Adult Health Urinary Disorders PDF

Urinary Disorders Chapter 50 Urine Composition and Characteristics  Normally 1000-2000 ml urine daily  95% water with rest nitrogenous wastes and salt  pH 4.6-8.0  Urinary Bladder  Bladder can hold 750-1000 ml urine.  Between 200-400ml a person has a desire to urinate Urine Abnor...

Urinary Disorders Chapter 50 Urine Composition and Characteristics  Normally 1000-2000 ml urine daily  95% water with rest nitrogenous wastes and salt  pH 4.6-8.0  Urinary Bladder  Bladder can hold 750-1000 ml urine.  Between 200-400ml a person has a desire to urinate Urine Abnormalities  Albumin – indicates possible kidney disease, increased BP, toxicity of the kidney cells  Glucose - presence of sugar in the urine, indicates high blood glucose  Erythrocytes – may indicate infection, tumors, kidney disease, or kidney stone  Ketone Bodies: excessive quantities of fatty acids are oxidized. Seen with DM, starvation, or metabolic conditions.  Leukocytes: infection of urinary tract Laboratory and Diagnostic Examinations  Urinalysis clean catch  Specific Gravity  Blood Urea Nitrogen  Serum Creatinine  24 hr urine for Creatinine Clearance  Prostate-Specific Antigen  Osmolality Laboratory and Diagnostic Examinations  Kidney-Ureter-Bladder Radiography  Intravenous Pyelogram/Intravenous Urography  Retrograde Pyelography  Voiding Cystourethrography  Cystoscopy  Renal Angiography  Renal Venogram Diagnostic Tests  Computed Tomography  Magnetic Resonance Imaging  Renal Scan  Ultrasonography  Transrectal Ultrasound  Renal Biopsy  Urodynamic Studies Catheter Types  Urinary drainage catheter is designed with balloon near its tip so the balloon may be inflated after insertion, holding the catheter in the urinary bladder for continuous drainage.  Coude’ catheter – tapered tip; is selected for ease of insertion when enlarged prostate is expected  Malecot and Pezzer - used to drain urine from renal pelvis of kidney  Robinson catheter -has multiple openings in its tip to facilitate intermittent drainage  Ureteral catheter - long and slender to pass into the ureters.  Whistle tip catheter-has slanted, larger orifice to be used if blood is present  Suprapubic catheter is introduced by physician through abdominal wall above symphysis pubis.  Divert urine flow from urethra to treat injury to bone pelvis, urinary tract, or surrounding organs, structures, or obstruction  Surgical incision or puncture of abdominal and bladder walls with trocar cannula.  When injury is healed, the catheter may be clamped so the patient can try to void naturally. If residual is less than 50 the cath may be removed.  Condom Catheters – noninvasive; make sure to leave room at end of catheter to prevent irritation to the meatus and promote drainage.  Removed daily for inspection and cleaning  To avoid penoscrotal fistula, tape the male catheter to the abdomen  External female catheter for incontinence. Has a wick between labia and gluteus attached to low suction with pulls urine away. Wick is change 2-3 times a day or when soiled.  Review the nursing techniques to employ with catheterization on page 1692. Self Catheterization  Spinal cord injury or other neurological disorders that interfere with urination  Promotes independent function  Clean technique  Instruct on S/S of infection Bladder Training  Developing use of muscles of perineum to improve voluntary control over voiding;  In preparation of removal of catheter doctor may order clamp/unclamp routine to improve bladder tone.  Stress incontinence – muscles are exercised to help stop flow (Kegel)  10 seconds, relaxing 10 seconds, in reps of 10 building to 20, QID. May take 4-6 weeks.  Habit training  Voiding habits monitored for a few days  Identify patterns, etc  Assist to void as scheduled  Re-evaluate plan prn  Modify as needed until goal reached  Urinary Retention  Inability to void even with an urge to void. Acute or Chronic.  Increases risk for infection  Discomfort and anxiety  Palpated above the symphysis pubis (egg-shaped)  Restlessness or irritability  May be caused from stress, sphincter muscle interference during surgery, calculi, infection, tumor; medication s/e, perineal trauma secondary to vaginal delivery Treatment  Urinary catheters or surgical release of obstructions  Analgesics and antispasmodics enhance patient relaxation.  When continence is established, have patient void (measure this), and catheterize to measure residual urine. Should be less than 50 ml.  Urinary Incontinence  Stress incontinence is leakage while lifting or sneezing, etc.  Complication of many disorders; infection, loss of sphincter control, change of pressure within abdomen, spinal cord injury  Stress incontinence relates to sphincter weakness may be treated with collagen implant injections  Urge incontinence – urge followed by incontinence before can get to BR  Overflow incontinence – repeated inability to fully empty bladder producing and overly full bladder which leaks unexpectedly.  