tubal ligatin

1. PREPARED BY: SHAMBEL DEBEBLE- IDNO-------------190/15
Submitted to: Mr. Tadele A. (MSc, Assistant professor)
Mr.Bikila T. (MSC ,Assistant professor )
June 13/06/ 2023
Fiche
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2.  Outlines
 Objectives
 Introduction
 Anatomy of Renal system
 Physiology of Renal system
 Assessment of Renal system
 Physical Examination of Renal system
 Diagnostic
 Summary
 Reference
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3.  Objectives
 At the end of this lesson students will be able to:
 Describes the anatomy and physiology renal system.
 Discuss information that will help you focus your renal and
urinary assessment.
 Describe abnormal renal and urinary assessment findings as
they are associated with specific disease states.
 Preformed physical examination after completed this courses.
 Identify normal and abnormal lab values and their impact on
your renal and urinary assessment.
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4.  INTRODUCTION
 Kidneys are the organ that filter waste products from the
blood.
 The kidneys serve three essential function:
 They function as filter, removing metabolic product and toxins
from the blood and excreting them through the urine.
 They regulate the body’s fluid status, electrolyte balance and
acid-base balance.
The kidney produce or activate hormones that are involved
erythrogenesis, Ca²˖ metabolism and the regulation of blood
pressure and blood flow.
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5.  Introduction cont.…
Renal function may be assessed by measuring blood urea and
serum creatinine. Renal function decreases with age , which
must be taken into account when interpreting test values.
These tests primarily evaluate glomerular function by assessing
the glomerular filtration
 In many renal diseases, urea and creatinine accumulate in the
blood because they are not excreted properly
These tests also aid in determining drug dosage for drugs
excreted through the kidneys
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6.  Overview Urinary system anatomy
 Main structures of the
urinary system:
Pair kidneys
Pair ureters
One bladder
One urethra
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7.  Kidneys cont.…
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8.  Kidney functions
Urine formation
 Excretion of waste products
 Regulation of electrolytes
 Regulation of acid-base balance
 Control of water balance
 Control BP
 Regulation of RBC production
 Synthesis of vitamin D to active form
 Secretion of prostaglandins
 Regulation of calcium and phosphorus balance
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9. Nephron
 Each kidney has approximately 1
million nephrons
 If the function is less than 20%
replacement therapy is usually
initiated
The nephron is responsible for the
initial formation of urine.
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10. ASSESSMENT
 History taking
Subjective data:- include all characterization of symptoms,
history of present illness, past medical and surgical history,
demographic data, and lifestyle factors.
Signs and symptoms involving the urinary tract may be due
to disorders of the kidneys, ureters, or bladder, surrounding
structures, or disorders of other body systems.
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11. Past Health History.
The patient should be questioned about the presence or history
of diseases that are related to renal or other urologic problems.
Some of these diseases are hypertension, diabetes mellitus,
metabolic problems, tuberculosis, viral hepatitis, congenital
disorders, neurologic conditions trauma.
Specific urinary problems such as any cancer, infections,
benign prostatic hyperplasia, and calculi should be noted.
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12. Medications.
An assessment of the patient's current and past use of
medications is important.
This should include over-the-counter drugs, as well as
prescription medications and herbs.
Drugs affect the urinary tract in several ways.
Many drugs are known to be nephrotoxic.
Certain drugs may alter the quantity and character of urine
output.
e.g., diuretics may increase the urine output.
Anticoagulants may cause hematuria.
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13. Past surgical history
The patient should also be questioned about any previous
hospitalizations related to renal or urologic diseases and all
urinary problems during past pregnancies.
The duration, severity, and patient's perception of any problem
and its treatment should be elicited.
Past surgeries, particularly pelvic surgeries, or urinary tract
instrumentation should be documented.
Information should be obtained from the patient about any
radiation or chemotherapy treatment for cancer
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14. Functional Health Patterns
• Health Perception–Health Management Pattern.
Ask about the patient's general health, particularly when disease
affecting the kidneys is suspected.
Sometimes responses such as “feeling tired all of the time,”
changes in weight or appetite, excess thirst, fluid retention, and
complaints of headache, pruritus, or blurred vision may be related
to abnormal kidney function.
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15. Similarly, the elderly patient may report malaise and nonlocal
zed abdominal discomfort as the only symptoms of a urinary
tract infection.
 An occupational history should be taken.
 Exposure to certain chemicals can affect the kidneys and
urinary tract system.
Aromatic amines and certain organic chemicals may increase
the risk of bladder cancers.
