Genitourinary System PDF

GENITOURINARY SYSTEM WHAT ARE THE FUNCTIONS OF THE GENITO- URINARY SYSTEM? ANATOMY AND PHYSIOLOGY KIDNEYS Each person has two kidneys; each is attached to the abdominal wall at the level of the thoracic and first three lumbar vertebr...

GENITOURINARY SYSTEM WHAT ARE THE FUNCTIONS OF THE GENITO- URINARY SYSTEM? ANATOMY AND PHYSIOLOGY KIDNEYS Each person has two kidneys; each is attached to the abdominal wall at the level of the thoracic and first three lumbar vertebrae. The kidneys are enclosed in the renal capsule. The cortex is the outer layer of the renal capsule which contains blood-filtering mechanisms. The medulla is the inner layer and is surrounded by the cortex which contains the renal pyramids. The nephron makes up the functional unit of the kidneys. FUNCTIONS OF KIDNEYS: 1. Maintain homeostasis of blood and acid- base balance. 2. Excrete end products of body metabolism. 3. Control fluid and electrolyte balance. 4. Excrete bacterial toxins, water-soluble drugs, and drug metabolites. 5. Secrete renin and erythropoietin, which play a role in the function of the parathyroid hormones and vitamin D. NEPHRON Glomerular Filtration Rate (GFR) the nephron ids the functional renal unit. Measure of functional capacity of the kidney The nephron is composed of glomerulus and tubules. Dependent on difference in pressures between Functional unit of the kidney (1,000,000) capillaries and Bowman’s space Responsible for urine formation: Normal = 120 ml/min =7.2 L/h=180 L/day!! (99% of fluid – Filtration filtered is reabs.) – Secretion Depends on the difference in hydrostatic and oncotic – Reabsorption pressure on either side of the glomerular basement GLOMERULUS membrane The glomerulus is encased in Bowman’s capsule. Filters the fluid out of blood TUBULES The tubules include proximal, distal and Henle’s loop Fluid is converted to urine in the tubules, and then the urine moves to the pelvis of the kidney. The urine flows from the pelvis of the kidney through the ureter and empties into bladder.  What is Reabsorbed Where? Urethra Proximal tubule - reabsorbs 65 % of filtered Na+ as Extends from the base of the well as Cl-, Ca2+, PO4, HCO3 -. 75-90% of H20. Glucose, bladder to the outside world. carbohydrates, amino acids, and small proteins are also Anatomical differences mean reabsorbed here. that male and female urethras are Loop of Henle - reabsorbs 25% of filtered Na+. different. Distal tubule - reabsorbs 8% of filtered Na+. Reabsorbs – Female: 3-5cm long HCO3- – Male: 14-16 cm long. Collecting duct - reabsorbs the remaining 2% of Na+ only if the hormone aldosterone is present. H20 depending on hormone ADH. Secretion ADRENAL GLANDS Proximal tubule – uric acid, bile salts, metabolites, One adrenal gland is on top of each kidney. some drugs, some creatinine The adrenal glands influence blood pressure and Distal tubule – Most active secretion takes place here sodium and water retention. including organic acids, K+, H+, drugs, Tamm-Horsfall PROSTATE GLAND protein (main component of hyaline casts). the prostate gland surrounds the male urethra Contains a duct that opens into the prostatic portion of the urethra and secretes the alkaline portion of seminal fluid, which protects passing sperm. ASSESSMENT Risk factors associated with Renal Disorders: chemical or environmental toxin exposure Contact sports Diabetes mellitus Family history of renal disease Frequent urinary tract infections. Heart failure High sodium diet LABORATORY / DIAGNOSTIC BLADDER TESTS The bladder detrusor muscle, composed of smooth muscle, distends during bladder filling and contracts URINE STUDIES during bladder emptying. 1. URINALYSIS The ureterovesical sphincter prevents reflux of urine - examination to assess the nature of the urine produced. from the bladder to the ureter. a. Evaluates color, pH, and specific gravity The total capacity of the bladder is 1L. COLOR: pale to amber Bladder- structure of VOLUME: 30 ml/hour 3 layers APPEARANCE: Clear Outer layer ODOR: aromatic then strong ammoniacal odor Loose connective tissue SPECIFIC GRAVITY: 1.015-1.025 (24 hr urine collection) Middle layer 1.003-1.030 (random specimen) Smooth muscle and elastic pH: 4.8-8.0 fibres b. Determines the presence of glucose, protein, ketones Inner layer and blood. Lined with transitional c. Analyzes sediment for cells - presence of WBC, casts epithelium bacteria, crystals Ureters Superiorly 2. URINE CULTURE and SENSITIVITY Continuous with the renal pelvis - diagnoses bacterial infections of the urinary tract. Inferiorly Pass through the abdominal 3. RESIDUAL URINE cavity, behind the peritoneum, - amount of urine left in the bladder after voiding