers to the stage of breakdown of the internal element. Casts are described as "granular" (coarse
or fine) and "waxy.
 o Crystals.

Crystals in the urine come from various salts. These particles may be a result of diet, drags, 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, but it can be contaminated easily by perineal bacteria or airborne pathogens during
collection.

o Urine for Culture and Sensitivity

The nurse may collect a sample of urine for laboratory determination of the number and types of pathogens
present. The presence of clinical symptoms and unexplained bacteria in a urinalysis specimen are
indications for urine culture and sensitivity testing. When bacterial colonies are present, they are placed in
a medium containing different antibiotic drugs to determine which drugs are effective in killing or
stopping the growth of the bacteria (sensitivity). Those drags to which the microorganisms are sensitive or
resistant are reported to guide decisions about needed therapy. A clean-catch or catheter-derived specimen
is always preferred for culture and sensitivity testing.

o Composite Urine Collections

When ordered, urine collections are made for a number of hours (e.g., 24 hours) for laboratory
quantitative and qualitative analysis of one or more substances. Collections are often ordered to measure
levels of urinary creatinine or urea nitrogen, sodium, chloride, calcium, catecholamines, or
other components. For a composite urine specimen, all urine within the designated time frame must be
collected. If other voided or catheterized specimens must be obtained while the collection is in progress,
the nurse measures and appropriately documents the amount collected but not added to the timed
collection.
The urine collection may need to be refrigerated or stored on ice to prevent changes in the urine during
collection time. The nurse follows the procedure from the laboratory for urine storage. The urine the
collection must be free from fecal contamination. Menstrual blood and toilet tissue also contaminate the
specimen and can invalidate the results.
The collection of urine for a 24-hour period is often more difficult than it seems. With hospitalized
clients, the cooperation of staff personnel, the client, family members, and visitors is essential. Placing
signs in the bathroom, instructing the client and family, and emphasizing the need to save the urine are
helpful.

o Creatinine Clearance Test

Creatinine clearance is a calculation of glomerular filtration rate. It is the best indication of overall
kidney function. The amount of creatinine cleared from the blood (e.g., filtered into the urine) is measured
in the total volume of urine excreted in a defined period. A urine specimen for a creatinine clearance test
is usually collected for 24 hours, but it can be collected for shorter periods (e.g., 8 or 12 hours). The
calculation requires a comparison with the blood creatinine level, and therefore a blood specimen for
creatinine must also be collected.
The laboratory or the physician calculates the creatinine clearance. Because the client's age, gender,
height, weight, diet, and activity level influence the expected amount of creatinine to be excreted, these
variables are considered in the interpretation of creatinine clearance test results.

The following formula is used to calculate creatinine clearance:

Creatinine clearance = U x V/P x T

Where U is creatinine in urine (mg/dL), V is volume of urine (mL/24 hr), P is creatinine in plasma or
blood (mg/dL), and T is time (minutes).

The rate of creatinine clearance is expressed as milliliters per minute per 1.73 m2 of body surface area.
The range for normal creatinine clearance is 90 to 139 mL/min for adult males and 80 to 125 mL/min
for females. Creatinine clearance measurements are necessary to determine the client's current kidney
function. Decreases in the creatinine clearance rate may require modification of drug dosing and often
signifies the need for further investigation of the cause of kidney deterioration.

o Urine Electrolytes

Urine samples may be collected for the analysis of urine electrolyte levels (e.g., sodium and chloride).
Normally the amount of sodium excreted in the urine is nearly equal to that consumed. Urine sodium
levels of less than 10 mEq/L indicate that the tubules are functioning to conserve (reabsorb) sodium.

o Osmolality

Osmolality is a measure of the concentration of particles in solution, in this case the concentration of
solutes in urine. These solutes include electrolytes and solutes such as glucose, urea, and creatinine.
 o Blood/Plasma Osmolality.

The kidneys excrete or reabsorb water to maintain a blood osmolality in the range of 285 to 295
mOsm/kg. Osmolality is slightly higher in older adult clients (285 to 301 mOsm/kg). When blood os-
molality is decreased, the release of antidiuretic hormone (ADH) is inhibited. Without ADH, the distal
tubule and collecting ducts are not permeable to water. As a result, water is excreted, not reabsorbed,
and blood osmolality increases. When blood osmolality increases, ADH is produced. With ADH
production, the distal tubule is made permeable to water. Consequently, water is reabsorbed, and blood
osmolality decreases.

o Urine Osmolality.

