Urinary Alterations PDF

Alterations in Urinary Elimination Urinary System Upper (kidneys and ureters) ○ KIDNEYS = principal organ - maintaining homeostasis Functions: regulate volume and composition of ECF, excrete waste products, control BP, make erythropoietin (RBC produ...

Alterations in Urinary Elimination Urinary System Upper (kidneys and ureters) ○ KIDNEYS = principal organ - maintaining homeostasis Functions: regulate volume and composition of ECF, excrete waste products, control BP, make erythropoietin (RBC production) , activate vitamin D, and regulate acid-base balance. Lower: ○ Bladder: serve as a reservoir for urine and to eliminate waste products from the body. Normal urine output = 1500 mL/day An adult will typically urinate 5-6 timers per day ○ Urethra Functions: allows passage of urine and semen Kidneys (Microstructure) - filter blood Nephron = functional unit of the kidney which contains: ○ Glomerulus: blood is filtered here! GFR - amount of blood filtered each minute by the glomeruli Normal rate = 125mL/min Want it to be > 60mL/min Low GFR is an indication that your kidney is failing. ○ Bowman’s capsule: unfiltered blood crosses the membrane and enters the Bowman's capsule ○ Tubular system: reabsorption of nutrients Blood flow to the kidneys = 1200 mL/min - accounts for 20-25% of CO Renal arteries -> arterioles -> capillaries -> glomerulus Aging & the Urinary System Decrease in size & weight with age Around age 70, glomeruli function is reduced Atherosclerosis - can cause reduced blood flow to GU system Altered urinary concentration & excretion - incontinence Not able to compensate as well Female - loss of elasticity & muscle support (encourage kegel exercise) Male - prostate enlarges ○ ¼ males will have BPH (enlarged prostate) Lab Changes ○ GFR ○ BUN/Creatinine ○ Creatinine clearance Assessment of the Urinary System 1. Health History: ask about presence or history of kidney disease or other urologic problems. Note specific urinary problems such as cancer, infection, BPH, and stones. a. Are there any other health problems that may affect kidney function? - HTN, diabetes, HIV, trauma, etc. HTN is #1 risk factor for kidney issues! 2. Current Symptoms/Vital Signs 3. Medications a. Many drugs are nephrotoxic and certain drugs may alter the quantity and character of urine output (diuretics). b. Anticoagulants may cause hematuria. c. Antibiotics: penicillins, gentamicin, steroids 4. Surgeries & radiation/chemo 5. Nutrition & fluid intake a. Dehydration may contribute to UTIs, stones, and kidney failure b. Large intake of dairy or high protein may lead to stone formation c. Asparagus can cause urine to smell musty d. Beets can cause red urine e. Caffeine can cause frequent urination 6. Elimination issues a. Daytime voiding frequency? b. Nocturia? c. Urgency, incontinence, retention? 7. Occupation Urinalysis - general exam of urine to establish baseline information or provide data to establish a tentative diagnosis and determine if further studies are needed. **clean catch (voided) ** catheter (from port) Test Normal Abnormal Possible Cause & Significance Bilirubin none present Liver problems. May appear before jaundice is visible. Casts None. occasional present Molds of the renal hyaline tubules that may contain protein, WBCs, RBCs, or bacteria. Noncellular casts (hyaline) occasionally found in normal urine. Color Amber yellow Dark, smoky color Hematuria Yellow-brown to olive Excess bilirubin. green  Orange-red to Phenazopyridine or orange-brown rifampin Cloudiness of fresh UTI urine Colorless urine Excess fluid intake, kidney disease, or diabetes insipidus. Culture for organisms No organisms in Bacteria counts > 10^5 UTI bladder Glucose none glycosuria Diabetes, low renal threshold for glucose. Pituitary problems. ketones none present Altered carbohydrate and fat metabolism in diabetes and starvation; dehydration, vomiting, severe diarrhea. odor aromatic Ammonia-like Urine allowed to