Urologic Disorders: Assessment, Diagnosis, and Treatment

1. Chapter 40 Urologic Disorders

2. Learning Objectives • List the data to be collected when assessing a patient who has a urologic disorder. • Describe the diagnostic tests and procedures for patients with urologic disorders. • Explain the nursing responsibilities for patients having tests and procedures to diagnose urologic disorders. • Describe the nursing responsibilities for common therapeutic measures used to treat urologic disorders. • Explain the pathophysiology, signs and symptoms, complications, and treatment of disorders of the kidneys, ureters, bladder, and urethra. • Assist in developing a nursing care plan for patients with urologic disorders.

3. Anatomy of the Urinary System

4. Components The urinary system consists of Two kidneys Two ureters The bladder The urethra

5. Figure 40-1

6. Kidneys and Ureters Kidneys are bean-shaped organs located just under and below the 12th rib near the waist in the body trunk The hilus, or entry, to the kidney is located on the concave surface of the kidney near the spine

7. Kidneys and Ureters Cortex: outer layer; medulla: inner layer Cortex receives a large blood supply; very sensitive to changes in blood pressure and blood volume Medulla organized into 8-18 pyramidal structures; concentrate and collect urine; drain it into the calices The calices then drain urine into the renal pelvis Renal pelvis forms funnel-shaped proximal end of ureter Ureter carries urine from renal pelvis to bladder

8. Figure 40-2

9. Figure 40-3

10. Kidneys and Ureters The nephron is the functional unit of the kidney 1 to 1.25 million nephrons in each kidney Vascular tubular system: glomerulus, Bowman’s capsule, and tubule Glomerulus: mass of blood vessels tucked into the cuplike Bowman’s capsule Each tubule consists of a proximal tubule, the loop of Henle, a distal tubule, and a collecting duct Nephron located mostly in the cortex of the kidney; loop of Henle dips into the medulla; and the collecting ducts travel through the medulla to the calices

11. Figure 40-4

12. Bladder and Urethra Bladder: muscular sac; stretches to store urine On floor of pelvic cavity behind the peritoneum In front of the rectum in men; in front of the vagina and uterus in women Trigone: triangular-shaped area on posterior wall Control possible by sensory and motor nerves Urethra: muscular tube lined with mucous membranes; carries urine from bladder out of the body

13. Figure 40-5

14. Physiology of the Urinary System Regulation and excretion Urine production Glomerular filtration, tubular reabsorption, and tubular secretion Urine elimination Regulation of serum calcium and phosphate Regulation of blood pressure Hormonal stimulation of red blood cell production

15. Figure 40-6

16. Age-Related Changes in the Urinary System Loss of nephrons, thickening of membranes in nephrons, and sclerosis of renal blood vessels Creatinine clearance decreases with age Nocturia: awaken from sleep to void Bladder muscles weaken; connective tissue increases Incontinence not normal consequence of age, but it is common In men, urethral obstruction often a problem

17. Health History Chief complaint Changes in urine quality or quantity, pain History of present illness Patient’s normal or usual pattern of urination Pain or discomfort Problem initiating or controlling urination Document circumstances under which these problems occur

18. Health History Past medical history A history of streptococcal infections, recurrent urinary tract infections (UTIs), renal calculi (“stones”), gout, or hypercalcemia Family history Congenital kidney problems, such as polycystic kidneys or urinary tract malformations, diabetes mellitus, and hypertension

19. Health History Review of systems Changes in skin color, respiratory distress, edema, fatigue, nausea, vomiting, chills, and fever Functional assessment Daily fluid intake Effects of the chief complaint on daily life

20. Physical Examination Skin color (ashen, yellow); crystals on skin (uremic frost) Tissue turgor: to detect dehydration or edema Periorbital edema: suggests fluid retention. Inspect the mouth for moisture and odor Observe respiratory rate, pattern, and effort Auscultate the lungs for crackles or rhonchi Inspect the abdomen for scars and contours, and palpate for tenderness and bladder distention Auscultate the kidney area over costovertebral angle (Figure 40-2) to detect renal bruits Edema Inspect the genitalia

21. Figure 40-2

22. Diagnostic Tests and Procedures Urine tests Urinalysis Urine culture and sensitivity Creatinine clearance Blood tests Blood urea nitrogen Serum creatinine Serum electrolytes

23. Diagnostic Tests and Procedures Radiographic tests and procedures Kidneys, ureters, bladder (KUB) Intravenous pyelogram Arteriogram Cystogram Renal scan CT scan and MRI

24. Diagnostic Tests and Procedures Ultrasonography Invasive procedures Renal biopsy Cystoscopy Urodynamic studies Cystogram and voiding cystourethrogram Cystometrogram

25. Therapeutic Measures Catheterization Ureteral catheter Nephrostomy tube Urinary stent Drug therapy Urologic surgery Nephrectomy Removal of calculi Lithotripsy Cystectomy Cystotomy Urinary diversions Cystostomy

26. Disorders of the Urinary Tract

27. Urethritis Inflammation of the urethra By microorganisms, trauma, or hypersensitivity to chemicals in products such as vaginal deodorants, spermicidal jellies, or bubble baths Signs and symptoms Dysuria, frequency, urgency, and bladder spasms Urethral discharge may be noted Medical diagnosis Based on patient signs and symptoms, urinalysis, and urethral smear

28. Urethritis Medical treatment Antimicrobials

29. Urethritis Assessment Comfort, possible causative factors, and understanding of treatment and prevention Interventions Sitz baths Instruct female patients to wipe from front to back after toileting; void before and after sexual intercourse Discourage bubble baths and vaginal deodorants Instruct uncircumcised male patients to clean the penis under the foreskin regularly

