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Nursing of Adults with Medical & Surgical Conditions Urinary Disorders.

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Presentation on theme: "Nursing of Adults with Medical & Surgical Conditions Urinary Disorders."— Presentation transcript:

1 Nursing of Adults with Medical & Surgical Conditions Urinary Disorders

2 Diagnostic Tests Urinalysis –Rationale Identifies normal and abnormal constituents in the urine See Table 10-2; Page 414 –Constituent –Normal Range –Influencing factors –Nursing Interventions Clean catch or catheterized specimen Sent to lab immediately

3 Culture and Sensitivity –Rationale Confirm suspected infections Identify causative organisms Determine appropriate antimicrobial therapy –Nursing Interventions Clean catch or catheterized urine specimen

4 Blood Urea Nitrogen –Rationale Determine the kidney’s ability to rid the blood of urea (results from protein breakdown). Normal range: –10-20 mg/dl Urea is excreated entirely by the kidneys and is therefore an indication of kidney function. –Nursing Interventions NPO for 8 hours Elevated BUN may cause disorientation or seizures

5 Blood Creatinine –Rationale Measures the amount of creatinine in the blood Creatinine is excreated entirely by the kidneys and is therefore an indication of kidney function. Normal range: – mg/dl

6 Creatinine Clearance –Rationale Determine the renal excretory function Normal range: –Serum: mg/dl –Urine: ml/min (male) ml/min (female) -Nursing Interventions: -Fasting blood sample is drawn at onset of testing and another at the conclusion -24 hour urine specimen -Discard first specimen -Collect ALL urine in 24 hour period

7 Prostate-Specific Antigen (PSA) –Rationale Glycoprotein produced by normal prostatic tissue Normal Range: –Less than 4 nanoagrams/ml –Nursing Interventions Be sure blood sample is obtained before physical exam. –Manipulation will cause elevated results Elevated levels result from prostate cancer, BPH, and prostatitis

8 Kidney-Ureter-Bladder Radiography (KUB) –Rationale Assesses the general status of the abdomen and evaluates the size, structure, and position of the urinary tract structures –Nursing interventions No special preparation

9 Intravenous Pyelogram (IVP) –Rationale Evaluates structures of the urinary tract, filling of the renal pelvis with urine, and transport of urine to the bladder Radiopaque dye is injected into a vein Radiographs are taken at intervals as dye is excreated by the kidneys –Nursing Interventions Ask patient if allergic to iodine NPO 8 hours Be sure it is scheduled before any barium studies

10 Retrograde Pyelography –Rationale Examination of the lower urinary tract with a cystoscope Radiopaque dye is injected directly into the ureters –Nursing Interventions No special preparation May be NPO if sedation is required

11 Voiding Cystourethrography –Rationale Used to detect abnormalities of the urinary bladder and urethra Dye is injected into an indwelling catheter to outline the lower urinary tract Radiographs are taken – pt. will be asked to void during radiographs –Nursing Interventions Enema before testing

12 Endoscopic Procedures (Cystoscope) –Rationale Visual examination to inspect, treat, or diagnose disorders of the urinary bladder and proximal structures using an instrument with a scope and light source Patient is sedated and local anesthetic is given –Nursing Interventions Preoperative preparation PostProcedure: Encourage fluids, monitor urine for amount, color, dysuria

13 Renal Angiography –Rationale Evaluation of blood supply to the kidneys, evaluated masses, and detects possible complications after renal transplant Radiopaque dye is inserted into an artery –Nursing Interventions NPO 8 hours Post Procedure: –Flat in bed for several hours –Assess puncture site for bleeding or hematoma –Maintain pressure dressing at the site –Assess circulatory status of the extremity q15min for 1hr then q2hrs for 24 hr.

14 Urodynamic Studies (Cytometrogram) –Rationale Indicated when neurological disease is suspected of being an underlying cause of incontinence Catheter is inserted into the bladder and connected to a cystometer, which measures bladder capacity and pressure The patient will be asked about sensations of heat, cold, and urge to void during exam

15 Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Renal Scan Ultraonography Renal Biopsy

16 Urinary Retention Etiology/Pathophysiology –The inability to void even with an urge to void –Acute or chronic –Contributing factors stress surgery or trauma to the perineum calcui infection tumor medications

17 Urinary Retention Signs & Symptoms –Distended bladder may be palpated above the symphysis pubis –Discomfort in pelvic region –Voiding frequent, small amounts

18 Urinary Retention Treatment –Warm shower or sitz bath –Natural voiding postion if possible –Urinary catheter –Surgical removal of obstruction –Analgesics