infront of the psoas muscle, into measured via the pelvic cavity where they enter catheter (permanent or temporary) in bladder. the posterior wall of the bladder - 25-30 cm in length 4. CREATININE CLEARANCE KUB - determines amount of creatinine (waste product of An x-ray of the urinary system and adjacent structures is protein breakdown) in the urine over 24 hours used to detect urinary calculi - measures overall renal function; measures GFR INTRAVENOUS PYELOGRAM (IVP) 5. BUN (BLOOD UREA NITROGEN) TEST Fluoroscopic visualization of the urinary tract after - measures the amount of urea nitrogen in your blood injection with a radiopaque dye. URINE COLLECTION METHODS NURSING CARE (PRE-TEST) 1.ROUTINE URINALYSIS Assess for iodine sensitivity. Wash perineal area if soiled. Obtain consent Obtain first voided morning specimen. Inform client he will lie on a table throughout procedure. Send to lab immediately. Administer cathartic or enema the night before. – - should be examined within 1 hour of voiding Keep the client NPO for 8 hours pretest. Inform client about possible throat irritations, flushing of 2. CLEAN CATCH (MIDSTREAM) SPECIMEN for face, warmth or a salty taste that may be experienced URINE CULTURE during the test Cleanse perineal area. NURSING CARE (POST-TEST) FEMALE Force fluids. – Spread labia and cleanse meatus front to back using Assess venipincture site for bleeding antiseptic sponges. Monitor V/S for U/O MALE – Retract foreskin (if uncircumcised) and cleanse glans CYSTOSCOPY with antiseptic sponges. Use of a lighted scope (cystoscope) to inspect the Have client initiate urine stream then stop. bladder. Collect specimen in a sterile container. - Inserted into the bladder via the urethra. Have client complete urination, but not in specimen - May be used to remove tumors, stones, or other foreign container material or to implant radium, place catheters in ureters. 3. 24-hour URINE SPECIMEN NURSING CARE (PRE-TEST) - preferred method for creatinine clearance test. Explain to client that the procedure will be done under Have client void and discard specimen; note time. general/local anesthesia. Collect all subsequent urine specimens for 24 hours. Obtain CONSENT If specimen is accidentally discarded, the test must be Confirm consent form is signed. Record exact start and finish of collection; include date Administer sedatives 1 hour before test, as ordered. and time General anesthesia: Keep client on NPO. Local anesthesia: offer liquid breakfast BLOOD STUDIES NURSING CARE (POST-TEST) BICARBONATE Monitor V/S & I/O - 22-26 mEq/L -PINK TINGED/TEA COLORED URINE is expected BUN -BRIGHT RED URINE/PRESENCE OF LARGE CLOTS - measures renal ability to excrete urea nitrogen should be reported - Normal: 5-20 mg/dl Advise client that burning on urination is normal and will CALCIUM subside. - 9.0-10.5 mg/dl Encourage DBE to relieve bladder spasms SERUM CREATININE Administer sitz baths for back & abdominal pain - Specific tests for renal disorders Administer analgesics as Rx - Reflects ability of kidneys to excrete creatinine Force fluids as prescribed - 0.7-1.5 mg/dl PHOSPHORUS RENAL ANGIOGRAPHY - 2.5-4.5 mg/dl the injection of a radiopaque dye through a catheter for Sodium examination of the renal artery supply - 136-145 mEq/L NURSING CARE ( PRE-TEST) Potassium Obtain consent - 3.5-5 mEq/L Assess client for allergies to iodine, seafoods & Serum uric acid level radiopaque dyes - 2.5 to 8.0 mg/d Inform patient about possible burning sensation along the vessel  Instruct client to void immediately before the NURSING CARE procedure Force fluids (3L/day) Shave injection sites as prescribed Warm sitz bath for comfort. Assess & mark the peripheral pulses Assess urine for odor, hematuria, & sediment. NURSING CARE ( POST TEST) Use strict aseptic technique in FBC Assess V/S & peripheral pulses Administer medications as ordered. Provide bedrest & use of sandbag @ the insertion site Client teaching for 4-8 hrs CLIENT TEACHING NPO postmidnight before the test Acidic urine diminish the action of aminoglycoside, Assess color & temp of the involved extremity sulfonamide, nitrofurantioin(macrodantin) Force fluids unless C/I Discourage caffeine products such as coffee, tea and Monitor urinary output cola Avoid alcohol DISORDERS OF THE Wipe perineal area from front to back GENITOURINARY SYSTEM Void and drink a glass of water after intercourse Void q 2H URINARY TRACT INFECTION Encourage menopausal women to use estrogen PREDISPOSING FACTORS vaginal creams to restore pH Poor hygiene Instruct female client to use water-soluble lubricants Irritation from bubble baths for coitus, especially after menopause Urinary reflux CLINICAL FINDINGS