stand. Unpleasant odor UTI Osmolality 50-1200 < 50 Tubular dysfunction > 1200 Kidney lost ability to concentrate or dilute urine pH 4.6-8.0 >8.0 UTI Protein Random protein Persistent proteinuria Acute and chronic kidney disease. HF RBCs 0-4 < 4.0 Respiratory or metabolic acidosis > 4.0 Stones, cystitis, cancer, UTI, trauma, etc. Specific Gravity 1.005-1.030` Low Dilute urine, excess diuresis, diabetes insipidus High Dehydration, glycosuria Fixed at 1.010 Renal inability to  concentrate urine; end stage renal disease. WBCs 0-5 >5 UTI, inflammation Diagnostics/Labs Diagnostic Test Description Therapeutic range/Test findings BUN/Creatinine Detect renal problems; regulated BUN: 10-20 by the rate at which urea is Cr: 0.5 - 1.2 excreted Creatinine Clearance Waste product of protein Male: 107-139 ** measure or creatinine in a breakdown (primarily body Female: 87-107 24-hour period muscle mass); approximates the GFR Culture/Sensitivity Tests to see if bacteria are Should be unremarkable ** tells us what antibiotic we present in urine. need to use Urine Cytology Takes biopsies of the bladder if Should be unremarkable ** looks for cancer cells there is a suspicion of bladder cancer KUB X Ray Look at kidneys, ureters, and the Should be unremarkable bladder. IVP (intravenous pyelogram) Evaluates size of the kidneys Should be unremarkable bladder and ureters after iodine injection. Can be nephrotoxic to pt; hydration is important **need dye! **should ask if they are allergic to dye Ultrasound/CT **ultrasound is safer than CT Should be unremarkable Urinary Tract Infection (UTI) Description Infections of the urinary tract. E.coli is the most common pathogen (75% of cases) Other: pseudomonas, streptococci, staphylococci, enterococci, fungal, klebsiella Classification - based on location. Upper ○ kidneys/ureters ○ Systemic symptoms ○ Pyelonephritis - inflammation of renal parenchyma and collecting system Inflammation of the renal parenchyma and collecting system. Most common cause is bacterial infection. (inflammation of kidneys) Clinical Manifestations - **systemic effects! fever/chills N/V Malaise Flank pain They may include - dysuria, urgency, frequency CVA tenderness usually present ] Treatment/Interprofessional Care Involves upper urinary system (can start from the bladder) Tests ○ Utilize many of same tests ar uncomplicated UTI ○ May also do CT, urogram, cystoscopy ○ Labs: CBC, CMP/BMP, urine cultures, blood cultures renal function studies ○ Urinalysis - results may show pyuria (WBCs), bacteriuria, and hematuria ○ Urine for culture and sensitivity ○ Ultrasound ○ CT - can assess for signs of infection in kidney and complications ○ CBC ○ Percussion for CVA tenderness (flank pain) Medication ○ Antibiotics (empiric until C&S returns) Ampicillin, fluoroquinolones (ciprofloxacin, levofloxacin), vancomycin (ototoxicity, red man's syndrome) May need to be given IV Longer course of antibiotics Goal = to convert to PO meds when/if possible Patient teaching ○ Finish all antibiotics ○ Do not hold in urine ○ May need to refer to kidney specialist ○ Drink more fluid Nursing diagnosis: altered urinary function, risk for decreased kidney perfusion Lower ○ bladder/urethra ○ Usually local symptoms ○ Cystitis - inflammation of the bladder (bladder infection) ○ Urethritis - inflammation of the urethra Causes: STI, ,bacteria, viruses, fungal  Treatment = depends on causative organism Difference between cystitis and urethritis is in urethritis you will see discharge. Often tied to chlamydia, so need to get the partner tested if they have urethritis. Urosepsis: UTI spread beyond GU system ○ life-threatening! ○ Can lead to shock and organ failure ○ Encourage fluid intake, avoidance of irritants, voiding hygiene, monitor VS! ○ Most common cause of bacterial sepsis in elderly ○ TIME (when it comes to sepsis, it’s about TIME) Temperature (higher or lower than normal) Infection (may have s/s) Mental Decline (confused, sleepy, difficult to arouse) Extremely