GENITOURINARY SYSTEM

Michelle GardnerNUR-224

URINARY SYSTEM

ASSESSMENT OF THE URINARY SYSTEM

Subjective Dataa. Good communication skillsb. Avoid medical terminologyc. Anxiety/embarrassment –

“forget/deny”--

ASSESSMENT DATA

Past Health Historya. Presence/history of diseases r/t

urologic problems – DM, HTNb. Neurologic conditions – back injury,

stroke, traumac. Urinary problems – BPH, renal

calculi, cancer, infection

ASSESSMENT DATA

Medicationsa. Prescription / OTC / Herbsb. Nephrotoxic medications -- antibioticsc. Quantity & character of urine output –

diuretic, anticholinergic, antihistamined. Change in color – Pyridium, Macrodantin

ASSESSMENT DATA

Surgerya. Previous hospitalizations r/t

urologic diseaseb. Pelvic surgeriesc. Urinary instrumentationd. Urinary problems during past

pregnanciese. Radiation/chemotherapy

ASSESSMENT DATA Pain Changes in voiding Affects of aging on the urinary

system a. Decrease muscle tone b. Decrease bladder capacity c. Prostate enlargement

d. Changes in metabolism

BLOOD CHEMISTRIES

Blood Chemistries Serum Creatinine: 0.6 – 1.2mg/dlo End product of muscle & protein

metabolismo Excellent indicator of kidney functiono Renal disease results in increase

creatinine

BLOOD CHEMISTRIES

BUN/Blood Urea Nitrogen: 7-18mg/dlo Used to identify renal problemso Nonrenal factors may increase BUN a. Fever b. Dehydration c. High protein diet d. Athletic activity e. Drugs and vitamins (acetaminophen,

ibuprofen, vitamin D)

DIAGNOSTIC STUDIES KUB (kidneys, ureters, bladder)o X- ray exam of abdomen & pelviso Used to detect abnormalities

o Urinary calculi o Cystso Tumorso Hydronephrosis

DIAGNOSTIC STUDIES IVP (INTRAVENOUS PYLEOGRAM)

Urographyo Intravenous injection of radiopaque

imaging dyeo X-ray imaging of dye through upper

and lower urinary system

INTRAVENOUS UROGRAPHY

INTRAVENOUS UROGRAPHY

Patient preparation:o Consent form o Cathartic/enema the night beforeo Identify allergies – shellfish,

iodineo Pre-medicate–antihistamine

(Benadryl) o NPO 8 hr. before procedure o Transitory effects – contrast medium

INTRAVENOUS UROGRAPHY

Post-procedureo Monitor vital signso Assess for s/s anaphylactic reactionso Monitor urine outputo Force fluids

RENAL ANGIOGRAPHY RENAL ANGIOGRAM:o Catheter inserted into femoral arteryo Contrast material injected through the

cathetero Visualize renal blood vessels Findings :1. Renal artery stenosis2. Differentiate renal cysts from tumors3. Evaluate hypertension

RENAL ANGIOGRAPHY Patient preparationo Consent formo Cathartic/enema the evening beforeo Assess allergic reactiono Mark peripheral pulses

RENAL ANGIOGRAPHY Post-Procedureo Monitor vital signso Pressure dressing over insertion siteo Assess insertion site - o Bedrest with affected leg straighto Palpate peripheral pulses

RENAL BIOPSY Done as a needle biopsy with needle

insertion into lower lobe of the kidney OR open biopsy via small flank incision

o Obtain renal tissue to determine type of renal disease

o Kidneys are vascular organs – hemorrhage/complication

RENAL BIOPSY

Patient preparationo Consent form signedo NPO status 8 hrs. prior to testo Assess baseline coagulation statuso Medications that may alter clotting

function

RENAL BIOPSY

RENAL BIOPSYPost-Procedureo Pressure dressing appliedo Check puncture site – swelling/tendernesso Prone position for 30-60 minuteso Monitor vital signso Observe for gross bleedingo Assess for flank pain, Hgb./Hct. levelso Avoid lifting heavy object/strenuous

activity – 7 days

UROLOGIC ENDOSCOPIC PROCEDURES

o Visualize/inspect the interior of the urethra and bladder with a tubular lighted scope (cystoscope)

o Used to:a. Treat bleeding lesionsb. Insert ureteral cathetersc. Remove calculi d. Obtain biopsy specimens

