Renal and Urinary Disorders

• Kidney function• Urological Assessment • Nursing History

▫ Reason for seeking care▫ Current illness▫ Previous illness▫ Family History▫ Social History▫ Sexual history▫ Urological Assessment

Key Signs and Symptoms of Urological Problems

EDEMA associated with fluid retention Renal dysfunctions usually produce

ANASARCA

PAIN Suprapubic pain= bladder Colicky pain on the flank= kidney

HEMATURIA Painless hematuria may indicate

URINARY CANCER! Early-stream hematuria= urethral lesion Late-stream hematuria= bladder lesion

DYSURIA Pain with urination= lower UTI

POLYURIA More than 2 Liters urine per day

OLIGURIA Less than 400 mL per day

ANURIA Less than 50 mL per day

Urinary Urgency - is a sudden, compelling urge to urinate Urinary retention - also known as ischuria is a lack of ability to urinate Urinary frequency - Urinating too often, at too frequent intervals, not due to an unusually large volume of urine, but rather to a decrease in the capacity of the bladder to hold urine.

PHYSICAL EXAMINATION

InspectionAuscultationPercussionPalpation

Laboratory examination1. Urinalysis2. BUN and Creatinine levels of

the serum3. Serum electrolytes4. Urological Assessment

Laboratory examinationRadiographic

▫ IVP ▫ KUB x-ray▫ KUB ultrasound▫ CT and MRI▫ Cystography

Implementation Steps for selected problems

1.Provide PAIN relief• Assess the level of pain• Administer medications usually narcotic

ANALGESICS• Implementation Steps for selected

problems

2.Maintain Fluid and Electrolyte Balance• Encourage to consume at least 2 liters of

fluid per day• In cases of ARF, limit fluid as directed• Weigh client daily to detect fluid

retention• Implementation Steps for selected

problems

3.Ensure adequate urinary elimination• Encourage to void at least every 2-3

hours• Promote measures to relieve urinary

retention:▫ Alternating warm and cold

compress▫ Bedpan ▫ Open faucet ▫ Provide privacy▫ Catheterization if indicated

STANDARDS OF CARE GUIDELINES\

• Patients at risk for renal impairment include those with cardiovascular disease, diabetes, and hypertension; postoperative patients; hypotensive patients; and those with prostate and other diseases of the urinary tract.

Thorough assessment of the urinary tract includes:

• Hourly intake and output measurement• Assessment of color, clarity, and

specific gravity of the urine• Palpation of the abdomen for suprapubic

tenderness• Percussion of the flanks for

costovertebral angle tenderness• Prostate examination• Subjective assessment for symptoms,

such as urgency, frequency, nocturia, hesitancy, dribbling, decreased force of stream, hematuria, and incontinence

• Be alert to drugs that may impair urinary and renal function, such as nonsteroidal anti-inflammatory drugs, anticholinergics, sympathomimetics, aminoglycoside antibiotics.

• Changes in Micturition (Voiding)

Changes in Amount or Color of Urine

• Hematuria - blood in the urine.▫ Considered a serious sign and

requires evaluation.▫ Color of bloody urine depends

on several factors including the amount of blood present and the anatomical source of the bleeding.

Dark, rusty urine indicates bleeding from the upper urinary tract.

Bright red bloody urine indicates lower urinary tract bleeding.

▫ Hematuria may be due to a systemic cause, such as blood dyscrasias, anticoagulant therapy, or extreme exercise.

▫ Painless hematuria may indicate neoplasm in the urinary tract.

▫ Hematuria is common in patients with urinary tract stone disease and may also be seen in renal tuberculosis, polycystic disease of kidneys, acute pyelonephritis, thrombosis and embolism involving renal artery or vein, and trauma to the kidneys or urinary tract.

Polyuria - large volume of urine voided in given time.

• Volume is out of proportion to usual voiding pattern and fluid intake.

• Demonstrated in diabetes mellitus, diabetes insipidus, chronic renal disease, use of diuretics.

Oliguria - small volume of urine.• Output between 100 and 500 mL/24

hours.• May result from acute renal failure,

shock, dehydration, fluid and electrolyte imbalance

Anuria - absence of urine output.• Output less than 50 mL/24 hours.• Indicates serious renal dysfunction

requiring immediate medical intervention.

• Symptoms Related to Irritation of the Lower Urinary Tract

Dysuria - pain or difficult urination.• Burning sensation seen in wide variety

of inflammatory and infectious urinary tract conditions.

Frequency - voiding occurs more commonly than usual when compared with the patient's usual pattern or with a generally accepted norm of once every 3 to 6 hours.

• Increasing frequency can result from a variety of conditions, such as infection and diseases of urinary tract, metabolic disease, hypertension, medications (diuretics).

Urgency - strong desire to urinate that is difficult to postpone.

• Due to inflammatory conditions of the bladder, prostate, or urethra; acute or chronic bacterial infections; neurogenic voiding dysfunctions; chronic prostatitis or bladder outlet obstruction in men; and urogenital atrophy in postmenopausal women.

