Nursing of Adults with Medical & Surgical Conditions

1. Nursing of Adults withMedical & 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: • 0.5-1.2 mg/dl

6. 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

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. 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

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 • Calcium sodium cellulose phosphate • Phosphorus aluminum hydroxide gel • Urate Zyloprim

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