Urine osmolality can vary from 50 to 1400 mOsm/kg water, depending on the clinical and hy-dration
status of the client and the functional status of the kidneys. With average fluid intake, the range for urine
osmolality is 300 to 900 mOsm/kg water. The fixed acids and other wastes that are continually produced
constitute a solute load that must be excreted in the urine on a regular basis. This is referred to
as obligatory solute excretion. If the client has lost excessive fluids, the renal response is to conserve
water, preserve blood osmolality, and excrete small amounts of highly concentrated urine. Many factors
such as diet, medications, and activity can influence urine osmolality. Thus increased urine osmolality
reflects a concentrated urine with less water than solutes. A decreased urine osmolality reflects a
dilute urine with more water than solutes.

 RADIOGRAPHIC EXAMINATIONS

Radiographic and other special procedures are used to diagnose abnormalities within the genitourinary
system. The nurse explains the procedures thoroughly to the client, prepares the client, and provides post-
procedural care.

Kidney, Ureter, and Bladder X-Ray Examination

Radiographic examination of the kidneys, ureters, and bladder (KUB) is a plain film of the abdomen
taken without any specific client preparation. The KUB study shows gross anatomic features and may
show obvious stones, strictures, calcifications, or obstructions in the urinary tract. This test identifies
the organs' shape, size, and relationship to other parts of the urinary tract. Other tests are necessary for
diagnosis of functional or structural abnormalities.
There is no discomfort or risk from this procedure. The nurse tells the client that the films will be taken
while the client is in a supine position. No specific post-procedure care is necessary.
 Intravenous Urography
Other names for intravenous urography include excretory urography and (the older term) intravenous
pyelography (IVP).

o Client Preparation:
 Before urography, the nurse assesses the client,institutes bowel preparation, and teaches the
client. Allergy information is reported to the physician. Contrast reactions can be minor (nausea
and vomiting, urticaria, itching, sneezing), moderate (nephrotoxic effects, congestive heart
failure, pulmonary edema), or severe (bronchospasm, anaphylaxis). If the diagnostic test is to
be performed in the presence of minor allergy, the physician orders preprocedural medications
such as a steroid (methyl-prednisolone or prednisone), and an antihistamine (diphenhy-dramine
hydrochloride to suppress the allergic response. The nurse explains the rationale for the
procedure to the client.
 Procedures to ensure that films provide adequate visualization vary according to the radiologist's
preferences. Some radiologists recommend a light evening meal or clear liquids, then fasting
(NPO status) from midnight on the night before the procedure. Others recommend increased
fluid intake to prevent dehydration up until the time of the procedure. Because of the possibility
of a vomiting reaction to the intravenous (IV) contrast, however, the physician may prefer the
client to remain on NPO status at least a few hours before the procedure. The physician orders
hydration with IV fluids as indicated.
 The physician orders a bowel preparation to remove fecal contents, fluid, and air from the gut,
which permits an adequate outline of the lower poles of the kidneys, ureters, and bladder. Bowel
preparation procedures vary but usually include the use of laxatives the day before the procedure.
Enemas also may be prescribed but are controversial because air and fluid can be introduced with
inadequate expulsion of fecal contents
 The contrast medium (dye) is potentially nephrotoxic. The risk for contrast-induced renal
failure is greatest in clients who are older or dehydrated, who have some renal insufficiency
(e.g., serum creatinine levels greater than 1.5 mg/dL), or who are also taking other nephrotoxic
drugs. These clients usually require additional IV fluids before the procedure to maintain
hydration and to decrease the nephrotoxic risk. Diuretics may be administered immediately after
the dye is injected to enhance its excretion.
 The nurse instructs the client in the preparation procedures for the urogram and explains the
procedure so he or she knows what to expect in the examination room. The nurse intervenes on
behalf of the client to ensure that questions are answered before the procedure.
 o Procedure