Nocturia - excessive urination at night, which interrupts sleep.

• Causes include urologic conditions affecting bladder function, poor bladder emptying, bladder outlet obstruction, or overactive bladder.

• Metabolic causes include decreased renal concentrating ability or heart failure, diabetes mellitus, and the increased urine production at rest that occurs with aging.

Strangury - slow and painful urination; only small amounts of urine voided.

• Blood staining may be noted.• Seen in severe cystitis and interstitial

cystitis.

Symptoms Related to Obstruction of the Lower Urinary Tract

• Weak stream - decreased force of stream when compared to usual stream of urine when voiding.

• Hesitancy - undue delay and difficulty in initiating voiding.May indicate compression of urethra, outlet obstruction, neurogenic bladder.

• Terminal dribbling - prolonged dribbling or urine from the meatus after urination is complete. May be caused by bladder outlet obstruction.

• Incomplete emptying - feeling that the bladder is still full even after urination. Indicates either urinary retention or a condition that prevents the bladder from emptying well; leads to infection.

Involuntary Voiding • Urinary incontinence - involuntary loss

of urine; may be due to pathologic, anatomical, or physiologic factors affecting the urinary tract

• Enuresis - involuntary voiding during sleep. May be physiologic during early

childhood; thereafter, may be functional or symptomatic of obstructive or neurogenic disease (usually of lower urinary tract) or dysfunctional voiding.

Urinary Tract Pain • Genitourinary (GU) pain is not always

present in renal disease, but is generally seen in the more acute conditions of the urinary tract.

• Kidney pain - may be felt as a dull ache in costovertebral angle; or may be a sharp, colicky pain felt in the flank area that radiates to the groin or testicle. Due to distention of the renal capsule; severity related to how quickly it develops.

• Ureteral pain - felt in the back and radiates to the groin or scrotum if the upper ureter is the source, to the suprapubic area, penis, and urethra if the lower ureter is the source.

• Bladder pain (lower abdominal pain or pain over suprapubic area) - may be due to bladder infection or overdistended bladder.

• Urethral pain - from irritation of bladder neck, from foreign body in canal, or from urethritis due to infection or trauma; pain increases when voiding.

• Pain in scrotal area - due to inflammatory swelling of epididymis or testicle, or torsion of the testicle.

• Testicular pain - due to injury, mumps, orchitis, torsion of spermatic cord.

• Perineal or rectal discomfort - due to acute prostatitis, prostatic abscess.

• Back and leg pain - due to cancer of prostate with metastases to bone.

• Pain in glans penis is usually from prostatitis; penile shaft pain is from urethral problems.

History• What are the patient's present and past

occupations? Look for occupational hazards related to the urinary tract, contact with chemicals, plastics, tar, rubber; also truck or school bus drivers.

• What is the past medical and surgical history, especially in relation to urinary problems?

• Is there any family history of renal disease?

What childhood diseases did the patient have?• Is there a history of urinary tract

infections (UTIs)? Did any occur before age 12?

• Did enuresis continue beyond the age when most children gain control?

• Any history of genital lesions or sexually transmitted diseases (STDs)?

• For the female patient: Number of children? Vaginal or cesarean delivery? Any forceps deliveries? When? Any signs of vaginal discharge? Vaginal/vulvar itch or irritation? Family history of pelvic organ prolapse (dropped bladder or uterus) or urinary incontinence?

DIAGNOSTIC TESTS/LABORATORY STUDIES

Tests of Renal Function• Renal function tests are used to

determine effectiveness of the kidneys' excretory functioning, to evaluate the severity of kidney disease, and to follow the patient's progress.

• There is no single test of renal function; best results are obtained by combining a number of clinical tests.

• Renal function is variable from time to time.

Nursing and Patient Care Considerations• Renal function may be within normal

limits until about 50% of renal function has been lost.

Renal concentration test • Specific gravity • Osmolality of urine

Purpose/Rationale • Tests the ability to concentrate solutes in

the urine. • Concentration ability is lost early in

kidney disease; hence, this test detects early defects in renal function

Creatinine clearance • Provides a reasonable approximation of

rate of glomerular filtration.

• Measures volume of blood cleared of creatinine in 1 minute.

• Most sensitive indication of early renal disease.

• Useful to follow progress of the patient's renal status.

Serum creatinine • A test of renal function reflecting the

balance between production and filtration by renal glomerulus.

• Most sensitive test of renal function.

Serum urea nitrogen (Blood urea nitrogen [BUN])

• Serves as index of renal excretory capacity.

• Serum urea nitrogen depends on the body's urea production and on urine flow. (Urea is the nitrogenous end-product of protein metabolism.)

• Affected by protein intake, tissue breakdown.

Protein • Random specimen may be affected by

dietary protein intake. Proteinuria >150 mg/24 hours may indicate renal disease.

Microalbumin/Creatinine ratio • Sensitive test for the subsequent

development of proteinuria; >30 mcg/mg creatinine predicts early nephropathy.