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16.  A smoking history should be obtained.
Cigarette smoking is a major factor in the risk for bladder
cancer.
Tumors occur 4 times more frequently in cigarette smokers
than in nonsmokers.
The presence of certain renal or urologic problems in a family
history increases the likelihood of similar problems occurring in
the patient.
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17. Nutritional-Metabolic Pattern.
The usual quantity and types of fluid a patient drinks are
important information related to urinary tract disease.
Dehydration may contribute to urinary infections, calculi
formation, and renal failure.
 Large intake of particular foods, such as dairy products or
foods high in proteins, may also lead to calculi formation.
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18. Nutritional-Metabolic Pattern.Cont.….
Caffeine, alcohol, carbonated beverages, or spicy foods
often aggravate urinary inflammatory diseases.
Many herbal teas also cause diuresis( increased production
of urine).
 An unexplained weight gain may be the result of fluid
retention secondary to a renal problem.
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19. Elimination Pattern.
 Ask about urine elimination patterns are the cornerstone of the
health history in the patient with a lower urinary tract disorder.
This line of inquiry begins with a question of how the patient
manages urine elimination.
The majority of patients eliminate urine by spontaneous voiding,
and they should be asked about daytime (diurnal) voiding
frequency and the frequency of night time or nocturia.
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20. Activity-Exercise Pattern.
The patient's level of activity should be assessed.
 A sedentary person is more likely to have stasis of urine than
an active individual, which can predispose to infection and
calculi.
Demineralization(loss of minerals) of bones in a person with
limited physical activity can cause increased urine calcium
precipitation.
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21. Sleep-Rest Pattern
Nocturia is a common and a particularly both some lower
urinary tract symptom that often leads to sleep deprivation,
daytime sleepiness, and fatigue.
multiple disorders affecting the lower urinary tract, including
urinary incontinence, urinary retention, and interstitial cystitis.
 Nocturia also may be attributable to polyuria owing to renal
disease, poorly controlled diabetes mellitus, alcoholism,
excessive fluid intake, or obstructive sleep apnea.
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22. Cognitive-Perceptual Pattern.
Pain is a frequent symptom of urinary tract disease.
Types of pain associated with renal and urologic problems
include dysuria, groin pain, costovertebral pain and suprapubic
pain.
 pain in the abdominal region just below the umbilicus.
Complaints of pain should be assessed and the location,
character, and duration documented.
Many urinary tract tumors are painless in the early stages.
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23. Self-Perception–Self-Concept Pattern.
Problems associated with the urinary system, such as
incontinence, urinary diversion procedures, and chronic fatigue
may indicate anemia, can result in loss of self-esteem and a
negative body image.
Sensitive questioning may elicit cues to problems in this area.
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24. Role-Relationship Pattern
Urinary problems can affect many aspects of a person's life,
including the ability to work and relationships with others.
These factors will have important implications for future
treatment and management of the patient's condition.
The nurse must be alert for indications from the patient.
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25. Sexuality-Reproductive Pattern.
The patient should be questioned about the effect of a renal or
urologic problem on her or his sexual patterns and satisfaction.
Problems related to personal hygiene and fatigue can seriously
affect a sexual relationship.
Although urinary incontinence is not directly associated with
sexual dysfunction, it often has a devastating effect on self-
esteem and social and intimate relationships.
 Counseling of both the patient and partner may be indicated
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26.  Urinary Tract Infections
UTI means infection of any part of urinary tract Kidney, Ureter,
Bladder and Urethra.
Defined by the presence of more than a hundred thousand
organisms per ml in midstream sample of urine.
Infections of the urethra and bladder are often considered
superficial or mucosal infections.
while prostatitis, pyelonephritis, and renal suppuration signify
tissue invasion.
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27.  Urinary Tract Infections
 Classification
Anatomic categories
- lower tract infection (urethritis, bladder cystitis)
- upper tract infection (acute pyelonephritis, and intrarenal and
perinephric abscesses).
Complicated UTI - there are underlying factors that predispose
to ascending bacterial infection catheterization, instrumentation,
anatomic or functional urologic abnormalities.
Uncomplicated UTI - Occurs without underlying abnormality or
impairment of urine flow.
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28.  Infecting organisms
Common agents are the gram-negative bacilli
Escherichia coli causes ~80% of acute infections in patients
without catheters, urologic abnormalities, or calculi
 Proteus Enterococci
 Klebsiella Staphylococci
Pseudomonas Candida
Enterobacter
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29.  Clinical Presentation
 Asymptomatic bacteriuria
Common in females & elderly.
