L13 Assess & common SS of renal disorders.pdf

Official (Open) ASSESSMENT AND COMMON SIGNS AND SYMPTOMS OF RENAL AND UROLOGICAL DISORDERS HS2261 / HS2232 - ADULT NURSING 2 Official (Open) Analyse significant information from patient assessment in relation to renal and urological disorders. LEARNING OBJECTIVES Recognise the common signs and sympt...

Official (Open) ASSESSMENT AND COMMON SIGNS AND SYMPTOMS OF RENAL AND UROLOGICAL DISORDERS HS2261 / HS2232 - ADULT NURSING 2 Official (Open) Analyse significant information from patient assessment in relation to renal and urological disorders. LEARNING OBJECTIVES Recognise the common signs and symptoms of renal and urological disorders. Determine the laboratory and diagnostic investigations in relation to renal and urological disorders. Develop an integrated management care plan for patient with renal and urological disorders based on the best evidences. Official (Open) COMMON RENAL AND UROLOGICAL DISORDERS Urinary Tract Infection (UTI) Cystitis, inflammation of the urinary bladder [most common UTI] Pyelonephritis, inflammation of the renal pelvis and parenchyma Urinary Calculi Urinary Tract Tumours Official (Open) URINARY TRACT INFECTION Urinary tract infection (UTI) is a collective term that describes any infection involving any part of the urinary tract, namely the kidneys, ureters, bladder and urethra. The urinary tract can be divided into the upper (kidneys and ureters) and lower tract (bladder and urethra). (Singapore Medical Journal, 2016) Out of 100 women, 50 will suffer from a UTI at some point in their life. (Office of Population Affairs, 2018) Worldwide, 150 million UTIs occur yearly, incurring $6 billion in healthcare expenditures. In healthcare settings, 40% of healthcare-associated infections (HAIs) are UTIs. (American Urological Society, 2018) Official (Open) PRINCIPLE CAUSES OF DEATH IN SINGAPORE (Ministry of Health, 2020) Official (Open) URINARY CALCULI Urinary calculi, stones in the urinary tract, are the most common cause of upper urinary tract obstruction. The term lithiasis means stone formation. When the stones form in the kidney, it is known as nephrolithiasis; when they form elsewhere in the urinary tract (e.g. Bladder), it is called urolithiasis. Stones may form and obstruct the urinary tract at any point. It is found to be more common in men with an average age at onset of 20-55 years. It has also found to have an increased incidence in white population, a previous history or family history of stone formation. (Mosby, 2014) Official (Open) URINARY TRACT TUMORS A malignancy can develops in any part of the urinary tract from the kidney pelvis to the urinary meatus. More than 81,000 cases of bladder cancer, 63,000 cases of kidney cancer, and 3800 cases of ureteral cancer are estimated. When diagnosed early, the 5 year survival rate of bladder cancer is 96%. (American Cancer Society, 2018) Most urinary tract malignancies arise from epithelial tissue. Transitional epithelium lines the entire tract from the renal pelvis through the urethra. Most bladder tumours are papillary lesions (papilloma). Official (Open) CASE STUDY - UTI (Singapore Medical Journal, 2016) Official (Open) SIGNIFICANT INFORMATION FROM PATIENT ASSESSMENT IN RELATION TO RENAL AND UROLOGICAL DISORDERS – UTI CHIEF COMPLAINT (CC) Acute Pain (most common manifestation) Fever (Temp more than 37.5 degree) HISTORY OF PRESENTING ILLNESS (HPI) Incontinence or cloudy or malodorous urine PHYSICAL EXAMINATION Tenderness to palpation (especially suprapubic) Costovertebral tenderness Official (Open) THE COMMON SIGNS AND SYMPTOMS OF RENAL AND UROLOGICAL DISORDERS- UTI Dysuria [painful or difficult urination] Urinary frequency and urgency [a sudden, compelling need to urinate] Nocturia [voiding two or more times at night] Foul smell urine Pyuria [cloudy urine] Haematuria [bloody urine] Suprapubic pain and tenderness Nocturia, incontinence, confusion, behaviour change, lethargy, and anorexia (older patients) Chills and fever [sign of infection] Official (Open) LABORATORY INVESTIGATIONS IN RELATION TO RENAL AND UROLOGICAL DISORDERS - UTI Urinalysis to assess for pyuria, bacteria and blood cells in the urine. A bacteria count >100,000 per ml is indicative of infection. Rapid tests for bacteria in the urine