CYSTOSCOPY Patient preparationo Signed consent formo NPO prior to the procedureo Local topical anesthetic o Lithotomy position – leg cramps

CYSTOSCOPY Post-procedureo Expected side effects - burning on

urination, blood-tinged urine, urinary frequency

o Encourage increased fluids o Warm sitz bath o Mild analgesics

RENAL CALCULI

UROLITHIASIS/NEPHROLITHIASIS

500,000 people in the U.S. have kidney stone disease

Incidence is highest in Southern & Midwest states.

Occurs between the 3rd-5th decade of life. Recurrence of stones – 50% of pts. More common in men than in women

RENAL CALCULI

Risk Factors Family history of stone formation Dehydration increase urine

concentrations Excess dietary intake of calcium, oxalate,

or proteins Sedentary lifestyle/immobility Genetic predisposition

RENAL CALCULIo Stones can be found anywhere from

kidney to bladdero Vary in size o Factors that contribute to urolithiasis * supersaturation * nucleation

RENAL CALCULI

Pathophysiology Concentration of an insoluble salt is

high in the urine supersaturation Crystals form from supersaturated

urine Growth continues by aggregation to

form larger particles – stone formation

RENAL CALCULI

RENAL CALCULI 4 Major Categories of Stones1. Calcium 2. Oxalate3. Uric acid4. Cystine

Calcium Calculi

High concentration of calcium in the blood/urine

70-80% of kidney stones are calcium stones

Smaller stones maybe trapped in the ureter

Seen more in men

Calcium Calculi (Oxalate)Risk factors Hypercalciuria/hypercalcemia,

immobility, vit.D, urine intoxication, dehydration

Management Thiazide diuretics Limit foods that acidify urine Hydration/exercise

Uric Acid Stones

Uric Acid Calculio Urine

concentration of uric acid is high

o Common in menCauses: 1.Gout2. Increased

dietary intake of purine

3.Acid urine

1. Reduce dietary purines– sardines, mussels, organ meats, aged cheese

2. Administer allopurinol (Zyloprim)

3. Reduce urinary concentration of uric acid

Struvite Calculi

Struvite Calculi (Staghorn) 15-20 % of stones -

magnesium/ammonium/phosphateRisk Factors UTIs, esp Proteus infections Stones are large fill renal pelvisManagement Antibiotics Surgical intervention/lithotripsy

Cystine Calculio Make up 1-2% of

all stoneso Caused by

genetic defecto Tend to form in

acid urineo Stones appear

during childhood / adolescence

o Rare in adults

o Increase hydrationo Low-protein diet

RENAL CALCULI Clinical Manifestations:o Severe flank pain / renal colic o Abdominal paino Hematuria o Oliguria/anuria o Nausea /Vomiting/Diarrhea

RENAL CALCULIDiagnostic Studies:o Urinalysiso 24 hr urinary measurement for calcium,

uric acido X-ray - KUB o Renal Ultrasonographyo CT Scan

RENAL CALCULIManagement

Pain management o Opiod analgesics – Morphineo NSAID Toradalo Comfort measureso Increase fluid intake (oral/intravenous)

RENAL CALCULI Stones may pass spontaneously Stones larger than 4mm are unlikely

to pass through the ureter Chemical analysis of the stone to

determine the composition of the stone

STRAIN ALL URINE

RENAL CALCULI THERAPUETIC INTERVENTIONS ESWL-Extracorporeal shock-wave lithotripsyo Non-invasive procedureo External shock-waves break up the stone o No damage to surrounding tissueo Stones are fragmented into fine sando Fragments are excreted in the urineo All urine is strained -- chemical analysiso Anesthesia is necessary