25% develop symptomatic UTI .
25% clear spontaneously.
Spontaneous cure & reinfection are common.
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30.  Clinical Presentation
Bladder Cystitis
• Symptoms: dysuria, frequency, urgency, and supra pubic pain
• Physical examination generally reveals only tenderness of the
supra pubic area
Acute Pyelonephritis:- is a bacterial infection causing
inflammation of the kidneys and is one most common diseases of
kidney.
• Symptoms generally develop rapidly over a few hours or a day
• fever, shaking chills, nausea, vomiting, abdominal pain, and
diarrhea
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31. Urinary Tract Pain
 Genitourinary pain:-is not always present in renal disease, but
is generally seen in the more acute conditions of the urinary
tract
 Kidney pain: may be felt as a dull ache in costovertebral
angle; or may be a sharp, colicky pain felt in the flank area that
radiates to the groin or testicle. Due to distention of the renal
capsule; severity related to how quickly it develops.

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32. Involuntary Voiding
Urinary incontinence: involuntary loss of urine; may be due to
pathologic, anatomical, or physiologic factors affecting the
urinary tract.
Ureteral pain: felt in the back and radiates to the groin or scrotum if
the upper ureter is the source, to the suprapubic area, penis, and
urethra if the lower ureter is the source.
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33. • Bladder pain (lower abdominal pain or pain over suprapubic area):
may be due to bladder infection or over distended bladder
• Urethral pain: from irritation of bladder neck, from foreign body in
canal, or from urethritis due to infection or trauma; pain increases
when voiding.
• Back and leg pain: due to cancer of prostate with metastases to bone.
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34. Physical Examination
Inspection.
The nurse should assess for changes in the following:
Skin: pallor, yellow-gray cast, excoriations, changes in turgor, bruises,
texture e.g., rough, dry skin.
Mouth: stomatitis, ammonia breath odor
Face and extremities: generalized edema, peripheral edema, bladder
distention, masses, enlarged kidneys
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35. Abdomen: skin changes described earlier, as well as striae,
abdominal contour for midline mass in lower abdomen may
indicate urinary retention or unilateral mass occasionally seen in
adult, indicating enlargement of one or both kidneys from large
tumor or polycystic kidney)
Weight: weight gain secondary to edema; weight loss and
muscle wasting in renal failure
General state of health: fatigue, lethargy, and diminished
alertness
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36. Palpation.
The kidneys are posterior organs protected by the abdominal
organs, the ribs, and the heavy back muscles.
A landmark useful in locating the kidneys is the costovertebral
angle or CVA formed by the rib cage and the vertebral column.
The normal-sized left kidney is rarely palpable because the
spleen lies directly on top of it.
Occasionally the lower pole of the right kidney is palpable.
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37. Palpation cont.
To palpate the right kidney, the examiner's left anterior hand is
placed behind and supports the patient's right side between the
rib cage and the iliac crest .
The right flank is elevated with the left hand, and the right hand
is used to palpate deeply for the right kidney.
The lower pole of the right kidney may be felt as a smooth,
rounded mass that descends on inspiration.
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39. Percussion.
Tenderness in the flank area may be detected by fist percussion kidney
punch.
This technique is performed by striking the fist of one hand against
the dorsal surface of the other hand, which is placed flat along the
posterior CVA margin.
Normally a firm blow in the flank area should not elicit pain.
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41. If CVA tenderness and pain are present, it may indicate a
kidney infection or polycystic kidney disease.
Normally a bladder is not percussible until it contains 150
ml of urine.
If the bladder is full, dullness is heard above the symphysis
pubis.
 A distended bladder may be percussed as high as the
umbilicus
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42. Auscultation.
The bell of the stethoscope may be used to auscultate over
both CVAs and in the upper abdominal quadrants.
With this technique, the abdominal aorta and renal arteries are
auscultated for a bruit (an abnormal murmur), which indicates
impaired blood flow to the kidneys.
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43. Diagnostic studies of the urinary system
Urinalysis
Urinalysis is a general examination of urine to establish
baseline information or provide data to establish a tentative
diagnosis and determine whether further studies are to be
ordered.
Try to obtain first urinated morning specimen.
Ensure that specimen is examined within 1 hr of urinating.
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44. Creatinine clearance
Creatinine is a waste product of protein breakdown (primarily
body muscle mass).
• Rate at which creatinine is removed from the blood.
• Useful measure of
- glomerular filtration rate
• - excreting capacity of the kidney.