Urine casts • Mucoproteins and other substances

present in renal inflammation; help to identify type of renal disease (eg, red cell casts present in glomerulonephritis, fatty casts in nephrotic syndrome, white cell casts in pyelonephritis).

Prostate-Specific Antigen• PSA is an amino acid glycoprotein that

is measured in the serum by a simple blood test.

• An elevated PSA indicates the presence of prostate disease, but is not exclusive to prostate cancer.

• Level rises continuously with the growth of prostate cancer.

• Normal serum PSA level is less than 4 mg/mL. Levels less than 10 mg/mL may be indicative of benign prostatic hyperplasia (BPH) and not necessarily prostate cancer.

• Patients who have undergone treatment for prostate cancer are monitored periodically with PSA levels for recurrence.

• PSANursing and Patient Care Considerations• No patient preparation is necessary.• Some clinicians prefer not to perform

digital rectal examinations of the prostate at the same time that a PSA is drawn, to prevent artificial elevation of PSA level, although this association has not been proved.

Urinalysis• Involves examination of the urine for

overall characteristics, including appearance, pH, specific gravity, and osmolality as well as microscopic evaluation for the presence of normal and abnormal cells.

• Appearance - normal urine is clear.• Cloudy urine (phosphaturia) is not

always pathologic, related only to the precipitation of phosphates in alkaline urine. Normal urine may also develop cloudiness on refrigeration or from standing at room temperature.

• Abnormally cloudy urine due to pus (pyuria), blood, epithelial cells, bacteria, fat, colloidal particles, phosphate, or lymph fluid (chyluria).

• Odor - normal urine has a faint aromatic odor.

• Characteristic odors produced by ingestion of asparagus, thymol.

• Cloudy urine with ammonia odor - urea-splitting bacteria such as Proteus, causing UTIs.

• Offensive odor may be due to bacterial action in presence of pus.

Color shows degree of concentration and depends on amount voided.

• Normal urine is clear yellow or amber because of the pigment urochrome.

• Dilute urine is straw-colored.

• Concentrated urine is highly colored; a sign of insufficient fluid intake.

• Cloudy or smoky colored may be from hematuria, spermatozoa, prostatic fluid, fat droplets, chyle.

• Red or red-brown due to blood pigments, porphyria, transfusion reaction, bleeding lesions in urogenital tract, some drugs and food (beets).

• Yellow-brown or green-brown may reveal obstructive lesion of bile duct system or obstructive jaundice.

• Dark brown or black due to malignant melanoma, leukemia.

• pH of urine reflects the ability of kidney to maintain normal hydrogen ion concentration in plasma and extracellular fluid; indicates acidity or alkalinity of urine.

• pH should be measured in fresh urine because the breakdown of urine to ammonia causes urine to become alkaline.

• Normal pH is around 6 (acid); may normally vary from 4.6 to 7.5.

• Urine acidity or alkalinity has relatively little clinical significance unless the patient is on a special diet or therapeutic program or is being treated for renal calculous disease.

• Specific gravity reflects the kidney's ability to concentrate or dilute urine; may reflect degree of hydration or dehydration.

• Normal specific gravity ranges from 1.005 to 1.025.

• In a person eating a normal diet, inability to concentrate or dilute urine indicates disease.

• Osmolality is an indication of the amount of osmotically active particles in urine (number of particles per unit volume of water). It is similar to specific gravity, but is considered a more precise test; it is also easy, only 1 to 2 mL of urine are required. Average value is 300 to 1,090 mOsm/ kg for females; 390 to 1,090 mOsm/kg for males.

Nursing and Patient Care Considerations• Freshly voided urine provides the best

results for routine urinalysis; some tests may require first morning specimen.

• Obtain sample of about 30 mL.• Urine culture and sensitivity tests are

typically performed using the same specimen obtained for urinalysis; therefore, use clean-catch or catheterization techniques.

X-ray of Kidneys, Ureters, and Bladder• Consists of plain film of the abdomen• Delineates size, shape, and position of

kidneys• Reveals deviations, such as

calcifications (stones), hydronephrosis, cysts, tumors, or kidney displacement

Nursing and Patient Care Considerations• No preparation is needed.• Usually done before other testing.• Patient will be asked to wear a gown

and remove all metal from the X-ray field.

Intravenous Pyelogram (Intravenous Urogram)• I.V. introduction of a radiopaque

contrast medium that concentrates in the urine and thus facilitates visualization of the kidneys, ureter, and bladder.

• The contrast medium is cleared from the bloodstream by renal excretion.

Nursing and Patient Care Considerations• Contraindicated in patients with renal

failure, uncontrolled diabetes, or multiple myeloma, in patients receiving drug therapy for chronic bronchitis, emphysema, or asthma and in patients taking metformin (Glucophage).

• Patients with known iodine/contrast material allergy must have steroid/antihistamine preparation; in some cases, an anesthesiologist must be available.

• Bowel preparation is necessary:▫ Clear liquids only the day

before the examination.▫ Cathartics/laxatives are given

the evening before the examination.

