Chapter 46 Nursing Management Renal and Urologic Problems S. Buckley, RN, MS Mosby pp Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier

Chapter 46Chapter 46

Nursing ManagementNursing ManagementRenal and Urologic ProblemsRenal and Urologic Problems

S. Buckley, RN, MSS. Buckley, RN, MS

Mosby ppMosby pp

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.


Infectious and Inflammatory Disorders of Infectious and Inflammatory Disorders of the Urinary Systemthe Urinary System


Acute PyelonephritisAcute Pyelonephritis

Etiology and pathophysiology-inflammation of the Etiology and pathophysiology-inflammation of the kidney following uti. (kidney following uti. (can progress to urosepsis: systemic can progress to urosepsis: systemic infection arising from urologic source) infection arising from urologic source)

Preexisting factorPreexisting factor: : vesicoureteral reflux, calculi, catheter, vesicoureteral reflux, calculi, catheter, stricture, pregnancy, neurogenic bladderstricture, pregnancy, neurogenic bladder

Clinical manifestations-fever, chills,N&V, abrupt Clinical manifestations-fever, chills,N&V, abrupt flank pain (CVA pain), LUTS, bacteriuria, pyuria flank pain (CVA pain), LUTS, bacteriuria, pyuria

Diagnostic studies-u/a reveals; pyuria, hematuria, Diagnostic studies-u/a reveals; pyuria, hematuria, WBC casts, CBC, blood culturesWBC casts, CBC, blood cultures

Collaborative care and Collaborative care and drug therapy-urine for C&S, imaging: ultrasound, drug therapy-urine for C&S, imaging: ultrasound, increase, NSAIDs, fluids, antibiotics (ampicillin, increase, NSAIDs, fluids, antibiotics (ampicillin, vancomycin, cipro), analgesia (pyridium), severe vancomycin, cipro), analgesia (pyridium), severe cases require hospitalization, emotional support, cases require hospitalization, emotional support, follow up, education.follow up, education.


Fig. 46-1


Causes of urinary tract obstructionCauses of urinary tract obstruction



Fig. 46-2


Chronic pyelonephritisChronic pyelonephritis

Kidney has atrophied, lost function r/t Kidney has atrophied, lost function r/t scarring. Often accompanied by scarring. Often accompanied by hypertension, significant cause of renal hypertension, significant cause of renal failure, responsible for 11-20% of all cases of failure, responsible for 11-20% of all cases of end-stage renal disease. end-stage renal disease.

Symptoms: onset insidious, polyuria, Symptoms: onset insidious, polyuria, nocturia, mild proteinuria, nocturia, mild proteinuria,

Diagnosed by radiologic imaging and Diagnosed by radiologic imaging and histology. histology.


urethritisurethritis

Inflammation of urethraInflammation of urethra Causes: trichomonas, monilial infection, Causes: trichomonas, monilial infection,

Chlamydia, gonorrhea.Chlamydia, gonorrhea. Often sexually transmittedOften sexually transmitted Symptoms: discharge, LUTS; dysuria, Symptoms: discharge, LUTS; dysuria,

urgency, frequent urinationurgency, frequent urination TX: id cause, often treated with Flagyl, TX: id cause, often treated with Flagyl,

mycelex, nystatin (mycostatin), fluconazole mycelex, nystatin (mycostatin), fluconazole (diflucan).(diflucan).


Urethral DiverticulaUrethral Diverticula


Interstitial Cystitis/Painful Bladder Interstitial Cystitis/Painful Bladder SyndromeSyndrome

Chronic, painful inflammatory disease of the bladder, affects Chronic, painful inflammatory disease of the bladder, affects ~700,000 Americans/yr. ~700,000 Americans/yr.

