MS CH 37 Nursing Care of Patients With Disorders of the Urinary System PDF

4068_Ch37_835-870 15/11/14 1:59 PM Page 835 Nursing Care of Patients With Disorders of the Urinary System MAUREEN MCDONALD LEARNING OUTCOMES 1. Explain the predisposing causes, symptoms, laboratory abnormalities, and treatment of urinary tract infections (UTIs). 2. Explain the predisposing causes,...

4068_Ch37_835-870 15/11/14 1:59 PM Page 835 Nursing Care of Patients With Disorders of the Urinary System MAUREEN MCDONALD LEARNING OUTCOMES 1. Explain the predisposing causes, symptoms, laboratory abnormalities, and treatment of urinary tract infections (UTIs). 2. Explain the predisposing causes, symptoms, treatment, and teaching for kidney stones. 3. List risk factors and signs and symptoms of cancer of the bladder. 4. List risk factors and signs and symptoms of cancer of the kidneys. 5. Discuss nursing care for a patient with an ileal conduit or continent reservoir. 6. Explain the pathophysiology and nursing care for diabetic nephropathy, nephrosclerosis, hydronephrosis, and glomerulonephritis. 7. Describe the signs and symptoms for patients with acute kidney injury. 8. Describe the signs and symptoms for patients with chronic kidney disease. 9. Plan nursing care for patients with acute kidney injury. 10. Plan nursing care for patients with chronic kidney disease. 11. Discuss nursing care for a vascular blood access site. 12. Plan nursing care for patients on hemodialysis. 13. Plan nursing care for patients on peritoneal dialysis. 37 KEY TERMS anuria (an-YOO-ree-ah) azotemia (AH-zoh-TEE-mee-ah) calculi (KAL-kyoo-lye) cystitis (siss-TYE-tiss) glomerulonephritis (gloh-MURR-yoo-loh-neh-FRY-tiss) hemodialysis (HEE-moh-dye-AH-lih-siss) hydronephrosis (HYE-droh-neh-FROH-siss) nephrectomy (neh-FREK-tuh-mee) nephrolithotomy (NEH-froh-lih-THAW-tuh-mee) nephropathy (neh-FROP-uh-thee) nephrosclerosis (NEH-froh-skleh-ROH-siss) nephrostomy (neh-FRAW-stoh-mee) nephrotoxin (NEH-froh-TOK-sin) oliguria (AW-lih-GYOO-ree-ah) peritoneal dialysis (PEAR-ih-toh-NEE-uhl dye-AL-ih-siss) polyuria (PAW-lee-YOOR-ee-ah) pyelonephritis (PYE-eh-loh-neh-FRY-tiss) stent (STENT) uremia (yoo-REE-mee-ah) urethritis (YOO-reh-THRYE-tiss) urethroplasty (yoo-REE-throw-PLAS-tee) urosepsis (YOO-roh-SEP-siss) 835 4068_Ch37_835-870 15/11/14 1:59 PM Page 836 836 UNIT NINE Understanding the Urinary System Disorders of the urinary tract include a v ariety of problems involving the kidneys, ureters, bladder, and urethra. These problems may arise from infection, obstructions, cancer , hereditary disorders, and metabolic, traumatic, or chronic diseases. Some may lead to chronic kidney disease (CKD) if not treated or controlled. Infection may be found in three anatomic parts of the urinary tract: the urethra, resulting in urethritis; the bladder, with a diagnosis of cystitis; or the kidneys, with a diagnosis of p yelonephritis. When problems occur with the kidney, homeostasis of the body is affected. URINARY TRACT INFECTIONS Urinary tract infection (UTI) refers to invasion of the urinary tract by bacteria. Normally, the urinary tract is sterile abo ve the urethra. UTI is the second most common bacterial disease. In the hospital, UTIs are the most common hospitalacquired infection (HAI). Lower UTIs include urethritis, prostatitis, and cystitis. Upper UTIs include pyelonephritis and ureteritis. Infections may result in sepsis or CKD. Risk Factors for Urinary Tract Infections UTIs are caused most often by an ascending infection, starting at the external urinary meatus and progressing toward the bladder and kidneys. Most UTIs are caused by the bacterium Escherichia coli, which is commonly found in feces. Other less common pathogens include Staphylococcus saprophyticus, Klebsiella spp., and Enterobacter. Risk factors for UTI include (a) incomplete emptying of the bladder; (b) contamination in the perineal and urethral area; (c) instruments or tubes inserted into the urinary meatus; (d) reflux of urine because of faulty valves; previous UTIs; (e) anatomical and genetic aspects of females; (f) pregnancy and asymptomatic bacteriuria; and aging. Incomplete Bladder Emptying Stasis of urine in the bladder can result from obstruction or simply from not voiding frequently enough. Urine overdistends the bladder, decreasing the blood supply to the w all of the bladder, which keeps white blood cells (WBCs) from fighting contamination that may have entered the bladder. The standing urine then serves as a culture medium for bacterial growth. Incomplete emptying of the bladder prevents flushing out of the bacteria and allows bacteria to ascend to higher structures. Contamination in Perineal and Urethral Areas Contamination in the perineal and urethral areas can be from fecal soiling, from se xual intercourse in which bacteria are massaged into the urinary meatus, or from infection in the area, such as vaginitis, epididymitis, or prostatitis. Instrumentation Infection Having instruments or tubes inserted into the urinary meatus can cause infection. The most common cause of instrumentation infection is urinary catheterization. Bacteria ascend around or within the catheter , causing infection. Within 48 hours of catheter insertion, bacterial colonization begins. Many patients develop a UTI within 2 weeks of placement of an indwelling urinary catheter. Faulty Valves Causing Reflux of Urine Faulty valves that do not maintain one-w ay flow can cause reflux of urine from the urethra to the bladder or the bladder to the ureter. Reflux can be congenital, or it may be acquired as a result of previous infections. Previous Urinary Tract Infections Previous UTIs are thought to provide a reservoir of persistent bacteria that cause reinfection. Incomplete bladder emptying can precipitate infections as well. Female Anatomic and Genetic Differences Women are more susceptible to UTIs than men because of the short length of the female urethra and its proximity to the anus and vagina. Some women with recurrent UTIs ha ve a shorter mean distance from the urethra to anus. This can facilitate colonization of the urinary tract. Genetic f actors have been found that may play a role in w omen who have a certain phenotype for developing UTIs. Pregnancy Pregnant women may have asymptomatic bacteriuria. Untreated, 40% to 50% will de velop pyelonephritis. Pregnant women may be prone to infection with group B streptococci. Most commonly, infection occurs in the second and third trimesters. Aging and the Urinary Tract Older adults have an increased incidence of UTIs due to diminished immune function, diabetes, and neurogenic bladder which fails to completely empty. Aging increases the risk of lower UTIs and may also mask symptoms. UTI is the most common cause of acute bacterial sepsis in patients over age 65. Older men are predisposed to infection because an enlar ged prostate obstructs urine flow. In older women, the decline in estrogen can also contribute to the risk of UTI. NURSING CARE TIP When caring for a patient at risk for a catheterrelated UTI, limit the use of a urinary catheter, use infection control procedures at all times, and discontinue the use of the catheter as soon as possible. Catheter-related UTI is a “never event”—that is, hospitals will not be paid by Medicare for the costs of care provided if this condition occurs during hospitalization. • WORD • BUILDING • urethritis: urethr—urethra (canal that discharges urine from bladder) + itis—inflammation