Renal Nursing

THE GENITOURINARY SYSTEM Urological Assessment Key Signs and Symptoms of Urological Problems EDEMA - associated with fluid retention - renal dysfunctions usually usu ally produce ANASARCA PAIN Suprapubic pain= bladder Colicky pain on the flank= kidney HEMATURIA Painless hematuria may indicate URINARY CANCER! Early-stream hematuria - urethral lesion Late-stream hematuria - bladder lesion DYSURIA - Pain with urination - lower UTI POLYURIA - More than 2 Liters urine per day OLIGURIA - Less than 400 mL per day ANURIA - Less than 50 mL per day Urinary Urgency Urinary retention Laboratory examination 1. Urinalysis 2. BUN an and Cr Creatinine le levels of of the the serum 3. Serum electrolytes Diagnostic examination 1. Radiographic 2. IVP 3. KUB x-ray 4. KUB ultrasound 5. CT and MRI 6. Cystography Implementation Steps for selected problems Provide PAIN relief 

● Assess the level of pain ● Administer medications usually narcotic ANALGESICS Maintain Fluid and Electrolyte Balance

●Encourage to consume at least 2 liters of fluid per day  ______________________________________________________________ 

●In cases of ARF, limit fluid as directed ●Weigh client daily to detect fluid retention Ensure Adequate urinary elimination ● Encourage to void at least every 2-3 hours ● Promote measures to relieve urinary retention: 1. Alternat nating wa warm and cold co compress 2. Bedpan 3. Open faucet 4. Provide privacy 5. Catheterization if if in indicated Urinary Tract Infection (UTI)

Bacterial invasion of the kidneys or bladder (CYSTITIS) usually caused by Escherichia coli Predisposing factors include 1. Poor oor hygi hygien ene e 2. Irrita Irritatio tion n from from bubble bubble baths baths 3. Urin Urinar ary y ref reflu lux x 4. Inst Instru rume menta ntati tion on 5. Residu Residual al urin urine, e, urina urinary ry stasi stasis s 6. Urinary Tract Infection (UTI) PATHOPHYSIOLOGY   The invading organism ascends the urinary tract, irritating the mucosa and causing characteristic symptoms Ureter - ureteritis Bladder - cystitis Urethra - urethritis Pelvis - pyelonephritis Assessment findings 1. Low-g Low-gra rade de feve feverr 2. Abdo Abdomi mina nall pain pain 3. Enure uresis 4. Pain/b Pain/burni urning ng on urinati urination on 5. Urina Urinary ry freq frequen uency cy 6. Hematuri uria

Assessment findings: Upper UTI 1. Fe Feve verr and and CHII CHIILS LS 2. Flank lank pain pain

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Costovertebral angle tenderness

Laboratory Examination 1. Uri Urinal nalysis ysis 2. Urine Culture Nursing interventions interventions 1. Admini Administe sterr antibiot antibiotics ics as ordered ordered.. 2. Provide Provide warm baths baths and allow allow client client to void void in water to allev alleviate iate painful painful voiding. 3. Force Force fluids. fluids. Nurses Nurses may give give 3 liters liters of fluid fluid per per day. 4. Encourage measures to acidify urine (cranberry juice, acid-ash diet). Provide client teaching and discharge planning concerning  1. Avoidance of tub baths 2. Avoi Avoida danc nce e of of bub bubbl ble e bat baths hs tha thatt mig might ht irri irrita tate te uret urethr hra a 3. Impo Import rtan ance ce for for gir girls ls to wipe wipe peri perine neum um from from fron frontt to to bac back k 4. Increase in foods/fluids that acidify urine. Pharmacology 1. Sulfa drugs Highly concentrated in the urine Effective against E. coli! 2. Quinolones Nephrolithiasis/Urolithiasis Presence of stones anywhere in the urinary tract calcium oxalate uric acid Nephrolithiasis/Urolithiasis Predisposing factors 1. Diet: Diet: large large amounts amounts of of calcium calcium and and oxalat oxalate e 2. Increa Increased sed uric uric acid acid leve levels ls 3. Sedenta Sedentary ry life-st life-style yle,, immobili immobility ty 4. Family Family hist history ory of of gout gout or calcu calculi li 5. Hype Hyperp rpar arat athy hyro roid idis ism m