A radiopaque contrast medium (dye) is injected intravenously with the client in a supine position.
As blood (with the dye) rapidly circulates into the kidney blood vessels and is filtered by the glomeruli,
the dye is excreted in the urine. A series of x-ray films are taken at various times after injection. When
ordered, nephrotomograms are taken at the same time as the urogram. Tomograms provide images
of different planes of tissue and show any abnormalities present at varying depths. The technologist
then asks the client to empty the bladder and return for a few more films. An outline of the kidneys,
ureters, and bladder results as urine containing the dye is excreted.
The urogram provides information about the following:

 The number, size, shape, and location of the kidneys

 The adequacy of uptake (filling) and the rate of excretion of contrast medium
 The number, size, location, appearance, and patency of the calices, pelves, and ureters
 The size, location, and nature of the urinary bladder

o Follow-Up Care.

After the urogram, the nurse monitors the client for altered renal function and other effects from the dye.
Adequate hydration is ensured by encouraging the client to take fluid orally or by administering IV
fluids. Hydration decreases the risk for renal deterioration. Blood creati-nine levels are monitored to
determine ongoing renal function.

Computed Tomography

o Client Preparation.
The nurse informs the client that a computed tomography (CT) scan is performed to provide three-
dimensional information about the kidneys, ureters, bladder, and surrounding tissues. A CT scan is
usually performed after other diagnostic procedures and can provide information about tumors, cysts,
abscesses, other masses, obstruction, and certain blood vessel abnormalities.
A bowel preparation with laxatives or an enema and a light meal the evening before the procedure is
needed. The client is given nothing by mouth (NPO status) after midnight on the night before the
examination. For clients having the CT scan with dye, the physician orders pre-procedural IV
hydration. The nurse assesses for any allergy to dye and intervenes as with IV urography.
 o Procedure.

The CT scan is performed in a special room, usually in the radiology department. An IV injection
of radiopaque dye may be administered before starting the imaging procedures. The use of dye may be
eliminated in clients at risk for contrast media-induced acute renal failure, but the images produced are
less distinct. Tomograms are obtained at various levels.

o Follow-Up Care.

No special follow-up care is necessary unless a dye was used. In that case, the follow-up care is the
same as for IV urography.

Cystography and Cystourethrography

o Client Preparation.
The nurse explains the procedure to the client undergoing a cystography or cystourethrography. A
urinary catheter is temporarily needed to instill a contrast medium (dye). The dye is necessary for vi-
sualization of the lower urinary tract.

o Procedure.

In both cystography and cystourethrography, dye is instilled into the bladder via a urethral
catheter. After bladder filling, a variety of films are obtained from the front, back, and side positions.
For the voiding cystourethro-gram (VCUG), the client is requested to void, and films are taken during
the voiding. A VCUG is obtained to determine whether a vesicoureteral reflux is present. The cystogram
is often indicated in cases of trauma when urethral or bladder injury is suspected.

o Follow-Up Care.

The nurse monitors for the development of infection as a result of catheterization. In this test, the dye is
not nephrotoxic because it is not injected into the bloodstream. Fluid intake is encouraged to dilute the
urine and reduce the burning sensation from catheter irritation after removal. Because pelvic or urethral
trauma may be present, the nurse also monitors for changes in urine output.
 OTHER RENAL DIAGNOSTIC TESTS
Renal Arteriography (Angiography)
o Client Preparation.
The nurse informs the client that an arteriography is used to assess the arterial blood supply of the
kidneys. A bowel preparation is given to remove fecal contents, gas, and fluid. A light evening meal is
given, and the client is on NPO status until after the procedure. An IV may be placed before the
procedure. IV fluids are often given to ensure adequate hydration because a contrast medium (dye) is
used as part of the procedure.
The nurse reviews the procedure with the client, answers questions, and reviews the medication
regimen and blood study results as indicated. For example, the nurse reviews the profhrombin time if
the client has been taking warfarin sodium (Coumadin, Warfilone^). The client also signs an informed
consent statement. Renal arteriography is performed to explore suspected causes of decreased renal
function such as renovascular hypertension, other vessel abnormalities, and bleeding from trauma.

o Procedure.

