Renal & Urinary Disorders Lecture Notes PDF

RENAL & URINARY DISORDERS PART I Savannah Thompson, MSN, RN  Describe the location and functions of the kidneys, ureters, bladder, and urethra. Describe age related changes in the urinary system and differences in assessment fi...

RENAL & URINARY DISORDERS PART I Savannah Thompson, MSN, RN  Describe the location and functions of the kidneys, ureters, bladder, and urethra. Describe age related changes in the urinary system and differences in assessment findings. Obtain significant subjective and objective data related to the urinary system from a patient. Describe the purpose, significance of results, and nursing responsibilities related to diagnostic studies of the urinary system. LEARNING Describe the pathophysiology and clinical OBJECTIVES: manifestations and related nursing implications of urinary tract infections, cystitis, renal calculi, glomerulonephritis, cancer of the urinary tract, acute kidney injury, and chronic kidney disease. Determine the nursing implications related to medications used in the management of patients with urologic dysfunctions. Explain the nursing management of the patient undergoing nephrectomy, urinary diversion surgery, lithotripsy, dialysis, and renal transplant URINARY TRACT INFECTIONS  Most common bacterial infection in women Catheter Acquired UTI (CAUTI) is the URINARY TRACT most common healthcare acquired infection INFECTIONS E. Coli is the most common pathogen CYSTITIS  Inflammation of urinary bladder Clinical Manifestations: dysuria, frequency, urgency, hesitancy, foul smelling urine, hematuria, cloudy CYSTITIS urine, fever, suprapubic discomfort Older adults: altered mental state, nonlocalized abdominal discomfort, less likely to be febrile  Risk factors: Anatomic factors Compromised immune system URINARY TRACT Urinary stasis/obstructions INFECTIONS Foreign bodies Functional disorders  Risk factors (continued): Habitual delay of urination (“nurse’s bladder”; “teacher’s bladder”) Pregnancy, menopause URINARY TRACT Poor personal hygiene INFECTIONS Use of spermicidal agents, contraceptive diaphragm, bubble baths, and feminine sprays  Diagnosis: Urinalysis Culture & CYSTITIS Sensitivity (CONTINUED) ACUTE PYELONEPHRITIS  Bacterial infection of renal pelvis, tubules, and interstitial tissue of one or both kidneys Bacterial infection from bladder ascends into the kidney A C U T E P Y E LO N E P H R I T I S Infection or recurrent infections cause scarring and decrease kidney function Risk is urosepsis Can result in chronic pyelonephritis  Clinical Manifestations: Chills, fever, leukocytosis, bacteriuria, and pyuria. Mild fatigue, malaise, N/V, headache A C U T E P Y E LO N E P H R I T I S Flank pain or back pain, costovertebral angle (CVA) tenderness Altered mental status  Renal Ultrasound Intravenous pyelogram A C U T E P Y E LO N E P H R I T I S - CT DIAGNOSTICS CBC Urinalysis Culture and sensitivity  Assess the patient Monitor VS and Temp AC U T E PYE LO N E P H R I T I S INTERPROFESSIONAL CARE I & O; IV fluids Antibiotics and analgesia Patient Edu  Health promotion/prevention: Empty bladder regularly (q2-3hrs) Teach female pts to wipe front to back Drink adequate liquids NURSING Avoid urinary irritants (cola, coffee, I N T E RV E N T I O N S tea, and alcohol) Daily intake of cranberry juice Bathe before intercourse and urinate after Avoid tight fitting pants  Prevention in hospitalized patients: Avoidance of unnecessary catheterization NURSING Aseptic technique with catheter I N T E RV E N T I O N S insertion (CONTINUED) Removal of indwelling catheter ASAP Routing and