19 Urinary Incontinence Etiology/Pathophysiology –Involuntary loss of urine from the bladder Total incontinence Dribbling Stress incontinence –Secondary infection loss of sphincter control sudden change in pressure in the abdomen –Permanent spinal cord injuries –Temporary pregnancy

20 Urinary Incontinence Signs & Symptoms –Involuntary loss of urine Leaking with coughing, sneezing, or lifting heavy objects

21 Urinary Incontinence Treatment –Treat underlying cause –Surgical repair of bladder –Temporary or permanent catheter –Bladder training –Kegel exercises

22 Neurogenic Bladder Etiology/Pathophysiology –Loss of voluntary voiding control –Results in urinary retention or incontinence –Lesion of the nervous system that interferes with normal nerve conduction to the urinary bladder Congenital(spina bifida) Neurological disease (multiple sclerosis) Trauma (spinal cord injury)

23 Neurogenic Bladder –Two Types Spastic –loss of sensation to void –loss of motor control –bladder empties on reflex –no control Flaccid –continues to fill and distend –pooling of urine –incomplete emptying –loss of sensation

24 Neurogenic Bladder Signs & Symptoms –Infrequent voiding –Incontinence –Diaphoresis, flushing, nausea prior to reflex incontinence

25 Neurogenic Bladder Treatment –Antibiotics –Urecholine increases contractility of the bladder –Intermittent catheterization –Bladder training using bladder compression or anal stimulation

26 Urinary Tract Infections Etiology/Pathophysiology –Type depends on location Urethritis (urethra), Cystitis (bladder), pyelonephritis (kidney), prostatitis (prostate) –Pathogens enter the urinary tract Nosocomial infection Bladder obstruction Insufficient bladder emptying Decreased bactericidal secretions of the prostate Perineal soiling in females Sexual intercourse –Chronic health conditions may predispose DM, MS, spinal cord injury, hypertension, kidney disease

27 Urinary Tract Infections Signs & Symptoms –Urgency –Frequency –Burning on urination –Hematuria –Nocturia –Abdominal discomfort –Perineal or back pain –Cloudy or blood tinged urine

28 Urinary Tract Infections Treatment –Antibiotics oral or parenteral bacterial specific –Urinary antiseptics/analgesics Mandelamine Pyridium –orange urine –Encourage fluids –Perineal care

29 Urinary Obstruction Etiology/Pathophysiology –Strictures –Kinks –Cysts –Tumors –Calculi –Prostatic hypertrophy

30 Urinary Obstruction Signs & Symptoms –Continued need to void –Voiding small amounts frequently –Pain dull to acute incapacitating –Nausea

31 Urinary Obstruction Treatment –Establish urinary drainage indwelling catheter suprapubic cystostomy ureterostomy nephrostomy –Relieve pain narcotics anticholinergics –Atropine –decrease smooth muscle motility

32 Hydronephrosis Etiology/Pathophysiology –Dilation of the renal pelvis and calyces –Unilateral or bilateral –Obstruction of the urinary tract Pressure from accumulated urine Functional and anatomical damage to the renal system –Untreated the kidney may be destroyed

33 Hydronephrosis

34 Signs & Symptoms –Dull flank pain Slowly developing disease –Severe stabbing pain Sudden obstruction of the ureter –Nausea and vomiting –Frequency, dribbling, burning, and difficulty starting urination

35 Hydronephrosis Treatment –Surgery to relieve obstruction –Nephrectomy Severely damaged kidney –Antibiotics –Narcotics Demerol & morphine

36 Urolithiasis Etiology/Pathophysiology –Formation of urinary calculi (stones) –Develops from minerals –Identified according to location Nephrolithiasis (kidney) Ureterolithiasis (ureter) Cystolithiasis (bladder) –Predisposing factors Immobility Hyperparathyroid Recurrent UTI’s

37 Common Locations of Renal Calculi

38 Urolithiasis Signs & Symptoms –Flank or pelvic pain –Nausea and vomiting –Hematuria

39 Urolithiasis Treatment –Antibiotics –Encourage fluids –Ambulate –STRAIN ALL URINE –Surgical procedures Cystoscopy Ureterolithotomy Pyelolithotomy Nephrolithotomy –Lithotripsy

40 Urolithiasis –Teaching Diet –Reduce calcium phosphorus and purines »Avoid cheese, greens, whole grains, carbonated beverages, nuts, chocolate, shellfish and organ meats 2000 cc’s fluid daily –Medications to reduce specific particles which formed stone Calciumsodium cellulose phosphate Phosphorusaluminum hydroxide gel UrateZyloprim

