Management of Patient with Altered Urinary Function - PDF

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					   Care of the Patient With
 Renal and Urinary Disorders -
           Handout
       Nursing IV - Medical Surgical
                Component




       Classroom Objectives
• Discuss the pathophysiology and clinical
  manifestations of renal failure
• Interpret the results of laboratory data &
  diagnostic tests associated with renal
  failure.
• Discuss three treatment modalities used
  in the collaborative management of
  chronic renal failure.




   Classroom Objectives Cont.
• Describe the kidney donor selection
  process.
• Discuss the drug therapy used to prevent
  transplant rejection.
               Continued
• Use Maslow’s hierarchy to prioritize
  assessments in the patient with CRF
  undergoing various treatment modalities.
• State four nursing diagnoses
  (NANDA)commonly associated with a
  patient in end-stage renal disease.




   Classroom Objectives Cont.
• List four corresponding nursing outcomes
  (NOC) associated with the diagnoses
  generated for the patient in end-stage
  renal disease.
• Discuss appropriate NIC based nursing
  interventions for the patient undergoing
  dialysis or renal transplant.
•




               Continued
• Discuss the nursing management of the
  end-stage renal patient at home and the
  use of community resources
Anatomic Location of the Organs
  of the Renal/Urinary System




                                  Slide 72.1




Bisection of the Kidney Showing
 Major Structures of the Kidney




                                  Slide 72.4




  Anatomy of the Nephron
 Sodium and Water Reabsorbtion by the Tubules of
              a Cortical Nephron




             Renal Function
• Excretory function- urine
  formation
• Regulatory functions -
  acid base balance
• Renal related endocrine
  functions
       Excretory Function/urine
             Formation*
• Glomerular filtration
• Tubular Reabsorption - proximal
  convoluted tubule
• Tubular secretion
• Active and passive reabsorption




        Regulatory Functions*
• Partial control of acid-base balance
• Renal regulation of water
• Renal regulation of electrolytes- Na+ & K+




      Renal Related Endocrine
            Functions*
•   Renin
•   Erythropoietin
•   Prostaglandins
•   Vitamin D/Calcium
•   Insulin
  The Juxtaglomerular Complex-
              Renin




                                                                            Slide 72.10




    Renal Hormone Production and
     Hormones Influencing Renal
             Function*
Hormones influencing                  • Makes DCT and CD
Renal function                          permeable to water to
• Antidiuretic hormone                  maximize
  (ADH)                                 reabsorption and
                                        produce a
                 • Released from
• Aldosterone                           concentrated urine
                   posterior pituitary
                                      • Promotes sodium
                                        reabsorption and
                 • Released from        potassium secretion
                   adrenal cortex       in DCT and CD;
                                        water and chloride
                                        follow sodium
                                        movement
                   DCT = distal convoluted tubule; CD = collecting ducts.
                                                                             Slide 72.3
   Renal Hormone Production and
    Hormones Influencing Renal
             Function Stimulates make red
                       marrow to
                                 bone

                   • Renal               blood cells
Renal hormone        parenchyma        • Promotes absorption
Production
                                         of calcium in the
• Erythropoietin
                    • Renal              gastrointestinal tract
• Activated vitamin D parenchyma       • Raises blood
                                         pressure as result
• Renin             • Juxtaglomerular    of angiotensin
                      cells of           (vasoconstriction)
                      the afferent and   and aldosterone
                      efferent           (volume expansion)
• Prostaglandins
                      arterioles         secretion
                                       • Regulate intrarenal
                    • Renal tissues      blood flow by vaso
                                         dilation or constriction
                                                              Slide 72.2




     Assessment of Renal/urinary
            Problems
 • Secondary Prevention: Early
   Detection
 • history
 • physical signs & symptoms
 • renal system lab tests




       Interview Your New Patient
     Very ill new admission - Suspect
    CRF, 7 lb weight gain in 3 wks, Hx
              diabetes and HTN
• What questions should you ask regarding
  symptoms?
• What risk factors for development of CRF
  does the new admission have?
• What cardiac and respiratory
  manifestations might you find on physical
  exam?