include using a nitrite dipstick (which turns pink in the presence of bacteria) and the leukocyte esterase test, an indirect method of detecting bacteria by identifying lysed or intact WBCs in the urine. Urine gram stain to identify the infecting organism by shape and characteristic (gram-positive or gram-negative) Official (Open) LABORATORY INVESTIGATIONS IN RELATION TO RENAL AND UROLOGICAL DISORDERS - UTI Urine culture and sensitivity to identify the infecting organism and the most effective antibiotic. Culture requires 24-72 hours, so treatment to eliminate the most common organisms is often initiated without culture. WBC with differential to detect typical changes associated with infection, such as leucocytosis (elevated WBC) and increased numbers of neutrophils. Official (Open) DIAGNOSTIC INVESTIGATIONS IN RELATION TO RENAL AND UROLOGICAL DISORDERS - UTI Intravenous pyelography (IVP) or CT scan to evaluate for structural or functional abnormalities, such as vesicoureteral reflux, of the kidneys, ureters, and bladder. Voiding cystourethrography to detect structural or functional abnormalities of the bladder and urethral strictures Official (Open) DIAGNOSTIC INVESTIGATIONS IN RELATION TO RENAL AND UROLOGICAL DISORDERS - UTI Cystoscopy to diagnose conditions such as prostatic hypertrophy, urethral strictures, bladder calculi, tumours, polyps or diverticula, and congenital abnormalities. A tissue biopsy may be obtained during the procedure and other interventions performed. (e.g. Stone removal or stricture dilation. Manual pelvic or prostate examination to assess for structural changes of the genitourinary tract, such as prostatic enlargement, cystocele, or rectocele. Official (Open) INTEGRATED MANAGEMENT CARE PLAN UTI PRIORITIES OF CARE 1 Relieve acute pain (most common manifestation of both lower and upper UTI) EXPECTED OUTCOME: Patient will express improved comfort and rate pain at an acceptable level. THE NURSE WILL… Official (Open) INTEGRATED MANAGEMENT CARE PLAN: UTI Relieve Acute Pain NURSING INTERVENTION RATIONALES Assess Pain including: timing, quality, intensity, location, duration, and aggravating and alleviating factors of pain. Pain Management Teach or provide comfort measures such as warm sitz baths, warm packs or heating pads, and balanced rest and activity. A change in the nature, location, or intensity of the pain could indicate an extension of the infection or a related but separate problem. Systemic analgesics, urinary analgesics, or antispasmodic medication may be used as ordered. Warmth relaxes muscles, relieves spasms, and increases local blood supply. As pain can stimulate a stress response and delay healing, it should be relieved when possible. Official (Open) INTEGRATED MANAGEMENT CARE PLAN: UTI Relieve Acute Pain NURSING INTERVENTION Encourage increased fluid intake unless contraindicated. RATIONALES Increased fluid dilutes urine, reducing irritation of the inflamed bladder and urethral mucosa. Instruct to notify primary care provider if pain Pain and discomfort in voiding are typically and discomfort continue or intensify after relieved within 24 hours of the initiation of therapy is initiated. antibiotic therapy. Continued discomfort may indicate a complicated UTI or other urinary tract disorder. Official (Open) INTEGRATED MANAGEMENT CARE PLAN for UTI PRIORITIES OF CARE 2 Restore normal urinary elimination. EXPECTED OUTCOME: The patient’s usual patterns of urinary elimination will be restored. THE NURSE WILL… Official (Open) INTEGRATED MANAGEMENT CARE PLAN: UTI Restore normal urinary elimination NURSING INTERVENTION Monitor (or instruct the patient to monitor) colour, clarity, and odour of urine. RATIONALES Urine should return to clear yellow within 48 hours, unless drug therapy causes a change in the colour of urine. If clarity does not return, further investigation may be necessary. Instruct to avoid caffeinated drinks e.g. coffee, tea & cola; citrus juicesdrinks containing artificial sweeteners alcoholic beverages. Caffeine, citrus juices, and artificial sweeteners irritate bladder mucosa and the detrusor muscle and can increase urgency and bladder spasms. Official (Open) INTEGRATED MANAGEMENT CARE PLAN: UTI Restore normal urinary elimination NURSING INTERVENTION RATIONALES Use strict aseptic