RENAL CALCULIo Cystoscopy passed – removes stones

located in the ureter close to the bladder o Stone removed -- grasping basket, forcepso Stent may be placedo Foley catheter -- facilitate passage stone

fragments o Minimal complications

RENAL CALCULI After episode of urolithiasis a. Increase fluid intake – 3000ml/day b. High urine output – 2L/day c. Water is the preferred fluid d. Avoid tea, coffee, colas e. Limit foods high in oxalate, calcium, & purinesSTRAIN ALL URINE -

BENIGN PROSTATIC HYPERPLASIA (BPH) Age–related, nonmalignant enlargement

of the prostate gland• Enlargement of the prostate gland --

compress the urethra/bladder This impedes the normal flow of urine Begins at the age of 40 and continues

slowly throughout the rest of life Symptoms appear slightly earlier in Afro-

American men

BPH

Begins with small layers in the periuretheral gland

Prostate enlarges through formation /growth of nodules and enlargement of glandular cells

Enlargement compresses against the urethra urologic symptoms

Changes occur over a long period of time

BPH

Clinical Manifestations Difficulty starting urinary stream Urinary frequency Nocturia Leakage or dribbling of urine Urgency

BPH

Complications Urinary retention Urinary tract infections Bladder stones

BPHDiagnostic Studies History & physical exam Urinalysis/ C&S Digital rectal exam (DRE) Prostatic Specific Antigen(PSA) -- R/O Prostate Cancer Serum Creatinine

MEDICATION THERAPY

ALPHA-ADRENERGIC BLOCKERS

Relax the smooth muscle of the bladder neck and prostate

• Improves urine flow• Relax smooth muscle of the prostate

BPH

ALPHA-ADRENERGIC BLOCKERS Flomax- (tamsulosin) Cardura - (doxazosin) Hytrin – (terazosin) Uroxatral – (alfuzosin)Side effect

orthostatic hypotension dizziness

BPH

5 ALPHA-REDUCTASE INHIBITORS Decreases the size of the prostate

gland Proscar (finasteride) Avodart – (dutasteride) Side effect - *decreases libido, *erectile dysfunction

BPH

Minimally Invasive Therapy

used when medication not effective relieves the manifestations of BPH less invasive than traditional surgery

BPH Transuretheral Needle Ablation

(TUNA)

Low-wave radio frequency – to burn away a region of the enlarged prostate

Improves the flow of urine 70% of pt. show marked improvement Little pain Early return to regular activities

TUNA

BPHTransuretheral Resection of the

Prostate (TURP) Removal of inner prostate tissue Most common procedureAdvantages1. No external incision made2. Shorter hospitalization3. Complications – clot retention,

hemorrhage, infection, catheter obstruction

TURP

CONTINOUS BLADDER IRRIGATION

3- way drainage system- useful in irrigating the bladder & preventing clot formation

3000 ml sterile normal saline Irrigation -- consist of continuous inflow &

outflow of solution & drainage Maintain patency of catheter & tubing Urine drainage – light pink Blood clots are expected 1st 24-36hrs.

after surgery

CBI

Catheter removal – assess amount, color and

consistency of urine may experience burning on

urination, dribbling is common

BPH

Complications Hemorrhage

Obstructed catheter

Urinary incontinence

URINARY DIVERSIONS Procedure performed to divert urine

from the bladder to a new exit site – STOMA

Used to treat a. Cancer of the bladder b. Congenital anomalies c. Trauma to the bladder d. Neurogenic bladder

URINARY DIVERSIONS 2 CATERGORIES1. Incontinent urinary diversion2. Continent urinary diversion

URINARY DIVERSIONS INCONTINENT DIVERSION• Urine drains through an opening

created in the abdominal wall• An appliance is needed • Most common – Ileal Conduit