      History/diseases RT. Renal
• HTN, D.M., SLE
•  Infectious diseases - Strep. UTI
• Drugs
• Congenital abnormalities, ie polycystic
  kidney disease
• Diet - ca++, higher mineral
• Immobility




     Commonly Used Renal and
         Urinary Terms*
    • Oliguria — decreased urinary output; Total
      urinary output between 100 and 400 ml in 24
      hr.
    • Polyuria — increased urinary output; Total
      urinary output usually greater than 2000 ml in
      24 hr.
    • Azotemia — increased BUN and serum
      creatinine levels- suggestive of renal impair.
      but without outward symp.of renal failure.
    • Uremia — full-blown signs and symptoms of
      renal failure; Sometimes referred to as the
      uremic syndrome, especially if cause
      unknown.                                     Slide 72.6
    Physical Signs & Symptoms of
           Renal Disease*
•   Fatigue
•   Change in mentation
•   Headache
•   HTN
•   Change in body weight
•   Pain –sharp or dull, localized or diffuse




    Clinical Manifestations of CRF*
• Cardiovascular             •   Integumentary
• Respiratory-sleep apnea,   •   Nutritional
  jittery                    •   Electrolyte Imbalances
• Hematologic                •   Metabolic
• Genitourinary
• Reproductive
• Gastrointestinal
• Musculoskeletal- renal
  osteodystrophy – 90%
• Neurological




           Blood Chemistries*
• BUN -greater than 20mg/dl - renal
  insufficiency
  normal =10-20mg/dl. Elderly sl. Higher
• Creatinine - 0.8 - 1.5 mg/dl
• Creatinine clearance - best indication of
  overall renal function- ave. 108- 120ml/min
• BUN/ Creatinine ratio: 10:1 to 20:1
        Acute Renal Failure
• Prerenal causes
• Renal causes
• Postrenal causes




  Medical Management During
            ARF*
• Dialysis
• Manage secondary infections &
  Pericarditis
• Careful fluid replacement
• Electrolyte replacement
• High calorie, low protein diet
• Symptomatic relief - seizures, anemia,
  bleeding tendencies




      Chronic Renal Failure*
• Progressive reduction of functioning renal
  tissue. Remaining kidney can no longer
  maintain body environment.
• Insidiously or after ARF.
• HTN and diabetes - most common causes.
  Progression Toward Chronic
         Renal Failure
• Stage I

• Stage II

• Stage III




                                                   Slide 75.6




Stage I: Diminished Renal Reserve.*

• Renal function is reduced, but no
  accumulation of metabolic wastes occurs.
• The healthier kidney compensates for the
  diseased kidney.
• Ability to concentrate urine is decreased,
  resulting in nocturia and polyuria.
• A 24-hour urine for creatinine clearance is
  necessary to detect that renal reserve is less
  than normal.




    Stage II: renal insufficiency.*

• Metabolic wastes begin to accumulate in the
  blood because the unaffected nephrons can
  no longer compensate.
• Responsiveness to diuretics is decreased =
  oliguria and edema.
• The degree of insufficiency is determined by
  decreasing GFR (glomerular filtration rate)
  and is classified as mild, moderate, or severe.
• Treatment is medical.
    Stage III: Renal Failure - end-stage renal
                     disease.*

• Excessive amounts of metabolic wastes
  such as urea and creatinine accumulate in
  the blood.
• The kidneys are unable to maintain
  homeostasis.
• Treatment is by dialysis or other renal
  replacement therapy.




Stage IV End Stage Renal Failure -
             Uremia
•   Anuria
•   Marked azotemia
•   Severe electrolyte imbalances
•   Pul edema , uremic lung
•   Uremic frost,pruritus
•   Anemia
•   Proteinuria
•   CHF




    GFR = Calculation of Age, Serum
         Creatinine, Race, Sex
• Stage 1 90 mL/min or more - Healthy kidneys
  or Kidney damage with normal or high GFR
• Stage 2 60 to 89 mL/min -Kidney damage and
  mild decrease in GFR
• Stage 3 30 to 59 mL/min - Moderate decrease
  in GFR
• Stage 4 15 to 29 mL/min Severe decrease in
  GFR
• Stage 5 Less than 15 mL/min or on dialysis -
  Kidney failure
    Clinical Manifestations of CRF*
• Cardiovascular             •   Integumentary
• Respiratory-sleep apnea,   •   Nutritional
  jittery                    •   Electrolyte Imbalances
• Hematologic                •   Metabolic
• Genitourinary
• Reproductive
• Gastrointestinal
• Musculoskeletal- renal
  osteodystrophy – 90%
• Neurological