The injection of a radiopaque dye into the renal arteries requires entry into an artery, usually
the femoral artery in the groin. After the client is sedated and the skin is prepared and draped, the
radiologist injects a local anesthetic. An arterial puncture is then performed through which the
angiographic catheter is inserted.
Using fluoroscopy, the radiologist guides the catheter into the abdominal aorta and the renal artery. When
the tip of the catheter is positioned at each renal artery, the radiologist injects dye and films are taken. The
speed of distribution of the dye and any areas of blood vessel narrowing are noted. Arterial blockage is
noted when the dye fails to circulate within the kidney. Extravasation (infiltration) of dye into surrounding
tissue indicates vessel rupture, which could be present after trauma.
Visualization of the renal vessels can be improved by using a digital subtraction technique. In the digital
subtraction arteriogram (DSA), a computer is used to "subtract out" loops of bowel, ribs, and other
structures normally seen on the x-ray film. As a result, even the small-vessel images are improved. In
addition, the use of a smaller amount of dye means less risk for nephrotoxicity. DSA procedures may not
provide sufficient detail for surgical intervention when used without full arteriography.

o Follow-Up Care.

Bleeding from the catheter insertion site and dye-induced reactions are the two most common
complications of renal arteriography. The nurse monitors the catheter insertion site for signs of bleeding
or swelling. A pressure dressing may have been placed as a preventive measure before the client returned
to the nursing area. The nurse ensures that a 5-pound sandbag and ice are available in case of
emergency.
The vital signs are monitored as per the physician's order or according to the agency's policy, usually
every 15 minutes for 1 hour, then every 30 minutes for 2 hours, then every hour for 4 hours, and then
every 4 hours. The nurse checks the temperature and color of the extremities and distal pulses. A sudden
absence of pulses in the catheterized vessel may reflect hematoma formation or embolization.
Hemoglobin and hematocrit levels are monitored closely for 24 hours after the procedure, usually every
6hours.The period of absolute bedrest (to prevent bleeding) after arteriography varies. In general, bedrest
is maintained for 4 to 6 hours. The nurse instructs the client about the importance of keeping the leg in a
straight position for those 4 to 6 hours. A restraint may be used on the leg with the client's consent. Ankle
flexing and weight shifting are encouraged to prevent deep vein thrombosis. If there is no evidence of
bleeding after 4 to 6 hours, the client may be permitted to stand to void or may use a bedside commode.

Serum creatinine tests are ordered for several days after the arteriogram to determine whether the
procedure has affected kidney function. For some clients with renal insufficiency, the administration of
dye may cause an episode of acute renal failure sufficient to require short-term dialysis. Because the test
is used to provide information for interventions to restore blood flow and thus preserve kidney function,
many clients are willing to accept the risk of short-term dialysis to prevent the need for permanent dialysis.
The client is urged to drink fluids after the procedure to ensure adequate excretion of the dye.

Renal Biopsy
o Client Preparation.
The nurse explains that a biopsy of the kidney is performed to determine a pathologic reason for
unexplained renal dysfunction and to direct or change a course of therapy. The client signs an informed
consent or operative permit.
In a closed biopsy, the physician obtains kidney tissue samples percutaneously (through the skin and
other tissues). In an open biopsy, the tissues are obtained surgically. Factors to consider include the
number of kidneys, the ability of the client to cooperate, and the need for abdominal surgical exploration.
If a percutaneous biopsy is selected, the client must have two kidneys, be able to breathe comfortably in
a prone position for 30 to 45 minutes, and be able to hold his or her breath on request for several seconds.
The client is on NPO status for 4 to 6 hours before the procedure in case a major complication requires
immediate surgery.
An open renal biopsy is performed when cancer is suspected or when the client has only one kidney,
cannot hold his or her breath, or is unable to tolerate a prone position. If abdominal surgery is necessary
for other reasons and a renal biopsy is also needed, the nephrologist may request the surgeon to perform
the biopsy, thereby eliminating the need for a second procedure. If an open biopsy is performed, client
preparation is the same as for general surgery and anesthesia.
Because of the risk for postprocedure bleeding, coagulation studies such as platelet count, activated
partial thrombo-plastin time (aPTT), prothrombin time (PT), and bleeding time are performed before
surgery. A blood transfusion may be needed to correct a low hemoglobin level before
biopsy. Hypertension and uremia increase the risk for bleeding and the physician may order
antihypertensive medications or dialysis before a biopsy.

o Procedure.