▫ Nothing by mouth (NPO) after midnight the day of the examination (if scheduled for afternoon, clear liquids only in the morning).

Retrograde Pyelography• Injection of opaque material through

ureteral catheters, which have been passed up ureters into renal pelvis by means of cystoscopic manipulation. The opaque solution is introduced by gravity or syringe injection.

• May be done when intravenous pyelography (IVP) is contraindicated or if IVP provides inadequate visualization of the collecting system.

Nursing and Patient Care Considerations• Contraindicated in patients with UTI, or

with suspected perforation of the ureter or bladder; allergic reactions to contrast material are rare in this examination.

Cystourethrogram• Visualization of urethra and bladder by

X-ray after retrograde instillation of contrast material through a catheter.

• An examination of only the bladder is a cystogram; of only the urethra is a urethrogram.

• Used to identify injuries, tumors, or structural abnormalities of the urethra or bladder; or to evaluate emptying problems or incontinence (voiding cystourethrogram).

Nursing and Patient Care Considerations• Carries risk of infection due to

instrumentation.• Allergy to contrast material is not a

contraindication.• Additional X-rays may be taken after

catheter is removed and patient voids (voiding cystourethrogram).

• Provide reassurance to allay patient's embarrassment.

Renal Angiography• I.V. catheter is threaded through the

femoral and iliac arteries into the aorta or renal artery.

• Contrast material is injected to visualize the renal arterial supply.

• Evaluates blood flow dynamics, demonstrates abnormal vasculature, and differentiates renal cysts from renal tumors.

Nursing and Patient Care Considerations

• Clear liquids only after midnight before the examination; adequate hydration is essential.

• Continue oral medications (special orders needed for diabetic patients).

• I.V. required.• May not be done on the same day as

other studies requiring barium or contrast material.

• Maintain bed rest for 8 hours after the examination, with the leg kept straight on the side used for groin access.

• Observe frequently for hematoma or bleeding at access site. Keep sandbag at bedside for use if bleeding occurs.

Renal Scans• Radiopharmaceuticals (also called

radiotracers or isotopes) are injected I.V.• Evaluates renal size, shape, position,

and function or blood flow to the kidneys.

• Studies are obtained with a scintillation camera placed posterior to the kidney with the patient in a supine, prone, or sitting position.

Nursing and Patient Care Considerations• The patient should be well hydrated.

Give several glasses of water or I.V. fluids as ordered before scan.

• Furosemide (Lasix) or captopril (Capoten) may be administered in conjunction with the scan to determine their effects.

Ultrasound• Uses high-frequency sound waves

passed into the body and reflected back in varying frequencies based on the composition of soft tissues. Organs in the urinary system create characteristic ultrasonic images that are electronically processed and displayed as an image.

• Abnormalities, such as masses, malformations, or obstructions, can be identified; useful in differentiating between solid and fluid-filled masses.

• A noninvasive technique.

Cystoscopy• Cystoscopy is a method of direct

visualization of the urethra and bladder

by means of a cystoscope that is inserted through the urethra into the bladder. It has a self-contained optical lens system that provides a magnified, illuminated view of the bladder.

• Uses include:▫ To inspect bladder wall directly

for tumor, stone, or ulcer and to inspect urethra for abnormalities or to assess degree of prostatic obstruction.

▫ To allow insertion of ureteral catheters for radiographic studies, or before abdominal or GU surgery.

▫ To see configuration and position of ureteral orifices.

▫ To remove calculi from urethra, bladder, and ureter.

▫ To diagnose and treat lesions of bladder, urethra, and prostate.

Nursing and Patient Care Considerations• Simple cystoscopy is usually performed

in an office setting. More complicated cystoscopy involving resections or ureteral catheter insertions are done in the operating room cystoscopy suite, where I.V. sedation or general anesthesia may be used.

• The patient's genitalia are cleaned with an antiseptic solution just before the examination. A local topical anesthetic (Xylocaine gel) is instilled into the urethra before insertion of cystoscope.

• Because fluid flows continuously through the cystoscope, the patient may feel an urge to urinate during the examination.

• Contraindicated in patients with known UTI.

Nursing interventions after cystoscopic examination:

• Monitor for complications: urinary retention, urinary tract hemorrhage, infection within prostate or bladder.

• Expect the patient to have some burning on voiding, blood-tinged urine, and urinary frequency from trauma to mucous membrane of the urethra.

• Administer or teach self-administration of antibiotics prophylactically as ordered to prevent UTI.

• Advise warm sitz baths or analgesics, such as ibuprofen or acetaminophen, to relieve discomfort after cystoscopy. Increase hydration.

• Provide routine catheter care if urine retention persists and an indwelling catheter is ordered.

Urodynamics• Urodynamics is a term that refers to any

of the following tests that provide physiologic and functional information about the lower urinary tract. They measure the ability of the bladder to store and empty urine. Most urodynamic equipment uses computer technology with results visible in real time on a monitor.