thorough peri-care Stabilization of catheter to leg Collection bag below bladder  Once UTI has occurred: Force fluids (2-4L/day unless NURSING contraindicated) I N T E RV E N T I O N S Avoid potential bladder irritants (CONTINUED) Intermittent local heat to suprapubic area or lower back Take full course of antibiotics (2 weeks)  Sulfonamides: Trimethoprim/sulfamethoxazole (TMP/SMX) (Bactrim) Cephalosporins: DRUG THERAPY Cephalexin (Keflex), cefadroxil (Duricef), cefixime (Suprax), cefepime (Maxipime)  Fluroquinolones (-oxacin) Ciprofloxacin (Cipro) DRUG THERAPY Penicillins (-illin) (CONTINUED) Amoxil (amoxicillin), Augmentin (amoxicillin/clavulanate)  Aminoglycosides (-micin/mycin) DRUG THERAPY Garamycin (gentamicin), Nebcin (CONTINUED) (tobramycin), streptomycin  Urinary Analgesics: Phenazopyridine (Pyridium, Urogesics) DRUG THERAPY (CONTINUED) Topical analgesic or local anesthetic effect on mucosa of urinary tract  UROLITHIASIS & NEPHROLITHIASIS  Occurs more often in men, 20-55 years of age Recurrence of stones about 50% Factors: UROLITHIASIS & Infection, urinary stasis, immobility NEPHROLITHIASIS Most common stones are calcium based.  Calcium Oxalate (most common): Elevated calcium; excessive intake of Vitamin D Calcium Phosphate: TYPES OF Hyperparathyroidism Uric Acid: STONES Gout; hereditary Struvite: Chronic UTIs and pyelonephritis  Flank or abdominal pain; referred pain to groin, testicles, labia Nausea/vomiting, pallor, diaphoresis CLINICAL Hematuria, frequency, dysuria M A N I F E S TAT I O N S Obstruction= Potential oliguria or anuria  Review meds and diet Urinalysis, Culture & Sensitivity CT (confirmation) 24-hour urine test DIAGNOSTICS Analysis of stone once passed Serum BUN, Cr, Na, K, Ca, Ph, uric acid, CBC  Goals of management: Eradicate stone Determine type MEDICAL Prevent nephron destruction MANAGEMENT Control infection Relieve any obstruction that may be present.  Pain Management Fluid balance Dietary restrictions Ambulation NURSING I N T E RV E N T I O N S Strain urine, send stone for analysis Prevent and treat infection especially before invasive procedures  Ureteroscopy Extracorporeal shock wave lithotripsy (ESWL) STONE Endourologic (percutaneous) stone RETRIEVAL removal Percutaneous nephrostomy Percutaneous nephrolithotomy  Nephrolithotomy: Incision into kidney to remove stone Pyelolithotomy: Incision into the pelvis Ureterolithotomy: SURGERIES Stone removal from ureter Cystotomy: Removal of stone from bladder KIDNEY CANCER  Cancer in the pelvis or calyces Occurs more in men, 50-70 yrs. Risk factors: KIDNEY Smoking Obesity CANCER African Americans Hypertension Exposure to industrial chemicals, such as cadmium and herbicides  Symptoms Gross hematuria, flank pain, and palpable mass in flank or abdomen KIDNEY CANCER Common sites for metastasis are CLINICAL M A N I F E S TAT I O N S lung, liver, and bone Unexplained weight loss, fatigue, and anemia  CT scan Ultrasound KIDNEY CANCER Angiography DIAGNOSTICS Biopsy MRI  Preventative Measures KIDNEY CANCER Chemotherapy P H A R M A C O LO G I C T H E RA P Y  Laparoscopic nephrectomy: most common approach Post-Op Care: Routine- VS, IVF, pain control, SCDs, IS, KIDNEY CANCER monitor incision/lap sites, monitor for NEPHRECTOMY ileus, ambulate Assess renal function- I&O, Cr Monitor H&H Discharge: 2-4 days Return to Work: 4-6 weeks BLADDER CANCER  Transitional cell carcinoma of the bladder- most common malignant tumor of the urinary tract Peak incidence 60-70 years; most common in men BLADDER Clinical Manifestations: CANCER Gross or microscopic, painless hematuria Dysuria, frequency, urgency