Immediately before a percutaneous biopsy, the nurse asks the client to void to decrease the possibility
of puncturing the bladder. The left kidney is biopsied because it is closer to the skin and is not near the
liver. The exact position of the kidney is determined via fluoroscopic or ultrasonographic examination
or by radionuclide scan. In some clients the nephrologist may locate the kidney by using landmarks
from previous images. In other clients the closed biopsy is performed directly during fluoroscopy or
ultrasonographic examination.
For a closed biopsy, the client is placed in a prone position. A roll of padding is placed under the client's
abdomen to angle the kidney closer to the skin. The skin is prepared and draped, and a local anesthetic
is injected. The depth of the kidney is identified by inserting a thin-gauge spinal needle. Movement of
the spinal needle with breathing helps to determine that the capsule of the kidney has been located. A
specially designed trocar is inserted in the path established by the spinal needle. While the client holds
his or her breath, tissue is obtained by inserting the biopsy needle through the trocar and capsule into
the kidney cortex. Automated spring-loaded and smaller biopsy needles have improved the tissue
samples obtained. Ideally, three tissue specimens are obtained.

o Follow-Up Care.

After a closed percutaneous biopsy, the major risk is bleeding from the biopsy site. For 24 hours after
the biopsy, the nurse monitors the dressing site, vital signs, urinary output, hemoglobin level, and
hematocrit (as for postarteriography protocols). Even if the dressing is dry and there is no hematoma,
the client could be bleeding from the site. An internal bleed is not readily visible but is suspected with
flank pain, decreasing blood pressure, decreasing urine output, or other signs of hypovolemia or shock.
The client follows a plan of strict bedrest, lying in a supine position with a back roll for additional support
for at least 6 hours after the biopsy. The head of the bed may be elevated, and the client may resume oral
intake of food and fluids. After 6 hours, the client may have limited bathroom privileges if there is no
evidence of bleeding.
The nurse monitors for hematuria, the most common complication of a percutaneous renal biopsy.
Hematuria occurs microscopically in almost all clients, whereas 5% to 9% have gross hematuria. This
problem usually resolves spontaneously 48 to 72 hours after the biopsy but can persist for 2 to 3 weeks.
In rare cases, transfusions and surgery are required. There should be no obvious blood clots in the urine.
The client may have some local discomfort after the percutaneous renal biopsy. If aching originates at
the biopsy site and begins to radiate to the flank and around the front of the abdomen, the nurse suspects
an onset of bleeding or the development of a perinephric hematoma. This pattern of discomfort with
bleeding occurs because blood in the perirenal tissues and musculature increases pressure on local
nerve tracts.
If bleeding occurs, IV fluid, packed red blood cells, or both may need to be administered to restore blood
pressure. In general, a small amount of bleeding creates enough pressure to compress bleeding sites; this
is called a tamponade effect. If tamponade does not occur and bleeding becomes extensive, surgical
intervention for hemostasis or even nephrectomy may be necessary. A perinephric hematoma may
become infected, requiring treatment with antibiotics and surgical drainage.
If no bleeding occurs, the client can resume general activities after 24 hours. The nurse instructs him or
her to avoid lifting heavy objects, exercising, or performing other strenuous activities for 1 to 2 weeks
after the biopsy procedure. Driving may also be restricted. Refer to Chapter 19 for general postoperative
care for the client undergoing an open renal biopsy.

Renography (Kidney Scan)

o Client Preparation.
The nurse explains to the client that a kidney scan is performed to provide general information about
renal blood flow. A small amount of radioactive material, a radionuclide, is used. The nurse reassures the
client that there is generally no danger from the small amount of radioactive material present in the agent.

o Procedure.

For a kidney scan, the radionuclide is injected intravenously. After injection, the radionuclide is ab-
sorbed into kidney tissue and gives off low-level radioactive emissions (scintillations). The amount of
emission is measured by a scintillator or a scintillation counter. A specially designed camera records the
emissions and produces an image. At the same time, the rate and location of the emissions are recorded
by computer, and information about renal blood flow, or glomerular filtration, is provided.
In some cases captopril (Capoten), an antihypertensive agent, is administered at the start of the
procedure to change blood flow in the kidney. This procedure is known as a Captopril Renal Scan. The
drug can cause severe hypotension during and after the procedure.

o Follow-Up Care.