1.Uroflowmetry (flow rate) - a record of the volume of urine passing through the urethra per unit of time (mL/s). It is shown on graph paper and gives information about the rate and flow pattern of urination.2. Cystometrogram - recording of the pressures exerted during filling and emptying of the urinary bladder to assess its function. Data about the ability of the bladder to store urine at low pressure and the ability of the bladder to contract appropriately to empty urine are obtained.3. Sphincter electromyelography (EMG) measures the activity of the pelvic floor muscles during bladder filling and emptying. EMG activity may be measured using surface (patch) electrodes placed around the anus or with percutaneous wire or needle electrodes.4. Pressure-flow studies involve all of the above components, along with the simultaneous measurement of intra-abdominal pressure by way of a small tube with a fluid-filled balloon that is placed in the rectum. This permits better interpretation of actual bladder pressures without the influence of intra-abdominal pressure.5. Video urodynamics use all of the above components. The fluid used to fill the bladder is contrast material, and the entire study is performed under fluoroscopy, providing radiographic pictures in combination with the recording of bladder and intra-abdominal pressures. Video urodynamics are reserved for patients with complicated voiding dysfunction.

Nursing and Patient Care Considerations• Contraindicated in patients with UTI.• Frequently performed by nurses;

essential to provide information and support throughout the test to ensure clinically significant results.

• Patients will have burning on urination afterward (due to instrumentation); encourage fluids.

• Short-term antibiotics are commonly given to prevent infection\

Needle Biopsy of Kidney• Performed by percutaneous needle

biopsy through renal tissue with ultrasound guidance or by open biopsy through a small flank incision; useful in securing specimens for electron and immunofluorescent microscopy to determine diagnosis, treatment, and prognosis of renal disease

Nursing and Patient Care Considerations• Prebiopsy nursing management

▫ Ensure that coagulation studies are carried out to identify the patient at risk for postbiopsy bleeding and that serum creatinine, urinalysis, and urine culture are done.

▫ Ensure that patient fasts for several hours before the procedure, as ordered.

▫ Establish an I.V. line, as ordered.

▫ Describe the procedure to the patient, including holding breath (to prevent movement of the thorax) during insertion of the biopsy needle.

Instruct the patient on the following after biopsy:

• Avoid strenuous activity, strenuous sports, and heavy lifting for at least 2 weeks.

• Notify health care provider if any of the following occur: flank pain, hematuria, lightheadedness and fainting, rapid pulse, or any other signs and symptoms of bleeding.

• Report for follow-up 1 to 2 months after biopsy; will be checked for

hypertension, and the biopsy area is auscultated for a bruit.

CATHETERIZATION• Catheterization may be done to relieve

acute or chronic urinary retention, to drain urine preoperatively and postoperatively, to determine the amount of residual urine after voiding, or to determine accurate measurement of urinary drainage in critically ill patients.

DIALYSIS• Dialysis refers to the diffusion of solute

molecules through a semipermeable membrane, passing from the side of higher concentration to that of lower concentration.

• The purpose of dialysis is to maintain the life and well-being of the patient.

• It is a substitute for some kidney excretory functions but does not replace the kidneys' endocrine and metabolic functions.

Methods of dialysis include:• Peritoneal dialysis.

▫ Intermittent peritoneal dialysis (acute or chronic)

▫ Continuous ambulatory peritoneal dialysis.

▫ Continuous cycling peritoneal dialysis uses automated peritoneal dialysis machine overnight with prolonged dwell time during day.

• Hemodialysis▫ Hemodialysis is a process of

cleansing the blood of accumulated waste products. It is used for patients with end-stage renal failure or for acutely ill patients who require short-term dialysis.

Methods of Circulatory Access• Arteriovenous fistula (AVF) - creation

of a vascular communication by suturing a vein directly to an artery

• AV fistula• Arteriovenous graft - arteriovenous

connection consisting of a tube graft made from autologous saphenous vein

or from polytetrafluoroethylene. Ready to use in 2 to 3 weeks.

• Central vein catheters - direct cannulation of veins (subclavian, internal jugular, or femoral); may be used as temporary or permanent dialysis access.

• Central venous catheterComplications of Vascular Access

• Infection• Catheter clotting• Central vein thrombosis or stricture• Stenosis or thrombosis• Ischemia of the hand (steal syndrome)• Aneurysm or pseudoaneurysm

Lifestyle Management for Chronic Hemodialysis

• Dietary management involves restriction or adjustment of protein, sodium, potassium, or fluid intake.

• Ongoing health care monitoring includes careful adjustment of medications that are normally excreted by the kidney or are dialyzable.

• Surveillance for complications.▫ Arteriosclerotic cardiovascular

disease, heart failure, disturbance of lipid metabolism (hypertriglyceridemia), coronary heart disease, stroke

▫ Anemia and fatigue▫ Gastric ulcers and other

problems▫ Bone problems (renal

osteodystrophy, aseptic necrosis of hip) from disturbed calcium metabolism

▫ Hypertension▫ Psychosocial problems:

depression, suicide, sexual dysfunction

Continuous Ambulatory Peritoneal Dialysis• Continuous ambulatory peritoneal

dialysis (CAPD) is a form of intracorporeal dialysis that uses the peritoneum for the semipermeable membrane

Advantages Over Hemodialysis

• Physical and psychological freedom and independence

• More liberal diet and fluid intake• Relatively simple and easy to use• Satisfactory biochemical control of

uremiaComplications

• Infectious peritonitis, exit-site and tunnel infections.

