Nursing: Elimination Health Deviations

Unit 5: Nursing Management of Elimination Health Deviations

• Unit focuses on nursing management of patients experiencing health deviations related to elimination
• Professor Ruth Thuo MSN-RN is the instructor

Required Readings

• Hinkle chapters 47, 49, and 53
• Karch chapters 9, 15, 41, and 52
• Kaplan Focused Review: Renal-Urologic System A

Objectives

• Explain key terms and medical terminology related to altered genitourinary function.
• Apply pathophysiology knowledge, including:
  • Hypospadias/epispadias, cryptorchidism, nephrotic syndrome
  • Glomerulonephritis, urolithiasis, Wilms tumor, enuresis
  • Male reproductive disorders, prostate disease, bladder cancer
  • Cancer of the testes, renal calculi, and urinary diversions.
• Determine unique teaching/learning needs of patients with altered genitourinary function.
• Apply the nursing process in maintaining health and promoting self-care in adult patients with altered GU function or genitourinary disorders.
• Relate diagnostic tests to patients with altered genitourinary function.
• Apply pharmacotherapeutics to treat selected genitourinary diseases.
• Articulate nursing responsibilities for patient nutritional requirements with altered genitourinary function.
• Discuss safety principles and efficient use of systems to care for patients with common elimination health deviations.
• Develop health promotion and maintenance practices for patients with altered genitourinary function.
• Demonstrate dignified nursing care, considering diverse cultural needs with altered GU function.
• Determine normal developmental changes and aging effects on patients with genitourinary diseases.
• Utilize effective verbal and non-verbal communication for patients with common health care deviations.

Physical Assessment: Bladder

• Palpate for bladder fullness
• Empty bladder is typically not palpable
• Dullness upon percussion indicates residual urine
• A midline mass suggests a full bladder

Physical Assessment: Renal

• Palpate at the costovertebral angle, specifically the 12th rib and spine
• Figure 47-5 and 47-7 provide an illustration
• Peripheral edema may suggest reduced kidney function
• Review Table 47-2 to recognize genitourinary pain characteristics

Diagnostic Studies of the Renal System

• Urinalysis and Urine Culture
• Renal Function Tests refer to Table 53-5
• Ultrasonography also known as KUB
• CT and MRI Scans
• Nuclear Scans
• Endoscopic Procedures
• Biopsies
• IV Urography
• Retrograde Pyelography
• Cystography
• Renal Angiography
• Refer to Chart 53-4

Urine Cultures

• Useful for identifying the specific organism responsible for a UTI
• A colony count of > 100,000 CFU/mL from a clean-catch midstream or catheterized specimen suggests infection.
• Multiple-test dipsticks often include leukocyte esterase and nitrite testing for WBC
• Tests for STIs are relevant in acute urethritis, which presents similar symptoms to those of UTIs.
• X-ray, CT scan, ultrasonography, and kidney scans aid in the detection of pyelonephritis, abscesses, obstructions, tumors, and cysts.

24-Hour Urine Testing

• Determines renal clearance and creatinine clearance
• Creatinine clearance reflects renal function
• Results may reflect disease progression

Serum Creatinine

• A normal serum creatinine is 0.6-1.2 mg/dL

BUN (Blood Urea Nitrogen)

• Normal blood urea nitrogen values range from 7-18 mg/dL.

Cystoscopy Procedures

• Operative Procedure
• Pre-procedure directives include being NPO, premedicated, anesthesized, and consent attained.
• Monitor output and check for blood-tinged urine, which can cause burning during post-op.

Kidney Functions

• Control blood pressure and water balance
• Excrete waste products
• Regulate electrolytes and acid-base balance
• Aid in red blood cell production via erythropoietin
• Stimulate bone marrow to produce RBCs
• Renal clearance
• Secrete prostaglandins
• Synthesize vitamin D to active form
• Form urine

Factors Contributing to UTI

• Bacterial invasion
• Urethrovesical reflux
• Uropathogenic bacteria
• Shorter female urethra

Risk Factors for UTIs

• Instrumentation including catheters
• Pre-existing conditions for example Diabetes and Pregnancy
• Immobility
• Incomplete bladder emptying
• Obstruction
• Immunosuppression

Urinary Tract Infections (UTIs)

• UTIs are caused by pathogenic microorganisms in the urinary tract.
• Classified by location they are either in the lower urinary tract or upper urinary tract
• Lower tract involves the bladder and structures below
• Upper tract involves the kidneys and ureters
• UTIs are the second most common type of infection in the body.
• 50% of hospital-acquired infections- CAUTIs, are associated with indwelling urinary catheters.

