Nursing of Adults with

Medical & Surgical Conditions

Urinary

Disorders

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

• 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

• 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

• 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

• 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

– 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

• 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

• 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

• 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

• No symptoms

– Advanced stages• Urinary obstruction

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

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

• 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

– 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