        Clinical Manifestations
              Continued*




     Key Features of Uremia- Excessive
      amounts of Urea & Nitrogenous
           Wastes ( Azotemia)*
•   Metallic taste
•   Anorexia
•   Nausea
•   Vomiting
•   Muscle Cramps
•   Itching
       Key Features of Uremia
            Continued*
•   Fatigue & Lethargy
•   Hiccups
•   Edema
•   Dyspnea
•   Muscle Cramps
•   Parenthesis




     Electrolyte Imbalances*N.B!
•   K+ increases
•   Phosphate increases
•   Sodium - normal or decreased
•   Magnesium increases
•   Calcium decreases
•   Metabolic acidosis




     The Effects of Renal Failure on
    Phosphate and Calcium Balance




                                       Slide 75.1
Focused Assessment for Care Clients
with Chronic Renal Failure (Acute Care Too)*
   Assess renal status, including

   • Amount, frequency, and appearance of
     urine (anuric clients)
   • Presence of bone pain

   • Presence of hyperglycemia secondary to
     diabetes



                                               Slide 75.19




 Focused Assessment for Care Clients
     with Chronic Renal Failure*
Assess cardiovascular and respiratory
 status, including
• Vital signs, with special attention to blood
  pressure
• Presence of S3 and/or pericardial friction
  rub
• Presence of chest pain


                                               Slide 75.18




      Assessment Continued*
• Presence of edema (periorbital, pretibial,
  sacral)
• Jugular vein distension
• Presence of dyspnea
• Presence of crackles, beginning at the
  bases, and extending upward
                                   Continued*

Assess hematologic status, including
• Presence of petechiae, purpura,
  ecchymoses
• Presence of fatigue or shortness of breath
Assess gastrointestinal status, including
• Presence of stomatitis
• Presence of melena




       Assessment Continued*
Assess integumentary status, including
• Skin integrity
• Presence of pruritis
• Presence of skin discoloration




    Review - Focused Assessment for
    Clients with Chronic Renal Failure
Assess NEUROLOGIC status, including
•   Changes in mental status
•   Presence of seizure activity
•   Presence of sensory changes
•   Presence of lower extremity weakness
  Assess NUTRITIONAL status,
          including

• Weight gain or loss
• Presence of anorexia, nausea, or vomiting




   Case Study-End Stage Renal
            Disease




 NURSING DIAGNOSES CRF
     Nursing Diagnoses for CRF
              Patient*
• Fluid Vol. deficit of      • Risk for Impaired Skin
  Fluid Vol Excess rt.         Integrity
  impaired Renal             • Knowledge Deficit rt.
  function                     disease process &
• Altered Nutrition less       treatment
  than Body                  • Risk for Ineffective
  Requirements rt              Management of
  anorexia, nausea             Therapeutic Regime
• Fatigue rt. anemia &       • Risk for Ineffective
  altered metabolic            Family Coping-
  state                        Financial - *80% fed.
                               Gov




     Nsg. Diagnoses Continued*
• Activity Intolerance rt.   • Fatigue rt. Altered
  Effects of Anemia            Body Chemistry
• Impaired Comfort :         • Risk for Injury rt. bone
  puritis                      changes, muscle
• Chronic Sorrow rt.           weakness
  Chronic Illness            • Decreased Cardiac
                               Output rt. elevated K+
                               levels




         Medical Goals of CRF
•   Preservation of Renal Function
•   Delay of need for Dialysis or transplant
•   Improvement of Body Chemistry
•   Alleviation of Extrarenal effects
•   Provide optimal quality of life
        Dietary Restrictions*
• Fluid
• Protein –on dialysis – high quality protein
  – not limited on hemodialysis
• Potassium 60-70 mEg./day
• Sodium
• Phosphorus




       Medications for CRF*
• Diuretics
• Vitamins and Minerals
• Sodium bicarbonate
• Erythropoietin
• Calcium Preparations & Phosphorus
  Binders
• Antihypertensives