Ration women to men: 10:1Ration women to men: 10:1 Etiology; unknown, r/t infections, nephro dysfunction.Etiology; unknown, r/t infections, nephro dysfunction. Symptoms: urgency, frequency and pain, relieved with urination, Symptoms: urgency, frequency and pain, relieved with urination,

exacerbated with sexual intercourse.exacerbated with sexual intercourse. Painful bladder syndrome: pain related to bladder filling in absence Painful bladder syndrome: pain related to bladder filling in absence

of uti.of uti. Diagnosis by exclusion; pain despite absence of uti.Diagnosis by exclusion; pain despite absence of uti. Collaborative care and drug therapy-dietary, lifestyle changesCollaborative care and drug therapy-dietary, lifestyle changes Nursing management: Interstitial cystitis/painful bladder syndrome-Nursing management: Interstitial cystitis/painful bladder syndrome-

relieve anxiety, monitor u/o and possible uti, lifestyle changes, push relieve anxiety, monitor u/o and possible uti, lifestyle changes, push fluidsfluids

Use of Prelief (calcium gycerophosphate-alkalinizes urine)Use of Prelief (calcium gycerophosphate-alkalinizes urine)


Renal TuberculosisRenal Tuberculosis

Secondary to TB of lungSecondary to TB of lung 5-8 yrs after primary disease5-8 yrs after primary disease Symptoms: low grade fever, cystitis, Symptoms: low grade fever, cystitis,

epididymitis, renal colic, lumbar and iliac pain, epididymitis, renal colic, lumbar and iliac pain, hematuria.hematuria.

diagnosis-based on tb bacilli in urine and IVPdiagnosis-based on tb bacilli in urine and IVP Tx-similar to tx for tb, depends on stage of Tx-similar to tx for tb, depends on stage of

disease and renal involvement.disease and renal involvement.


Immunologic DisordersImmunologic Disordersof the Kidneyof the Kidney


GlomerulonephritisGlomerulonephritis

Immunologic process resulting in Immunologic process resulting in inflammation of the glomerulus.inflammation of the glomerulus.

33rdrd leading cause of renal failure in the US. leading cause of renal failure in the US. Autoantibodies production Autoantibodies production stimulated by stimulated by

exogenous agents (hydrocarbon, viruses (hep. B, C, exogenous agents (hydrocarbon, viruses (hep. B, C,

rubella, bacteria (streptococcal), chemicals, drugsrubella, bacteria (streptococcal), chemicals, drugs), ), diseases or endogenous (SLE)diseases or endogenous (SLE)

Clinical manifestations: Clinical manifestations: hematuria,hematuria, excretion of RBCs, WBC, casts, decrease excretion of RBCs, WBC, casts, decrease GFR, azotemia, oliguria, hypertension, GFR, azotemia, oliguria, hypertension, periorbital edemaperiorbital edema



Acute Poststreptococcal Acute Poststreptococcal GlomerulonephritisGlomerulonephritis

Clinical manifestations and Clinical manifestations and complications-develops 5-21 days post complications-develops 5-21 days post infection of throat by strep.infection of throat by strep.

Diagnostics: hx, physical assessment, Diagnostics: hx, physical assessment, CBC, throat swabCBC, throat swab

Tx; rest, sodium and fluid restriction, Tx; rest, sodium and fluid restriction, diuretics, antihypertensive therapy, diuretics, antihypertensive therapy, emotional support, education, decrease emotional support, education, decrease dietary protein.Antibiotics(if strep still dietary protein.Antibiotics(if strep still present), corticosteroids.present), corticosteroids.


Chronic glomerulonephritisChronic glomerulonephritis

End stage of acute diseaseEnd stage of acute disease Symptoms: proteinuria, hematuia slow Symptoms: proteinuria, hematuia slow

development of uremia, progresses toward development of uremia, progresses toward renal failurerenal failure

Dignostic: u/a, vs, ultrasound, CT, renal Dignostic: u/a, vs, ultrasound, CT, renal biopsybiopsy

Tx-supportive an symptomatic: control Tx-supportive an symptomatic: control hypertension and uti’s, protein and phosphate hypertension and uti’s, protein and phosphate restriction may slow the rate of progression.restriction may slow the rate of progression.