Pathophysiology

Supersaturation of crystals due to stasis Stone formation

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May pass through the urinary tract OBSTRUCTION, INFECTION and HYDRONEPHROSIS Assessment findings 1. Abdominal or flank pain 2. Renal nal colic radiating to the groin 3. Hematuria 4. Cool, moist skin 5. Nausea and vomiting Diagnostic tests 1. KUB Ultrasound and X-ray : pinpoints location, number, and size of stones 2. IVP: identifies site of obstruction and presence of nonradiopaque stones 3. Urinalysis: indicates presence of bacteria, increased protein, increased WBC and RBC (hematuria) Medical management 1. Surgery a. Percutaneous nephrostomy: tube is inserted through skin and underlying tissues into renal pelvis to remove calculi. b. Percutaneous nephrostolithotomy: delivers ultrasound waves through a probe placed on the calculus. 2. Extr Ex trac acor orpo pore real al shoc shockk-wa wave ve lith lithot otri rips psy: y: deli delive vers rs shock waves from outside the body to the stone, causing pulverization a. Pain management : Morphine or Meperidine b. Diet modification modification Nursing interventions 1. Stra Strain in all all uri urine ne thro throug ugh h gau gauze ze to dete detect ct ston stones es and and cru crush sh all clots. 2. Force fl fluid uids (3 (3000—4000 cc cc/day). 3. Enco Encour ura age ambul mbula atio tion to to pre prev vent ent sta stasis. sis. 4. Reli Re liev eve e pain pain by by adm admin inis istr trat atio ion n of anal analge gesi sics cs as as orde ordere red d and application of moist heat to flank area. 5. Monitor intake and output 6. Prov Provid ide e modi modifi fied ed diet diet,, depe depend ndin ing g upon upon ston stone e consi consist stenc ency: y: Calcium, Oxalate and Uric acid stones

Calcium stones - limit milk/dairy products;  provide acid-ash diet to acidify urine (cranberry or prune juice, meat, eggs,  poultry, fish, grapes, and whole grains)

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Oxalate stones - avoid excess intake of foods/ fluids high in oxalate (tea, chocolate, rhubarb, spinach); maintain alkaline-ash diet to alkalinize urine (milk; vegetables; fruits except prunes, cranberries, and plums)

Uric acid stones - educe foods high in purine (liver, beans, kidneys, venison, shellfish, meat soups, gravies, legumes); maintain alkaline urine 7. Admi Admini nist ster er allo allopu puri rino noll (Zyl (Zylop opri rim) m) as orde ordere red, d, to decr decrea ease se uric acid production. 8. Prov Provid ide e clie client nt teac teachi hing ng and and disc discha harg rge e plan planni ning ng concerning:

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Prevention of Urinary stasis by maintaining increased fluid intake especially in hot weather and during illness; mobility; voiding whenever the urge is felt and at least twice during the night

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Adherence to prescribed diet

Need for routine urinalysis (at least every 3—4 months)

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Need to recognize and report signs/ symptoms of  recurrence (hematuria, flank pain).

Acute Renal Failure Sudden interruption of kidney function to regulate fluid and electrolyte balance and remove toxic products from the body PATHOPHYSIOLOGY  ● Pre-renal failure ● Intra-renal failure ● Post-renal failure Prerenal CAUSE: Factors interfering with perfusion and resulting in diminished blood flow and glomerular filtrate, ischemia, and oliguria; include CHF, cardiogenic shock, acute vasoconstriction, vasoconstriction, hemorrhage, burns, septicemia, hypotension, anaphylaxis Intrarenal CAUSE: Conditions that cause damage to the nephrons; include acute tubular necrosis (ATN), endocarditis, diabetes mellitus, malignant  hypertension, hypertension, acute glomerulonephritis, tumors, blood transfusion transfusion