PYELONEPHRITIS Low-grade fever Inflammation of the renal pelvis & parenchyma, Abdominal pain commonly caused by bacterial invasion Pain/burning on urination Acute Infection Frequency - usually ascends from the lower urinary tract or Hematuria following an invasive procedure of the urinary tract NURSING CARE - can progress to bacteremia or chronic pyelonephritis Administer antibiotics as ordered. ASSESSMENT - prevention of kidney infection/glomerulonephritis. Fever & Chills - obtain cultures before starting antibiotics N/V Provide warm sitz baths to alleviate painful voiding. CVA tenderness, flank pain on the affected side Force fluids. Headache, muscular pain, dysuria Encourage measures to acidify urine. Frequency & urgency Provide client teaching and discharge planning Chronic Infection - Major cause is ureterovesical reflux CYSTITIS - Result of recurrent infections is eventual parenchymal CLINICAL FINDINGS deterioration and possible renal failure Abdominal or flank pain/tenderness ASSESSMENT Frequency and urgency of urination Client usually unaware of the disease Pain on voiding May have bladder irritability Nocturia Chronic fatigue Fever Slight dull ache over the kidneys DIAGNOSTIC TESTS Eventually develops hypertension, atrophy of the Urine culture and sensitivity kidneys - presence of E. coli (80%) Azotemia NURSING CARE most common causative agent: E. coli, enterobacter, Monitor I & O Pseudomonas & Serratia Encourage adequate rest Causes: bubble bath, allegergens, bladder distention, Administer antibiotics, analgesics as ordered. invasive urinary tract procedures, Support client and significant others and explain Sexually active & pregnant women are most the possibility of dialysis, transplant options if vulnerable significant renal deterioration. to cystitis Provide client teaching and discharge planning: Poor-fitting diaphragms - Medication regimen Use of spermicides - DieT: high calorie, low protein Wet bathing suits  NEPHROTIC SYNDROME (NEPHROSIS) ACUTE GLOMERULONEPHRITIS GENERAL INFORMATION GENERAL INFORMATION Autoimmune process leading to structural alteration of Immune complex disease resulting from an antigen- glomerular membrane that results in increased antibody reaction. permeability Secondary to a beta-hemolytic streptococcal infection to plasma proteins, particularly albumin. occurring elsewhere in the body. Course of the disease consists of exacerbations and Occurs more frequently in boys, usually between ages remissions over a period of months to years. 6-7 years Commonly affects preschoolers. Usually resolves in about 14 days - boys more often than girls Self-limiting Prognosis is good unless edema does not respond to CLINICAL FINDINGS steroids History of a precipitating streptoccal infection, usually URTI or impetigo Edema, anorexia, lethargy Hematuria or dark-colored urine Fever Hypertension DIAGNOSTIC FINDINGS U/A - reveals RBCs, WBCs, CHON, cellular casts Urine specific gravity increased BUN and serum creatinine increased ESR elevated CLINICAL FINDINGS Hgb and Hct decreased Proteinuria, hypoproteinemia, hyperlipidemia NURSING CARE Dependent body edema MIO, BP, urine and WOD. - puffiness around eyes in morning provide diversional therapy. - ascites Provide client teaching and planning concerning: - scrotal edema - Medication administration - ankle edema - Prevention of infection Anorexia, vomiting, diarrhea, malnutrition - Signs of renal complications Pallor, lethargy - Importance of long-term follow-u Hepatomegaly MEDICAL MANAGEMENT HYDRONEPHROSIS Drug therapy CLINICAL FINDINGS - Corticosteroids Repeated UTIs - to resolve edema Failure to thrive - Antibiotics Abdominal pain, fever - for bacterial infections Fluctuating mass in region of kidney - Thiazide diuretics MEDICAL MANAGEMENT - edematous stage Surgery to correct or remove obstruction Bedrest NURSING CARE Diet modification monitor V/S frequently - High CHON - Low Na monitor for F/E imbalances including NURSING CARE dehydration after the obstruction is relieved. Provide bed rest. monitor diuresis w/c could lead to fluid depletion - Conserve energy. WOD - Find activities for quiet play. monitor urine fro specific gravity, albumin & glucose Provide high CHON, low sodium diet during edema phase administer fluid replacement as prescribed only. NURSING CARE (Post-op care) Maintain skin integrity. Monitor drains. - Don’t use Band-Aids. - may have one from bladder and one from each ureter - Avoid IM injections (ureteral stents) - medication is not absorbed in edematous tissue. Check output from all drains and record carefully. Obtain morning urine for CHON studies. - expect bloody urine initially Provide scrotal support. Observe drainage from