    NIC Label: Nutrition Therapy

• Nursing Diagnosis:
• Imbalanced Nutrition, less than body
  requirements
    NOC Label: Nutritional Status
            1= extremely compromised
           3= moderately compromised
                Outcomes
• Demonstrates improved nutritional status
• Consumes adequate nutrition
• Identifies nutritional requirements




           NIC Interventions
• Collaborate with dietician
• Teach family and client about prescribed
  diet
• Monitor and calculate food intake




     NOC Label: Fluid Balance
          1= extremely compromised
             to 5=not compromised
                  Outcomes
•    Remains free of edema, anasarca.
•    Maintains clear lungs.
•    Remains free of restlessness, anxiety, or
     confusion.
•    Explains measures to prevent & treat
     excess fluid
 NIC Label: Fluid Management
• Nursing Diagnosis:
• Excess Fluid Volume




          NIC Interventions
• Monitor location of edema
• Monitor daily weight
• Monitor vitals: decreased. BP, tachycardia,
  tachypnea. Monitors gallop rhythm
• Teach patient & family about sx. of both
  excess and deficient fluid volume.




          Goals for Dialysis
• removal of end products of protein
  metabolism from blood- urea, creatinine
• maintenance of safe concentration of
  serum electrolytes
• correction of acidosis, replenishment of
  bicarbonate buffer system
• removal of excess fluid from blood
    Hemodialysis vs. Peritoneal -
       Finding the Best Fit*
• Hemodialysis - a quick      • Peritoneal - slower, less
  fix                           aggressive
• Not appropriate when        • Not appropriate for those
  hemodynamically               with impaired respiratory
  unstable                      excursion
• Not appropriate when        • Not appropriate in sepsis,
  trained personnel &           peritonitis, abdominal
  vascular access not           adhesions, abdominal
  available                     adhesions or abdominal
• Not appropriate for those     trauma
  unable to tolerate
  anticoagulation




       Key concepts of Dialysis*
•   Diffusion
•   Filtration/Ultrafiltration
•   Concentration gradient
•   Osmosis




           Vascular Access for
             Hemodialysis
• Subclavian / internal jugular double lumen
  (Udall)
• AV fistula/AV graft
A Surgically Created Venous
           Fistula




                              Slide 75.7




 An Arteriovenous Shunt of
        the Forearm




                              Slide 75.9
Examples of Multilumen caths




     A Hemodialysis Circuit




                               Slide 75.5
   Nursing Care of A-V Fistula*
• Initially assess hemorrhage, infection,
  edema. elevate arm
• No B/P, venipunctures, I.V.s in access arm
• assess function of fistula - bruit & thrill
• assess distal pulse circulation
• Allen’s test
• no carrying heavy objects etc.




   A Surgically Created Venous
              Fistula




                                                       Slide 75.7




 Native Arteriovenous (AV) Fistula
• the preferred type of vascular access for
  patients with end stage renal disease.

• AV fistulae result in significantly lower rates of
  complication (such as infection and clotting),
  longer patency, fewer hospitalizations, lower
  patient morbidity, and significantly lower costs
  compared to other accesses
      Dialysis - Nursing Care*
• Prior to Dialysis
• During Dialysis




       KB – Dialysis at 10AM
• Meds: Atacand, Lasix, Regular insullin,
  Digoxin, Tums – What do you give?
• Other Nsg. Duties?
• Nausea, hypertensive,




       The Client Undergoing
           Hemodialysis
   • Weigh the client before and after
     dialysis.
   • Know the client's dry weight.
   • Decide whether any of the client's meds
     should be withheld until after dialysis.
   • Be aware of events that occurred during
     the dialysis treatment.
   • Measure blood pressure, pulse rate,
     respirations, and temperature..

                                                Slide 75.17
                 Continued
• Assess for symptoms of orthostatic hypotension.
• Assess the vascular access site.
• Observe for bleeding.
• Assess the client's level of consciousness and
  assess for headache, nausea, and vomiting.