30. Cystitis Inflammation of the urinary bladder Common cause is bacterial contamination Other factors: prolonged immobility, renal calculi, urinary diversion, and indwelling catheters Signs and symptoms Urgency, frequency, dysuria, hematuria, nocturia, bladder spasms, incontinence, and low-grade fever Urine may be dark, tea-colored, or cloudy Fever, fatigue, and pelvic or abdominal discomfort

31. Cystitis Medical diagnosis Urinalysis, culture, and sensitivity White blood cells (WBCs) Medical treatment Antibiotics Mild analgesic; hyoscyamine (Cystospaz) and flavoxate (Urispas)

32. Cystitis Assessment Patient symptoms, causative factors, and understanding of treatment and prevention Interventions Patient teaching regarding medications, fluids, and prevention

33. Interstitial Cystitis Pathophysiology and diagnosis Inflammatory disease of the bladder, usually chronic Cause is unknown Bladder/pelvic pain; urinary frequency and urgency Diagnosed by cystoscopy Medical treatment Symptom management; attempts to treat causes Nursing care Primary role is teaching and support

34. Pyelonephritis Inflammation of the renal pelvis Acute pyelonephritis most often caused by ascending bacterial infection, but it may be bloodborne Chronic pyelonephritis often the result of reflux of urine from inadequate closure of the ureterovesical junction during voiding

35. Pyelonephritis Signs and symptoms Acute pyelonephritis High fever, chills, nausea, vomiting, and dysuria; severe pain or a constant dull ache occurs in the flank area Chronic pyelonephritis Bladder irritation, chronic fatigue, and slight aching over one or both kidneys

36. Pyelonephritis Medical treatment Antibiotics, urinary tract antiseptics, analgesics, and antispasmodics Drink at least eight 8-ounce glasses of fluids daily Intravenous fluids may be ordered if nausea and vomiting Dietary salt and protein restriction for patient with chronic disease

37. Pyelonephritis Assessment Related signs and symptoms, history of urinary tract disorders, predisposing factors, and effects of the infection on daily activities Interventions Acute Pain Activity Intolerance Deficient Fluid Volume and Imbalanced Nutrition Ineffective Management of Therapeutic Regimen

38. Polycystic Kidney Disease Hereditary disorder Two types: childhood and adult In adults usually manifested by age 40 years Grapelike cysts in place of normal kidney tissue Cysts enlarge, compress functional renal tissue, and result in renal failure Signs and symptoms Dull, aching abdominal, lower back or flank pain, or colicky pain that begins abruptly

39. Figure 40-7

40. Polycystic Kidney Disease Medical treatment Supportive treatment is recommended to preserve kidney function, treat UTI, and control hypertension Infections treated promptly with antibiotics Dialysis, nephrectomy, and transplantation once end-stage renal disease develops

41. Acute Glomerulonephritis Pathophysiology Immunologic disease: inflammation of the capillary loops in the glomeruli Signs and symptoms Urine becomes tea colored as output decreases Peripheral and periorbital edema As glomerular filtration decreases, mild to severe hypertension occurs and hypervolemia results Medical diagnosis Patient assessment and laboratory tests Urinalysis, BUN, creatinine, and albumin Renal ultrasound, renal biopsy, or both

42. Acute Glomerulonephritis Medical treatment Diuretics, antihypertensive medications, and antibiotics Bed rest; activity restriction Fluids, sodium, potassium, and protein may be restricted If renal failure develops, dialysis is necessary

43. Acute Glomerulonephritis Assessment Signs and symptoms, recent infections, and changes in urine Interventions Excess Fluid Volume Activity Intolerance Self-Care Deficit Anxiety

44. Renal Calculi Urinary tract obstruction Pathophysiology Precipitations of calcium salts (calcium phosphate or calcium oxalate), uric acid, magnesium ammonium phosphate, or cystine All are normally found in the urine Factors for development of calculi Concentrated urine; excessive intake of calcium, vitamin D, protein, oxalates, calcium-based antacids; familial tendency; hyperparathyroidism; immobility, urinary stasis; sedentary lifestyle; altered urine pH; lack of kidney substance that inhibits calculi formation

45. Renal Calculi Signs and symptoms Pain Dull flank pain: a calculus in the renal pelvis or stretching of the renal capsule from urine retention (hydronephrosis) If calculus lodges in a ureter, excruciating pain in the abdomen that radiates to the groin or the perineum Nausea, vomiting, hematuria may accompany pain Medical diagnosis KUB, IVP, retrograde pyelogram, or ultrasound

46. Renal Calculi Medical treatment Most calculi are passed spontaneously Ambulation and adequate hydration facilitate passage Opioid analgesics/antispasmodics relieve pain Lithotripsy Endourologic procedures Surgical procedures Nephrolithotomy Pyelolithotomy Ureterolithotomy

47. Figure 40-8

48. Figure 40-9

49. Renal Calculi Prevention High fluid intake to keep urine dilute, dietary restrictions for specific elements (i.e., calcium and purines), regular exercise, medications to alter urine pH Assessment Patient’s usual fluid intake and diet, including vitamin and mineral supplements Location, severity, and nature of the pain Changes in urine amount or characteristics

50. Renal Calculi Interventions Acute Pain Impaired Urine Elimination Risk for Deficient Fluid Volume Risk for Infection Decreased Cardiac Output Ineffective Breathing Patterns