• Noninfectious catheter malfunction, obstruction, dialysis-sate leak.

• Peritoneal pleural communication, hernia formation.

• GI bloating, distention, nausea.• Hypervolemia, hypovolemia.• Bleeding at catheter site..• Obstruction may occur if omentum

becomes wrapped around the catheter or the catheter becomes caught in a loop of bowel.

LOWER URINARY TRACT INFECTIONS• A UTI is caused by the presence of

pathogenic microorganisms in the urinary tract with or without signs and symptoms. Lower UTIs may predominate at the bladder (cystitis) or urethra (urethritis).

• Urinary Tract Infection (UTI)• Bacterial invasion of the kidneys or

bladder (CYSTITIS) usually caused by Escherichia coli

• Urinary Tract Infection (UTI)Predisposing factors include

1. Poor hygiene2. Irritation from bubble baths3. Urinary reflux4. Instrumentation5. Residual urine, urinary stasis• Urinary Tract Infection (UTI)

PATHOPHYSIOLOGY• The invading organism ascends the

urinary tract, irritating the mucosa and causing characteristic symptoms

▫ Ureter= ureteritis▫ Bladder= cystitis▫ Urethra=Urethritis▫ Pelvis= Pyelonephritis▫ Women are more susceptible to

developing acute cystitis because of shorter length of urethra, anatomical

proximity to vagina, periurethral glands, and rectum (fecal contamination), and the mechanical effect of coitus.

• Poor voiding habits may result in incomplete bladder emptying, increasing the risk of recurrent infection.

• Acute infection in women most commonly arises from organisms of the patient's own intestinal flora (Escherichia coli).

In men, obstructive abnormalities (strictures, prostatic hyperplasia) are the most frequent cause.

Assessment findings• Low-grade fever• Abdominal pain• Enuresis• Pain/burning on urination• Urinary frequency• Hematuria• Fever and CHIILS• Flank pain• Costovertebral angle tenderness

Laboratory Examination1. Urinalysis2. Urine Culture

Nursing interventions• Administer antibiotics as ordered• Provide warm baths and allow client to

void in water to alleviate painful voiding.

• Force fluids. Nurses may give 3 liters of fluid per day

• Encourage measures to acidify urine (cranberry juice, acid-ash diet).

• Urinary Tract Infection (UTI)Provide client teaching and discharge planning concerning

a. Avoidance of tub baths b. Avoidance of bubble baths that might irritate urethrac. Importance for girls to wipe perineum from front to backd. Increase in foods/fluids that acidify urine.

Pharmacology1. Sulfa drugs

▫ Highly concentrated in the urine▫ Effective against E. coli!

2. Quinolones• Bacteriuria refers to the presence of

bacteria in the urine (105 bacteria/mL of urine or greater generally indicates infection).

• In asymptomatic bacteriuria, organisms are found in urine, but the patient has no symptoms.

Recurrent UTIs may indicate the following:• Relapse - recurrent infection with an

organism that has been isolated during a prior infection

• Reinfection - recurrent infection with an organism distinct from previous infecting organism

Complications• Pyelonephritis• Hematogenous spread resulting in sepsis

Nursing Diagnoses• Acute Pain related to inflammation of

the bladder mucosa• Deficient Knowledge related to

prevention of recurrent UTI Nephrolithiasis/Urolithiasis Presence of stones anywhere in the

urinary tract Calcium oxalate and uric acid

Nephrolithiasis/Urolithiasis Pathophysiology

Predisposing factorsa. Diet: large amounts of calcium and

oxalateb. Increased uric acid levelsc. Sedentary life-style, immobilityd. Family history of gout or calculie. Hyperparathyroidism

Nephrolithiasis/Urolithiasis Pathophysiology Supersaturation of crystals due to stasisStone formationMay pass through the urinary tract

OBSTRUCTION, INFECTION and HYDRONEPHROSIS

Nephrolithiasis/Urolithiasis Assessment findings

1. Abdominal or flank pain2. Renal colic radiating to the groin

3. Hematuria 4. Cool, moist skin5. Nausea and vomiting

Nephrolithiasis/Urolithiasis Diagnostic tests 1. KUB Ultrasound and X-ray: pinpoints location, number, and size of stones 2. IVP: identifies site of obstruction and presence of non-radiopaque stones 3. Urinalysis: indicates presence of bacteria, increased protein, increased WBC and RBC (hematuria)

Nephrolithiasis/UrolithiasisMedical management1. Surgery

a. Percutaneous nephrostomy: tube is inserted through skin and underlying tissues into renal pelvis to remove calculi.

b. Percutaneous nephrostolithotomy: delivers ultrasound waves through a probe placed on the calculus.