           Post- Dialysis Nsg.
             Management*
• Disequilibrium syndrome
• Monitor for bleeding, hematoma & patency
• Neuro assessment, LOC




          Peritoneal Dialysis*

•   Osmosis
•   Diffusion
•   Dialysate Concentrations
•   Dwell time
 Manual Peritoneal Dialysis Via Implanted
 Abdominal Catheter (Tenckhoff Catheter)




                                        Slide 75.13




     Nursing Management of
       Peritoneal Dialysis*
• installations and dwell periods
• dialysate
• outflow times
    Peritoneal Dialysis - types
• Continuous Ambulatory Peritoneal Dialysis
  (CAPD)
• Automated Peritoneal Dialysis (ADP) can
  be run at different time intervals -
• Two forms of ADP
  1. (CCPD) continuous cyclic with 3 cycles
  at noc and one 8 hr. in morning -
  2.(IPD)intermittent 10-14 hrs/ 3-4 x wk.,
  NPD nightly peritoneal dialysis 8-12 hrs at
  noc.




            The used Dialysis Bags are 'Clinical Waste'. The Renal
            Unit will contact the local authority for you and arrange
               for free yellow coloured clinical waste bags to be
             delivered to your home (usually four a week. You will
                need only two bags but they need to be double
              wrapped). They will also arrange for a free weekly
                            collection of the full bags.

            Flatten your cardboard boxes (see diagram on the box)
                 and put out for your regular rubbish collection.

               Please click on the links below for further CAPD info.
               Weight & Fluid Balance | Clean Procedures : Infection |
                                     General Info




   Complications of Peritoneal
           Dialysis*
• Peritonitis- meticulous aseptic technique.
  Check fever, rebound tenderness, nausea,
  WBCs, malaise
• Hyperglycemic & hyperosmolar states
  Esp. with high glucose dialysate
• Cath. Displacement
• Abd. Discomfort
• Lack of compliance when self dialysing
                Assess laboratory data,
                 including
                • BUN & Creatinine
                • Creatinine clearance
                • CBC
                • Electrolyte
                Assess psychosocial
                 status, including
                • Presence of anxiety
                • Presence of maladaptive
                  behavior
                                                           Slide 75.20




     Nsg. Management of ESRD at
               Home
                    Monitoring
                Community Resources




              Kidney Transplant*
•   Living Related
•   Living Unrelated
•   Cadaver
•   United Network for Organ Sharing, Richmond Va.
•   National kidney transplant waiting list - 38,760
•   First successful transplant -1954 - Dr. Jos. Murray,
    Brigham & Women’s Hospital Boston MA.
              Kidney Donor

              Selection Process




    Hand-assisted Laproscopic Donor
             Nephrectomy
•   www.or-live.com/meritcare/1145/
•   www.matchingdonors.com
•   3-5 incisions in donor abdomen
•   Full recovery in up to 6 weeks




     Placement of a Transplanted
    Kidney to the Right Iliac Fossa




                                      Slide 75.16
     Nursing Responsibilities

             Post Transplant




          Renal Transplant
           Complications*
• Graft rejection -
  hyperacute, acute, or chronic
• Other complications: infection, disease
  recurrence, complications of drug therapy,
  ulcers, HTN, steroid-induced diabetes etc.




      Hyperacute Rejection*
              Hyperacute Rejection
           Onset
           • Within 48 hr after surgery

           Clinical Manifestations
           • Increased temperature
           • Increased blood pressure
           • Pain at transplant site
             Treatment
           • Immediate removal of the transplanted
             kidney
                                BUN = blood urea nitrogen.
                                                                       Slide 75.21




                   Acute Rejection*




                    Acute Rejection
Onset
• 1 wk to 2 yr postoperatively (most common
  in first 2 wk)
Clinical Manifestations
•   Oliguria or anuria
•   Temperature over 37.8° C (100° F)
•   Increased blood pressure
•   Enlarged, tender kidney
•   Lethargy
•   Elevated serum creatinine, Blood Urea Nitrogen, potassium levels
•   Fluid retention

Treatment
• Increased doses of immunosuppressive drugs
                                BUN = blood urea nitrogen.
                                            .                          Slide 75.22
           Chronic Rejection*




            Chronic Rejection
   Onset
   • Occurs gradually during a period of
     months to years
     Clinical Manifestations
   • Gradual increase in Blood Urea Nitrogen and
     serum creatinine levels
   • Fluid retention
   • Changes in serum electrolyte level
   • Fatigue