technique and a closed urinary drainage system when inserting a straight or indwelling urinary catheter. Bacteria colonizing the perineal tissues or on the nurse’s hands can be introduced into the bladder during catherization. Unless contraindicated, instil anaesthetic lubricating gel into the urethra prior to catheter insertion. Aseptic technique reduces this risk. Maintain the closed urinary drainage system, and use aseptic technique when emptying the catheter drainage bag. Maintain gravity flow, preventing reflux of urine into the bladder from the drainage system. Anaesthetic gel promotes comfort, protects fragile urethral tissues from trauma, and reduces the risk for CAUTI. Official (Open) INTEGRATED MANAGEMENT CARE PLAN: UTI Restore normal urinary elimination Nursing intervention Rationales Provide perineal care on a regular basis and following defecation. Regular cleansing of perineal tissues reduces the risk of colonization by bowel or other bacteria. Use antiseptic preparations only as ordered. While antiseptic solutions may be ordered for catheter care, they can dry perineal tissues and reduce normal flora, increasing the risk of colonization by pathogens, and should not routinely be used. When possible, use intermittent straight catheterization to relieve urinary retention. Remove indwelling urinary catheters as soon as possible. Official (Open) INTEGRATED MANAGEMENT CARE PLAN UTI PRIORITIES OF CARE 3 Promote self-management through education. EXPECTED OUTCOME: Patient will verbalize understanding of the infectious process and its treatment and ways to reduce risk for future UTIs. THE NURSE WILL… Official (Open) INTEGRATED MANAGEMENT CARE PLAN: UTI Promote self-management through education NURSING INTERVENTION RATIONALES Teach how to obtain a midstream clean-catch urine specimen. Cleansing of the urinary meatus and perineal area reduces contamination of the specimen by external cells and bacteria. Assess knowledge about the disease process, risk factors, and preventive measures. The patient may have little understanding of UTI, its causes, and contributing factors. Official (Open) INTEGRATED MANAGEMENT CARE PLAN: UTI Promote self-management through education NURSING INTERVENTION Discuss the prescribed treatment plan and the importance of taking all prescribed antibiotics. RATIONALES Symptoms are largely relieved within 24 to 48 hours of starting antibiotic therapy. However, bacteria may remain in the urinary tract. Hence, completing the prescribed regimen is important to prevent recurrent infections and resistant bacteria. Help the patient develop a plan for taking medications. Missed doses of antibiotic can result in subtherapeutic blood levels and reduced effectiveness. Official (Open) INTEGRATED MANAGEMENT CARE PLAN: UTI Promote self-management through education NURSING INTERVENTION Instruct to keep appointments for followup and urine culture. Teach measures to prevent future UTI. RATIONALES Follow-up urine culture - often scheduled 7 to 14 days after completion of antibiotic therapy. It is to ensure complete eradication of bacteria and prevent relapse or recurrence. A history of UTI is an independent risk factor for future infections. Teaching measures to manage other risk factors can reduce the patient’s risk for future UTIs. Official (Open) CASE STUDY URINARY CALCULI Mr H.C., a 45 years old man, comes to the ED with severe right flank pain. He states that the pain just started this morning. He also noticed that his urine is pink-tinged. Official (Open) SIGNIFICANT INFORMATION FROM PATIENT ASSESSMENT URINARY CALCULI CHIEF COMPLAINT (CC) Renal coli, acute, severe flank pain on the affected side HISTORY OF PRESENTING ILLNESS (HPI) Dull suprapubic pain with exercise or after voiding (Bladder calculi) Nausea Vomiting Pallor Cool and clammy skin PHYSICAL EXAMINATION Acute, severe flank pain on the affected side (Ureteral spasm) Official (Open) COMMON SIGNS AND SYMPTOMS OF URINARY CALCULI Dull, aching flank pain Dull suprapubic pain with exercise or after voiding Renal colic, acute, severe flank pain [develops when a stone obstructs the ureter, causing ureteral spasm] The pain may radiate to the suprapubic region, groin, and external genitals. Nausea and vomiting Pallor Cool and clammy skin Gross or microscopic haematuria [trauma to the urinary tract by the calculi] Official (Open) LABORATORY INVESTIGATIONS of URINARY CALCULI Urinalysis [to assess haematuria and the presence of WBCs and crystal fragments. The urine PH is helpful in identifying the type of stone. Chemical analysis [to determine the type of stone and suggests measures to prevent further stone formation.] Urine calcium, uric acid, and oxalate [to measure the amount of these substances excreted over a 24 hour period and may be assessed to help identify possible causes of lithiasis. Serum calcium, phosphate, and uric acid [ to help identify factors contributing to calculus formation] Official (Open) DIAGNOSTIC INVESTIGATIONS URINARY CALCULI KUB (kidney, ureters and bladder) x-rays [may show calculi as opacities in the kidney, ureters, and bladder] Renal ultrasonography [to detect stones and evaluate the kidneys for possible hydronephrosis] Spiral computed tomography (CT) [to identify calculi, ureteral obstruction, and other renal disorders] Cystoscopy [to visualize and possibly remove calculi from the urinary bladder and distal ureters] Official (Open) INTEGRATED MANAGEMENT CARE PLAN FOR PATIENT WITHURINARY CALCULI PRIORITIES OF CARE 1 Relieve Acute Pain (pain the primary outward manifestation of urolithiasis, particularly when a stone lodges within a ureter, causing acute obstruction and distention.) EXPECTED OUTCOME: Patient will report pain at a level of 2 or lower on a scale of 0 to 10. THE NURSE WILL… Official (Open) INTEGRATED MANAGEMENT CARE PLAN - URINARY CALCULI Relieve Acute Pain NURSING INTERVENTION Assess and manage pain Assess pain using a standard pain scale and its characteristics. RATIONALES The intensity, type of pain, and its responsiveness to analgesia provide valuable clues as to its cause. Regular administration of prescribed Administer analgesia as ordered and monitor analgesics controls pain more effectively than its effectiveness. waiting until pain becomes intolerable. Administering an ordered NSAID on a routine schedule may significantly reduce the need for narcotic analgesia in patients with renal colic. Official (Open) INTEGRATED MANAGEMENT CARE PLAN - URINARY CALCULI Relieve Acute Pain NURSING INTERVENTION RATIONALES Encourage fluid intake and ambulation in the Increased fluids and ambulation increase patient with renal colic unless urinary output, facilitating movement of the contraindicated. calculus through the ureter and decreasing pain. Use nonpharmacologic measures such as Positioning moist heat, relaxation techniques guided imagery, and diversion as adjunctive therapy for pain relief. Adjunctive pain relief measures can enhance the effectiveness of analgesics and other prescribed treatment. Official (Open) INTEGRATED MANAGEMENT CARE PLAN FOR PATIENT WITHURINARY CALCULI PRIORITIES OF CARE 2 Restore normal urinary elimination EXPECTED OUTCOME: Patient’s urinary output and renal function studies will remain within expected parameters. THE NURSE WILL… Official (Open) INTEGRATED MANAGEMENT CARE PLAN - URINARY CALCULI Restore normal urinary elimination NURSING INTERVENTION Monitor amount and character of urine output. RATIONALES The amount of urine output helps determine urinary tract patency and adequacy of hydration. If catheterized, measure output hourly. Haematuria, gross or microscopic, is often associated Document any hematuria, dysuria, frequency, urgency, with calculi and with procedures used to remove and pyuria. stones, such as cystoscopy or lithotripsy. Strain all urine for stones, saving any recovered stones for laboratory analysis. A change in the amount of hematuria may indicate stone passage or a complication. Dysuria, frequency, urgency, and cloudy urine are symptoms of UTI, often associated with urolithiasis. Antibiotic therapy may be required. Analysis of stones recovered from the urine can direct measures to prevent further lithiasis. Official (Open) INTEGRATED MANAGEMENT CARE PLAN - URINARY CALCULI Restore normal urinary elimination NURSING INTERVENTION RATIONALES Maintain patency and integrity of all catheter A kinked or plugged catheter, particularly a systems. ureteral catheter or nephrostomy tube, may damage the urinary system. Secure catheters well, label as indicated, and use sterile technique for all ordered Labelling