ill (“i feel like I might die,” severe pain or discomfort) ○ Nursing Care Ensure adequate fluid intake Educate pt to avoid irritants Encourage pt to void Correct cleaning after voiding Monitor VS for s/s of sepsis Medication administration Uncomplicated: occurs in pts with no urinal structure/function deficit ○ Localized infection in lower urinary tract; typically bladder ○ Usually respond well to antibiotics. Complicated: occurs in pts with an underlying disease or with a structural or functional problem in the urinary tract. ○ Ex: obstruction, stones, catheters, AKI, CKD, diabetes, kidney transplant, etc. ○ They can also occur when a person has developed antibiotic resistance, is immunocompromised, has pregnancy-induced changes, or has recurrent infection. Risk Factors Problems with urine flow/bladder emptying (urethra issues) Instrumentation ○ Catheters (CAUTI’s), procedures Urethral trauma/injury to urinary tract Foreign bodies (douching, tampons) Anatomical issues - women have shorter urethras Irritants, dehydration immunosuppression/comorbidities: cancer, HIV, etc. Clinical Manifestations Lower Upper Symptoms usually local to bladder Systemic effects!! (uncomplicated) Infection spreads upward (ascends) May have some/be asymptomatic May have symptoms of lower UTI + Frequency: more than 8x in 24 hrs Abdominal pain Dysuria: pain/burning/itching back/flank pain Odor Fever Hematuria Chills hesitancy/incomplete emptying Nausea Incontinence Vomiting  Suprapubic pain cloudy urine Diagnostic Studies Urinalysis: to identify presence of nitrates, WBCs, maybe RBcs ○ Correct technique is important (clean catch or cath port) Urine culture & sensitivity: can determine bacteria’s susceptibility to a variety of antibiotics. The results allow HCP to choose an antibiotic known to destroy the bacteria causing the UTI. ○ Empiric therapy first! Treatment Length: 3-14 days Common: Bactrim (trimethoprim/sulfamethoxazole), macrodantin/macrobid, Pyridium (phenazopyridine) Patient Teaching Urine may turn orange/red from Pyridium TAKE ALL antibiotics as prescribed Practice appropriate hygiene Empty bladder before sexual intercourse Void regularly Maintain adequate fluid intake Glomerulonephritis Description Inflammation of glomeruli - can cause changes in other parts of kidney **accumulation of waste (high BUN, creatinine, low GFR) Usually affects kidneys bilaterally Can be acute or chronic 3rd leading cause of End stage renal disease (ESRD) Acute Poststreptococcal Glomerulonephritis Most common in children 5-7 yrs old and adults older than 60 APSGN develops about 1-2 weeks after strep throat Pt produce antibodies to strep antigen-complexes deposit in glomeruli & cause scarring/damage Causes ○ infections : endocarditis (inflammation of heart) & viruses ○ Immune: Lupus (SLE), scleroderma (hardening of skin), GoodPasture Syndrome (group of illnesses that affect lungs and kidneys) ○ Vasculitis: inflammation of blood vessels ○ Comorbid conditions that scar kidneys ○ IV/Illegal drug use Clinical Manifestations Early ○ Hematuria ○ Proteinuria ○ Azotemia - elevation of BUN and creatinine ○ Increasing urine specific gravity ○ Increased ESR ○ Oliguria (small amount of urine output) ○ Pain in abd/flank pain  Late ○ Edema ○ Hypertension ○ Kidney failure ○ Pain in abd/flank ○ Develop s/s of renal failure Diagnostics H&P Labs: ○ ASO titers (antistreptolysin-O): rules out infection caused by strep ○ BUN/Creatinine ○ Renal Biopsy (checking for cancer) ○ urinalysis : checking for protein and RBC casts ○ Urine microscope (erythrocyte casts) Treatment Depends on cause (infection/immune) ○ Antibiotics for infection ○ Edema - restrict sodium fluids, meds if needed (diuretics) ○ HTN - meds ○ Possibly steroids ○ Diet: low protein, low sodium, fluid restriction, possible potassium restriction This is because of the high BUN level -> causes high protein ○ Kidney support if severe Obstructive Disorders (kidney stones, BPH,) Description Anatomic