Pelvic or back pain  Risk factors: Smoking (#1) Exposure to arsenic, paint, dye, metal, BLADDER and petroleum products Family Hx of bladder cancer CANCER Pelvic radiation therapy or treatment for other cancers Chronic use of analgesics with phenacetin  CT MRI Ultrasound BL ADDER CANCER DIAGNOSTICS Tumor markers Biopsies of tumor and adjacent mucosa Cytologic examine of urine  Transurethral resection (TURBT) with fulguration BL ADDER Post-operative management: CANCER Drink large volumes water SURGICAL Continuous bladder irrigation (CBI) TREATMENT Opioid analgesics with stool softener, laxatives F/U cystos every 3-6 months BL ADDER CANCER Cystectomy SURGICAL Partial or segmental TREATMENT (CONTINUED) Radical- requires urinary diversion  Radiation BLADDER Chemotherapy- IV cisplatin, CANCER vinblastine OTHER Intravesical Therapy- BCG (Bacille Calmette- Gierin) or chemo THERAPIES  Encourage increased fluid intake RESPONSIBILITIES OF Smoking cessation THE NURSE Assess for UTI Stress need for follow-up URINARY DIVERSIONS  May be performed with or without cystectomy May be incontinent or continent diversion URINARY Used to treat: DIVERSION Bladder cancer, colon cancer Congenital anomalies Chronic infections Interstitial cystitis  Ureters connected to diverted segment of ileum; stoma is created Requires an ostomy bag due to continually collect urine INCONTINENT Complications: DIVERSION: ILEAL CONDUIT Infection Urinary leakage Small bowel obstruction Gangrene of the stoma  Nursing Management: INCONTINENT Stoma and skin care DIVERSION: ILEAL Caring for ostomy CONDUIT Encourage fluids Relieve anxiety  Wash peristomal area with warm water Change permanent appliance (urostomy bag) every 3-5 days Opening in appliance cut 0.1in larger than stoma STOMA CARE Apply skin barrier Restrict fluids shortly before changing appliance Keep urine acidic (monitor) Empty appliance frequently (1/3 full) Monitor for complications  Bladder fashioned from intestines CONTINENT Void voluntarily every 2-4hours DIVERSION: Incontinence is a possible problem, ORTHOTOPIC intermittent catheterization may be NEOBL ADDER needed  Patient Teaching Voiding in a sitting position using the CONTINENT Valsalva maneuver DIVERSION: Kegel exercises ORTHOTOPIC NEOBL ADDER Bowel regimen to prevent constipation Void regularly, q2-3hours  Intra-abdominal reservoir: CONTINENT Made from ileum and cecum to form a DIVERSION: reservoir for urine INDIANA POUCH Self-catheterize every 4-6hours No external appliance needed  Assess patient’s ability and readiness to learn PREOPERATIVE Discuss psychosocial aspects- body MANAGEMENT image, sexuality Family should be involved Consult enterostomal therapy nurse  Assess frequently: VS, IVF, I&O, bowel sounds IS, SCD, anticoagulants, analgesics Early ambulation P O S T O P E RAT I V E M A N AG E M E N T Assess stoma and prevent injury to stoma Meticulous care to skin around stoma- ileal conduit and Indiana pouch  Teach patients with neobladder to void every 2-4hours; teach patient how to self-catheterize Indiana pouch, teach self- P O S T O P E RAT I V E catheterization every 4-6hours; M A N AG E M E N T irrigate pouch daily (CONTINUED) Supportive care with body image changes Teach S&S of obstruction, infection, and stoma care  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2019). Lewis’s medical surgical nursing: Assessment and management of clinical problems: 11th edition. Elsevier. REFERENCES Hinkle, J., Cheever, K.H. & Overbaugh, K. (2021). Lippincott Course Point + Enhanced for Brunner & Suddarth’s Textbook of Medical surgical Nursing (15th ed). Wolters Kluwer.