   Treatment
   • Conservative management until dialysis is
     required
                                                   Slide 75.23




  Immunosuppressive therapy
    after Renal Transplant*
• Corticosteroids -     • FK-506 - 100 X more
  Prednisone or           potent than
  methylprednisone        cyclosporin
  (Solu-medrol)         • OKT-3 - monoclonal
• Azathioprine (Imuran,   antibody
  CellCept,             • Antilymphocyte
• Cyclosporine - used     globulin - Atgam
  with steroids           (ALG)
  (Sandimmune or
  Neoral)
          Nursing Problems rt.
          Immunosuppression
•   increased risk of infection
•   bone marrow suppression
•   incidence of malignancy- lymphoma
•   c/o with steroids - gastritis & peptic ulcer
    disease, bone weakness, GI bleeding,
    steroid induced DM, F&E imbalance




        Common Types and
     Locations of Renal Trauma
                   Minor Trauma




                                                   Slide 74.7




        Common Types and
     Locations of Renal Trauma
                   Pedicle Injury




                                                   Slide 74.8
   Common Types and
Locations of Renal Trauma
        Major Trauma




                             Slide 74.9




   Common Types and
Locations of Renal Trauma




                            Slide 74.11
   NURSING MANAGEMENT




     The Patient with Bladder
             Cancer*
• Primary prevention: Stop Smoking – doubles the
  risk
• Secondary prevention: Hematuria?
• Men 3X more likely
• Chemicals in the workplace – dye, leather,
  rubber
• Whites more likely
• Age – late 60’s
• 53,000 new cases in 2000
• 94% survival rate




                Symptoms
Blood in the urine (slightly rusty to deep red
  in colour).
Pain during urination.
Frequent urination, or feeling the need to
  urinate without results.
Bladder Cancer




Bladder Tumors
       Treatment Modalities*
• Chemotherapy
• Radiation
• Surgery: Partial Cystectomy
            Total Cystectomy
             TURP




       Treatment Continued




 Total Cystectomy with Urinary
          Diversion*
• Ileal Conduit
• Continent Internal Ileal Reservoir (Kock
  Pouch)
• Cutaneous Ureterostomy
• Vesicostomy
Urinary Diversion Procedures Used
in the Treatment of Bladder Cancer




                                      Slide 73.9




Urinary Diversion Procedures Used
in the Treatment of Bladder Cancer




                                     Slide 73.10




Urinary Diversion Procedures Used
in the Treatment of Bladder Cancer




                                     Slide 73.11
    Urinary Diversion Procedures Used
    in the Treatment of Bladder Cancer




                                         Slide 73.12




               Hollister*
•                    •
       Sure-Fit Natura




  Face Plate –Cut to Fit Skin
           Barrier*




Karaya 5 Lo-Profile Urostomy
           Pouch
    Nursing Management of
   Patients Requiring Urinary
           Diversion*
                     • Psychological Needs
                     • Immediate Post-op




   Postoperative Nursing Care of
   Patient with Urinary Diversion*
• Immediate Post-op: Hypovolemia,
  hematuria, stoma checks
• 48 hrs. or more: peritonitis
• Stoma care




             Case Study

       Patient with Ileal Conduit
 Nsg. Dx & Outcomes rt. Pt with
         Ileal Conduit*
• Knowledge Deficit rt     • Demonstrates how to
  Stoma Care                 perform pouch
                             change & ostomy
• Social Isolation rt
                             care 1=no knowledge 5=
  Fear of Accidental         extensive knowledge
  leakage                  • Participates in activities
                             to level of ability &
• Risk for Imapired Skin     desire 1= no social
  Integrity                  involvement;5= extensive
                           • Regains integrity of
• Disturbed Body             skin surface.
  Image




 Client Education of the Patient
     with a Urinary Diversion
      Developing a Teaching Care Plan




      Cancer of the Prostate*

         Function of Prostate Gland-
        Prevention of Prostate Cancer
                and Detection
               Anatomy