Nephrolithiasis/UrolithiasisMedical management2. Extracorporeal shock-wave lithotripsy: delivers shock waves from outside the body to the stone, causing pulverization

3. Pain management : Morphine or Meperidine

4. Diet modification Nephrolithiasis/Urolithiasis

Nursing interventions 1. Strain all urine through gauze to

detect stones and crush all clots. 2. Force fluids (3000—4000 cc/day). 3. Encourage ambulation to prevent

stasis. Nephrolithiasis/Urolithiasis

Nursing interventions 4. Relieve pain by administration of

analgesics as ordered and application of moist heat to flank area.

5. Monitor intake and output Nephrolithiasis/Urolithiasis

Nursing interventions

6. Provide modified diet, depending upon stone consistency: Calcium, Oxalate and Uric acid stones

Nephrolithiasis/UrolithiasisNursing interventionsCalcium stones

limit milk/dairy products; provide acid-ash diet to acidify urine (cranberry or prune juice, meat, eggs, poultry, fish, grapes, and whole grains)

Nephrolithiasis/UrolithiasisNursing interventionsOxalate stones

avoid excess intake of foods/ fluids high in oxalate (tea, chocolate, rhubarb, spinach); maintain alkaline-ash diet to alkalinize urine (milk; vegetables; fruits except prunes, cranberries, and plums)

Nephrolithiasis/UrolithiasisNursing interventionsUric acid stones

reduce foods high in purine (liver, beans, kidneys, venison, shellfish, meat soups, gravies, legumes); maintain alkaline urine

Nephrolithiasis/UrolithiasisNursing interventions

7. Administer allopurinol (Zyloprim) as ordered, to decrease uric acid production

Nephrolithiasis/Urolithiasis8. Provide client teaching and discharge planning concerning

Prevention of Urinary stasis by maintaining increased fluid intake especially in hot weather and during illness; mobility; voiding whenever the urge is felt and at least twice during the night

Adherence to prescribed diet Need for routine urinalysis (at least

every 3—4 months) Need to recognize and report signs/

symptoms of recurrence (hematuria, flank pain).

Acute renal failure Sudden interruption of kidney

function to regulate fluid and electrolyte balance and remove toxic products from the body

Acute renal failure

PATHOPHYSIOLOGY1. Pre-renal failure2. Intra-renal failure3. Post-renal failure Acute renal failure

PATHOPHYSIOLOGYPrerenal CAUSE:

Factors interfering with perfusion and resulting in diminished blood flow and glomerular filtrate, ischemia, and oliguria; include CHF, cardiogenic shock, acute vasoconstriction, hemorrhage, burns, septicemia, hypotension, anaphylaxis

Acute renal failurePATHOPHYSIOLOGYIntrarenal CAUSE:

Conditions that cause damage to the nephrons; include acute tubular necrosis (ATN), endocarditis, diabetes mellitus, malignant hypertension, acute glomerulonephritis, tumors, blood transfusion reactions, hypercalcemia, nephrotoxins (certain antibiotics, x-ray dyes, pesticides, anesthetics)

Acute renal failurePATHOPHYSIOLOGYPostrenal CAUSE:

Mechanical obstruction anywhere from the tubules to the urethra; includes calculi, BPH, tumors, strictures, blood clots, trauma, and anatomic malformation

Acute renal failureThree phases of acute renal failure

1. Oliguric phase 2. Diuretic phase 3. Convalescence or recovery phase Acute renal failure

Four phases of acute renal failure (Brunner and Suddarth)

1. Initiation phase 2. Oliguric phase 3. Diuretic phase 4. Convalescence or recovery phase Acute renal failure

Assessment findings: The Three Phases of Acute Renal Failure 1. Oliguric phase

Urine output less than 400 cc/24 hours duration 1—2 weeks

Manifested by dilutional hyponatremia, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia, and metabolic acidosis

Diagnostic tests: BUN and creatinine elevated

Acute renal failureAssessment findings: The Three Phases of Acute Renal Failure 2. Diuretic phase

Diuresis may occur (output 3—5 liters/day) due to partially regenerated tubule’s inability to concentrate urine

Duration: 2—3 weeks; manifested by hyponatremia, hypokalemia, and hypovolemia

Diagnostic tests: BUN and creatinine slightly elevated

Acute renal failureAssessment findings: The Three Phases of Acute Renal Failure 3. Recovery or convalescent phase:

Renal function stabilizes with gradual improvement over next 3—12 months

Acute renal failureLaboratory findings:

1. Urinalysis: Urine osmo and sodium2. BUN and creatinine levels increased3. Hyperkalemia 4. Anemia5. ABG: metabolic acidosis Acute renal failure

Nursing interventions Monitor fluid and Electrolyte Balance Reduce metabolic rate Promote pulmonary function Prevent infection Provide skin care Provide emotional support Acute renal failure

Nursing interventions1. Monitor and maintain fluid and electrolyte balance.

Measure l & O every hour. note excessive losses in diuretic phase

Administer IV fluids and electrolyte supplements as ordered.