catheters can prevent mistakes, irrigations or other procedures. such as inappropriate irrigation or clamping. Any catheter increases the risk of infection; use of aseptic technique in all procedures reduces this risk. Official (Open) INTEGRATED MANAGEMENT CARE PLAN FOR PATIENT WITHURINARY CALCULI PRIORITIES OF CARE 3 Teach self-care EXPECTED OUTCOME: Patient will verbalized an understanding of the disease, factors contributing to its development, recommended treatment, and self-care strategies to prevent future episodes of stone development. THE NURSE WILL… Official (Open) INTEGRATED MANAGEMENT CARE PLAN - URINARY CALCULI Teach self-care Nursing intervention Rationales Assess understanding and previous learning. Relating information to previously learned material enhances retention and understanding. Present all material in a manner appropriate to knowledge base, developmental and educational level, and current needs. Learning is an active process that requires the patient’s participation. Tailoring teaching to the individual increases involvement. Teach about all diagnostic and treatment procedures. Knowing what to expect reduces anxiety, enhances compliance, and hastens recovery. Official (Open) INTEGRATED MANAGEMENT CARE PLAN - URINARY CALCULI Teach self-care Nursing intervention If the patient will be manged in the community, teach to: Collect and strain all urine, saving any stones. Report stone passage to the physician and bring the stone in for analysis. Report any changes in the amount or character of urine output to physician. Teach measures to prevent further urolithiasis: Increase fluid intake to 2500 to 3500 ml/day. Follow recommended dietary guidelines. Maintain activity level to prevent urinary stasis and bone resorption. Rationales Official (Open) INTEGRATED MANAGEMENT CARE PLAN - URINARY CALCULI Teach self-care NURSING INTERVENTION Take medications as prescribed. RATIONALES The risk of recurrent lithiasis is approximately. 50%; This risk can be reduced by following measures to prevent conditions favouring stone formation. Teach about the relationship between UTI promotes urolithiasis and thus requires urinary calculi and UTI, emphasizing prompt treatment to reduce this risk. preventive measures and the importance of prompt treatment. Official (Open) CASE STUDY - URINARY TRACT TUMORS Ben Wong, a 61-year-old married man with five adult children. One week ago, Mr Wong became alarmed when his urine became bright red. Even though he had no other symptoms, he called his physician. The physician ordered a urinalysis and urine cytology, revealing gross haematuria and poorly differentiated abnormal cells. Cystoscopy and tissue biopsy confirm a stage C tumour involving the bladder trigone. Mr Wong is admitted for a radical cystectomy and continent urinary diversion. Official (Open) SIGNIFICANT INFORMATION FROM PATIENT ASSESSMENT IN RELATION TO - URINARY TRACT TUMORS CHIEF COMPLAINT (CC) Painless haematuria (presenting sign of 75% of urinary tract tumours) – either gross or microscopic and is often intermittent HISTORY OF PRESENTING ILLNESS (HPI) Significant weight loss for the past few months Manifestations of a UTI (may arise from inflammation surrounding the tumour) Colicky pain from obstruction (Ureteral tumours) Flank pain or sign of renal failure PHYSICAL EXAMINATION Abdominal tenderness Official (Open) COMMON SIGNS AND SYMPTOMS OF URINARY TRACT TUMORS Painful haematuria [75% of urinary tract tumours] Gross or microscopic haematuria [often intermittent] Urinary frequency Urinary urgency Dysuria Colicky pain [ureteral tumours] Official (Open) LABORATORY AND DIAGNOSTIC INVESTIGATIONS URINARY TRACT TUMORS Urinalysis [to evaluate for haematuria] Urine cytology [to identify abnormal cells (tumour or pretumor cells)] Ultrasound bladder [intravenous pyelography may reveal a rigid deformity of the bladder wall, obstruction of urine flow at the point of the tumour, or bladder filling or emptying defects.] Cystoscopy and ureteroscopy [to provide definitive diagnosis of urinary tract tumours] CT scan and MRI [to evaluate tumour invasion or metastasis] Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR PRIORITIES OF CARE 1 Promote normal urinary elimination EXPECTED OUTCOME: Patient’s urine output will remain within expected