The Prostate Gland with Cancer and
   Benign Prostatic Hyperplasia




                                       Slide 79.12




 Diagnostic Tests and Physical
            Exam*
• PSA assay
• Rectal exam
• Transrectal /Transperineal and
  Percutaneous needle aspiration and
  Biopsy
• Other diagnostic tests
       Treatment Modalities and
       Management of Prostate
              Cancer*
•   Hormone therapy
•   Chemotherapy
•   Radiation
•   Surgery




      Pharmacology - Hormone
             therapy*
• Androgen supressing
  agents – ex.
  finasteride (Proscar)
  flutamide (Eulexin) - a
  new androgen
  blocker
• leuprolide (Lupron) -
  a gonadotropin
  analogue




    Leuprolide (Lupron) s.c. - Side
                Effects
•   Dizziness, HA
•   N&V, Anorexia, Constipation
•   Peripheral edema, Cardiac Arrhythmias
•   Hot flashes, sweats
   Chemotherapy or Radiation

                Cytoxan

               Adriamycin




    Types Prostate Surgery*
• Laser
• Cryosurgery
• Robotic Prostatectomy –
  www.davinciprostatectomy.com




 Radical Open Prostatectomy*

• Suprapubic approach
• Retropubic approach
• Perineal approach
Suprapubic, or Transvesical,
      Prostatectomy




                               Slide 79.6




Retropubic, or Retrovesical,
      Prostatectomy




                               Slide 79.7




Three Way Foley Catheter
      Perineal Prostatectomy




                                              Slide 79.8




      Nursing Care Following
        Prostate Surgery*
• Hematuria
• Bladder spasms
• Hemorrhage
• Retropubic - care of the low ABD incision
  & Suprapubic catheter
• Discharge teaching




         Effects of Surgery*
• Client is STERILE
• Erective Dysfunction – (if pudental nerve
  fx. Spared – 3-6 mos of ED ( impotence)
• Urinary Incontinence – if internal &
  external urinary sphincters involved.
       Care Immediately after Radical
              Prostatectomy
• Encourage the client to use patient-controlled
  analgesia (PCA) as needed.
  The PCA device may be used through the second
  postoperative day.
• Keep the client on bed rest on the day of surgery. Help
  the client to get out of bed and ambulate for a short
  distance by the first postoperative day.
• Keep the client on NPO status as ordered, usually until
  the first or second postoperative day.




                                                     Slide 79.11




          Care after Radical
       Prostatectomy Continued
• Maintain the sequential compression device until the
  client begins to ambulate.
  Apply antiembolic stockings until discharge.
• Monitor the client for deep vein thrombosis and
  pulmonary embolus.
• Keep an accurate record of intake and output,
  including Jackson-Pratt or other drainage device
  drainage.



                                                     Slide 79.11




      Teaching Following Radical
           Prostatectomy*
           You are developing a handout for
            patients following radical open
             prostatectomy . What are the
                      essentials?
          Pt. Teaching following Radical
                  Prostatectomy
• Keep the urinary meatus clean using soap and water.
• Avoid rectal procedures or treatments.
• Teach the client how to care for the urinary catheter
  because he will be discharged with the catheter in
  place.
• Teach the client how to use a leg bag.
• Emphasize the importance of not straining during
  bowel movement. Advice the client to avoid
  suppositories or enemas.
• Remind the client about the importance of follow-up
  appointments with the physician to monitor progress.
                                                     Slide 79.11




                     Leg Bag




    Discharge Teaching following
       Radical Prostatectomy
  • Remind client about importance of follow-
    up appointments with M.D.
  • Exercises for Urinary Incontinence :tighten
    perineal muscles, biofeedback
  • Function – ED alternatives:prostheses,
    vaccum devices, viagra.
Nsg. Diagnoses Associated with
    Radical Prostatectomy*
• Knowledge Deficit rt Self Care & Home
  Maintenance
• Acute Pain rt. Bladder Spasm
• Risk for Urinary Incontinence
• Risk for Sexual Dysfunction – NOC
  Outcomes: expresses comfort with sexual
  expression 1-= never demonstrated; 5 = consistently
  demonstrated




       Potential Complications
• Sexual dysfunction with radical perineal
  prostatectomy
• Urinary incontinence with radical
  prostatectomy




                   The End

				
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Description: Management of Patient with Altered Urinary Function document sample