Weigh daily and report gains. Monitor lab values; assess/treat fluid

and electrolyte and acid-base imbalances as needed

Acute renal failureNursing interventions2. Monitor alteration in fluid volume.

Monitor vital signs, PAP, PCWP, CVP as needed.

Weigh client daily. Maintain strict I & O records. Acute renal failure

Nursing interventions2. Assess every hour for hypervolemia

Maintain adequate ventilation.

Restrict FLUID intake Administer diuretics and

antihypertensives Acute renal failure

Nursing interventions3. Promote optimal nutritional status.

Weigh daily. Administer TPN as ordered. With enteral feedings, check for

residual and notify physician if residual volume increases.

Restrict protein intake to 1 g/kg/day Restrict POTASSIUM intake HIGH CARBOHYDRATE DIET,

calcium supplements Acute renal failure

Nursing interventions4. Prevent complications from impaired mobility (pulmonary embolism, skin breakdown, and atelectasis) 5. Prevent fever/infection.

Assess for signs of infection. Use strict aseptic technique

for wound and catheter care. Acute renal failure

Nursing interventions6. Support client/significant others and reduce/ relieve anxiety.

Explain pathophysiology and relationship to symptoms.

Explain all procedures and answer all questions in easy-to-understand terms

Refer to counseling services as needed

7. Provide care for the client receiving dialysis

Acute renal failureNursing interventions

8. Provide client teaching and discharge planning concerning

Adherence to prescribed dietary regimen

Signs and symptoms of recurrent renal disease

Importance of planned rest periods Use of prescribed drugs only Signs and symptoms of UTI or

respiratory infection need to report to physician immediately

Chronic Renal Failure Gradual, Progressive irreversible

destruction of the kidneys causing severe renal dysfunction.

The result is azotemia to UREMIA Chronic Renal Failure

Predisposing factors: DM= worldwide leading cause Recurrent infections Exacerbations of nephritis urinary tract obstruction hypertension

Chronic Renal FailurePATHOPHYSIOLOGYAs renal functions decline Retention of end-products of metabolism

Chronic Renal FailurePATHOPHYSIOLOGYSTAGE 1= reduced renal reserve, 40-75% loss of nephron functionSTAGE 2= renal insufficiency, 75-90% loss of nephron functionSTAGE 3= end-stage renal disease, more than 90% loss. DIALYSIS IS THE TREATMENT!

Chronic Renal FailureAssessment findings

1. Nausea, vomiting; diarrhea or constipation; decreased urinary output

2. Dyspnea 3. Stomatitis 4. Hypertension (later), lethargy,

convulsions, memory impairment, pericardial friction rub

Chronic Renal Failure Chronic Renal Failure

Diagnostic tests: a. 24 hour creatinine clearance

urinalysis

b. Protein, sodium, BUN, Crea and WBC elevated

c. Specific gravity, platelets, and calcium decreased

D. CBC= anemia Chronic Renal Failure

Medical management 1. Diet restrictions 2. Multivitamins 3. Hematinics and erythropoietin 4. Aluminum hydroxide gels 5. Anti-hypertensive 6. Anti-seizures DIALYSIS Chronic Renal Failure

Nursing interventions1. Prevent neurological complications.

Assess every hour for signs of uremia (fatigue, loss of appetite, decreased urine output, apathy, confusion, elevated blood pressure, edema of face and feet, itchy skin, restlessness, seizures).

Chronic Renal FailureNursing interventions1. Prevent neurological complications.

Assess for changes in mental functioning.

Orient confused client to time, place, date, and persons; institute safety measures to protect client from falling out of bed.

Monitor serum electrolytes, BUN, and creatinine as ordered

Chronic Renal FailureNursing interventions2. Promote optimal GI function.

Assess/provide care for stomatitis Monitor nausea, vomiting, anorexia Administer antiemetics as ordered. Assess for signs of Gl bleeding Chronic Renal Failure

Nursing interventions 3. Monitor/prevent alteration in fluid

and electrolyte balance 4. Assess for hyperphosphatemia

(paresthesias, muscle cramps, seizures, abnormal reflexes), and administer aluminum hydroxide gels (Amphojel) as ordered

Chronic Renal FailureNursing interventions

5. Promote maintenance of skin integrity. Assess/provide care for pruritus. Assess for uremic frost (urea

crystallization on the skin) and bathe in plain water

Chronic Renal FailureNursing interventions6. Monitor for bleeding complications, prevent injury to client.

Monitor Hgb, hct, platelets, RBC. Hematest all secretions. Administer hematinics as ordered. Avoid lM injections Chronic Renal Failure

Nursing interventions7. Promote/maintain maximal cardiovascular function.

Monitor blood pressure and report significant changes.

Auscultate for pericardial friction rub.

Perform circulation checks routinely. Chronic Renal Failure

Nursing interventions7. Promote/maintain maximal cardiovascular function.

Administer diuretics as ordered and monitor output.

Modify drug doses8. Provide care for client receiving dialysis.