abdominal dressing and note MIO, V/S and WOD color, amount and frequency. Administer steroids to suppress autoimmune response as Administer medication for bladder spasms as ordered ordered. Protect from known sources of infection  NEPHROLITHIASIS/UROLITHIASIS NURSING CARE GENERAL INFORMATION Strain all urine through gauze to detect stones and Presence of stones anywhere in the urinary tract. crush all Frequent compositions of stones: clots. - calcium (phosphate), uric acid and cystine (rare) stones Force fluids (3000 – 4000 ml/day). Most often occurs in men age 20-55 years; more Encourage ambulation to prevent stasis. common in the summer Relieve pain by administration of analgesics as ordered PREDISPOSING FACTORS and application of moist heat to flank area. Diet: large amount of calcium, oxalate Monitor I & O. Increased uric acid levels Provide modified diet, depending upon stone Sedentary lifestyles, immobility consistency Family history of gout or calculi DIET MODIFIED/STONE Hyperparathyroidism CALCIUM STONES CLINICAL FINDINGS Low calcium diet ( 400 mg daily) Abdominal pain or flank pain Achieved by eliminating milk/dairy products Renal colic Provide acid-ash diet to acidify urine - severe pain in the kidney area radiating down the flank - Cranberry or prune juice to the pubic area - Meat Hematuria, frequency, urgency, nausea - Eggs History of prior associated health problems - Poultry - gout, parathyroidism, immobility, dehydration, UTI - Fish Diaphoresis - Grapes Pallor - Whole grains Grimacing - Take vitamin A & C, Folic acid supplements and Vomiting Riboflavin Pyuria if infection is present The acid-ash diet mainly comprises moderate- and MEDICAL MANAGEMENT high-protein foods like fish, shellfish, meats, eggs, 1. SURGERY cheese and grains. According to the Food & Nutrition A. PERCUTANEOUS NEPHROSTOMY Encyclopedia, roast beef, chicken, ham, lamb, pork, veal - Tube is inserted through skin and underlying tissues and bacon qualify as acid- forming animal proteins. into renal pelvis to remove calculi. OXALATE STONES B. PERCUTANEOUS NEPHROLITHOTOMY Avoid excess intake of foods/fluids high in oxalate - Delivers U/S waves thorough a probe placed on the - Tea calculus - Chocolate 2. PERCUTANEOUS ULTRASONIC LITHOTRIPSY - Rhubarb (PUL) - Spinach - Nephroscope is inserted through skin into kidney. Maintain alkaline-ash diet to alkalinize urine - Ultrasonic waves disintegrate stones that are then - Milk removed by suction and irrigation - Vegetables 3. EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY - Fruits except prunes, cranberries and plums (ESWL) Alkaline ash, on the other hand, they believe is - Client is placed in water and exposed to shock waves protective and that by “alkalizing” the diet and balancing that disintegrate stones so that they can be passed with the body's pH, it is possible to improve health. The food urine. eaten includes vegetables, fruits, almonds, lentils, soy - This procedure is non-invasive products, tofu, and sprouted grains. URIC ACID STONES Uric acid is a metabolic product of purines Reduce foods high in purine - Liver, brains, kidneys, venison, shellfish, meat soups, gravies, legumes and whole grains Maintain alkaline urine - Alkaline-ash diet CYSTINE STONES (rare) Low methionine - Methionine is the essential amino acid from which the non- essential amino acid cystine is formed Limit protein foods - Meat, milk, eggs, cheese Maintain alkaline-ash die NURSING CARE Description Administer Allopurinol (Zyloprim) as ordered. Is the sudden loss of kidney function and is caused - to decrease uric acid production by renal cell damage from ischemia or toxic - force fluids when giving Allopurinol substances. Encourage daily weight-bearing exercise Occurs abruptly and can be reversible. Provide client teaching and discharge planning It leads to hypoperfusion, cell death, and concerning: decompensation in renal function - Prevention of urinary stasis by EOF esp. in hot weather Pathophysiology and during illness, mobility, voiding whenever the urge is Acute renal failure (ARF) is a reversible clinical felt and at least twice during the night. syndrome where there is a sudden and almost - Adherence to prescribed diet. complete loss of kidney function (decreased GFR) - Need for routine U/A (at least every 3-4 months) over a period of hours to days with failure to excrete - Need to recognize and report S/Sx of recurrence nitrogenous waste products and to maintain fluid - hematuria, flank pain and electrolyte homeostasis. Provide care ff a nephrolithotomy or PUL= ARF manifests as an increase in serum creatinine Percutaneous lithotomy and BUN - Change dressings frequently during the first 24 hours