41 Renal Tumors Etiology/Pathophysiology –Adenocarcinomas that develop unilaterally –Renal cell carcinomas arise from cells of the proximal convoluted tubules –Risk factors Smoking, familial incidence and preexisting renal disorders

42 Renal Tumors Signs & Symptoms –Early Intermittent, painless, hematuria –Late Weight loss Dull flank pain Palpable mass in flank area Gross hematuria

43 Renal Tumors Treatment –Radical nephrectomy –Radiation –Chemotherapy

44 Renal Cysts Etiology/Pathophysiology –Cysts form in the kidneys –A single cyst usually causes no problems –Polycystic Kidney Disease –Cysts cause pressure on the kidney structures and compromise function

45 Polycystic Kidney Disease

46 Renal Cysts Signs & Symptoms –Abdominal and flank pain –Voiding disturbances –Recurrent UTI’s –Hematuria –Hypertension

47 Renal Cysts Treatment –No specific treatment –Relieve pain –Heat (unless bleeding) –Analgesics –Antibiotics –Antihypertensives –Dialysis –Renal transplant

48 Tumors of the Urinary Bladder Etiology/Pathophysiology –Most common site of cancer in the urinary tract –Range from benign papillomas to invasive carcinoma

49 Tumors of the Urinary Bladder Signs & Symptoms –Painless, intermittent hematuria –Changes in voiding patterns

50 Tumors of the Urinary Bladder Treatment –Localized Remove tissue with by burning –Cauterization, laser, chemotherapy instillation, radiation –Invasive lesions –Partial or total cystectomy Urinary diversion

51 Benign Prostatic Hypertrophy Etiology/Pathophysiology –Enlargement of the prostate gland –Common in men 50 yrs and older –Cause is unknown Possibly hormonal influence

52 Benign Prostatic Hypertrophy Signs & Symptoms –Frequent urination –Difficulty starting urination –Dysuria –Frequent UTI’s –Hematuria –Oliguria –Nocturia

53 Benign Prostatic Hypertrophy Treatment –Relieve obstruction Foley catheter –Prostatectomy Transurethral Suprapubic Radical perineal Retropubic –Postoperative TURP –Bladder irrigations (continuous or intermittent) –Urine will be pink to cherry red Suprapubic or abdominal –Assess dressings

54 Prostatectomy

55 Cancer of the Prostate Etiology/Pathophysiology –Malignant tumor of the prostate gland –Common in men 50 yrs and older –Frequently metastasis to pelvic lymph nodes and bone

56 Cancer of the Prostate Signs & Symptoms –Initially No symptoms –Advanced stages Urinary obstruction

57 Cancer of the Prostate Treatment –Localized Radiation Surgery –Men over 70 yrs Radiation Hormone therapy –Advanced Estrogen therapy –Blocks androgen production to alter tumor growth Orchiectomy –Eliminate testosterone production Radiation therapy Chemotherapy

58 Urethral Strictures Etiology/Pathophysiology –Narrowing of the lumen of the urethra that interferes with urine flow –Congenital –Acquired Chronic infection, trauma, or tumor

59 Urethral Strictures Signs & Symptoms –Dysuria –Weak urinary stream –Nocturia –Pain with bladder distention

60 Urethral Strictures Treatment –Correction of stricture Dilation Urethrotomy –Analgesics

61 Nephrotic Syndrome Etiology/Pathophysiology –Physiologic changes of the glomeruli interferes with selective permeability

62 Nephrotic Syndrome Signs & Symptoms –Proteinuria –Hypoalbuminemia –Generalized edema Hands, face, and feet –Anorexia –Fatigue –Oliguria less than 500 cc’s in 24hrs

63 Nephrotic Syndrome Treatment –Corticosteroids –Diuretics –Diet Low sodium High protein

64 Acute Glonerulonephritis Etiology/Pathophysiology –Previous infection with B-hemolytic streptococcus (2-3 weeks prior) –Preexisting mulitsystem diseases SLE

65 Acute Glonerulonephritis Signs & Symptoms –Edema of the face, esp eyes –Pallor –Malaise –Anorexia –Dyspnea with exertion –Hematuria –Changes in voiding patterns –Oliguria –Dysuria

66 Acute Glonerulonephritis Treatment –Antibiotics –Treat primary symptoms –Diuretics –Antihypertensives –Diet Protein restrictions Sodium restrictions Increase calories

67 Chronic Glomerulonephritis Etiology/Pathophysiology –Slow, progressive destruction of glomeruli –Commonly caused by other chronic illnesses DM SLE