Upper Urinary Tract Infection: Pyelonephritis (Acute)

• Chills, fever, and UTI symptoms
• Low back/flank pain
• Costovertebral tenderness
• Generalized malaise

Upper Urinary Tract Infection: Pyelonephritis (Chronic)

• Inflammation
• Scarring
• Pus
• Atrophy of Cortex

Upper UTI Characteristics

• Pyelonephritis presents as acute and chronic.
• Chills, fever, leukocytosis, bacteriuria, and pyuria.
• Associated with low back/flank pain, nausea and vomiting, headache, malaise, and painful urination.
• Physical exam may reveal pain/tenderness in the costovertebral angle

Lower UTI Characteristics

• Cystitis inflammation of the urinary bladder
• Prostatitis inflammation of the prostate gland
• Urethritis inflammation of the urethra

Urethrovesical and Ureterovesical Reflux

• In urethrovesical reflux, urine flows backward from the urethra into the bladder, introducing bacteria.
• Ureterovesical or vesicoureteral reflux involves the backward flow of urine from the bladder into one or both ureters.
• Ureterovesical reflux is caused by ureterovesical valve impairment leading bacteria to reach and eventually destroy the kidneys

Gerontologic Considerations

• Older adults are susceptible to kidney injury due to renal structural and functional changes
• Structural and functional changes include Sclerosis and Decreased blood flow
• Structural and functional changes also include Decreased GFR and Altered tubal function
• Older adults experiencing kidney issues may exhibit incomplete emptying of the bladder, urinary stasis, and decreased nerve innervations
• Decreased drug clearance leads to increased drug interactions
• Cognitive impairment
• Frequent antimicrobial use
• High incidence of multiple chronic medical conditions
• Immune compromised
• Low fluid intake and excessive fluid loss
• Obstructed urine flow as a result of urethral strictures, neoplasms, or a clogged indwelling catheter
• Poor hygiene practices
• E. coli infection is the most common organism seen in older patients in community or hospital
• Patients with indwelling catheters are more likely to be infected by Proteus, Klebsiella, Pseudomonas, or Staphylococcus
• UTI early symptoms for older adults include Malaise, nocturia, urinary incontinence, and foul smelling urine
• Early UTI symptoms include Burning, urgency, fever, incontinence, and delirium
• Treatment regimens are similar for younger adults, but monitor kidney function and change medication since absorption decreases

Urinary Tract Infection: (U.T.I) Cystitis

• Frequency
• Urgency
• Suprapubic Pain
• Dysuria
• Hematuria
• Fever
• Confusion in Older Adults
• Diagnosis via Dipstick for Leukocyte Esterase and Nitrates and UA / C & S
• Increased risk in older adults
• Treatment via Anti-Microbials and Increased Fluid Intake and Prevention
• Symptomatic Relief and Teaching & Prevention
• Showers Better Than Baths with Perineal Cleansing, washing "Front To Back" and Voiding After Intercourse

Urinary Tract Infection: (U.T.I) Cystitis Continued....

• Anti-Microbial Therapy and No Scented Toilet Paper
• No Perfumes, etc. to Perineal
• Empty Bladder Regularly

Urinary Tract Infection: (U.T.I) Pylonephritis

• Flank Pain
• Dysuria
• Pain At Costovertebral Angle

Collaborative Problems and Potential Complications

• Sepsis (urosepsis)
• Acute kidney injury
• Chronic kidney disease

Nursing Interventions for Urinary Irritation

• Relieve Bladder Irritability
• Provide Pain relief
• Administer ordered Antibiotics, Analgesics, and Antispasmodic Medications
• Apply heat to the perineum for spasm relief
• Promote Renal blood flow
• Increase Fluid Intake to Flush bacteria from the urinary tract
• Avoid taking Urinary Tract Irritants, such as Coffee, Tea, Citrus, Spices, Cola, and Alcohol
• Lower urine bacterial counts
• Encourage voiding and prevent stasis, and reinfection

Nursing Interventions

• Fluid management via 1500-1600 ml/day
• Avoid Caffeinated products
• Enforce a voiding schedule of every 2 hours
• Bladder retraining by extending voiding schedule
• Enforce pelvic muscle use with 2-3 times a day kegel exercises

Sulfonamides

• Sulfonamides inhibit folic acid synthesis
• Reaches peak absorption in the GI track around 3 to 6 hours
• GI adverse effects include nausea, vomiting, diarrhea, abdominal pain, anorexia, stomatitis, and hepatic injury
• Other adverse effects include Nephrotoxicity, photosensitivity, and Steven-Johnson syndrome
• Do not take if you have a previous allergy and if you are currently breastfeeding
• Take with caution if you have kidney disease or have kidney stones

Urinary Antiseptics

• Such as Nitrofurantoin, phenazopyridine, and trimethoprim sulfamethoxazole
• Acts quickly within the urinary tract to destroy bacteria by preventing direct cell wall absorption
• Don't take if allergic, have renal dysfunction, pregnancy, or lactation
• Side effects include nausea, diarrhea, and vaginitis