cystitis: cyst—closed sac containing fluid + itis—inflammation pyelonephritis: pyelo—pelvis + nephr—kidney + itis— inflammation 4068_Ch37_835-870 15/11/14 1:59 PM Page 837 Chapter 37 Nursing Care of Patients With Disorders of the Urinary System Signs and Symptoms UTIs are characterized by common symptoms of dysuria, ur gency, frequency, incontinence, nocturia, hematuria, back pain, and cloudy, foul-smelling urine (Table 37.1). In the older adult, the most common presenting symptom of UTI is generalized fatigue. Atypical symptoms or a change in cognitive functioning, especially noted in patients without dementia, can be seen. A decline in mental status and fever in any patient with an indwelling catheter meets the diagnostic criteria for a UTI. Types of Urinary Tract Infections Urethritis Urethritis is inflammation of the urethra that may result from a chemical irritant, bacterial infection, trauma, or e xposure to a se xually transmitted infection (STI). Posttraumatic urethritis can occur with intermittent catheterization or instrumentation of the urethra. Bubble bath and bath salts are common urethral irritants and should not be used by anyone with a history of UTIs. Urethritis can also be caused by spermicidal agents. Gonorrhea and chlamydiosis are STIs that can cause urethritis in men. It is common to have some degree of urethritis in association with bladder or prostatic infections. Symptoms of urethritis include urinary frequenc y, urgency, and dysuria. The male patient may ha ve discharge TABLE 37.1 URINARY TRACT INFECTION (URETHRITIS, CYSTITIS, PYELONEPHRITIS) SUMMARY Signs and Symptoms Urinary urgency, frequency, dysuria Flank pain, fever, chills, costovertebral tenderness Cloudy urine with casts, bacteria, and WBCs Urine positive for nitrites Diagnostic Tests Urinalysis culture greater than 100,000 bacteria Elevated WBCs Elevated sedimentation rate Increased neutrophils Therapeutic Measures Antibiotic therapy sensitive to organism cultured from urine Force fluids Complications Pyelonephritis Urosepsis CKD Priority Nursing Diagnoses Pain Impaired Urinary Elimination: Frequency Ineffective Health Maintenance Note. CKD = chronic kidney disease; WBCs, white blood cells. 837 from the penis. A urinalysis or urine culture is done to diagnose urethritis. The treatment of urethritis is based on the cause. If it is a chemical irritant, it is avoided. If urethritis is caused by bacteria, an antibiotic is prescribed based on the results of a culture. Phenazopyridine (Pyridium), a urinary analgesic, is often used to treat dysuria. The patient should be forewarned that urine will turn orange while taking phenazopyridine. If urethritis was sexually transmitted, it is important that the sexual partner also be treated. Cystitis Cystitis is inflammation and infection of the bladder wall. It can be due to bacteria, viruses, fungi, or parasites.About 90% of UTIs are caused by Escherichia coli. In most cases, the causative organisms first grow in the perineal area and then ascend into the bladder. Symptoms include dysuria, frequenc y, urgency, and cloudy urine. Cystitis acquired outside the hospital is diagnosed with a routine urinalysis collected as a midstream, clean-catch specimen. Changes seen in the urinalysis include cloudy urine and the presence of WBCs, bacteria, and sometimes red blood cells (RBCs) in the specimen. Nitrites are usually positive. Some laboratories also e xamine for leukocyte esterase, which is positi ve if infection is present in the urine. In complicated UTIs, such as one acquired in the hospital or a repeat infection, a urine culture and sensiti vity should be done. Hospital-acquired UTIs are often caused by bacteria that are resistant to the usual antibiotics used for UTIs. A sensitivity test can identify which antibiotics will be effective against the offending organism. Treatment of uncomplicated c ystitis is most often a combination of sulfa medication, such as sulf amethoxazole and trimethoprim (Bactrim, Septra), or nitrofurantoin (Macrodantin). Complicated cystitis is often treated with ciprofloxacin (Cipro). Other antibiotics may be prescribed depending on the results of the urine culture and sensitivity. Estrogen used as an intravaginal cream may prevent recurrent UTIs in postmenopausal women. The patient is told to f inish all prescribed medications, force fluids unless contraindicated, and return for a follow-up urinalysis or culture after the antibiotic course is complete to ensure that the infection is gone. Pyelonephritis PATHOPHYSIOLOGY. Pyelonephritis is infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys. Pyelonephritis usually begins with colonization and infection of the lower urinary tract by means of the ascending urethral route. A preexisting condition is usually present, such as obstruction, strictures, stones, or vesicoureteral reflux. Risk factors include urological surgery, lymphatic infection, urinary stasis, and decreased immunity. Acute pyelonephritis begins in the renal medulla and spreads to the adjacent cortex. Pathophysiology includes formation of small abscesses throughout the kidney and gross enlargement of the kidney. On occasion, kidney infection is caused by bacteria spreading 4068_Ch37_835-870 15/11/14 1:59 PM Page 838 838 UNIT NINE Understanding the Urinary System from a distant site through the bloodstream and entering the kidney through the glomerulus. Urosepsis is a severe infection of the urinary tract with systemic inflammatory response syndrome. Prompt diagnosis and treatment are essential to prevent septic shock and death. SIGNS AND SYMPTOMS. Symptoms include fatigue, urgency, frequency, dysuria, flank pain, fever, and chills. Costovertebral tenderness on the right or left side (tenderness posteriorly at angle where rib and vertebrae join when struck gently with heel of examiner’s closed fist), which is associated with renal disease, is noted. The urine is cloudy with increased WBCs, bacteria, casts, RBCs, and positi ve nitrites. In contrast to cystitis, the patient with p yelonephritis is much sick er and shows signs of systemic disease. In acutely ill patients, blood cultures may be obtained. DIAGNOSTIC TESTS. Several tests are helpful to dif ferentiate pyelonephritis from cystitis. With kidney infection, the urinalysis will show casts. Casts are microscopic particles formed in the kidney from abnormal constituents in the urine such as WBCs, RBCs, or pus. The urine specimen will have more than 100,000 colonies of bacteria per milliliter . The presence of casts always indicates a problem in the kidneys. The complete blood cell (CBC) count will sho w an elevated WBC count. There will also be an increase in sedimentation rate. THERAPEUTIC MEASURES. Treatment of pyelonephritis includes administration of antibiotics based on the results of the culture and sensitivity (Table 37.2). With severe Gram-negative infections, the patient is hospitalized for intravenous (IV) antibiotics. The patient with acute p yelonephritis generally heals completely after treatment and has no lasting kidney damage. COMPLICATIONS. Repeated kidney infections can result in scarring and loss of kidney function, leading to CKD. Nursing Process for the Patient With a Urinary Tract Infection Data Collection Listen to the patient’ s concerns about the diagnosis. Ask about pain on urination, flank pain, or general symptoms of infection, such as fe ver, chills, and malaise. The patient’s usual pattern of voiding and any urinary frequency, burning, or pain on urination is documented. Note presence of pain in the lower abdomen, flank, or costovertebral angle. Document the presence of a catheter, recent instrumentation, surgery, or other predisposing f actors. Inspect the urine for v olume, color, concentration, cloudiness, blood, or foul odor. Review urinalysis and culture results. Nursing Diagnoses, Planning, and Implementation Acute Pain related to inflammation of the urethra, bladder, and other urinary structures EXPECTED OUTCOME: The patient will report relief from pain and discomfort. • Administer antimicrobial therapy as ordered to relieve pain and discomfort from inflammation and infection. • Administer antispasmodic agents as ordered to relieve bladder irritability and pain. • Encourage fluids at 2 to 3 L per day to flush bacteria from urinary tract and promote renal blood flow. • Apply heat to suprapubic area to relieve discomfort. • Encourage voiding every 3 hours to empty the bladder, lower bacterial counts, reduce stasis, and prevent reinfection. • Suggest consuming cranberry juice or capsules to prevent bacteria from sticking on the walls of the bladder (see “Evidence-Based Practice”). • Teach patient to finish all prescribed medications to prevent recurrent infection. • Teach patient to avoid cola, coffee, tea, and alcohol because they are urinary irritants. • Teach patient to empty bladder as soon as urge is felt and after sexual intercourse to flush bacteria out of the body. • Teach patient to avoid substances such as bubble bath and scented toilet paper, which can be irritants. • Teach patient to wear cotton underwear to reduce perineal moisture. EVIDENCE-BASED PRACTICE Clinical Question Do cranberries or cranberry juice prevent UTI? Evidence In a systematic review of studies that compared the use of cranberries containing products to prevent UTI with placebo or nonplacebo controls, it was found that cranberry-containing products are associated with a protective effect against UTIs. Cranberries contain a substance that can prevent bacteria from sticking on the walls of the bladder. Other compounds found in cranberries inhibit the adherence of E. coli to the urogenital mucosa (Wang et al, 2012). It was also found that cranberries are effective in reducing the annual number of UTI episodes by 63.9% in clients after renal transplantation (Pagonas et al, 2012). Implications for Nursing Practice Teach patients that cranberry products might help prevent recurrent UTI. REFERENCE Pagonas, N., Hörstrup, J., Schmidt, D., Benz, P., Schindler, R., Reinke, P., . . . Westhoff, T. H. (2012). Prophylaxis of recurrent urinary tract infection after renal transplantation by cranberry juice and L-methionine. Transplant Proceedings, 44, 3017–3021. Wang, C., Fang, C. C., Chen, N. C., Liu, S. S., Yu, P. H., Wu, T. Y., . . . Chen, W. T. (2012). Cranberry-containing products for prevention of urinary tract infections in susceptible populations. Archives of Internal Medicine, 172, 988–996. • WORD • BUILDING • urosepsis: uro—urine + sepsis—infection in the blood 4068_Ch37_835-870 15/11/14 1:59 PM Page 839 Chapter 37 Nursing Care of Patients With Disorders of the Urinary System 839 TABLE 37.2 MEDICATIONS USED TO TREAT URINARY TRACT INFECTIONS Medication Class/Action Example Nursing Considerations Antibiotics Effective against Escherichia coli, Klebsiella spp., Serratia aztreonam (Azactam) Contraindicated in patients allergic to penicillins and cephalosporins or if creatinine clearance is less than 30 mL/min. Check blood urea nitrogen and creatinine before administration. Effective against E. coli and Enterococcus faecalis fosfomycin (Monurol) Dissolve packet in 3–4 oz of cold water. Effective against E. coli, enterococci, Staphylococcus aureus, Klebsiella spp., and Enterobacter. nitrofurantoin (Macrobid, Macrodantin) Give with food or milk and full glass of water. Avoid antacids. ciprofloxacin (Cipro) levofloxacin (Levaquin) Absorption may be decreased if given within 2 hr of aluminum antacids. Give with large amounts of water. Teach to avoid sunlight and report tendon aches promptly. trimethoprimsulfamethoxazole (Bactrim, Septra) Teach to avoid sunlight. Give with large amounts of water. Contraindicated in severe renal or liver disease. cinoxacin (Cinobac) Teach to avoid sunlight. Encourage fluids. May discolor urine. Absorption may be decreased if given within 2 hr of aluminum or magnesium antacids. Fluoroquinolones Effective against E. coli, Klebsiella spp., Pseudomonas, and other organisms. Sulfonamides Effective against E. coli and Pseudomonas. Used for uncomplicated UTIs. Urinary Antiseptic Antibacterial action in the urine; not systemic. Effective against E. coli, Klebsiella spp., and other Gram-negative organisms. Urinary Analgesic Topical analgesic. phenazopyridine Relieves pain urgency and frequency (Pyridium) associated with UTI. Impaired Urinary Elimination related to frequency, nocturia, dysuria, and incontinence Urine color changes to red-orange. Avoid in renal insufficiency. Changes urine glucose testing. Risk for Injury related to sepsis, kidney disease, or kidney injury EXPECTED OUTCOME: The patient will return to previous EXPECTED OUTCOME: The patient will be free from injury due to sepsis or recurrent infection. • Monitor urinary elimination, including frequency, consistency, volume, and color, to identify signs and symptoms of UTI. • Administer antimicrobial drugs as ordered to eliminate symptoms produced by microbial growth. • Encourage adequate fluids to prevent infection and dehydration. • Encourage women to void after sexual intercourse to flush bacteria out of the urethra. • Teach patient to recognize signs and symptoms of UTI to monitor effectiveness of treatment and detect recurrence. • Administer antimicrobial drugs as prescribed to prevent recurrent infection or complications. • Monitor intake and output to ensure adequate intake and normal output. • Monitor patient for signs and symptoms of bacteriuria and bacteremia such as fever, chills, recurrent pain. • Explain need for follow-up urine culture and imaging studies when indicated by recurrent symptoms. • Teach need for adequate fluid intake to prevent dehydration and renal impairment. • Teach signs and symptoms of UTI so patient can detect recurrence or complications. voiding patterns. 4068_Ch37_835-870 15/11/14 1:59 PM Page 840 840 UNIT NINE Understanding the Urinary System Evaluation The outcomes have been met if the patient v erbalizes relief of pain and discomfort, returns to previous voiding patterns, and is free from injury related to sepsis, CKD, or recurrent infection. CRITICAL THINKING Mrs. Milan ■ Mrs. Milan is a 25-year -old woman who recently had a 3-day week end getaway with her husband. On Monday she notices that she has symptoms of dysuria, frequency, and ur gency. She visits her health care provider (HCP) and is diagnosed with a UTI. She is placed on an antibiotic. 1. What do you think could have predisposed Mrs. Milan to developing a UTI? 2. What should Mrs. Milan be taught to prevent further occurrences of a UTI? 3. What urinalysis findings would you expect for Mrs. Milan? 4. What should you include in her teaching plan based on her therapeutic regimen? Suggested answers are at the end of the chapter. Patient Education It is v ery important that patients be advised to tak e the entire prescribed antibiotic until it is gone. It is not un common for patients to tak e medication for se veral days until symptoms are gone, and then stop. Stopping the antibiotic too early allo ws the infection to continue. It may become chronic and resistant to antibiotics as a result. In addition to encouraging fluids, cranberry products may be helpful. Patients who have one UTI commonly develop repeat infections. It is important that such patients recei ve education to prevent repeated infections of the urinary tract (Box 37-1 and “Nutrition Notes”). Nutrition Notes Urinary Tract Infections An effective intervention for UTI is increasing fluid intake, both for its flushing ef fect and to e xcrete urinary drugs. Instructions to increase fluid intake should specify amounts to consume or the amount of urine to be produced. Patients have developed electrolyte imbalances by overenthusiastically forcing fluids. Box 37-1 Patient Education Preventing Urinary Tract Infection 1. Void frequently—at least every 3 hours while awake. 2. Drink up to 3000 mL of fluid a day if there are no fluid restrictions from the HCP. Preferably drink water. 3. Drink one glass of cranberry juice (10 oz) per day. 4. Take showers; avoid tub baths. 5. Wipe perineum from the front to the back after toileting. 6. Urinate after sexual intercourse. 7. Avoid bubble bath and bath salts, perfumed feminine hygiene products, synthetic underwear, and constricting clothing such as tight jeans. 8. Take medication prescribed for urinary tract infection (UTI) until it is all gone. 9. If UTI is associated with another source of infection, such as vaginitis or prostatitis, ensure that both infections are treated. UROLOGICAL OBSTRUCTIONS Urinary tract obstruction is an interference with the flo w of urine at any location along the urinary system. It is always a significant problem. The obstruction of urine flow causes dilation and thinning of the renal tubules with eventual atrophy of renal tissues. Renal blood flo w is compromised. Eventually renal tissue is destroyed by the compression. Urethral Strictures A urethral stricture is a narrowing of the lumen of the urethra caused by scar tissue. Urethral strictures are becoming more prevalent due to the rising incidence of STIs in young adults. Most strictures are acquired from injury or infection. Some strictures are a result of trauma from insertion of catheters or surgical instruments, untreated gonorrhea, and congenital abnormalities. The patient with a urethral stricture has a diminished urinary stream and is prone to developing UTIs because of obstruction of urine flo w. Urethral strictures are often seen in older men. The problem becomes more apparent when attempts to insert a urinary catheter are unsuccessful because of the narrowed lumen. Initially the treatment of a urethral stricture is mechanical dilation by the urologist, who inserts instruments to stretch open the urethra and then inserts a urinary catheter . If the stricture continues to be a problem after dilation, the area can be surgically repaired (urethroplasty) and a stent inserted. • WORD • BUILDING • urethroplasty: urethro—urethra + plasty—surgical repair 4068_Ch37_835-870 15/11/14 1:59 PM Page 841 Chapter 37 Nursing Care of Patients With Disorders of the Urinary System 841 The dilation process can be done at the bedside. This is a painful experience for the patient, and it is helpful and caring to administer pain medication before the procedure. The nursing diagnosis of Acute Pain is very relevant. An indwelling catheter is typically inserted after the dilation, so the nursing diagnosis of Risk for Infection is also present. P atients are taught about UTI prevention (see Box 37-1). are formed when urinary salts are concentrated enough to settle out; the salts often collect and deposit around a nucleus (see Table 37.3). Substances that can serv e as a nucleus include pus, blood, dead tissue, a catheter, and crystals. Stones usually grow on the papillae or in the renal tubules, calyces, or renal pelvis. Stones may also form in the ureter or bladder. Stones less than 5 mm are readily passed in the urine. Renal Calculi Etiology Renal calculi (kidney stones; one stone is a calculus) are hard, usually small stones that form somewhere in the renal structures (Table 37.3). The stones are masses of crystals and protein that form when the urine becomes supersaturated with a salt capable of forming solid crystals. Diet and lifestyle can account for the prevalence of stones in some patients. Symptoms occur when the stones become impacted in the urinary tract. When stones are found in the kidneys, the condition is called nephrolithiasis (Fig. 37.1). Causes of calculi formation include a family history of stones, chronic dehydration (causing more concentrated urinary salts), and infection, because the latter provides a nucleus for stone formation. Additional contributing causes of calcium stones include dietary factors (“Nutrition Notes”) and medications (Table 37.4). Excessive amounts of calcium in the water in some geographic areas may also be a factor. Immobility causes stone formation because of the resulting urinary stasis; in addition, calcium leaves the unstressed bones during immobility, so more calcium is in the blood, which is then filtered through the kidneys. Stones are more common in men than women. A diet high in sodium and animal protein increases the amount of calcium in the urine (hypercalciuria) Pathophysiology Normally, substances dissolved in urine, including urinary salts, are diluted and readily excreted from the body. Calculi TABLE 37.3 OVERVIEW OF RENAL CALCULI Type of Stone Calcium oxalate, calcium phosphate, or mixture Features Accounts for two-thirds of stones Small, rough, and hard Shaped like needles Colors vary from gray to white Possible Causes Excessive calcium Excessive urea Hyperparathyroidism, Cushing’s disease, immobility, osteolysis from tumors of the breast, lung Interventions Force fluids. Restrict protein and sodium in the diet. Administer hydrochlorothiazide. Treat hyperparathyroidism. Cellulose sodium phosphate (Calcibind) may prevent calcium stones by binding calcium from food in the GI system. Struvite—magnesium ammonium phosphate Calculi crumble easily Stones have a yellow color Infection by urea splitting microbes, usually Proteus. May cause abscess formation in the kidney. Force fluids. Decrease urine pH. Administer antibiotics. Uric acid stones Dye enhancement needed for x-ray visualization Small Color varies from yellow to red Hard Gout High uric acid levels Decreased fluid intake Force fluids. Administer sodium citrate to alkalinize urine. Administer allopurinol to reduce urinary uric acid levels. Low-purine diet. Avoid shellfish, anchovies, asparagus, organ meats, and mushrooms. Cystine stones Small, smooth calculi Smooth, waxy stones Cystine-containing crystals appear in the urine Force fluids. Use low-protein diet; urine is alkalinized. Give penicillamine to decrease amount of cystine in urine. 4068_Ch37_835-870 15/11/14 1:59 PM Page 842 UNIT NINE 842 Understanding the Urinary System Stone in calyx Stone free in pelvis and may contribute to the formation of stones. The risk peaks between ages 30 and 50. Signs and Symptoms Staghorn stone Hydroureter Ureteral stone Symptoms of renal calculi include e xcruciating flank pain and renal colic. When a stone is lodged in the ureter , it is common to have pain radiate down to the genitalia. The pain results when the stone pre vents urine from draining. Additional symptoms include hematuria from irritation by the stone, dysuria, frequency, urgency, and enuresis. The patient also may ha ve costovertebral tenderness. Some people develop nausea, vomiting, and diarrhea because of the proximity of the GI structures. Table 37.5 summarized the discussion of renal calculi. Prevention Bladder stones Urethral stone FIGURE 37.1 Location of calculi in the urinary tract. TABLE 37.4 MEDICATIONS AFFECTING STONE FORMATION Acetazolamide (Diamox) Decreases urinary citrates and increases uric acid concentration in urine. Consult with the HCP and dietitian to determine if an y foods should be a voided, depending on the type of stone found. “Nutrition Notes: Renal Calculi” discusses foods that may contribute to calculi development (see also “Cultural Considerations”). Encourage fluid intak e to prevent dehydration. Encourage the patient to w alk, which promotes the excretion of stones and reduces bone calcium resorption (release). Urocit(r)-K (potassium citrate), which restores chemicals in the urine that pre vent crystals from forming to decrease calcium oxalate and uric acid stones, might be prescribed. Complications The presence of renal calculi increases the risk for UTIs because of obstruction of the free flow of urine. Untreated obstruction of a stone in a ureter or the urethra can also result Adrenocorticosteroids Increases urinary calcium. Allopurinol Used to prevent uric acid calculi. May cause the rarer xanthine calculi. Antacids such as magnesium trisilicate (Gaviscon) May cause rare silicon-based calculi. Phosphate binding nonabsorbable antacids can increase urinary calcium. Aspirin Increases urinary uric acid levels in patients with hyperuricemia. Chemotherapeutic agents and external radiation May cause cellular breakdown and cause acute hyperuricemia. Hydrochlorothiazide (used to prevent calcium calculi) May cause uric acid calculi by increasing urinary uric acid levels. Furosemide (Lasix) May cause hyperuricemia. Vitamin C in large doses Increases oxalate excretion in urine. Vitamin D Increases calcium and oxalate excretion in urine. Nutrition Notes Renal Calculi Concentrated urine enhances the formation of crystals, so sufficient fluid should be consumed to produce 2000 mL of urine per day. About 3000 mL or 13 cups of water per day are needed to produce this amount of urine. About 80% of kidney stones are composed of calcium oxalate, which led to early prescriptions for lo wcalcium diets, but it was later found that a high-calcium intake binds dietary oxalate in the gastrointestinal (GI) tract and prevents its absorption, thereby reducing urinary oxalate formation. If a lo w-oxalate diet is prescribed, a long list of foods may be restricted beginning with spinach, rhubarb, beets, nuts, chocolate, tea, wheat bran, and strawberries. Uric acid kidney stones can be a complication of gout, which is a disorder of purine metabolism. Purines are end products of digestion of certain proteins and are present in some medications. High-purine foods include organ meats, anchovies, herring, sardines, meat extracts, consommé, and gravies. 4068_Ch37_835-870 15/11/14 1:59 PM Page 843 Chapter 37 Nursing Care of Patients With Disorders of the Urinary System 843 Cultural Considerations Recurrent Calculus Development Filipino immigrants are at high risk for developing renal stones, hyperuricemia, and gout. A shift from a traditional Filipino diet to an American diet increases the occurrence of hyperuricemia, with some older Filipinos developing gout. The nurse may need to assist Filipino patients to identify food choices that will help prevent these conditions. Caucasians have the highest incidence of kidney stones, followed by Mexican Americans. African Americans have the lowest risk. Prevalence of stones is increased in the southern United States and lowest in the western United States. TABLE 37.5 RENAL CALCULI SUMMARY Signs and Symptoms Costovertebral angle pain Groin pain Renal colic Flank pain radiating to genitalia Hematuria Anuria Restlessness Pallor Temperature Diminished or absent bowel sounds with ileus Diagnostic Tests Urinalysis Crystals and urine pH 24-hour renal creatinine clearance BUN Creatinine KUB—reveals most calculi Retrograde pyelography Ultrasound Therapeutic Measures Treat pain Chemolysis—stone dissolution using infusions of chemicals to dissolve stone Lithotripsy Surgery—Nephrolithotomy Pyelolithotomy Percutaneous nephrostomy tube Complications Shock Sepsis Hydronephrosis Hydroureter CKD Priority Nursing Diagnoses Acute Pain Risk for Infection Deficient Knowledge Note. BUN = blood urea nitrogen; CKD = chronic kidney disease; KUB = kidney, ureter, and bladder x-ray. in retention of urine and damage to the kidney. This process is called hydronephrosis (discussed later). Diagnostic Tests Helical computed tomography (CT) without contrast is the preferred diagnostic test. It requires no contrast agent and has the ability to detect stones in the distal ureters as well as small stones less than 1 to 2 mm. Other tests include an abdominal x-ray or an IV p yelogram, which will identify the anatomic location of the stone. Renal ultrasound may be done to identify a stone in the renal pelvis, calyx, or ureter. This is the preferred test for pregnant women suspected of having a kidney stone. Urinalysis may indicate gross or microscopic hematuria and could indicate abrasion of the urinary tract. The presence of crystals or urinary pH may indicate calculus type. Two consecutive 24-hour urine collections should be done while the patient follows his or her usual diet. The 24-hour urine collection should measure total urine v olume, calcium, oxalate, citrate, uric acid, sodium, potassium, phosphorus, pH, and creatinine as well as cystine and magnesium. Therapeutic Measures Renal calculi are treated medically if possible. Most small stones are flushed out of the body during urination. P atients can pass stones in the urine if the y are 5 mm or smaller . Drinking 2 to 3 quarts of fluids, taking analgesics such as Tylenol or ibuprofen, and perhaps a prescribed alpha-blocker medication (such as tamsulosin [Flomax]) to relax ureter muscles will help pass a small stone. Patients who develop severe renal colic are usually admitted to the hospital. IV fluids are given to hydrate the patient and help flush the stone out of the body. All urine is strained to detect passage of stones, and pain medication is gi ven. If the patient is unable to pass the stone and infection, impaired renal function, or se vere pain continues, interv ention is needed. The solubility of stone-forming substances can be changed by altering the pH of the urine. Calcium stones may be treated with thiazide diuretics and allopurinol (Aloprim, • WORD • BUILDING • hydronephrosis: hydro—pertaining to water + nephrosis— degenerative change in kidney 4068_Ch37_835-870 15/11/14 1:59 PM Page 844 844 UNIT NINE Understanding the Urinary System Zyloprim). Surgical removal may be required for large stones, obstructions, or intractable pain. LITHOTRIPSY. Lithotripsy is the use of sound, laser, or dry shockwave energies to break the stone into small fragments. Types of lithotripsy include e xtracorporeal shock-wave lithotripsy (ESWL), electrohydraulic lithotripsy, laser lithotripsy, and percutaneous ultrasonic lithotripsy. With ESWL, a form of lithotripsy , sedated or anesthetized patients lie down on the lithotriptor with a w ater-filled device supporting their back. Ultrasonic shock waves are used to break up the stone into sand particles, which are then urinated out over a week with small discomfort or be small enough to be removed. Some lithotripsy procedures do not require submersion and use other means of initiating shock waves (Fig. 37.2). Occasionally, a stent is placed in the ureter to facilitate the passage of the stone fragments. After the procedure, the patient is usually discharged home after being told to increase fluid intake to help flush the sand particles out, strain the urine to catch stone fragments for analysis, and notify the urologist if there are any problems. Blood in the urine is common after lithotripsy. ESWL is most effective with stones that are in the kidne y. ESWL may increase the risk of kidney disease or hypertension later in life. SURGERY FOR RENAL CALCULI. Some patients may need sur- gery for stone remo val. The particular procedure chosen— endoscopic or open surgery—depends on the location of the stone. Endoscopic procedures for the bladder include cystoscopy for small stones and c ystolitholapaxy for larger stones. For cystolitholapaxy, an instrument is inserted through the urethra to the bladder to crush the stone. The stone is then w ashed out with an irrigating solution. If the stone is lodged in a ureter, the urologist may insert an instrument into the ureter through a cystoscope to crush the stone or use an ultrasonic lithotripsy instrument to break the stone into fragments. Postoperative care following these procedures is similar to care following any cystoscopy (see Chapter 36). The open surgery procedure for stones in the bladder is a cystotomy and for the ureter an ureterolithotomy. For kidney stones, a percutaneous nephrolithotomy is performed in which a scope is inserted through the skin into the kidney to aid in breaking up the stone and to irrigate the renal pelvis. A nephrostomy tube is often left in place at first to prevent stone fragments from passing through the urinary system. If the stone is very large, a nephrolithotomy may be needed, which involves a surgical incision into the kidney to remove the stone. A pyelolithotomy is done to remove stones lodged in the renal pelvis. Nursing Process for the Patient With Renal Calculi DATA COLLECTION. Patients with stones are often in e xtreme pain and should be monitored for pain. Patients over age 60 should ha ve an abdominal aneurysm ruled out. A health history may identify a f amily or patient history of previous stone formation. People who have had stones usually have a recurrence. Why would renal colic usually begin suddenly, progress rapidly, and peak over a 30-minute period? Because it occurs as urine attempts to pass the stone. Flank pain may radiate to the genitals. Diminished or absent bowel sounds may progress to an ileus. The patient may also be restless, pale, and lightheaded. Nursing care of a patient with a renal calculus in volves careful measurement of intake and output and observation of urine for abnormalities such as hematuria, pyuria, or passage of a stone. Obstruction may occur at the bladder neck or urethra. With obstruction, anuria (less than 50 mL of urine output daily) or oliguria (less than 400 mL of urine output daily) is noted. This is an emergency situation and must be treated immediately to preserv e kidney function. Temperature is monitored for onset of fever, which would indicate infection. • WORD • BUILDING • lithotripsy: litho-stones + tripso-breaking stones nephrolithotomy: nephro—kidney + lith—stone + otomy— incision anuria: an—without + uria—urine oliguria: olig—small + uria—urine Monitors Waterfilled bags Patient’s kidney stone Water column ECG monitor Shock wave generator Ellipsoidal reflector FIGURE 37.2 Extracorporeal shock-wave lithotripsy. 4068_Ch37_835-870 15/11/14 1:59 PM Page 845 Chapter 37 Nursing Care of Patients With Disorders of the Urinary System Blood pressure may decrease if severe pain causes shock. A special strainer is used to strain all urine for stones. If a stone is found, it is saved for analysis in the laboratory. The patient is also asked about a recent history of infection, diet or activity changes, or other risk factors for renal calculi. If the cause can be identified, teaching can be done to help prevent recurrent calculi. NURSING DIAGNOSIS, PLANNING, AND IMPLEMENTATION. Acute Pain related to the presence of, obstruction, or movement of a stone within the urinary system EXPECTED OUTCOME: The patient will verbalize the relief of pain or ability to tolerate pain. • Ask severity, location, and duration of pain using a pain scale. Pain is typically in the flank or costovertebral angle and may radiate to the pelvic, groin, or abdominal area. • Monitor patency of drains, and catheters. Obstruction of urine flow will increase pain. • Encourage fluid intake, unless contraindicated, to promote the passage of stone, dilute the urine, and reduce the risk of further stone formation. • Administer pain medication as ordered to promote comfort. • Apply heat to flank area to reduce pain and promote comfort. • Ambulate if possible to facilitate the passage of the stone through the urinary system. • Strain urine through gauze or strainer to identify stones that may have been passed providing pain relief. Risk for Infection related to the introduction of bacteria from obstructed urinary flow and instrumentation EXPECTED OUTCOME: The patient will remain infection free. • Monitor vital signs, and observe for chills, cloudy, foulsmelling urine, or bleeding. Abnormalities may indicate an infection. • Monitor urine amount, color, clarity, and odor to ensure patency of urinary system or tubes. Foul-smelling or cloudy urine may indicate an infection. • Encourage fluid intake to flush bacteria and stones and prevent further stone formation. Deficient Knowledge related to lack of knowledge about prevention of recurrence, diet, and symptoms of renal calculi EXPECTED OUTCOME: The patient will verbalize an understanding of the factors related to the recurrence of renal calculi, infection, and treatment options. • Note recurrence of renal stones. Recurrence may indicate knowledge deficit. • Note family history of renal stones and explain relevance to patient. Stones have a higher incidence in patients with a positive family history. • Determine the relationship between activity and stones. Sedentary lifestyle or limited mobility may increase risk of stone formation. • Ask the patient’s understanding of possible courses of therapy to treat renal stones to establish baseline knowledge. • Teach the importance of maintaining a fluid intake of 2 to 3 quarts per day. Low-solute (dilute) urine helps prevents stone formation. 845 • Teach patient about medications used to prevent recurrence of renal stones: • Diuretics (thiazide type) increase tubular reabsorption of calcium, making it less available for calculi formation in the urinary tract. • Allopurinol (Zyloprim) reduces uric acid production. • Antibiotics prevent chronic UTI, which may precede renal calculus formation. • As applicable, teach patient about management of stones. Most stones pass spontaneously. There may be pain, nausea, and vomiting. Medical management consists of fluids, pain management, and antibiotics. Mechanical interventions with percutaneous catheters and nephroscopic procedures, lithotripsy, or surgery can be used to eliminate stones. • Teach patient to strain all urine. Stone fragments may continue to pass for weeks after stone crushing or lithotripsy. • Teach patient to report signs of infection, pain not relieved by medication, nausea, chills, or the appearance of foulsmelling urine for treatment. EVALUATION. Outcomes have been achieved if the patient remains comfortable, free from infection, and gains under standing about prevention of the reoccurrence of renal stones. Hydronephrosis Hydronephrosis is distention of the renal pelvis and calices. This condition results from untreated obstruction of urine flow in the urinary tract. The kidney enlarges as urine collects in the pelvis and kidne y tissue. Hydronephrosis is usually treatable once the condition is detected. Obstruction of urine flow can result from a stricture in a ureter or the urethra, kidney stones, a tumor, or an enlarged prostate. Because of the unrelieved obstruction, urine backs up and distends the ureters and then progresses to the kidney (Fig. 37.3). The capacity of the renal pelvis is normally 5 to 8 mL. Obstruction in the renal pelvis quickly distends it. Kidney pressure increases as the volume of urine increases. This enlargement of the kidney can be either unilateral or bilateral. Unrelieved pressure on the kidneys from urine causes the kidneys to become sacs filled with urine instead of functioning kidneys. Sometimes, in a matter of hours, the blood v essels and renal tubules can be damaged extensively. If the onset of obstruction is gradual, the patient initially may be asymptomatic. Patients commonly develop UTIs because of the obstruction of urine flo w and may have symptoms of frequenc y, urgency, and dysuria. As the disease progresses, flank and back pain may occur . Eventually the patient develops symptoms of CKD (discussed later). Treatment of hydronephrosis always involves relieving the obstruction. Initial removal of the obstruction may be done by insertion of an indwelling urinary catheter. Long-term correction depends on the cause and includes treatments and surgeries to relieve obstruction from strictures, stones, tumor, or an enlarged prostate. At times, the obstruction cannot be relieved because a stone is too large or removal of tumor growth would result in the patient’s death. In these situations, stents, which are tiny tubes, may be placed inside the ureters during 4068_Ch37_835-870 15/11/14 1:59 PM Page 846 846 UNIT NINE Understanding the Urinary System FIGURE 37.3 Hydronephrosis. Progressive thickening of bladder wall and dilation of ureters and kidneys results from obstruction of urine flow. a cystoscopy and pyelogram (C&P) to hold the ureters open, or a nephrostomy tube may be inserted directly into the kidney pelvis to drain urine. A nephrostomy tube exits through an incision in the flank area and allo ws urine to drain into a collecting bag so that function of the kidne y can be maintained. Figure 37.4 shows a stent in place in a ureter and a nephrostomy tube. Complications associated with hydronephrosis include increased incidence of UTIs because of obstruction of urine flow and kidney failure from unrelieved pressure on the kidneys. Intake and output are carefully measured. Urine retention can worsen the condition and must be recognized and reported promptly. If the patient has a nephrostomy tube, ensure that it is draining adequately and prevent kinking or clamping of the tube. Kinking of the tube results in continuation of the hydronephrosis, and the resulting pressure will destro y kidney function. If both a nephrostomy tube and urinary catheter are present, output from each should be measured and documented separately. TUMORS OF THE RENAL SYSTEM Cancer of the Bladder Cancer of the bladder is the most common kind of cancer of the urinary tract. It is most common in men, with the average age being 73. It is more common in Caucasians than in African Americans. The incidence of bladder cancer has been rising in the United States, and theAmerican Cancer Society (ACS) estimates that more than 72,570 new cases of bladder cancer occurred in 2013. urothelium. They are called transition cell cancers. They come in a variety of forms and can behave in different ways. Some occur as small w artlike growths on the inside of the bladder. Others form large tumors that grow into the muscle wall of the bladder and require surgical removal. If the cancer affects only the inner lining of the bladder , it is known as a superficial cancer. If it has spread to the muscle w all, it is called an invasive cancer. Common sites for metastasis include the liver, bones, and lungs. Etiology There is a strong correlation between cigarette smoking and bladder cancer. Those who smoke get bladder cancer twice as often as people who do not smoke. Specific chemicals that cause bladder cancer have been found in cigarette smoke. The more cigarettes smoked, the greater the risk. The lung absorbs the chemicals from tobacco. These chemicals are then passed via the bloodstream to the kidneys and collected in the urine. From there, they accumulate in the urine and damage the cells that line the bladder. Exposure to industrial pollution such as aniline dyes, benzidine and naphthylamine, leather finishings, metal machinery, and petroleum processing products also increases the incidence. It can take about 25 years after exposure to chemicals for bladder cancer to de velop. Bladder cancer is often diagnosed at a later stage in women. Signs and Symptoms Cancer of the bladder usually causes painless hematuria.The patient may notice that the urine is darker or more reddish in color than usual. Blood in the urine is one of theACS’s seven warning signs of cancer. Initially the bleeding is intermittent, Pathophysiology Cancer of the bladder often starts as a benign gro wth on the bladder wall that undergoes cancerous changes. Most bladder cancers begin in the inner lining of the bladder called the • WORD • BUILDING • nephrostomy: nephr—pertaining to the kidney + ostomy— surgically formed artificial opening to the outside 4068_Ch37_835-870 15/11/14 1:59 PM Page 847 Chapter 37 Nursing Care of Patients With Disorders of the Urinary System 847 be made with c ystoscopy and transurethral biopsy. An IV pyelogram or CT scan also may be done. Therapeutic Measures Stent in place Stent being inserted A Catheter Entry through skin Tape Drainage tubing B Posterior view FIGURE 37.4 (A) Ureteral stents. (B) Nephrostomy tube inserted into renal pelvis; catheter exits through an incision on flank. which often causes the patient to delay seeking treatment.As the disease progresses, the patient develops frank hematuria, bladder irritability, urine retention from clots obstructing the urethra, and fistula formation (an opening between the bladder and an adjoining structure such as the v agina or bowel). Other common signs and symptoms of bladder cancer include pelvic pain, pain in the lower back, painful urination, changes in bladder habits, and inability to void. Diagnostic Tests Routine urinalysis can detect e vidence of bladder cancer. A urine test for the enzyme telomerase has been found to be 90% accurate in detecting bladder cancer in early and late stages. Urine for c ytology can be obtained to determine if cancer cells are present in the urine. Urine culture should also be done. Symptoms of bladder infection may be similar to those of bladder cancer. Diagnosis of bladder cancer may also Treatment depends on the type and staging (se verity) of the bladder cancer. For small, confined tumors, chemotherapeutic agents are instilled into the bladder through a urinary catheter, allowed to dwell, and then removed along with the catheter. Systemic chemotherapy is also used and can be helpful to prolong life when other treatments are no longer indicated. The bacille Calmette-Guérin vaccine may be instilled into the bladder to prevent recurring tumors. Photodynamic therapy, in which drugs are given that make tumors sensitive to light, may be used. When light is applied to the tumor area, cancer cells are killed. Surgical treatment of bladder cancer includes a number of procedures. A cystoscopy and pyelogram with fulguration (destruction of tissue with electrical current) may be done to burn off cancerous tissue. An alternate method is use of a laser to destroy tumor tissue. Partial cystectomy can be done for cancer limited to one area. Advances in surgical techniques involve robotic and laparoscopic techniques. If the bladder requires removal, robotic laparoscopic radical c ystectomy with urinary diversion is an option. In this procedure, robotic surgical equipment, which imitates sur gical movements guided by the surgeon, allows more precision, steadiness, and maneuverability than manual surgery, as well as the use of small openings rather than larger incisions into the abdomen. Recovery time is reduced as a result. INCONTINENT URINARY DIVERSION. If the patient has a potentially curable disease with significant bladder involvement, complete removal of the bladder and creation of a urinary diversion may be done. A urinary diversion means that urine leaves the body in a different manner. A common surgery for urinary diversion is called an ileal conduit, an in volved surgery in which a 6- to 8-inch section of the ileum or colon is removed and used as a conduit for urine. The remaining portions of the bowel are stitched back together. The surgeon is careful to keep the blood and neurologic supply intact to the section of bowel that has been removed. The isolated section of bowel is closed off on one end, the ureters are stitched into it, and the other end is brought out as a stoma on the abdomen (urostomy) that almost continuously drains urine (Fig. 37.5). The urine from an ileal conduit contains mucus because it comes through the ileum, which normally secretes mucus. The patient must wear an ostomy appliance at all times over the stoma to collect urine. Box 37-2 e xplains how to apply an appliance to an ileal conduit stoma. CONTINENT URINARY DIVERSION. Continent urinary diversion surgeries are being done for patient convenience. One version is the Kock pouch (continent internal ileal reser voir), which is created from a se gment of ileum that has been made into a reserv oir for urine (see Fig. 37.5B). The ureters are implanted into the side of the reservoir. A special nipple valve is constructed and is the passage way through which the patient inserts a catheter at 4- to 6-hour intervals 4068_Ch37_835-870 15/11/14 1:59 PM Page 848 848 UNIT NINE Understanding the Urinary System Box 37-2 Isolated segment of ileum with ureters implanted in posterior portion Stoma on abdomen Peristalsis A Stoma sutured to body wall Ureters implanted into pouch Catheter The patient uses a catheter to drain urine Fluid pressure closes valve Pouch created from a segment of ileum B Ureters implanted into pouch Portion of terminal ileum exits abdominal wall Indiana pouch formed from cecum C FIGURE 37.5 Urinary diversion surgery. (A) Ileal conduit. (B) Kock pouch. (C) Indiana pouch. to drain urine. Another version of this surgery is the Indiana pouch (see Fig. 37.5C). A reservoir is created using a portion of the ascending colon and terminal ileum, making a larger pouch than the K ock pouch. Additional versions of this type of surgery use other parts of the bowel and include the Mainz pouch or Florida pouch. Application of a Disposable Pouch to an Ileal Conduit 1. Gather all supplies: a washcloth, towels, and water; a pouch to apply with a Stomahesive flange; and wicks such as gauze to absorb continually flowing urine. Wear clean gloves. 2. Empty the old pouch. 3. Gently remove soiled pouch by pushing down on skin while lifting up on the flange. Discard soiled pouch and flange. 4. Place a towel around the stoma to catch urine. 5. Mold or cut an opening in the flange that is only 1/16 to 1/8 inch larger than the stoma. Once stomal shrinkage is complete, a presized pouch can be used that fits the stoma. 6. Remove paper backing from the Stomahesive and set the flange to one side. 7. Clean the skin around the stoma with water. Pat dry. Immediately wrap the stoma in wicks to absorb urine. Otherwise urine will leak onto the skin, and the flange will not adhere. 8. Center the flange over the stoma, remove the wick, and immediately apply the flange. Then snap the pouch onto the flange. Note: The flange and pouch may be snapped together before application to the stoma. 9. Use the heat of your hand to compress the flange to ensure a good seal. 10. Ensure that the bottom of the pouch is closed off, or connect to a urinary catheter bag at night or if patient is in bed most of the time. ORTHOTOPIC BLADDER SUBSTITUTION. This surgery involves formation of an orthotopic bladder using a section of the intestine to make a neobladder (neo = new) and implanting both the ureters and the urethra into the neobladder. Various types of orthotopic bladder substitution surgery include the Studer pouch, hemi-Kock pouch, and ileal W-neobladder. After this surgery, the patient can void through the urethra, although incontinence may be a problem and intermittent catheterization may be needed. Nursing Care Nursing care of the postoperative patient is similar to care following any major surgical procedure (see Chapter 12). It is important to ensure adequate urinary output and to detect and report any obstruction of urine drainage early to prevent complications. The skin around the stoma will require special care to prevent skin breakdown. The patient is taught how to care for the urinary diversion after surgery, either by frequent draining with a catheter or by wearing an appliance. Be sensiti ve to the patient’s anxiety about caring for the urinary diversion. 4068_Ch37_835-870 15/11/14 1:59 PM Page 849 Chapter 37 Nursing Care of Patients With Disorders of the Urinary System Body image disturbance may occur because of the change in body function. A consultation with a nurse who specializes in wound, ostomy, and continence care (WOC nurse) or an ostomy support group may be helpful both before and after surgery. Cancer of the Kidney Pathophysiology and Etiology Cancer of the kidney is among the 10 most common cancers in both men and w omen. The ACS (2013) estimates about 65,150 new cases of kidney cancer will occur in 2013. The lifetime risk of kidney cancer is 1 in 63. Risk factors include genetics, smoking, obesity, hypertension, years of kidne y dialysis, and exposure to radiation, asbestos, and industrial pollution. Most patients with kidney cancer are over age 55. It is rare under the age of 45. Men ha ve twice the incidence of women. Often the cancer has metastasized before it is diagnosed because the kidney has such a large volume of circulating blood, which increases the risk of tumor spread. In addition, the disease has few early symptoms. Signs and Symptoms The three classic symptoms of kidney cancer are hematuria, dull pain in the flank area, and a mass in the are