Week 3 Nursing

Question 1

Bladder

Answer 1

▪ 3 layers of smooth muscle
▪ Middle layer forms an involuntary sphincter that guards the opening between the bladder & urethra
▪ Reservoir for Urine
▪ Innervated by the ANS
▪ Bladder wall stretches until the nerves are stimulated = need to urinate

Question 2

Urethra

Answer 2

▪ Convey urine from the bladder to the exterior of the body
▪ The male urethra functions in the excretory & reproductive system. It is 13.7 - 16.2 cm long
▪ The female urethra is 3.7 to 6.2 cm long. No portion of the female urethra is external to the body

Question 3

Physical Examination: Inspection

Answer 3

▪ Skin, Hair and Nails
– Look for a sallow complexion also known as uraemic tinge.
– Look for Mees’ lines which indicate chronic renal failure.
▪ Face and Mouth
– Look for oedema around the eyes.
– Smell for uraemic fetor from urea breakdown in saliva.
▪ The Extremities
▪ Look for scratch marks from uraemic pruritus.
▪ Look for an Arterio-venous fistula in the forearm.
▪ Look for oedema in the legs (or sacrum) from renal failure.
▪ The Abdomen
▪ Look for scars - nephrectomy and/or transplant.
▪ Look for an enlarged abdomenascites or polycystic kidney disease.

Question 4

Physical Examination: Palpation

Answer 4

▪ Kidneys
▪ Kidneys are usually not palpable unless enlarged.
▪ The right is lower than the left due to the liver.
▪ Bladder
▪ The bladder is usually a pelvic organ and is not palpable.
▪ Palpation is in an upward motion from the pubic symphysis.

▪ Oedema
▪ Pitting oedema occurs when excess fluid accumulates in the interstitial space.
▪ Pitting oedema is classified as:
+1 = 2mm of pitting
+2 = 4mm of pitting
+3 = 6mm of pitting
+4 = 8mm of pitting

Question 5

Physical Examination: Auscultation

Answer 5

▪ Renal Arteries
▪ Renal artery blood flow is best heard above the umbilicus.
▪ Position bell of stethoscope 2cm to the right and the left.
▪ Presence of a bruit is abnormal in renal arteries.
▪ A bruit indicates renal artery stenosis / narrowing.
▪ Commonly caused by atherosclerosis.

▪ Blood Pressure
– Up to 75% of patients with kidney disease will have hypertension.
– Hypertension decreases renal blood flow and exacerbates kidney disease.

Question 6

Physical Examination: Percussion

Answer 6

▪ Bladder
▪ Assessment of bladder distension (enlargement).
▪ Start at the symphysis pubis moving upwards to the umbilicus.
▪ A urine filled bladder produces a dull sound.
▪ Tympany indicates the border of the bladder.
▪ Document as “bladder is __ cm below umbilicus”.

Question 7

Fluid Balance and Voiding Charts

Answer 7

Fluid Balance Chart
▪ A fluid balance chart is essential for anyone receiving intravenous fluids.
▪ Commonly used for patient’s with renal/cardiac failure.
▪ Requires accurate measurement of input/output.

Voiding Chart
▪ Also known as a bladder chart or diary.
▪ Records voiding patterns, volume, incontinence, pain and associated symptoms.
▪ Intake of fluids may also be included on the chart.

0.5mL/kg/hr. or 30- 40mL/hr. normal output

Question 8

Full Ward Test (FWT)

Answer 8

▪ Also known as a ward urinalysis test (common on admission).
▪ Non sterile specimen collected (clean catch).
▪ Uses reagent strips to detect abnormalities

Question 9

Midstream Collection (MSU)

Answer 9

▪ Sterile specimen container.
▪ Clean the perineal area with soap and water.
▪ First part of void is discard.
▪ CAPTURE MIDDLE PART OF VOID.
▪ Finish voiding in the toilet.
▪ May be stored in ward fridge for up to 1 hour.
▪ Used for culture of microbes and sensitivity to antibiotics.

Question 10

Catheter Collection (CSU)

Answer 10

▪ Sterile specimen container.
▪ Catheter clamped to prevent free flow of urine into drainage bag.
▪ Swab the access port on the catheter drainage tube.
▪ Withdraw urine using a sterile syringe.
▪ Inject urine into a specimen container and unclamp catheter.
▪ May be stored in ward fridge for up to 1 hour.
▪ Used for culture and sensitivity.

