Nursing of Adults with Medical & Surgical Conditions Urinary Disorders

Diagnostic Tests Urinalysis Rationale Nursing Interventions 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

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

Blood Urea Nitrogen Rationale Nursing Interventions 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

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: 0.5-1.2 mg/dl

Creatinine Clearance Rationale Nursing Interventions: Determine the renal excretory function Normal range: Serum: 0.5-1.2 mg/dl Urine: 90-139 ml/min (male) 80-125 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

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

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

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

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

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

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

Renal Angiography Rationale Nursing Interventions 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.

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

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

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

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

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

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

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

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

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)

Neurogenic Bladder Two Types Spastic Flaccid 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

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

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

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

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

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

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

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

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

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

Hydronephrosis

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

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

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

Common Locations of Renal Calculi

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

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

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 Calcium sodium cellulose phosphate Phosphorus aluminum hydroxide gel Urate Zyloprim

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

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

Renal Tumors Treatment Radical nephrectomy Radiation Chemotherapy

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

Polycystic Kidney Disease

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

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

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

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

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

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

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

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

Prostatectomy

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

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

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

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

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

Urethral Strictures Treatment Correction of stricture Analgesics Dilation Urethrotomy Analgesics

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

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

Nephrotic Syndrome Treatment Corticosteroids Diuretics Diet Low sodium High protein

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

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

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

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

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

Chronic Glomerulonephritis Treatment Same as Acute Glomerulonephritis Renal dialysis Kidney transplant

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

Acute Renal Failure Three Phases Oliguric Phase Diuretic 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

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

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

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

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

Chronic Renal Failure Treatment Dialysis Renal transplant Medications to treat symptoms Diet High in calories Restricted protein Restricted potassium and sodium Restricted fluids 300-600 cc’s above urine output

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

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

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 30-40 minutes each time

Peritoneal Dialysis

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

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

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

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