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reactions, hypercalcemia, nephrotoxins (certain antibiotics, x-ray dyes, pesticides, anesthetics)

Postrenal CAUSE: Mechanical obstruction anywhere from the tubules to the urethra; includes calculi, BPH, tumors, strictures, blood clots, trauma, and anatomic malformation

Three phases of acute renal failure 1. Olig Oligur uric ic pha phase se 2. Diur Diuret etic ic pha phase se 3. Conval Convalesc escenc ence e or recove recovery ry phase phase Four phases of acute renal failure (Brunner and Suddarth) 1. Init Initia iati tion on phas phase e 2. Olig Oligur uric ic pha phase se 3. Diur Diuret etic ic pha phase se 4. Conval Convalesc escenc ence e or recove recovery ry phase phase Assessment findings: The Three Phases of Acute Renal Failure 1. Oliguric phase Urine output less than 400 cc/24 hours duration 1—2 weeks Manifested by dilutional hyponatremia, hyponatremia, hyperkalemia, hyperphosphatemia, hypocalcemia , hypermagnesemia, and metabolic acidosis Diagnostic tests: BUN and creatinine elevated 2. Diuretic phase Diuresis may occur (output 3—5 liters/day) due to partially  regenerated tubule’s inability to concentrate urine Duration: 2—3 weeks; manifested by hyponatremia, hyponatremia, hypokalemia, and  hypovolemia Diagnostic tests: BUN and creatinine slightly elevated

3. Recovery or convalescent phase Renal function stabilizes with gradual improvement over next 3—12 months Laboratory findings: ● Urinalysis: Urine osmo and sodium ● BUN and creatinine levels increased ● Hyperkalemia ● Anemia ● ABG: metabolic acidosis Nursing interventions interventions ● Monitor fluid and Electrolyte Balance ● Reduce metabolic rate ● Promote pulmonary function ● Prevent infection

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Provide skin care Provide emotional support

Nursing interventions interventions 1. Monitor Monitor and maintain maintain fluid fluid and electroly electrolyte te balance. balance. a. Measure l & O every hour. note excessive losses in diuretic phase b. Administer IV fluids and electrolyte supplements as ordered. c. Weigh daily and report gains. d. Monitor lab values; assess/treat fluid and electrolyte and acid-base imbalances as needed 2. Monitor Monitor altera alteration tion in in fluid fluid volume. volume. a. Monitor vital signs, PAP, PCWP, CVP as needed. b. Weigh client daily. c. Maintain strict I & O records. 3. Assess every hour for hypervolemia a. Maintain adequate ventilation. b. Restrict FLUID intake c. Administer diuretics and antihypertensives 4. Promote Promote optimal optimal nutrit nutritional ional status. status. a. Weigh daily. b. Administer TPN as ordered. c. With enteral feedings, check for residual and notify physician if  residual volume increases. d. Restrict protein intake to 1 g/kg/day e. Restrict POTASSIUM intake d. HIGH CARBOHYDRATE DIET, calcium supplements 5. Prevent complications complications from from impaired impaired mobility (pulmonary embolism, skin breakdown, and atelectasis) 6. Prevent Prevent fever/inf fever/infecti ection. on. a. Assess for signs of infection. b. Use strict aseptic technique for wound and catheter care. 7. Support client/significant client/significant others and and reduce/ reduce/ relieve relieve anxiety. anxiety. a. Explain pathophysiology and relationship to symptoms. b. Explain all procedures and answer all questions in easy-tounderstand terms c. Refer to counseling services as needed 8. Provide Provide care care for the client client receiving receiving dialys dialysis. is. 9. Provide client teaching and discharge discharge planning concerning a. Adherence to prescribed dietary regimen b. Signs and symptoms of recurrent renal disease c. Importance of planned rest periods d. Use of prescribed drugs only e. Signs and symptoms of UTI or respiratory infection need to report to physician immediately Chronic Renal Failure Gradual, Progressive irreversible destruction of the kidneys causing severe renal dysfunction.  The result is azotemia to UREMIA