Question 11

24 Hour Urine Collection

Answer 11

▪ Place a sign in patients bathroom of the start & end times.
▪ Provides a 24 hour sample of renal function.
▪ Measures levels of hormones and steroids.
▪ Creatinine clearance and protein can be measured.

Question 12

Bladder Scan

Answer 12

▪ Device which measures volume of urine in the bladder.
▪ Should be used before considering catheterisation.
▪ Can be used to determine if the bladder is emptying correctly.
▪ Male and female setting available (to compensate for uterus).
▪ Can provide a print out of the scan and results which can go in the patients medical history.

Question 13

Post Void Residual Volumes (PVR)

Answer 13

▪ Measured to determine how completely the bladder empties with voiding.
▪ Less than 50ml PVR is considered normal.
▪ When 100ml or more is retained further testing is indicated.
▪ High PVR volumes can increase the risk of urinary tract infection.
▪ The amount of urine left in the bladder is measured with the bladder scanner

Question 14

Dialysis

Answer 14

▪ Used to treat people who experience severely decreased or total loss of kidney function. ▪ A mechanical way of filtering waste from the blood.
▪ Two categories: Haemodialysis and Peritoneal dialysis
▪ HD requires vascular access - arteriovenous (AV) fistula or AV graft
▪ PD involves using blood vessels in the peritoneum to fill in for the kidneys. A fluid called dialysate is washed in & out of the peritoneal space.
▪ Care of either catheter site is a nursing responsibility.

Question 15

Nursing Assessment of Dialysis Fistula

Answer 15

▪ Dialysis Fistula
▪ A functioning fistula produces a bruit on auscultation & a thrill on palpation
▪ Checked every shift
▪ A bruit is normal in a fistula but abnormal in other arteries.
▪ The sound is produced by turbulent flow through the fistula.
▪ No ID band, cannulation, venepuncture or BP

Question 16

Common Renal Conditions

Answer 16

Acute Disease
▪ Temporary loss of kidney function – unable to filter waste products
▪ Short term – < 3 months
▪ Rapid onset – few days
▪ In response to an injury or illness affecting the kidneys, drugs, blockages of the kidney or other factors.

Chronic Disease
▪ Occurs when kidneys have been damaged in a way that cannot be reversed.
▪ Present for at least three months.
▪ Causes include: Genetics, infection, immune disorders that attack the kidneys, diabetes, and high BP

Question 17

Common Renal Conditions: UTI

Answer 17

▪ Inflammation & infection of the urinary tract – lower or upper
▪ Risk Factors – Iatrogenic; Medications; Behavioural; Anatomic; Genetic
▪ Around 20,500 hospital acquired UTIs occur each year in Australian hospitals
▪ Bacterial infections are the most common cause of a UTI – E Coli; Klebsiella; Candida Albicans; Pseudomonas
▪ Signs & Symptoms – Dysuria; Urgency & Frequency; Pain during intercourse; Offensive smelling urine
▪ Management – Antibiotics; Fluids; Hygiene; Cotton and loose fitting underwear

Question 18

Infants and Children

Answer 18

▪ Kidneys occupy a large proportion of the abdomen at birth.
▪ Urine formation occurs at the third month of fetal development.
▪ At about 2 -3 years of age the child becomes aware of bladder filling and begins to inhibit voiding.

Question 19

Pregnancy

Answer 19

▪ Full ward test can detect protein in the urine and elude to pre -eclampsia
– Further investigation can then be initiated
▪ Cannot perform a bladder scan on a woman who is pregnant or postpartum
– When fundus is palpable above the pubic symphysis

Question 20

Adults and Late Adulthood (65+ years)

Answer 20

▪ By 70 years of age 30- 50% of glomeruli have stopped functioning.
▪ Decreased oestrogen results in changes to the female urethra, bladder, vagina and pelvic floor.
▪ In men the prostate gland enlarges and can obstruct the flow of urine through the urethra.

Question 21

Social and Cultural Considerations

Answer 21

▪ There has been a 130% increase in chronic kidney disease (CKD) in last 10 years from diabetes.
▪ Higher incidence of CKD in Maori and Pacific Islander people.
▪ Urinary incontinence affects 50% of women over 50 years of age and 30% of men over 70.