Mixed –both stress and urge incontinence  Functional –physical or mental impairment causing inability to make it to the bathroom to urinate  Total incontinence - Involuntary loss of urine from the bladder. Doesn’t respond to tx  Surgical repair may be necessary  Injecting bulking materials into tissue surrounding the urethra  Botox for overactive bladder  Temporary or permanent urinary diversion  Nerve stimulator  Pessary for clients who aren’t candidates for other treatments or first line treatment  Don’t allow to decrease fluids, the bladder mucosa will become irritated. Shift fluids to early in day.  Incontinence pads  Bladder Retraining Program  evaluate when resident is incontinent. Then take them to the bathroom when they’re usually incontinent. Evaluate and change if necessary. Once continence achieved slowly length times toileted.  Kegel exercises – increase strength in perineal muscles  Transvaginal sling  Oxybutynin  Avoid caffeine and alcohol  Self catheterization Neurogenic Bladder  Loss of voluntary voiding control, resulting in urinary retention or incontinence.  Caused by lesion of nervous system that interferes with normal nerve conduction to urinary bladder. May be congenital, neurological, or trauma  Two types: spastic and flaccid.  Spastic-  loss of sensation to void and a loss of motor control. The bladder then atrophies, decreasing bladder capacity.  Release of urine occurs on reflex, with little or no conscious control  Flaccid-  bladder continues to fill and distend, with pooling, of urine and incomplete emptying. Because of the accompanying loss of sensation, the patient may not even experience discomfort that would indicate retention. Clinical Manifestations  Infection  Retention may lead to backup of urine (reflux) into the upper urinary tract and to the distention of the structures of the urinary tract.  c/o diaphoresis, flushing, nausea prior to reflex incontinence, or infrequent voiding. Treatment  Antibiotics to treat infection  Parasympathomimetic medication (urecholine)  Urinary catheter may be indicated.  Nerve stimulators Urinary Tract Infection  Presence of  Immobility microorganisms in any urinary system  Sensory impairment structure.  Females are more  Multiple organ susceptible. impairment  Blood in urine appears smokey.  Sexual encounters  Causes  DM  Catheter  MS  Bladder obstruction  Insufficient bladder  Spinal cord injuries emptying  Decreased  HTN bactericidal  Diseases of kidney secretions of prostate  Common organisms are usually from the GI tract and ascend through the urinary meatus. Incomplete bladder emptying or urine retention supports bacteria growth  s/s  Back pain  Urgency  Abdominal discomfort  Frequency  Perineal pain  Burning on  Confusion-elderly urination  Urosepsis – septic  Microscopic to poisoning due to retention and gross hematuria absorption or urinary  Nocturia products in the tissues.  Asthenia – tiredness and listlessness Nursing Interventions for patients receiving antibiotics for UTIs.  Hydrate the patient to produce daily urine output of 2000ml, unless contraindicated.  Instruct the patient to take all the medication, even though the symptoms may subside quickly.  Acid ash diet to maintain urine pH of 5.5  Monitor for allergic response.  Report s/s of continued infection. Prevention of Urinary Infections  Change sanitary pads/tampons frequently  Cotton underwear  Avoid irritating feminine products  Wiping front to back  Urinate before and after sexual encounters  Adequate fluid intake  Appropriate Vitamin C intake  Drink 3-4 glasses of water daily  Proper catheter care  Handwashing Urethritis  Inflammation of urethra  Classified by presence or absence of gonorrhea.  Inflammation of the urethra with pus formation  Gonorrheal urethritis is acute infection of mucous membrane of the urethra that causes a purulent exudate from meatus  c/o or burning or pain on urination Cystitis  Inflammation of wall of urinary bladder. R/T introduction of catheter, or contamination from feces  More common in women  Dysuria, urinary frequency, nocturia, pyuria, lower abdominal discomfort  Diagnosis is with UA with C&S  Teaching  Drink 2000 ml per day  Good perineal hygiene  Early detection  Void asap after intercourse  Alcohol, tea, chocolate, and coffee are all urinary irritants. Urinary irritants may exacerbate such conditions as interstitial cystitis. Possible substitutes include apricots, pears, papaya juice, herbal tea  Follow up Prostatitis  Inflammation and or infection of the prostate gland  Bacterial caused by infectious organisms traveling up the urethra  Nonbacterial results from variety of reasons related to occlusion of the urethra  Prostatodynia is pain in the prostate gland.  