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Predisposing factors: a. DM= worldwide leading cause b. Recurrent infections c Exacerbations of nephritis d. urinary tract obstruction e. hypertension Pathophysiology STAGE 1= reduced renal reserve, 40-75% loss of nephron function STAGE 2= renal insufficiency, 75-90% loss of nephron function STAGE 3= end-stage renal disease, more than 90% loss. DIALYSIS IS THE TREATMENT! Assessment findings 1. Nausea, vomiting; diarrhea or constipation; decreased urin ary output 2. Dyspnea 3. Stomatitis 4. Hypertension (later), lethargy, convulsions, memory impairment, pericardial friction rub Diagnostic tests: a. 24 hour creatinine clearance urinalysis b. Protein, sodium, BUN, Crea and WBC elevated c. Specific gravity, platelets, and calcium decreased D. CBC= anemia Medical management 1. Diet restrictions 2. Multivitamins 3. Hematinics an and er erythropoietin 4. Aluminum hydroxide gels 5. Anti-hypertensive 6. Anti-seizures 7. DIALYSIS Nursing interventions interventions 1. Prevent Prevent neurologic neurological al complica complications. tions. a. Assess every hour for signs of uremia (fatigue, loss of  appetite, decreased urine output, apathy, confusion, elevated blood pressure, edema of face and feet, itchy skin, restlessness, seizures). b. Assess for changes in mental functioning. c. Orient confused client to time, place, date, and persons; institute safety measures to protect client from falling out of  bed. d. Monitor serum electrolytes, BUN, and creatinine as ordered

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2. Promot Promote e optima optimall GI funct function ion.. a. Assess/provide care for stomatitis b. Monitor nausea, vomiting, anorexia c. Administer antiemetics as ordered. 3.

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Monitor/prevent alteration in fluid and electrolyte balance Assess Assess for hyperphosphate hyperphosphatemia mia (paresthes (paresthesias, ias, muscle muscle cramps, cramps, seizures, seizures, abnormal reflexes), and administer aluminum hydroxide gels (Amphojel) as ordered Promote Promote maintena maintenance nce of skin integrity. integrity. a. Assess/provide care for pruritus. b. Assess for uremic frost (urea crystallization on the skin) and bathe in plain water Monitor Monitor for bleeding bleeding compli complicati cations, ons, prevent prevent injury injury to client. client. a. Monitor Hgb, hct, platelets, RBC. b. Hematest all secretions. c. Administer hematinics as ordered. d. Avoid lM injections Promote/mai Promote/maintain ntain maxima maximall cardiova cardiovascular scular functi function. on. a. Monitor blood pressure and report significant changes. b. Auscultate for pericardial friction rub. c. Perform circulation checks routinely. Promote/mai Promote/maintain ntain maxima maximall cardiova cardiovascular scular functi function. on. a. Administer diuretics as ordered and monitor output. b. Modify drug doses Provide Provide care care for for client client receiving receiving dialysis. dialysis.

DIALYSIS

a procedure that is used to remove fluid and uremic wastes from the body when the kidneys cannot function Two methods 1. Hemo Hemodi dial alys ysis is 2. Perit Periton onea eall dialy dialysi sis s Nursing management 1. Meet Me et the the pati patien entt's psyc psycho hoso soc cial ial need needs s 2. Reme Re memb mber er to avoi avoid d any any pro proce cedu dure re on the the arm arm with with the the fistula (HEMO) 3. Moni Mo nito torr WEI WEIGH GHT, T, bloo blood d pre press ssur ure e and and fist fistul ula a sit site e for for bleeding 4. Monitor sy symptoms of of ur uremia 5. Dete Detect ct comp compli lica cati tion ons s lik like e infe infect ctio ion, n, blee bleedi ding ng (Hep (Hepat atit itis is B/C and HIV infection in Hemodialysis) 6. Warm Wa rm the the sol solut utio ion n to incr increa ease se dif diffu fusi sion on of of was waste te prod produc ucts ts (PERITONEAL) 7. Manage di discomfort an and pa pain 8. To det deter ermi mine ne eff effec ecti tive vene ness ss,, chec check k seru serum m crea creati tini nine ne,, BUN BUN and electrolytes