Urine volume may be normal, or changes may occur. after a nephrolithotomy. Possible changes include oliguria (less than 400 - Maintain patency of ureteral catheter as well as mL/day), non- oliguria (greater than 400 mL/day), or urethral catheter to prevent hydronephrosis. anuria (less than 50 mL/day). - Encourage use of incentive spirometry and coughing Some of the factors may be reversible if identified and deep breathing to prevent atelectasis and treated promptly, before kidney function is impaired RENAL FAILURE Phases of Acute Renal Failure There are four clinical phases of ARF: PRERENAL INTEARENAL POSTRENAL 1. Initiation Period – begins with the initial insult and CAUSES CAUSES CAUSES ends when oliguria develops 2. Oliguria Period – is accompanied by an increase in ACUTE the serum concentration of substances usually excreted TUBULAR by the kidneys (urea, creatinine, uric acid, organic acids, HYPOTENSION CALCULI and the intracellular cations [potassium and NECROSIS magnesium]) (ATN) Oliguric Phase 1. Duration of 5 to 8 days; and the longer the duration, CARDIOGENIC DIABETES TUMORS the less chance of recovery SHOCK MELLITUS 2. Sudden drop in urine output; urine output less than 400 mL/day ACUTE MALIGNANT 3. Urine specific gravity of decreased VASOCONSTRI BLOOD CLOTS HYPERTENSION 4. Anorexia, nausea and vomiting CTION 5. Hypertension 6. Decreased skin turgor ACUTE HEMORRHAGE 7. Pruritus GLOMERULON BPH 8. Tingling of the extremities EPHRITIS 9. Drowsiness progressing to disorientation to coma 10. Edema BURNS TUMORS STRICTURES 11. Dysrhythmias 12. Signs of congestive heart failure (CHF) and pulmonary edema BLOOD 13. Signs of pericarditis SEPTICEMIA TRANSFUSION TRAUMA 14. Signs of acidosis REACTIONS 3. Diuresis Period – is marked by a gradual increase in urine output, which signals that glomerular filtration has ANATOMIC CHF NEPHROTOXINS MALFORMATION started to recover Diuretic Phase 1. Urine output rises slowly, and then diuresis occurs (4 to 5 L/day) 2. Excessive urine output indicates recovery of damaged nephrons 3. Hypotension occurs A renal sonogram or a CT or MRI scan may show 4. Tachycardia occurs evidence of anatomical changes. 5. Level of consciousness improves The BUN level increases. 4. Recovery Period – signals the improvement of renal Serum creatinine increases. Serum creatinine levels function and may take 3 to 12 months. are useful in monitoring kidney function and disease Recovery Phase (convalescent) progression 1. Recovery is a slow process; complete recovery may Hyperkalemia take 1 to 2 years Metabolic acidosis 2. Urine volume is normal Increase in blood phosphate concentrations 3. Increase in strength occurs Calcium levels may be low 4. Level of consciousness occurs Anemia is another common laboratory finding in 5. Blood urea nitrogen is stable and normal ARF, as a result of reduced erythropoietin 6. Client can develop chronic renal failure production, uremic GI lesions, reduced RBC life span, and blood loss, usually from the GI tract CLINICAL FINDINGS Medical Management The objectives of treatment of ARF are to restore OLIGURIC DIURETIC CONVALESCENT normal chemical balance and prevent complications PHASE PHASE PHASE until repair of renal tissue and restoration of renal function can occur. Maintaining fluid balance Normal Urine Avoiding fluid excesses Hypernatremia Hyponatremia Volume Possibly performing dialysis Prerenal azotemia is treated by optimizing renal perfusion Hypocalcemia Hypokalemia Increase in LOC Postrenal failure is treated by relieving the obstruction Intrarenal azotemia is treated with supportive BUN stable and Hyperkalemia Hypovolemia therapy, with removal of causative agents normal A. Pharmacologic Therapy The elevated potassium levels may be reduced by ACUTE administering carbon-exchange resins (sodium HEMORRHAGE GLOMERULON BPH polystyrene sulfonate [Kayexalate]) orally or by EPHRITIS retention enema. Sorbitol may be administered in combination with Kayexalate to induce a diarrhea-type effect (it BURNS TUMORS STRICTURES induces water loss in the GI tract) Kayexalate retention enema is administered BLOOD If the patient is hemodynamically unstable (low SEPTICEMIA TRANSFUSION TRAUMA blood pressure, changes in mental status, REACTIONS dysrhythmia) IV dextrose 50%, insulin and calcium replacement ANATOMIC may be administered to shift potassium back into the CHF NEPHROTOXINS MALFORMATION cells. Adjust antibiotic medications (aminoglycosides), digoxin, ACE inhibitors, and magnesium-containing Clinical Manifestations agents The patient may appear critically ill and lethargic. Diuretic agents The skin and mucous membranes are dry from Severe acidosis dehydration. B. Nutritional