If the client is able, urination into a commode is acceptable without risk from the small amount of
radioactive material to be excreted. If the client is incontinent, the nurse changes the bed linens promptly
and wears gloves to maintain standard precautions. If captopril was used during the procedure, the
client's blood pressure is assessed frequently. The client is cautioned about rapid position changes
and the risk for falling associated with orthostatic (positional) hypotension.

Ultrasonography
o Client Preparation.
The nurse informs the client that ultrasonography does not cause discomfort and is without risk. This test
involves applying sound waves to structures of different densities to produce images of the kidneys,
ureters, and bladder and surrounding tissues. Ultrasonography allows assessment of kidney size, cortical
thickness, and status of the calices. The test can be used to identify obstruction in the urinary tract, tumors,
cysts, and other masses without the use of nephrotoxic contrast material (dye).

o Procedure.

The client undergoing renal ultrasound is usually placed on a table in a prone position. A sono-
graphic gel is applied to the skin over the back and flank areas to promote the conduction of sound
waves. A transducer in contact with and moving across the skin delivers sound waves and measures the
echoes. Images of the internal structures are produced.

o Follow-Up Care.

Skin care to remove the gel is all that is necessary after ultrasonography.

 OTHER URINARY TRACT DIAGNOSTIC TESTS

Cystoscopy and Cystourethroscopy
o Client Preparation.
Cystoscopy and cystourethroscopy are considered operative procedures and thus require completion of
a preoperative checklist and an informed consent statement. The nurse provides a complete description of
and reasons for the procedure. Cystoscopy may be performed for diagnosis or treatment. Diagnostic
indications include examination for bladder trauma (cystoscopy) or urethral trauma (cystourethroscopy)
and identification of the causes of urinary tract obstruction from stones or tumors. Cystoscopy may be
indicated to remove bladder tumors or an enlarged prostate gland.
Cystoscopy may be performed under general or local anesthesia with sedation. The client's age, general
health, and expected duration of the procedure are some of the considerations in the decision about
anesthesia. A light evening meal may be eaten. Usually the client is on NPO status after midnight on
the night before the cystoscopy. A bowel preparation with laxatives or enemas is performed the evening
before the procedure.
 o Procedure.

The cystoscopic examination is performed in a specially designed cystoscopic examination room. If

the procedure is performed in a surgical suite under general anesthesia, traditional surgical support
personnel are present. This procedure is more often performed in outpatient settings, such as a clinic, an
ambulatory surgery or short-procedure unit, or a urologist's office.
The client is assisted onto a table and, after sedation, is placed in the lithotomy position. After the
administration of anesthesia, skin cleaning, and draping, a cystoscope is inserted via the urethra into the
urinary bladder. If visualization of the urethra is also indicated, a urethroscope is used. Examinations
commonly include the use of both the cystoscope and the urethroscope.

o Follow-Up Care.

After cystoscopic examination with general anesthesia, the client is returned to a postanes-thesia care
unit (PACU) or area. If local anesthesia and sedation were used, the client may be returned directly to
the hospital room. Clients undergoing cystoscopic examinations as outpatients are transferred to an
area for monitoring before discharge to home. The nurse monitors the client for airway patency and
breathing, alterations in vital signs (including temperature), and changes in urine output. The nurse
also observes for the complications of bleeding and infection.
A catheter may or may not be present after cystoscopy. The client without a catheter has urinary
frequency due to irritation from the catheter. The urine may be pink tinged, but gross bleeding is not
expected. Bleeding or the presence of clots may obstruct the catheter and decrease urine output.
The nurse monitors urine output and notifies the physician of obvious blood clots or a decreased or
ceased urine output. The Foley catheter is irrigated with sterile saline, as ordered. The physician is
notified if the client has a fever (with or without chills) or an elevated white blood cell (WBC) count,
which suggests infection. The client is encouraged to take oral fluids to promote adequate urine output
(which helps prevent clotting) and to reduce the burning sensation on urination.