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Male reproductive disorders DIGITAL RECTAL EXAMINATION- DRE Recommended for men annually with age over 40 years Screening test for cancer Ask patient to BEAR DOWN • • •

TESTICULAR EXAMINATION EXAMINATION Palpation of scrotum for nodules and masses or inflammation BEGINS DURING ADOLESCENCE ADOLESCENCE • •

Prostate specific antigen (PSA) Elevated in prostate cancer Normal is 0.2 to 4 n nanograms/mL anograms/mL Cancer - over 4 • • •

BENIGN PROSTATIC HYPERPLASIA - Enlargement of the prostate that causes outflow obstruction - Common in men older than 50 years old Assessment findings 1. DRE: DRE: enl enlar arge ged d pro prost stat ate e gla gland nd that that is rubb rubber ery, y, larg large e and and NON-tender 2. Incr Increa ease sed d fre freq quenc uency, y, urg urgenc ency and and hesi hesittanc ancy 3. Nocturia, DECREASE IN THE VOLUME AND FORCE OF URINE STREAM Medical management 1. Immediate catheterization 2. Prostatectomy 3. TRAN TRANSU SURE RETH THRA RAL L RES RESEC ECTI TION ON of the the PROS PROSTA TATE TE (TUR (TURP) P) 4. Pharm Pharmac acol olog ogy: y: alph alphaa-bl bloc ocke kers, rs, alpha alpha-re -redu duct ctas ase e inhi inhibi bito tors. rs. SAW palmetto Nursing Intervention 1. Enco Encour ura age fluid uids up to 2 lit liters ers per day day 2. Insert ert ca cathet heter fo for ur urinar nary dr drainage 3. Admi Admini nist ster er med medic icat atio ions ns – alp alpha ha adr adren ener ergi gic c blo block cker ers s and and finasteride 4. Avoid anticholinergics 5. Prepare fo for surgery or TURP 6. Teac Te ach h the the pati patien entt per perin inea eall mus muscl cle e exe exerc rcis ises es.. Avo Avoid id valsalva until healing Nursing Intervention: Interventi on: TURP 1. Main Ma inta tain in the the thr three ee way way bla bladd dder er irri irriga gati tion on to prev preven entt hemorrhage 2. Only Only init initia iall lly y the the drai draina nage ge is pink pink-t -tin inge ged d and and neve neverr reddish 3. Admi Admini nist ster er ant antii-sp spas asmo modi dic c to to pre preve vent nt blad bladde derr spa spasm sms s PROSTATE CANCER

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- a slow growing malignancy of the prostate gland - Usually an adenocarcinoma - This usualy spread via blood stream to the vertebrae Predisposing factor Age ➢ Assessment Findings 1. DRE: DRE: hard hard,, pea pea-s -siz ized ed nodu nodule les s on on the the ante anteri rior or rect rectum um 2. Hematuria 3. Urinary ob obstruction 4. Pain Pain on the the per perineu ineum m rad radiati iating ng to the leg Diagnostic tests 1. Prostatic specific anti ntigen (P (PSA) 2. Elevated SERUM ACID PHOSPHATASE indicates SPREAD or  Metastasis Medical and surgical management 1. Prostatectomy 2. T U RP 3. Chem Chemot othe hera rapy py:: hor hormo mona nall the thera rapy py to slow slow the the rat rate e of  of  tumor growth 4. Radiation therapy Nursing Interventions 1. Prepare patient for chemother herapy 2. Prepare for surgery Nursing Interventions: Interventions: Post-prostatectomy Post-prostatectomy 1. Main Ma inta tain in cont continu inuou ous s blad bladde derr irr irrig igat atio ion. n. Note Note that that drai draina nage ge is pink tinged w/in 24 hours 2. Moni Mo nito torr uri urine ne for for the the pres presen ence ce of bloo blood d clo clots ts and and hemorrhage 3. Ambu Ambula late te the the pat patie ient nt as soon soon as urin urine e beg begin ins s to to cle clear ar in color

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