Therapy Central nervous system signs and symptoms include The patient is weighed daily drowsiness, headache, muscle twitching, and Dietary proteins seizures High-carbohydrate meals Assessment and Diagnostic Findings Foods and fluids containing potassium or Urine output varies (scanty to normal volume), phosphorus (eg, bananas, citrus fruits and juices, hematuria may be present, and the urine has a low coffee) are restricted specific gravity (compared with a normal value of Parenteral nutrition 1.003 to 1.030) Following the diuretic phase, the patient is placed on Ultrasonography is a critical component of the a high- protein diet and is encouraged to resume evaluation of patients with renal failure. activities gradually Nursing Management A. Monitoring Fluid and Electrolyte Balance CLINICAL FINDINGS Parenteral fluids, all oral intake, and all medications are screened carefully Nausea and vomiting Uremic frost Patient’s cardiac function and musculoskeletal status are monitored closely for signs of Decreased urinary hyperkalemia. Dyspnea output B. Reducing Metabolic Rate Bed rest Azotemia Hypotension (early) Fever and infection are prevented or treated C. Promoting Pulmonary Function Hypertension (later) Lethargy Attention is given to pulmonary function The patient is assisted to turn, cough, and take deep Convulsions Memory impairment breaths frequently D. Preventing Infection Pericardial friction rub CHF Asepsis is essential with invasive lines and catheters Indwelling urinary catheter is avoided NURSING CARE: E. Providing Skin Care Prevent neurologic complications. Meticulous skin care is important Promote optimal GI function. Turning the patient frequently, bathing him or her Monitor/prevent alteration in F/E. with cool water, and keeping the skin clean and well Promote maintenance of skin integrity. moisturized and the fingernails trimmed to avoid Monitor for bleeding complications, and prevent injury excoriation Assess for hyperphosphatemia F. Providing Support - Paresthesias The patient with ARF may require treatment with - Muscle cramps Hemodialysis, peritoneal dialysis, to prevent serious - Seizures complications - Abnormal reflexes Administer Aluminum hydroxide gels as ordered CHRONIC RENAL FAILURE - Amphogel, AlternaGEL Progressive, irreversible destruction of the kidneys that Promote/maintain maximal cardiovascular function. continues until nephrons are replaced by scar tissue. Provide care for client receiving dialysis Loss of renal function is gradual. Hypervolemia can occur owing to the inability of the DIALYSIS kidneys to excrete sodium & water, or hypovolemia can (DIFFUSION, OSMOSIS, occur owing to inability of the kidneys to conserve ULTRAFILTRATION sodium & water TYPES Hemodialysis CLINICAL FINDINGS GENERAL INFORMATION Shunting of blood from the client’s vascular system STAGE 1 STAGE 2 STAGE 3 through an artificial dialyzing system and return of dialyzed blood to the client’s circulation. DIMINISHED RENAL Dialysis coil acts as the semi-permeable membrane. RENAL END STAGE INSUFFICIENCY Dialysate is a specially prepared solution RESERVE Peritoneal dialysis STAGE 1 DIMINISHED RENAL RESERVED 1) CAPD Renal function decrease 2) APD No accumulation of metabolic wastes a) CCPD the healthier kidney compensates b) IPD Nocturia & polyuria occur as a result of decrease c) NPD ability to concentrate urine STAGE II RENAL INSUFFICIENCY Metabolic wastes begin to accumulate oliguria & edema occur as a result of decrease responsiveness to diuretics STAGE III END STAGE Excessive accumulation of metabolic wastes kidneys are unable to maintain homeostasis dialysis or other renal replacement treatment is required  PERITONEAL DIALYSIS GENERAL INFORMATION Introduction of a specially prepared dialysate solution into the abdominal cavity, where the peritoneum acts as a semi-permeable membrane between the dialysate and blood into the abdominal vessels NURSING CARE Chart client’s weight. Assess V/S before, q15 min during first exchange, &qH thereafter. Assemble specially prepared dialysate solution with added medications. Have client void. Warm dialysate solution to body temperature. Assist physician with trocar insertion. Inflow: Allow dialysate to flow unrestricted into peritoneal cavity. - 10-20 minutes Dwell: Allow fluid to remain in peritoneal cavity for prescibe period - 30-45 minutes Drain: Unclamp outflow tube and allow to flow by gravity Observe characteristics of dialysate outflow. a. CLEAR PALE YELLOW HEMODIALYSIS - normal NURSING CARE: b. CLOUDY (BEFORE and DURING HEMODIALYSIS) - infection, peritonitis Have client void. c. BROWNISH Chart client’s weight. - bowel perforation Assess vital signs before and every 