68 Chronic Glomerulonephritis Signs & Symptoms –Malaise –Morning headaches –Dyspnea with exertion –Visual and digestive disturbances –Generalized edema –Weight loss –Fatigue –Hypertension –Anemia –Proteinuria

69 Chronic Glomerulonephritis Treatment –Same as Acute Glomerulonephritis –Renal dialysis –Kidney transplant

70 Acute Renal Failure Etiology/Pathophysiology –Kidney function altered Interference with ability to filter blood Decrease in blood flow to the kidney –Causes may be Hemorrhage, trauma, infection, and decreased cardiac output

71 Acute Renal Failure –Three Phases Oliguric Phase –BUN and creatinine levels rise –Urine output decreases –Lasts 4-6 weeks Diuretic Phase –BUN and creatinine begin to return to normal –Urine output increases Recovery Phase –Normal BUN and Creatinine –Normal urine output

72 Acute Renal Failure Signs & Symptoms –Anorexia –Nausea –Vomiting –Edema –Dry mucous membranes –Poor skin turgor –Urine output less than 400 cc/24hrs (Oliguric phase)

73 Acute Renal Failure Treatment –Administer fluids Monitor carefully –Assess for and treat electrolyte imbalances –Dialysis –Diet Low protein, High carbohydrate, Low potassium and sodium –Diuretics –Kayexalte Decrease potassium –Antibiotics

74 Chronic Renal Failure Etiology/Pathophysiology –End-Stage Renal Failure –Kidneys are unable to regain normal function –Develops slowly over an extended period of time –Result of kidney disease or other disease process that compromises renal blood flow –Causes Pyelonephritis, chronic glomerulonephritis, glomerulosclerosis, chronic urinary obstruction, severe hypertension, DM, gout, polycystic kidney disease

75 Chronic Renal Failure Signs & Symptoms –Headache –Lethargy –Decreased strength –Anorexia –Pruritus –Anuria –Muscle cramps or twitching –Impotence –Dusky yellow-tan or gray skin color –Disorientation & Mental lapses –Anemia

76 Chronic Renal Failure Treatment –Dialysis –Renal transplant –Medications to treat symptoms –Diet High in calories Restricted protein Restricted potassium and sodium –Restricted fluids cc’s above urine output

77 Dialysis A medical procedure for the removal of certain elements from the blood through a semipermeable membrane (external or pertoneum) Mimics kidney function Two types: –Hemodialysis –Peritoneal dialysis

78 Hemodialysis Requires an access to the patient’s circulatory system to route blood through the artificial kidney (dialyzer) for removal of wastes, fluids, and electrolytes and then return the blood to the patient’s body –Access Temporary –Subclavian or femoral catheters –External shunt in the forearm Permanent –Arteriovenous fistual in the forearm –Frequency Three time a week for 3 to 6 hours

79 Peritoneal Dialysis The peritoneum is used as the semipermeable membrane instead of the dialyzer. A catheter is placed in the peritoneal space A dialyzing fluid is instilled for a predetermined period of time, then drained. Frequency 4 times a day; 7 days a week approximately minutes each time

80 Peritoneal Dialysis

81 Surgical Procedures for Urinary Disorders Nephrectomy –Surgical removal of the kidney –Post-Op Assess for hemorrhage Monitor v/s Maintain urinary drainage system

82 Surgical Procedures for Urinary Disorders Nephrostomy –Incision to drain the pelvis of the kidney –Post-Op –Maintain urinary drainage system –Assess for hemorrhage –Keep dressing clean and dry –Never clamp a nephrostomy tube

83 Surgical Procedures for Urinary Disorders Kidney Transplantation –Nonfunctioning kidney remains in place –Donor kidney is placed in the iliac fossa –Post-Op Assess for s/s of rejection and infection –Apprehension, edema, fever, increased blood pressure, oliguria, tenderness over graft site Immunosuppressive agents –Cyclosporine Corticosteroids Mycophenolate mofetil –New drug helps prevent rejection

84 Surgical Procedures for Urinary Disorders Urinary Diversion –Ileal Conduit Ureters are implanted into a lop of the ileum that is isolated and brought to the surface of the abdominal wall Drainage bag is placed over the stoma to collect the urine –Continent Ileal Urinary Reservoir or Kock’s Pouch Implantation of the ureters into a segment of the small intestine which has been removed Control of urine is achieved by the use of a nipplelike valve that prevents leakage of urine The patient inserts a catheter through the valve at regular intervals to drain the reservoir


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