or functional condition that blocks or impeded the flow or urine Damaging effects from urinary tract obstruction affect the system above the level of obstruction Severity depends on location, duration, amount of pressure or dilation, or presence of urinary stasis or infection. Increased pressure in renal arteries; damages tissue/scarring/failure Strictures, kidney stones, hydronephrosis (too much water), BPH Patho: blockage causes backflow, dilated kidney, increased pressure on renal arteries, damages tissue/scarring/failure Management Treat underlying cause: find/relieving blockage Nephrostomy tube: drains urine straight from kidney Stent: opens stricture to allow urine to flow Dialysis Medications: ○ Pain management (opioids) ○ Antispasmodics (Ditropan, Detrol) - control abdominal cramping, fecal urgency, diarrhea discomfort ○ Antibiotics - if concurrent infection Nursing Diagnoses Acute pain r/t inflammation, obstruction of urinary tract Impaired urinary elimination r/t obstruction of ureters or urethra Risk for infection r/t nephrostomy, stent, procedure Nephrolithiasis (Kidney Stones) Men > women Can be seen in families (sometime hereditary) Can reoccur Stones made of calcium, struvite, uric acid, or cystine diet can be a risk factor ○ Increased protein/calcium/calcium oxalate/uric acid ○ Low fluid intake/dehydration Meds - asked about prescribed/OTC meds **can cause infections, hydronephrosis & problems with kidney function Symptoms Depends on location Sharp, severe pain - “renal colic” - with obstruction/stretching Locations: flank/lower abdomen/groin/back N/V, Restlessness Urinary: hematuria, pyuria (puss in urine), urgency, frequency Diagnostic Tests Spiral CT scan (no contrast) U/A + RBCs, check pH, crystalluria Labs: CBC, CMP/BMP, calcium, phosphorus, uric acid, urine culture Maybe ultrasound KUB IVP (check iodine allergy) Treatment **preserve renal function Treating the pain, infection, and/or obstruction and removing blockage Medications: ○ Alpha-adrenergic blocker: Tamulosin (flomax), terazosin ○ antiemetics Surgical: ○ Cystoscopy: may be indicated for bladder stones ○ Nephrolithotomy: an incision into kidney to remove stone ○ Lithotripsy: procedure used to eliminate stones from urinary tract Nutritional ○ Pt should drink adequate fluids to avoid dehydration ○ Encourage high fluid intake to produce urine output at least 2.5 L/day ○ Low Oxalate diet: limit dark green vegetables, nuts, chocolate, Vit C, beans, beer, coffee, cola, soy, black tea ○ Low sodium diet (less than 2g) ○ Low Purine diet: limit red meat, venison, duck, tuna, sardines, herring, mussels, scallops, organ meats ○ Low calcium (if hypercalcemia is present) Endourologic Procedures ○ Cystoscopy - remove stone in bladder ○ Cystolitholapaxy - large stones broken up with lithotrite (stone crusher) ○ Cystoscopic lithotripsy - ultrasonic waves break stones Complications: retained stone fragments, infection ○ Ultrasonic, laser, or electrohydraulic lithotripsy - used to break stones during: Flexible ureteroscopes - remove stones from renal pelvis and upper urinary tract  Percutaneous nephrolithotomy - nephroscope inserted through the skin into the pelvis of the kidney; stone fragmented and removed, followed by irrigation. May place nephrostomy tube Complications: bleeding, injury, and infection Nursing Care Monitor I/O Monitor for bleeding/infection Pain management Patient teaching - symptoms, infection, when to call, diet, repeat testing, fluids Strain urine after procedures Benign Prostatic Hyperplasia Prostate increases in size Risk factors: ○ Age (older men > 50 yrs old) ○ obesity/sedentary ○ ETOH intake ○ Erectile dysfunction ○ Smoking ○ DM Manifestations - due to blockage & irritation Nocturia - most common to bring people to the doctor Frequency, urgency, dysuria Bladder pressure/fullness/retention/dribbling Incontinence Decreased force of stream Problems initiating stream (hesitancy), Dribbling Possible recurrent UTI due to