30 mins. during d. BLOODY procedure. - common during first few exchanges Withhold antihypertensives, sedatives, and vasodilators. - ABNORMAL: if continuous -to prevent hypotensive episode (unless ordered MIO and maintain records. otherwise). Assess for complications Ensure bed rest with frequent position changes for A. PERITONITIS comfort. B. RESPIRATORY DIFFICULTY Inform client that headache and nausea may occur. C. PROTEIN LOSS Monitor closely for signs of bleeding since blood has - Most serum proteins pass through the peritoneal been heparinized for procedure membrane and are lost in the dialysate fluid. (POST- DIALYSIS) - Monitor serum protein levels closely Chart client’s weight. Assess for complications. A. HYPOVOLEMIC SHOCK - may occur as a result of rapid removal or ultrafiltration of fluid from the intravascular compartment. B. DIALYSIS DISEQUILIBRIUM SYNDROME - Urea is removed more rapidly from the blood than from the brain. - Assess for nausea, vomiting, elevated BP, disorientation, leg cramps, and peripheral paresthesias CONTINUOUS AMBULATORY PERITONEAL DIALYSIS Provide client teaching and discharge planning concerning: GENERAL INFORMATION - Medication regimen - S/Sx of tissue rejection and the need to report it A continuous type of peritoneal dialysis at home by the immediately to the physician client or significant others. - Dietary restrictions Dialysate is delivered from flexible plastic containers - Restricted Na and calories through a permanent peritoneal catheter. - Increased CHON Following infusion of the dialysate into the peritoneal - Daily weights cavity, the bag is folded and tucked away during the - Daily measurements of I & O dwell period - Resumption of activity and avoidance of contact sports NURSING CARE in which the transplanted kidney may be injured Provide client teaching and discharge planning NEPHRECTOMY concerning: INDICATIONS - Need to assess the permanent peritoneal catheter Renal tumor for complications: Massive trauma a. Dialysate leak Removal for a donor b. Exit site infection Polycystic kidneys c. Bacterial/Fungal contamination NURSING CARE: PRE-OP d. Obstruction Provide routine pre-op care. Ensure adequate fluid intake. Adherence to high-protein (if indicated), well-balanced Assess electrolyte values and correct any imbalances diet. before surgery. Importance of periodic blood chemistries. Avoid nephrotoxic agents in any diagnostic tests. Daily weights. Advise client to expect flank pain after surgery if retroperitoneal approach (flank incision) is used. KIDNEY TRANSPLANTATION Explain that the client will have chest tube if thoracic NURSING CARE: PRE-OP approach is used Provide routine pre-op care. NURSING CARE:POST-OP Provide routine post-op care. Discuss the possibility of post-op Assess urine output every hour. dialysis/immunosuppressive drug therapy with client and Observe urinary drainage on dressing and estimate significant others amount. NRSG CARE: POST-OP Weigh daily. Provide routine post-op care. Maintain adequate functioning of chest drainage, Monitor fluid and electrolyte balance carefully. ensure adequate oxygenation and prevent pulmonary - Monitor I & O hourly and adjust IV fluid administration complications. accordingly. Administer analgesics as ordered. Encourage early ambulation - Anticipate possible massive diuresis. Teach client to splint incision while turning, coughing, Encourage frequent and early ambulation. and deep breathing. Monitor V/S esp. temperature and report significant Teach client teaching and discharge planning changes. concerning: Provide mouth care and Nystatin (Mycostatin) - Prevention of urinary stasis mouthwashes for Candidiasis. - Maintenance of acidic urine Administer immunosuppressive agents as ordered - Avoidance of activities that might cause trauma to Assess for signs of rejection. remaining kidney - contact sports, horse back riding Note for: - No lifting of heavy objects for at least 6 months - Decreased urine output - Need to report unexplained weight gain, decreased - Fever/pain over transplant site urine output, flank pain on unoperative side, hematuria - Edema Teach client teaching and discharge planning - Sudden weight gain concerning: - Increasing BP - Need to notify physician if cold or other infection - Generalized malaise present for more than 3 days - Rise in serum creatinine - Medication regimen and avoidance of OTC drugs that may be nephrotoxic (except with physician approval) - Decrease in creatinine clearance  DISORDERS OF THE MALE REPRODUCTIVE SYSTEM PROSTATITIS EPIDIDYMITIS Prostate- located below the bladder and front of the Epididymis rectum ▪ 1st part of the ductal system - secretes milk fluid that aids the passage of sperm and ▪ Stores spermatozoa while they mature keeps them viable. EPIDIDYMITIS- inflammation of epididymis, one of the PROSTATITIS- Inflammatory condition that affects the most common intrascrotal infections. prostate gland ▪ Etiology: may be sexually transmitted, usually caused Types: by N. gonorrhea, C.trachomatis, also caused by GU instrumentation, urinary reflux, UTI or prolonged used of 1. Acute bacterial prostatitis Foley catheter. 