Retrograde Procedures
o Client Preparation.
The client is prepared for retrograde procedures (retrograde pyelography, retrograde cystography, and
retrograde urethrography) in a manner similar to that for the cystoscopic examination.
Retrograde means going against the normal flow of urine. The nurse explains that a retrograde
examination of the ureters and pelves (pyelogram), the bladder (cystogram), and the urethra (ure-
throgram) involves the direct injection of radiopaque contrast medium (dye) into the lower urinary
tract. Because the dye is instilled directly to obtain an outline of the structures desired, the dye does not
enter the bloodstream. Therefore the client is not at risk for dye-induced acute renal failure or a systemic
allergic response.

o Procedure.

Retrograde films are obtained during the cystoscopic examination. After placement of the cystoscope
by the urologist, catheters are placed into each ureter, and contrast medium is instilled into each ureter
and renal pelvis. The catheters are removed by the urologist, and films are taken by the radiology
technician to outline these structures as the dye is excreted. The procedure identifies any obstruction or
structural abnormality.
For clients undergoing retrograde cystoscopy or urethrography, contrast medium is instilled similarly into
the bladder or urethra. Cystography and urethrography also identify structural abnormalities, such as
fistulas, diverticula, and tumors.

o Follow-Up Care.

After retrograde procedures, the nurse monitors the client for the development of infection as a result
of instrumentation of the urinary tract. Because these procedures are performed during cystoscopic
examination, follow-up care is the same as that for cystoscopy.

Urodynamic Studies
Urodynamic studies describe the processes of voiding and include the following:
 Tests of bladder capacity, pressure, and tone
 Studies of urethral pressure and urine flow
 Examination of the function of perineal voluntary muscles
These tests are often used along with excretory urographic or cystoscopic procedures to evaluate
problems with urine flow.

Cystometrography
o Client Preparation.

The nurse explains that the purpose of a cystometrogram (CMG) is to determine the effectiveness and
sensitivity of the bladder wall (detrusor) muscle. Determinations about bladder capacity, bladder
pressure, and voiding reflexes may be made with these measurements of detrusor muscle quality. A
urinary catheter may be needed temporarily during the procedure.
 o Procedure.

The nurse asks the client to void normally. The nurse records measurements of the amount, rate of flow,
and time of voiding. A urinary catheter is inserted to measure the residual bladder urine volume. The
cystometer is attached to the catheter, and fluid is instilled via the catheter into the bladder. The point at
which the client first notes a feeling of the urge to void and the point at which the client notes a strong urge
to void are recorded. Bladder capacity and bladder pressure readings are recorded graphically. The client
is asked to void when the bladder instillation is complete (about 500 mL). The urinary residual after
voiding is noted, and the catheter is removed. Electromyography of the perineal muscles may also be
performed during the cystometric examination.

o Follow-Up Care.

As with any instrumentation of the urinary tract, the nurse monitors for infection. The
client's temperature, the characteristics of the urine, and the amount of urine output are recorded.

Urethral Pressure Profile

o Client Preparation.

The nurse explains that a urethral pressure profile (also called a urethral pressure pro-filometry [UPP])
can provide information about the nature of urinary incontinence or urinary retention. A urinary catheter
may be temporarily placed during the procedure.

o Procedure.

A special catheter with pressure-sensing capabilities is inserted into the bladder. Variations in the pres-
sure of the smooth muscle of the urethra are recorded as the catheter is slowly withdrawn.

o Follow-Up Care.

As with other studies involving instrumentation of the urinary tract, the client is monitored for the
development of infection.

К Electromyography
o Client Preparation.

The nurse explains that electromyography (EMG) of the perineal muscles may be useful in evaluating
the strength of the muscles used in voiding. This information may assist in identifying methods of
improving continence. The nurse informs the client that some temporary discomfort may accompany
placement of the electrodes.
 o Procedure.

In EMG of the perineal muscles, electrodes are placed in either the rectum or the urethra to measure
muscle contraction and relaxation.

o Follow-Up Care.

After the completion of EMG, the nurse administers analgesics to promote the client's comfort. Any
discomfort is usually mild and of short duration.

Urine Stream Test

o Client Preparation.

The nurse explains that a urine stream test evaluates pelvic muscle strength and the effectiveness of
pelvic muscles in interrupting the flow of urine. It is useful in evaluating urinary incontinence.

o Procedure.