Adult Voiding Dysfunction

• Urinary Incontinence which includes unplanned or unvoluntary loss of urine from the bladder
• Urinary retention is the lack of inability to fully empty the bladder while trying to
• Neurogenic bladder is dysfunction from a disorder of the nervous system that becomes urinary incontinence
• Urolithiasis and nephrolithiasis refers to stones in the urinary track or kidney respectively
• Genitourinary trauma is injures in the flank, back, or upper abdomen
• Urinary Track Cancer which includes those in the urinary bladder, Kidney and renal Pelvis
• Also including ureters and other urinary structures like the prostate

Urinary Incontinence

• Effects more than 25 million adults in the U.S.
• It is underdiagnosed and underreported
• Effects men and women
• Risk Factor can be charted at 55-6
• Is a symptom of possible disorders

Types of Urinary Incontinence

• Stress Incontinence occurs when stress is exhibited when sneezing or changing position
• Urge Incontinence is having a strong urge to use the restroom but it can not be suppressed
• Functional Incontinence is physical or cognitive impairment in conditions like dementia can make it hard for one to reach the restroom
• Iatrogenic Incontinence is the loss of urine to factors including medication
• Mixed Incontinence is all of the types of urinary incontinence are combined making it when some involuntary such as sneezing happen
• Overflow Incontinence is continual leakage

Transient Incontinence

• The incontinence that is resolved once located
• Causes for the condition being
• Delirium, Infection, Atrophic Urethritis, Pharamaceuticals, Excess Urine Output, and restricted mobility
• Stool impactation the last one

Patient Education for Urinary Incontinence

• Urinary Incontinence in treatable not inevitable
• Management takes time so provide support, and encourgement
• Behavioral intervention through a diary schedule
• Medication Education related to Medication

Urinary Retention

• Defined as the inability of the bladder to empty completely.
• Manifests as residual urine volume
• Adults 60 years and up may have ~50-100 mL
• Other common occurrences include
• Postoperative spasms, medications, prostate growth, and neuropathy
• There are also medications

Neurogenic Bladder Management

• Disorder characterized as the urinary system not retaining or having incontinence.
• Usually a Spastic (or reflex) bladder and flaccid bladder
• To treat you can try-Intermittent catheterization can help as well having reduced mobility
• Liberal fluid intake is encouraged to reduce the urinary track count
• You can also use double void techniques as well as a re training program to give more flaccid usage

Anticholinergic Urinary Antispasmodics

• Such as Oxybutnin
• You can also directly relax smooth muscle by preventing some things
• Don't if allergic or have obstruction and also acute hemorrhage
• There are a lot of adverse effects including drowsiness and blurred vision

Urolithiasis and Nephrolithiasis Symptoms

• May include infection with chills and fever
• Excruciating intermittent pain
• Nausea, vomiting, bloody urine
• Stones in the ureter cause pain that radiates to the genitalia
• Diagnosis with Ultrasound, cytoscopy
• Managed short term with opioid analgesics: long term often need stone removal

Calcium Channel Blockers

• Nifedipine (Procardia) indicated for decreased BP and myocardial O2 consumption
• Blocks movement of calcium ions slowing cardiac
• Used for smooth muscle spasm in the ureter during stone expulsion
• Adverse effects include Dizziness and Nausea

Loop Diuretics

• Furosemide (Lasix) works to decrease tubular reabsorption of sodium and chloride
• Contraindicated in severe renal failure
• Adverse effects include hypotension and hypokalemia

Glucocorticoid

• Prednisone is often uses here
• Short term inflammatory
• Can cause vertigo

What should you check for in patients with Urolithiasis?

• Monitor for pain
• Make sure that the patient is able to understand about their condition and what is going on
• Keep them informed on what can happen

Genitourinary Trauma

• Including motor vechile accidents, sport injures, and accidental falls
• Bladder: pelvic fracture, multiple trauma, blow to the lower abdomen
• Medical management with infection control
• Surgical management can result from urigouria. Eduacate what that can look like

How to treat Bladder Cancer

• Grade the Tumor by Chemotherapy and radiation
• Surgical Management by removing what you can to prevent more damage

Bladder Cancer Nursing Management

• Immediate monitor volume
• Test urine to see if something is going on

Types of Urinary Diversions

• Cutaneous urinary diversion
• Continent urinary diversion

Testicular Cancer

• Common caner in men between 15 -40 yaers
• Most of the time it is treatable
• Testical Cancer is often a pain less lump or mass for indication
• The examination often occurs monthly
• To treat, orchidectomy and retroperitoneal, radiation

Nursing Management

• Assessment the overall health
• Support Coping
• There is often issues of body image and sexuly
• Encourage a positive attitude
• TSE care after you help

Testicular Self Exams

The nurses should explain a patient to do one after a warm shower for best results