URINARY DIVERSIONS INCONTINENT DIVERSIONS – ileal

conduit• Ureters are excised from the bladder

& resected to a part of the ileum• Proximal end is sewn closed• Distal end created to form a stoma• Remaining intestinal segments –

anatomosed

URINARY DIVERSIONS INCONTINENT DIVERSIONS• Stents -- prevent occlusion from

post-surgical edemaDisadvantages:• Requires a external collection device • Visible stoma

URINARY DIVERSIONS INCONTINENT DIVERSIONSPre-op Management• Discuss social aspects of living with a

stoma 1. Clothing2. Changes in body image3. Odor4. Sexuality 5. Exercise

URINARY DIVERSIONS

INCONTINENT DIVERSIONSPost-op Management• Assess for complications a. Paralytic ileus/SBO• Make sure urinary stents are draining• U/O < 30cc/hr – dehydration/obstruction• Hematuria –1st 24-48 hours• Mucous threads in urine – normal

occurrence

URINARY DIVERSIONS

Post-op management (cont’d)• Check stoma color– beefy red• Increase fld. intake• Empty pouch when 1/3 full/q2-3 hr.• Meticulous skin care • Avoid foods that give strong odor–

cheese, eggs, asparagus

URINARY DIVERSIONS CONTINENT DIVERSIONS• Intra-abdominal urinary reservoir• Self catheterize every 4-6 hours• No need external attachments • Reservoirs constructed from

different parts of the ileum/colon• Kock, Indiana, Charleston pouch

URINARY DIVERSION CONTINENT DIVERSIONSPost-op Management• Teach patient to catheterize pouch• Irrigate pouch • Adhere to strict catheterization

schedule• Enterostomal therapy nurse

QUESTION

A patient returns to the unit following a TURP . His urinary drainage bag is filled with dark red fluid with obvious bloods clots. And he is having bladder spasms. What would you do first?a. Assess his intake/output since surgeryb. Administer pain medication as orderedc. Report your assessment to the urologistd. Nothing, these are manifestations that are

expected following a TURP

QUESTION The nurse evaluates her teaching as

effective when a patient with a newly continent ileal diversion is able to do which of the following?

a. Demonstrate care for the collection deviceb. State the importance of reporting cloudy

urine to the physicianc. Demonstrate self-catherization of the stomad. Identify factors that contribute to this

condition

Urinary Tract Cancers

Prostate CancerCancer of the Bladder

Cancer of the Prostate Most common cancer among men

after skin cancer Highest incidence in African-

American men Risk Factors

increases rapidly after age 50 Family history High intake of red meat and high fat

dairy products

Cancer of the ProstateSigns and Symptoms

Often asymptomatic As malignancy enlarges, may have

symptoms of urinary obstruction Blood in urine, semen and painful

ejaculation may occur C/O back and hip pain, weight loss,

anemia, oliguria may indicate metastases

Cancer of the ProstateAssessment and Diagnosis

Screening tools DRE PSA

Normal: 0-4 ng/mL Transrectal Ultrasound (TRUS) Biopsy

Cancer of the ProstateTreatment

Surgical removal of the prostate TURP Laproscopic radical prostatectomy

Radiation Teletherapy Brachytherapy

Hormone Therapy Casodex DES

Chemotherapy

Cancer of the Bladder Most commonly seen in ages 50-70

Transitional-cell carcinoma of the bladder

Papilillomatous growths in the bladder Risk factors

Cigarette smoking (twice as much) Environmental carcinogens Frequent/recurrent bacterial infections History of urogenital cancers

Cancer of the BladderAssessment and Diagnosis

Hematuria Bladder irritability Pelvic or back pain Diagnostic tests:

Cystoscopy Ultrasound/CT Biopsies

Cancer of the BladderTreatment

Transurethral Resection of Bladder Tumor (TURBT)

Chemotherapy/Radiation BCG Methotrexate/5-FU/

vinblastin/Adriamycin Cystectomy

Cancer of the BladderTreatment

Transurethral Resection of Bladder Tumor (TURBT)

Chemotherapy/Radiation BCG Methotrexate/5-FU/

vinblastin/Adriamycin/cisplatin Cystectomy

Partial Radical