2. Chronic bacterial prostatitis ❖ Usually caused by E. coli, N. gonorrhea, Enterobacter Predisposing factors: or Proteus species and group D streptococci may be sexually transmitted, usually caused by N. 3. Abacterial prostatitis- caused by viral illness or gonorrhea, C.trachomatis, also caused by GU decrease in sexual activity, Lower UTI’s instrumentation, urinary reflux, UTI or prolonged use d of Foley catheter Assessment findings: Infective organism passes upward through the Urethra 1. Acute- fever, chills, dysuria, urethral discharge, and ejaculatory duct along the vas deferens prostatic tenderness, copious purulent discharge upon palpation, presence of WBC in prostatic secretions To the epididymis 2. Chronic- backache, perineal pain., mild dysuria, frequency, enlarged firm, hematuria, slightly tender Assessment findings: ▪ Sudden scrotal pain prostate upon palpation ▪ Scrotal edema 3. Diagnostic test: ▪ Tenderness over the spermatic cord a. WBC elevated ▪ Groin pain, swelling in groin b. bacteria in initial urinalysis specimens ▪ Pus in the urine ▪ Fever and chills Nursing interventions ▪ + bacteria in urine 1. administer antibiotics, analgesics, antispasmodic and ▪ Abscess development ▪Diagnostic test: urine culture reveals specific organism stool softeners as ordered 2. Increased OFI Nursing interventions: 3. Provide sitz bath/ rest to relieve discomfort ▪ Administer antibiotics and analgesics as ordered 4. Provide client teaching ▪ Provide bed rest with elevation of the scrotum to a. maintaining adequate hydration prevent traction on the spermatic cord to facilitate b. antibiotic therapy drainage and relieve pain c. activities that drain the prostate ( masturbation, ▪ Apply ice packs to scrotal area to decrease edema ▪ Increased fluid intake sexual intercourse, prostatic massage) ▪ Instruct to use sitz bath ▪ Avoid lifting, straining and sexual contact until the infection subsides.  BENIGN PROSTATIC HYPERTROPHY NURSING CARE - Mild to moderate glandular enlargement, hyperplasia, Administer antibiotics as ordered. and overgrowth of the smooth muscles and connective Provide client teaching concerning medications tissue - Terazocin (Hytrin) - As the gland enlarges, it compresses the urethra - relaxes bladder spincter and makes it easier to urinate resulting to urinary retention. - may cause hypotension and dizziness GENERAL INFORMATION - Finasteride (Proscar) Most common problem of the male reproductive - shrinks enlarged prostate system Force fluids. - occurs in 50% of men over age 50 Provide care for the catheterized client. - 75% of men over age 75 Provide care for the client with prostatic surgery ETIOLOGY Unknown PROSTATIC SURGERY - may be related to hormonal mechanism GENERAL INFORMATION Unknown, Aging process, hormonal(testosterone) Indicated for benign prostatic hypertrophy and prostatic cancer Increased size of prostate gland TYPES 1.TRANSURETHRAL RESECTION Narrowing of the urethral lumen 2.SUPRAPUBIC PROSTATECTOMY 3.RETROPUBIC PROSTATECTOMY Change in bladder patterns 4. RADICAL PERINEAL PROSTATECTOMY frequency, residual >50ml, nocturia, hesitancy, decrease TRANSURETHRAL RESECTION OF THE PROSTATE in urinary dynamic flow - prostatic tissues are excised through a resectoscope -Does not cause incontinence or impotence Renal insufficiency --Continuous bladder irrigation(CBI) CLINICAL FINDINGS --done post-op to irrigate the bladder & remove blood Nocturia clots. Frequency --done through 3 way foley catheter Decreased force and amount of urinary stream Hesitancy TURP-Continuous Bladder Irrigation - difficulty in starting voiding Prevent bleeding & infection Hematuria Teach kegel exercise prevent retention & dribbling Enlargement of prostate gland upon palpation by Avoid vigorous exercise,Heavy lifting, sexual intercourse digital rectal exam DIAGNOSTIC TESTS for 3 weeks after discharge Urinalysis Avoid straining, prolonged sitting/standing, crossing - alkalinity increased legs, long trips for 2 weeks after discharge - specific gravity normal or increased BUN and creatinine elevated SUPRAPUBIC PROSTATECTOMY - if long standing BPH Involves removal of the prostate gland through Prostate-specific antigen (PSA) elevated abdominal & bladder incision - Normal: