Nursing Care of the Patient with Renal and Urological Problems

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Nursing Care of the Patient with Renal and Urological Problems Powered By Docstoc
					Care of the Patient with
 Renal and Urological
      Adult Health I
Classifications of Infections of the
Urinary Tract
   Lower                           Uncomplicated
       Cystitis                        Community acquired
       Prostatitis                      infection
       Urethritis                      Common in young
   Upper
       Acute pyelonephritis
                                    Complicated
       Chronic pyelonephritis          Often nosocomial
                                         and/or related to
       Renal abscess                    catheters
                                        Occurs in those with
                                         urologic abnormalities,
                                         pregnant, DM
Lower Urinary Tract Infections
   Normally bladder can rid self of bacteria
   UTI usually results from normal flora of GI tract
   Certain agents can interfere
       Aspartame, saccharin, tryptophan metabolites
   Reflux can increase risk of infection
   Bacteruria – 100,000 colonies of bacteria per ml
    of urine
   Routes of infection
       Transurethral
       Bloodstream
       Fistula
Clinical Manifestations
 Dysuria
 Frequency
 Nocturia
 Pelvic pain
 Hematuria
 Back pain
Assessment and Diagnostics
 Urinalysis (UA)
 Urine Culture
 STD testing
 CT
 Ultrasound
Medical Management
   Uncomplicated
       3 day regimen of antibiotics
   Complicated
       7 – 10 day regimen of antibiotics required
       Best to ID organism
   Antibiotics include
       Bactrim, Ampicillin, Cephalosporins,
        Aminoglycosides, Nitrofurantoin
   Phenazopyridine can help with dysuria
Medical Management
 Prophylactic use of antibiotics is
 Cranberry may be beneficial
Nursing Management
   Relieve pain
       Push fluids
       Avoid bladder irritants (alcohol, caffeine, etc)
       Frequent voiding
   Monitor for potential complications
       Urosepsis
       Renal failure
 Teach patients proper hygiene
 Avoid / limit indwelling catheter use
Acute Pyelonephritis
   Bacteria invades
    upper urinary tract
Clinical Manifestations
   Fever
   Chills
   Leukocytosis
   Bacteruria
   Pyuria
   Low back pain
   Nausea and vomiting
   Headache
   Malaise
   Dysuria
Assessment and Diagnostics
 Urinalysis (UA)
 Urine Culture
 STD testing
 CT
 Ultrasound
 IVP (not often used)
Medical Management
   2 week course of antibiotics
       Bactrim
       Fluroquinolones
       Gentamicin ± Ampicillin
       3rd generation cephalosporin (ex. Ceftrioxone)
 Hydration
 Long-term antibiotic use in chronic
Nursing Management
 Pain management
 Adequate hydration (at least 3l/day unless
 Monitor vital signs and for clinical s/s
 Teach patient: proper hygiene, frequent
  toileting, medications, s/s recurrent
  infection, etc
Types of Urinary Incontinence
   Urge
       Loss associated with strong urge that cannot be suppressed
   Stress
       Loss of urine associated with stressor (coughing, sneezing,
   Reflex
       Loss due to hyper-reflexia, as occurs with spinal cord injury
   Overflow
       Loss of urine associated with overfilled bladder
   Functional
       Loss of urine associated with cognitive impairment
   Iatrogenic
       Loss of urine caused by extrinsic factors, such as medications
   Mixed
       More than 1 type of incontinence present
Causes of Transient Incontinence
 Delerium
 Infection of the urinary tract
 Atrophic vaginitis
 Pharmacologic agents
 Psychological factors
 Excessive urine production
 Restricted activity
 Stool impaction
Assessment and Diagnostics
 UA
 Urine culture
 Urodynamics studies
 Review of medications and diary of I&O
 Residual urine testing
Medical Management
   Behavioral therapy
       Kegel exercises
       Prompted voiding
       Biofeedback
   Pharmacologic therapy
       Anticholinergics (inhibit bladder contraction)
       Pseudoephedrine (promotes urinary retention)
       TCAs
   Pessary
Medical Management
   Surgery
       Bladder suspension surgery
       TURP
       Urethral Bulking
       Artificial Sphincter
Nursing Management
 Teach behavioral therapies
 Monitor for surgical complications
 Instruct pt on use, dose, side effects of
 Keep skin clean and dry
 Manage fluid intake
 Avoid constipation
 Avoid known bladder irritants
Urinary Retention
 Inability of the bladder to completely
  empty with voiding
 Normal residual urine <50 -100 ml
 Caused by: medications, enlarged
  prostate, neurologic disorders, urethral
  pathology, diabetes
 Complications:
       Renal calculi, hydronephrosis, renal failure,
Nursing Management
 Promote voiding
 Warmth (sitz bath, warm tea, etc)
 Triggers (turning on the water)
 Catheterization
       Intermittent
       Indwelling
Neurogenic Bladder
 Dysfunctional bladder caused by
  neurological injury
 2 types
       Spastic
            Loss of sensation and control
            Empties on reflex (if at all)
       Flaccid
            Results from trauma
            Often has overflow incontinence
Assessment and Diagnostics
 UA
 Urine culture
 Urodynamics studies
 Residual urine colume
Medical Management
   Antispasmotics
       Bethanecol
   Surgery
       Urinary diversion
   Catheterization
       Intermittent
       Indwelling
       Suprapubic
Nursing Management
 Prevent infection
 Minimize trauma
 Bladder retraining
 Assist with intermittent catheterization
Urolithiasis and Nephrolithiasis
   Stone formation results in uric acid stones,
    calcium oxalate or calcium phosphate stones –
    may also contain struvite, cystine
   Exact mechanism not known
   Precipitating factors
       Bladder stasis
       Dehydration
       Infection
       Prolonged immobility
       Certain medications (antacids, Acetazolamide, etc)

Clinical Manifestations
 UTI sx
 Hematuria
 CVA tenderness
 Nausea, vomiting
 Urinary retention
 Hydronephrosis
 Patients may be asymptomatic unless s/s
  renal failure or uti seen
Assessment and Diagnostics
 KUB xray
 Ultrasound
 CT
 UA
 Urine c/s
 Stone analysis
Medical Management
   Nutrition
       Moderate protein
       Encourage fluids
       Reduce sodium intake
       Avoid foods high in purine (shellfish, organ
        meats, asparagus, anchovies, etc)
       Avoid oxalate containing foods (strawberry,
        rhubarb, tea, peanuts, wheat bran)
       Moderate calcium intake
Medical Management
   Interventional Procedures
       Cystoscopy
       Extracorporeal shock wave lithotripsy (ESWL)
       Stent Placement
       Percutaneous Nephrolithotomy
       Chemolysis
   Pharmacologic Therapy
       Allopurinol
       Hydrochlorothiazide
       Other agents may be used (Sodium cellulose
        phosphate, Cupramine, AHA)
Nursing Management
 Pain control
 Prevention of infection
 Monitor I&O
 Teach patients dietary and lifestyle
  changes to reduce risk of recurrence
Bladder Cancer
 More common in 50-70 age group
 More common in men and caucasians
 Risk Factors:
       Smoking
       Exposure to toxins
       Recurrent / chronic infection of urinary tract
       Bladder stones
       High urine ph
       High cholesterol intake
       Pelvic radiation
       Cancers arising from prostate, rectum, colon
Clinical Manifestations
 Painless hematuria (may be gross
  hematuria or microscopic)
 s/s infection may be present
 Pelvic or back pain occurs with metastasis
Assessment and Diagnostics
 Ultrasound
 CT
 Cystoscopy
 Urine for cytology
 UA
 Urine c/s
Medical Management
   Surgery
       TURBT
       Cystectomy (requires urinary diversion)
            Simple
            Radical
 Chemotherapy
 Radiation
Urinary Diversion
   Ileal conduit most
       Creates a stoma in
        which urine constantly
        exits, requiring a pouch

   Continent Diversion
    (Indiana or Kock
       Pouch created and urine
        is drained via catheter
Common Types of Surgeries
Nursing Management
 Monitor I & O
 Monitor stent function and placement
 Monitor vital signs
 Monitor for complications
 Provide stoma and skin care
 Pain control
 Encourage fluids
 Teach patient self-care
 Improve body image issues
Case Study
LG, a 55y old farmer has been healthy all
   his life. He tells you that 2 weeks ago he
   had a single episode of urine that was a
   little bloody.
1. What other history is important to
2. What advice would have for LG?
3. What testing (if any) might be
Practice Question
A patient with bladder cancer undergoes
  cystectomy with ileal conduit formation. During
  the first post-op day, the nurse plans to:

  a. measure and fit the patient for a permanent
  b. teach the patient to self-catheterize q4-6h
  c. encourage high oral intake to flush out the
  mucousy discharge
  d. empty the drainage bag q2h and monitor urine
Practice Question
On assessment of the patient with renal
 calculi passing down the ureter, the nurse
 would expect the patient to report:

 a. dull costovertebral pain
 b. history of chronic uti’s
 c. severe colicky back pain that radiates to
 the groin
 d. a feeling of bladder fullness with
 urgency and frequency

Description: Student Nurse Lecture Notes for Nursing Care of the Patient with Renal and Urological Problems