Normal values
men : 90-140 ml/sec/m²
women: 72-110 ml/sec/m²
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45. Urine culture
Urine culture is done to confirm suspected urinary tract infection and
identify causative organisms.
Use sterile container for collection of urine.
Concentration test
Study evaluates renal concentration ability.
Concentration is measured by specific gravity of urines.
Normal values 1.020-1.035
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46. Blood Chemistries
BUN( blood urea nitrogen)
BUN is most commonly used to identify presence of renal
problems.
Concentration of urea in blood is regulated by rate at which
kidney excretes urea.
Be aware that, when interpreting BUN, non renal factors
may cause increase.
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47. Normal finding: 10-30 mg/dl (1.8-7.1 mmol/L)
Creatinine
Creatinine is more reliable than BUN as a determinant of renal
function.
Creatinine is end product of muscle and protein metabolism
and is liberated at a constant rate.
Normal finding: 0.5-1.5 mg/dl (44-133 μmol/L).
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48. Uric acid
Uric acid study is used as a screening test primarily for
disorders of purine metabolism but can indicate kidney disease
as well.
Normal finding: 2.5-5.5 mg/dl (149-327 mol/L) for women; 4.5-
6.5 mg/dl (268-387 mol/L) for men
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49. Sodium (Na+)
Sodium is main extracellular electrolyte determining blood
volume.
Usually, values stay within normal range until late stages of
renal failure.
Normal finding: 135-145 mEq/L (135-145 mmol/L)
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50. Potassium (K+)
Kidneys are responsible for excreting majority of body's
potassium.
In renal disease, K+ determinations are critical because K+ is
one of the first electrolytes to become abnormal.
Elevated K+ levels of >6 mEq/L can lead to muscle weakness
and cardiac dysrhythmias.
Normal finding: 3.5-5.0 mEq/L (3.5-5.0 mmol/L)
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51. Calcium (Ca2+)
Calcium is main mineral in bone and aids in muscle contraction,
neurotransmission, and clotting.
In renal disease, decreased reabsorption of Ca2+ leads to renal
osteodystrophy.
Normal finding: 9-11 mg/dl (4.5-5.5 mEq/L, 2.25-2.74 mmol/L)
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52. Phosphorus
In renal disease, phosphorus levels are elevated because the
kidney is the primary excretory organ.
Normal finding: 2.8-4.5 mg/dl (0.95-1.45 mmol/L)
Bicarbonate (HCO3
−)
Most patients in renal failure have metabolic acidosis( when the
body produce more acid or kidneys are not removing enough
acid from body) and low serum HCO3
− levels.
Normal finding: 22-26 mEq/L (22-26 mmol/L)
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53.  Renal disorders
Acute renal failure:-is a rapid loss of renal function due to
damage to the kidneys.
 Depending on the duration and severity of ARF, a wide range of
potentially
• life-threatening metabolic complications can occur, including
metabolic acidosis as well as fluid and electrolyte imbalances.
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54.  Chronic renal failure
Chronic, irreversible loss of kidney function attributable to loss of
functional nephron mass – pathophysiologic processes for more
than 3 months.
Nephrotic syndrome:-is a kidney disorder that causes your
body to pass too much protein in your urine.
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55. RFT (Renal Function Test)
•is used to evaluate the severity of kidney disease and to follow
the patient's clinical progress.
Tests involved in RFT
• Urea Uric acid
• Ammonia Calcium
• Parathyroid Potassium
• Hormone
• Creatinine clearance and Glomerular filtration rate
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56. Summary
An assessment of the urinary system is used to gather information
about the urinary structures and urinary elimination.
The nursing student is assessing factors that may affect a patient’s
ability to urinate normally.
 An assessment of the patient’s elimination history, possible
symptoms of a urinary problem, and complaints are important
Understanding the importance and function of the renal system is
essential for performing a comprehensive nursing assessment and
identifying renal issues.
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57.  Summary cont.…
The renal system includes the kidney, 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.
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58. Reference
1. Nursing Health Assessment A Critical Thinking, Case Studies
Approach Patricia M. Dillon, DNSC, R N
2. Brunner And Suddarth’s Texbook Of Medical-surgical Nursing 10th
Edition By Suzanne C.O’connell;bare Brenda G Smeltzer(2003-07).
3. Essentials Of Human Anatomy And Physiology 11th Edition
4. Barbara Bates: a Guide To Physical Examination And History Taking
,A guide To Clinical Thinking.
5. Cox’sclinical Applications Of Nursingdiagnosis 5th Editionadult, Child,
Women’s, Mental Health,gerontic, And Home Health Considerations
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