Nephrotic SyndromeNephrotic Syndrome

results when: glomerulus is permeable to plasma results when: glomerulus is permeable to plasma protein, causing proteinuria, low plasma albumin protein, causing proteinuria, low plasma albumin and tissue edemaand tissue edema

Symptoms: peripheral edema, massive proteinuria, Symptoms: peripheral edema, massive proteinuria, hypertension, , hyperlipidemia, hypoalbuminemia, hypertension, , hyperlipidemia, hypoalbuminemia, ascites, anasarca, calcium abnormalitiesaltered ascites, anasarca, calcium abnormalitiesaltered immune response, altered coagulation (hyper)immune response, altered coagulation (hyper)

Collaborative care-symptom management; relieve Collaborative care-symptom management; relieve edema, cure primary disease, low Na diet, low edema, cure primary disease, low Na diet, low protein, diuretics, NSAIDs, anticoagulant therapy, protein, diuretics, NSAIDs, anticoagulant therapy, corticosteroids.corticosteroids.


Nephrotic syndromeNephrotic syndromenursing interventionsnursing interventions

Control edema: daily weights, I & o, girth or Control edema: daily weights, I & o, girth or extremity size, bp, trending of data, care of extremity size, bp, trending of data, care of skin (hygiene and avoid trauma)skin (hygiene and avoid trauma)

May become malnurished, may become May become malnurished, may become anorexic; serve small, frequent meals: low na, anorexic; serve small, frequent meals: low na, low proteinlow protein

Susceptible to infections; avoid exposure, Susceptible to infections; avoid exposure, emotional support re: poor body imageemotional support re: poor body image

Educate Educate


Obstructive UropathiesObstructive Uropathies


Renal disease and HIVRenal disease and HIV

Incidence of renal disease and HIV is about Incidence of renal disease and HIV is about 10% (higher with IV drug use)10% (higher with IV drug use)

Syndromes: proteinuria, nephrotic syndrome, Syndromes: proteinuria, nephrotic syndrome, nephropathy -progressing to end stage renal nephropathy -progressing to end stage renal disease and acute renal failure (mostly in pts disease and acute renal failure (mostly in pts with AIDs) with AIDs)

Survival and recovery depends on the Survival and recovery depends on the treatment of the primary cause.treatment of the primary cause.


Obstructive UropathiesObstructive Uropathies

Any anatomic or functional condition that Any anatomic or functional condition that blocks or impedes the flow of urine, may be blocks or impedes the flow of urine, may be congenital or acquired.congenital or acquired.


Fig. 46-3


hydronephrosishydronephrosis

Results from obstruction in urinary system, Results from obstruction in urinary system, causing reflux of urine and increased causing reflux of urine and increased pressure, ureteral dilation, kinking, and pressure, ureteral dilation, kinking, and dilation and or enlargement of the renal dilation and or enlargement of the renal pelves and calyses. pelves and calyses.

Causes pyelonephritis and renal atropy.Causes pyelonephritis and renal atropy. If one kidney involved, other will compensate.If one kidney involved, other will compensate. Symptoms: alterations in kidney function (per Symptoms: alterations in kidney function (per

assessment, labs; increased BUN, creatinine, assessment, labs; increased BUN, creatinine, oliguria or anuria.oliguria or anuria.