Clinical Manifestations  Burning sensation  Discomfort in perineum  Dysuria  Lower back and abdominal pain  Frequency and urgency  Edema may serve as occlusion  Complications include: epididymitis, pyelonephritis, and bacteremia  Chronic may be asymptomatic; acute may mimic UTI Treatment and Teaching  Broad-spectrum anti-infective therapy is administered from 2- 16 weeks (whether acute or chronic).  IV antibiotics may be necessary  Sexual arousal and intercourse should be avoided in the acute phase so the prostate can rest.  Intercourse may be beneficial in chronic cases  Pyelonephritis  Inflammation of the structures of the kidney – renal pelvis, renal tubules, and interstitial tissue. Usual bacteria is E. Coli  Usually in association with pregnancy, chronic health problems, such as DM or polycystic or hypertensive kidney disease, catheterization, infection, obstruction, or trauma  Kidney becomes edematous and inflamed, and blood vessels are congested.  Cloudy urine and contains pus, mucus, and blood. Small abscesses may form  Unilateral or bilateral  Chills, fever, prostration, and flank pain, CVA (costovertebral angle pain)  May become chronic causing destruction of nephrons  Azotemia – retention in blood of excessive amounts of nitrogenous compounds.  Diagnosis  U/A-presence of bacteria and pus in urine, hematuria, WBCs, and leukocytosis  C&S-identifies the bacteria  Ultrasound-abnormalities, obstruction, or hydronephrosis  IVP-check for presence of obstruction or degenerative changes caused by infectious process.  BUN, and Cr levels of blood and urine Medical Management  Mild s/s - outpatient antibiotics-14- 21 days  Inpatient – IV antibiotics then to oral when tolerated for 14-21 days  C&S-specific antibiotic therapy  Adequate fluids  Urinary analgesics  f/u urine culture Urinary Obstruction  Causes of obstruction include strictures, kinks, cysts, tumors, calculi, and prostatic hypertrophy.  May lead to alterations in blood chemistry, infection resulting from urine stasis, ischemia due to compression, or atrophy of renal tissue.  Clinical Manifestations and Diagnosis  Complaint of continued need to void  Pain – dull to incapacitating with nausea  Distended bladder  Kidney, ureter, and bladder (KUB) radiograph  Renal ultrasonography or IVP, or endoscopy  Blood chemistries Medical Management  Insertion of indwelling catheter  Pain medication  Anticholinergic agent (decreases smooth muscle motility)  Suprapubic catheter  Stent (temporary or permanent) Hydronephrosis  Dilation of renal pelvis and calyces  Unilateral or bilateral  Can be congenital  Caused by obstructions in urinary tract.  Obstruction generates pressure from building urine. May cause functional and anatomical damage. Renal pelvis and ureters dilate and hypertrophy  If prolonged, causes fibrosis and loss of function in affected nephrons  Clinical Manifestations  Pain  Nausea/Vomiting  Frequency, difficulty starting a stream of urine, dribbling at end of voiding, nocturia, burning on urination  Hematuria  Urinary output  Edema  Palpable mass in abdomen  Bladder distention and tenderness over kidneys or bladder. Treatment  Surgical intervention is used to relieve obstruction and preserve renal function  If severely damaged a nephrectomy may be necessary  Treat infections and pain Urologic Obstructions  Relief may be through  Cystostomy tube – surgically inserted directly into bladder through the abdominal wall.  Ureterostomy tube is inserted into one of the ureters through a flank incision.  A retention catheter, such as a Foley catheter, is inserted through the urethra. Urolithiasis  Urinary calculi can develop in any area of urinary tract  Nephrolithiasis – stones in kidney  Ureterolithiasis – stones in the ureter  Cystolithiasis – stones in the bladder  Calculi is also used Clinical Manifestations  Pain that is intractable  N/V  Hematuria  Feeling of needing to continue to void  Diagnosis and Treatment  KUB and IVP  UA  IV fluids to flush urinary system  Surgery - watch for ability to void after  Main complication is retention which is checked by residual urine  Cystoscopy – dysuria post procedure  Lithotripsy  Urine must be strained  Decrease calcium phosphorus foods along w/animal protein and salt  2000mL day water  Avoid cheese, greens, whole grains, carbonated beverages, nuts, chocolate, shellfish, and organ meat  Calcium stone: Calcium binding meds  Aluminum hydroxide will bind with phosphorus  Allopurinol reduces urate levels  Nutritional Therapy for Kidney Stones  Limit foods high in  Do not restrict oxalate calcium  All berries, Rhubarb  Increase fruits and  Plums, Figs vegetables  Okra, mustard, collard  Meat at moderate greens, spinach levels  Tomatoes  Decrease salt  Chocolate  Tea, Beer  Grits  Peanuts/peanut butter Renal Cysts  Polycystic kidney disease  Genetic disorder characterized by growth of numerous fluid-filled cysts, which can slowly replace much of the kidney  Pressure of cysts on kidney structures, infections and scarring compromises function  Abdominal and flank pain, headache, gastrointestinal complaints, voiding disturbances, and history of recurrent UTIs  Hematuria  Elevated BP  No specific treatment except treating the symptoms Benign Prostatic Hypertrophy  Enlargement of the prostate gland is common in men over 50.  