parameters for amount, colour, clarity, and odour. THE NURSE WILL… Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Promote normal urinary elimination NURSING INTERVENTION Monitor urine output from all catheters, stents, and tubes for amount, colour, and clarity hourly for the first 24 hours postoperatively, then every 4-8 hours. RATIONALES Decreased urine output may indicate impaired catheter or drainage system patency. Prompt intervention is necessary to prevent hydronephrosis. A change in colour or clarity may indicate a complication such as haemorrhage or infection. Label all catheters, stents, and their drainage containers. Clear identification of each tube can prevent errors in irrigating and calculating outputs. Maintain separate closed gravity drainage systems for Separate closed systems minimize the risk and extent of each. potential bacterial contamination and resultant infection. Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Promote normal urinary elimination NURSING INTERVENTION RATIONALES Secure ureteral catheters and stents with tape prevent for kinking or occlusion maintain gravity flow by keeping drainage bag below level of kidneys. Impaired urine flow can lead to urinary retention distention of the bladder a newly created reservoir renal pelvis (hydronephrosis) Encourage fluid intake of 3000ml/day. Increased fluid intake maintains a high urinary output, reducing the risk of infection. Dilute urine is less irritating to the skin surrounding the stoma site. Electrolyte reabsorption from reservoirs may increase risk of calculi; high fluid intake and urine output reduce this risk. Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Promote normal urinary elimination NURSING INTERVENTION RATIONALES Monitor urine output closely for first 24 hours after stents or ureteral catheters are removed. Edema or stricture of ureters may impede output, leading to hydronephrosis and kidney damage. Encourage activity to tolerance. Ambulation promotes drainage of urine from reservoirs and helps prevent calcium loss from bones, which could precipitate calculus formation. Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Reduce risk for impaired skin integrity PRIORITIES OF CARE 2 Reduce risk for impaired skin integrity EXPECTED OUTCOME: Patient’s peristomal skin will remain intact without evidence of irritation or impeding breakdown. THE NURSE WILL… Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Reduce risk for impaired skin integrity NURSING INTERVENTION Assess peristomal skin for redness, excoriation, or signs of breakdown. Assess for urine leakage from catheters, stents, or drains. Keep the skin clean and dry. RATIONALES Change wet dressings. Intact skin is the first line of defence against infection. Impaired skin integrity may lead to local or systemic infection and impaired healing. Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Reduce risk for impaired skin integrity NURSING INTERVENTION RATIONALES Ensure gravity drainage of urine collection device or empty bag every 2 hours. Overfilling of the collection bag may damage the seal, allowing leakage and control of urine with skin. Change urine collection appliance as needed, removing any mucus from stoma. Meticulous care and protection of skin surrounding stoma can maintain integrity and prevent breakdown. Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Promote healthy body image. PRIORITIES OF CARE 3 Promote healthy body image. EXPECTED OUTCOME: Patient will acknowledge impact of bladder cancer treatment or surgery on personal roles and relationships. THE NURSE WILL… Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Promote healthy body image. NURSING INTERVENTION RATIONALES Use therapeutic communication techniques; Patients must know their feelings and actively listening concerns are respected and valued. responding to the patient’s and family’s concerns. Denial, anger, guilt, bargaining, or depression are common during grieving and normal for a patient undergoing a significant change in body image. Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Promote healthy body image. NURSING INTERVENTION Recognize and accept behaviours that indicate use of coping mechanisms, encouraging adaptive mechanisms. RATIONALES The patient may initially use defensive coping mechanisms such as denial, minimization, and dissociation from the immediate situation to reduce anxiety and maintain psychologic integrity. Adaptive mechanisms including learning as much as possible about the surgery and its effects, practicing procedures, setting realistic goals, and rehearsing various alternative outcomes. Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Promote healthy body image. NURSING INTERVENTION Encourage looking at, touching, and caring for the stoma and appliance as soon as possible. RATIONALES Accepting the stoma as part of the self is vital to adapting to the changed body image and is indicated by a willingness to provide self-care. Allow the patient to proceed gradually, providing support and encouragement. Discuss concerns about returning to usual activities, perceived relationship changes, and resumption of sexual relations. Provide referral to support group or contact with someone who has successfully adjusted to a urinary diversion. Patients and families may be reluctant to discuss topics of concern. An atmosphere of openness and acceptance facilitates expression of concerns and anxieties related to the changed body image. Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR PRIORITIES OF CARE 4 Reduce risk for infection. EXPECTED OUTCOME: Patient will remain free of urinary tract infection THE NURSE WILL… Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Reduce risk for infection NURSING INTERVENTION RATIONALES Maintain separate closed drainage systems keeping drainage bags lower than the kidney prevent loops or kinks in drainage tubing, which impede urine flow. Although urine is sterile when it leaves the kidney, bacteria grow rapidly in urine. Teach about impaired immune function(due to aging or the effects of chemotherapy) urine cloudiness (related to the effects of urine on ileal mucosa) This can mask usual signs of UTI such as fever and altered urine clarity. Prevention of urine reflux is essential to preventing UTI. Be alert for more generalized manifestations such as increased fatigue and malaise. Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Reduce risk for infection NURSING INTERVENTION Monitor for signs of infection: elevated temperature cloudy or foul-smelling urine Haematuria general malaise back or abdominal pain nausea and vomiting. RATIONALES Infection undermines the healing process. Early detection and treatment help prevent long-term consequences such as chronic pyelonephritis. Official (Open) INTEGRATED MANAGEMENT CARE PLAN URINARY TRACT TUMOR Reduce risk for infection NURSING INTERVENTION Teach signs and symptoms of infection and self-care measures to prevent UTI. RATIONALES The patient with a cystectomy and ileal diversion, urostomy, or continent reservoir is at risk of UTI for life because of impaired urinary defence mechanisms. Using clean or aseptic technique in providing care, increasing fluid intake, and using measures to acidify urine minimize the risk to a certain degree but do not eliminate it. Official (Open) REFERENCES American Cancer Society. (2018). Cancer facts and figures 2018. Atlanta, GA: Author. Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annualcancer-facts-and-figures/2018/cancer-facts-and-figures-2018.pdf American Urological Society. (2018). UTI epidemiologic and socioeconomics education. Retrieved from www.auanet.org/education/auauniversity/medical-student-education/medical-studentcurriculum/adult-uti Bauldoff, G., Gubrud, P., & Carnoy, M. (2020). LeMone & Burke’s Medical-Surgical Nursing: Clinical reasoning in patient care (7th ed.). New Jersey: Pearson Education, Inc. Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L. (2014). Medical-Surgical Nursing: Assessment and management of clinical problems (9th ed.). St. Louis: Elsevier. Ministry of Health (MOH). (2020). Principal Causes of Death. Retrieved from https://www.moh.gov.sg/resources-statistics/singapore-health-facts/principal-causes-of-death Office of Population Affairs. (2018). Urinary tract infection (UTI). Retrieved from https://www.hhs.gov/opa/reproductive-health/fact-sheets/urinary-tract-infections/index.html Tan, C.W., & Chlebicki, M.P. (2016). Urinary tract infections in adults. Singapore Medical Journal, 57(9), 485490. doi: 10.11622/smedj.2016153