Three to five seconds after urination begins, the examiner gives the client a signal to stop urine flow. The
length of time required to interrupt the flow of urine is recorded.

o Follow-Up Care.
Cleansing of the perineal area, as after any voiding, is all that is necessary after the urine stream test.

JOURNAL ABSTRACT

 Honor G : Journal Of Pediatric Health Care : Official Publication Of National Association Of

Pediatric Nurse Associates & Practitioners, 2007, 21(3):162-170
DOI: 10.1016/J.Pedhc.2006.05.012; PMID: 17478305 ;Genitourinary Assessment: An Integral
Part Of A Complete Physical Examination. Children's Hospital, Center for Child and Family
Advocacy, Columbus, OH 43205, USA. [email protected]

This article provides primary care providers, including pediatric nurse practitioners, with a framework
for completing a genitourinary assessment. Many primary care providers are reluctant to examine the
genitalia of their patients. Routine genital examinations increase diagnostic skills, provide a baseline
for future examinations, may improve parent and child compliance with the examination, and may
reveal previously undiscovered anomalies or trauma. An assessment of the reproductive and urologic
systems should begin with obtaining a focused history from the parent from birth to present.
Techniques for performing a focused genitourinary examination will be discussed.

CONCLUSION

The renal and urinary system is critical to the function of the entire body. An accurate assessment will
help to ensure that any impact on the renal system is recognized and addressed to prevent damages to
the kidneys or other components of the urinary system.

Prior to performing a focused renal/urinary history and physical exam, the healthcare professional
should be cognizant of not only the patient’s history but the patient’s familial history as well. As the
patient’s nurse, you must critically analyze all of the data you are obtaining, synthesize the data into
relevant problem focus, and identify a plan of care for your patient based upon this synthesis. Materials
protected by copyright

As the plan of care is being carried out, reassessments must occur on a periodic basis. How often these
reassessments occur is unique to each patient, based upon their physical disorder. Knowing when and
how often to reassess is another critical thinking skill that comes with patient care experience.

BIBLIOGRAPHY

 Joyce M Black;(2006): Medical and surgical nursing;7th edition published by Elsevier; Page
No:908-920
 Lewis; Driksen ; (2016); Medical Surgical Nursing: Second South Asian edition published by
Elsevier: 1130-1136
 Hockenberry MJ, Wilson D. (2007): Wong’s nursing care of infants and children. 8th edition
published by St. Louis, MO: Mosby Elsevier; Page No:1242-48.
 CPM Resource Center. (2010a). Clinical practice guideline: Acute renal failure/acute kidney
disease. Grand Rapids, MI: Elsevier.
 CPM Resource Center. (2010b). Clinical practice guideline: Chronic kidney disease/adult.
Grand Rapids, MI: Elsevier.
 Fischbach, F., & Dunning, M. (2008). Manual of laboratory and diagnostic tests (8th ed.).
Philadelphia: Lippincott Williams & Wilkins.
 Hall, J., Schmidt, G., & Wood, L. (2005). Principles of critical care (3rd ed.). New York:
McGraw-Hill.
 Jarvis, C. (2008). Physical examination and health assessment, (5th ed). St. Louis: W.B.
Saunders.
 National Institute of Diabetes and Digestive and Kidney Diseases. (2007). Kidney & urologic
diseases. Retrieved June 1, 2011 from http://kidney.niddk.nih.gov/kudiseases/a-z.asp
 https://study.com/academy/lesson/renal-system-assessment-techniques-for-nurses.html
 https://tdmuv.com/kafedra/theacher/meds/vnm_horodeckiy/Engl/Recommendations%20for%
20preparing%20practical%20classes/Assessment_of_the_Renal-Urinary_System.htm
 HOLY CROSS COLLEGE OF NURSING, KOTIYAM

ADVANCED NURSING PRACTICE

PRESENTAION TOPIC

ON

URINARY SYSTEM ASSESSMENT

SUBMITTED BY, SUBMITTED TO,

MR. GIREESH S PILLAI MS. ARATHY M

I YEAR MSc NURSING LECTURER

HOLY CROSS COLLEGE OF HOLY CROSS COLLEGE OF

NURSING NURSING

SUBMITTED ON:05.02.2020