Enlarges and exerts pressure on urethra and neck of bladder, which prevents emptying  UTI s/s, hematuria, oliguria, and signs of renal insufficiency, nocturia, problems initiating the stream,  Coude’ catheter – used in urinary retention/obstruction; point the penis toward to toes to help pass the prostate. Diagnosis and Treatment  Rectal examination reveals enlarged prostate gland  Cystology to determine benign or malignant  Or IVP, residual urine, blood chemistry  Foley insertion; No more than 1000 ml should be removed from a distended bladder initially  Prostatectomy is the removal of the prostate indicated to relieve and prevent further obstruction of urethra.  Pre-op enema to reduce straining after surgery. Techniques of Prostatectomy Open procedures  1. Suprapubic prostatectomy is accomplished by an incision through the abdomen; the bladder is opened, and the gland is removed from above with the finger. (See 1703-B)  2. Radical perineal prostatectomy requires an incision through the perineum between the scrotum and the rectum (C) Open Procedures  3. Retropubic prostatectomy is the method which a low abdominal incision is made, but the bladder is not opened. The gland is removed by making an incision into the capsule encasing the gland. (D) Techniques of Prostatectomy – TURP (Most common)  4. Transurethral resection of the prostate (TURP) is less invasive and less stressful  Removal of tissue is done through the urethra  The outer capsule of the prostate is left in place. This maintains the continuity between the bladder and the lower urethra  Care is centered on observation of urine character and maintaining patency of Foley Catheter (A) Post op  May have continuous closed bladder irrigation or intermittent irrigation to prevent occlusion of the catheter with blood clots, which would cause bladder spasms.  Tell patient and family that hematuria is expected after prostatic surgery  Monitor vital signs and urine color every 2 hours for 24 hours. With continuous irrigation the color will be pink or light red. Intermittent will be clear cherry red. Post op  Three way catheter one for irrigation, one for drainage, one for balloon.  To determine output subtract the irrigant from the total urine output.  Avoid kinks and tension on catheter  Hemorrhage is possible, don’t strain  Belladonna and opium (B&O) suppositories helpful to relieve bladder spasms. Contraindicated in the retropubic approach r/t rectal stimulation  Prevent constipation Post Op  Prolonged sitting is avoided r/t increased intra-abdominal pressure increases  When urine is clear, foley may be removed.  Tell pt that he will experience frequency, voiding small amounts with some dribbling. Instruct to void with the first urge  Rest/no driving for 48 hours to prevent bleeding  Avoid anticoagulants Post Op  Avoid sexual activity for 2 weeks  Watch for s/s UTI  Usually several weeks to achieve continence. Continence may improve for 12 months  2000-3000 ml/day  Treatment if needed for erectile dysfunction  If pt goes home with indwelling catheter, educate patient Cancer of the Prostate  Common in men over 50  Painless hematuria is most common symptom.  Linked to cigarette exposure  When urinary symptoms are noted, it is advanced.  Metastasis is common, pelvic lymph nodes and bone.  Men at age 50 or 45 if at high risk should have annual rectal examinations and PSA measurements helps with early treatment Post op Care  Maintenance of bowel and bladder function  Prevent trauma to perineum  Nothing should enter the rectum  No tension should disturb the surgical area  Drain care  Treatment:  based on stage of cancer, metastasis  Hormone therapy, Radiation or surgery may be recommended  Radical prostatectomy is used in early stage clinical disease. Removes entire prostate, capsule, seminal vesicles and portion of bladder neck  Goals post-op:  Removal of tumor  Preserving urine control  Preserving sexual function  Nephrotic Syndrome  Usually result of URI or allergic  Dietary management reaction  Protein  Proteinuria  Moderate—0.8-1.0  Hypoalbuminemia gm/kg/day of hi biological value (all essential amino  Hyperlipidemia acids – meat, fish, poultry, cheese, eggs)  Edema  Varies according to protein  S/S losses  Fluid in peritoneal cavity  Iron and vitamin (Ascites) supplements  Fluid in pleural cavity (pleural  NA restricted to 1000 mg/day effusion)  Fluids  Severe edema anasarca (periorbital, pitting edema in  Output plus 500 ml legs)  Nursing interventions  Anorexia, fatigue  Dly Weight  Foamy urine (protein)  Abdominal girth  Oliguria (