retention Diagnostics Digital rectal exam (DRE): asymmetrical, large and firm - painful and most do not want to do it. Labs: prostate specific antigen (PSA)B: screen for prostate cancer U/A and C&S, CBC/CMP, check flow of urine Urodynamics - check flow of urine Treatment Pt education - lifestyle changes Medications ○ Alpha-blockers - doxazosin, tamsulosin, prazosin, terazosin ○ 5-alpha reductase inhibitors ○ Tadalafil (cialis) - viagra Procedures ○ Ablation - used to kill cancer cells ○ Thermotherapy ○ Laser prostatectomy ○ TURP - Transurethral Resection of Prostate Removal of prostate tissue using a resectoscope inserted through urethra Cauterize tissue Continuous bladder irrigation (prevents obstruction of catheter after surgery) Nursing Care As day progresses, drainage should have less blood and no clots Monitor for post-op complications Ensure CBI is working correctly  Manual irrigation Monitor I/O Positioning patient Administer oxybutynin (ditropan); belladonna/opium suppositories Voiding trial - see if they can go by themselves Monitor for infection Patient education ○ Ejacualtion, arousal will be different Kidney Cancer Renal Cell Carcinoma (adenocarcinoma) Women 2x more likely than men Ages 50-70 Risk factors: smoking!!!, first relative with renal Ca; obesity, HTN, exposure to asbestos, cadmium, gasoline Advanced cases can spread to lungs, lymph nodes, liver, bones Manifestations and Diagnostics Early - usually no symptoms Painless hematuria*** Almost ⅓ have mets by the time they are diagnosed Can cause compression on structures - shows up as flank pain Other s/s: weight loss, pain/mass in flank or abdomen, fever, HTN, anemia Diagnosis - CT, U/S, MRI, renal biopsy, angiography Treatment Resistant to most chemo & radiation Radical nephrectomy Immunotherapy (help boost immune system) ○ Alpha-interferon ○ Interleukin-2 ○ Opdivo Kinase Inhibitors-Targeted therapy Bladder Cancer Description Most common cancer in the urinary system Most common in older adults. RIsk factors ○ Common ages 60-70 ○ 4x more likely in men than women ○ ½ relates to smoking ○ Exposure to dyes/chemicals ○ Women treated for cervical cancer with radiation ○ Patients taking Actos, cyclophosphamide, chronic recurrent stones/UTIs Manifestations Painless hematuria Dysuria Frequency Urgency Tests U/A CT/MRI Ultrasound Cystoscopy with biopsy - this is how cancer is confirmed Management Surgery ○ Transurethral resection of bladder tumor ○ Cystectomy: removal of bladder ○ Radical cystectomy***: bladder, prostate & seminal vesicles (men) & bladder, uterus, ovaries & urethra in women - need urinary diversion Chemo directly into bladder (intravesical) BCG or alpha-interferon Chemo antibiotics - mitomycin, valrubicin, thiotepa Radiation Urinary Diversion - urine is diverted to new exit (similar to ostomy) ○ Ileal conduit ○ Cutaneous ureterostomy ○ neobladder/indiana pouch ○ Possible complications: Peritonitis - inflammation of lining of abdomen Stoma ischemia/necrosis (could mean infection is going on) Stoma retraction/separation ○ Nursing diagnoses Knowledge deficit r/t management of urinary diversion Disturbed body image Impaired skin integrity ○ Nursing management Monitor I/O (hourly post-op)/VS/BS Monitor for s/s of infection and sepsis stoma/skin care - monitor for changes Patient acceptance Promote fluid intake/good nutrition Pt Teaching - post-op expectations & progression, stoma care Catheterization (sterile technique) & how often to do ○ Other information Pouch system - wafer & pouch Pouches can be rinsed/cleaned daily & changes every few days Clean around stoma when changing pouch, dry & apply protective powder Consult enterostomal therapy May need to limit activity while stoma is new (until healed) ○ Ostomy Care Skin barrier Changing bag Control odor Ascorbic acid (acidify urine); vinegar (deodorizes bag) Opening may need to be recalibrated every 3-6 weeks for first few months Permanent appliance - no > ¼ inches larger than stoma.