Fig. 46-4


Urinary Tract CalculiUrinary Tract Calculi

500,000 people/yr develop lithiasis, more common in warm 500,000 people/yr develop lithiasis, more common in warm climates (dehydration)climates (dehydration)

Various types of calculi (p.1170), recurrence of stones -50%.Various types of calculi (p.1170), recurrence of stones -50%. Clinical manifestations-Pain in flank area (depends on Clinical manifestations-Pain in flank area (depends on

location of stone), severe, hematurin, reanl colic, N&V, location of stone), severe, hematurin, reanl colic, N&V, Diagnostic studies-u/a, culture,VP, ultrasound, cystoscopy. Diagnostic studies-u/a, culture,VP, ultrasound, cystoscopy. Collaborative care-keep urine dilute and free Collaborative care-keep urine dilute and free

flowing,reduces risk of formation., analyze stone to flowing,reduces risk of formation., analyze stone to determine cause and prevent recurrance; screening of determine cause and prevent recurrance; screening of urine, CBC, urine ph. urine, CBC, urine ph. Endourologic procedure-bladder-cystoscopy, ureteroscopes,Endourologic procedure-bladder-cystoscopy, ureteroscopes, Lithotripsy-pulverizes stons with ultasonic vibrations.Lithotripsy-pulverizes stons with ultasonic vibrations. Surgical therapy-nephrolithotomy-incision into kidney to remove Surgical therapy-nephrolithotomy-incision into kidney to remove

stonestone


Fig. 46-5


Fig. 46-6


Nursing Management Nursing Management Renal CalculiRenal Calculi

Nursing assessment-screen for Nursing assessment-screen for litiasis, mange acute attack; litiasis, mange acute attack; pain control (opiods), infection pain control (opiods), infection and/or obstruction elimination , and/or obstruction elimination , hx, increase fluids hx, increase fluids (3000ml/day) after acute (3000ml/day) after acute attack, discourage foods that attack, discourage foods that increase stones.increase stones.

Diet; low na, modify depending Diet; low na, modify depending on type of stone (p.1171)on type of stone (p.1171)


StricturesStrictures

Ureteral and urethral strictures-narrowing of Ureteral and urethral strictures-narrowing of lumen, associated with unintended reslut of lumen, associated with unintended reslut of sugical intervention, adhesions, scars or sugical intervention, adhesions, scars or geneticgenetic

Symptoms: diminshed force of urinary stream, Symptoms: diminshed force of urinary stream, staining to void, split urine stream, frequency, staining to void, split urine stream, frequency, nocturia. Can lead to urinary retention and uti.nocturia. Can lead to urinary retention and uti.

Diagnostic; retrograde urethrography (RUG).Diagnostic; retrograde urethrography (RUG). Management; dilation of stricture by stent Management; dilation of stricture by stent

placemtn, self-catherterization, or urethroplasty.placemtn, self-catherterization, or urethroplasty.


Renal traumaRenal trauma

Increased r/t violent crimes, mva,sports, Increased r/t violent crimes, mva,sports, usually younger men causing blunt trauma.usually younger men causing blunt trauma.

Findings; hematuriaFindings; hematuria Diagnostic: IVP, u/a, ultrasound, CTDiagnostic: IVP, u/a, ultrasound, CT Tx; bed rest, fluids, analgesia, surgical Tx; bed rest, fluids, analgesia, surgical

exploration , repair or nephrectomy.exploration , repair or nephrectomy. Interventions; emotional support, pain control, Interventions; emotional support, pain control,

monitoring for shock, monitor I&O, observe monitoring for shock, monitor I&O, observe for hematuria, monitor nephrotoxic antibiotics.for hematuria, monitor nephrotoxic antibiotics.


Renal artery stenosisRenal artery stenosis

Partial occlusion of one or both renal arteries.Partial occlusion of one or both renal arteries. Results in hypertension and low perfusion to Results in hypertension and low perfusion to

kidneyskidneys Goals of therapy; control hypertension , Goals of therapy; control hypertension ,

increase profusion.increase profusion. Collaborative care; percutaneous Collaborative care; percutaneous

transluminal renal angioplasty, surgical transluminal renal angioplasty, surgical revascularization of kidney.revascularization of kidney.


Hereditary Renal DiseasesHereditary Renal Diseases


Polycystic Kidney DiseasePolycystic Kidney Disease

Most common life-threatening genetic disease in Most common life-threatening genetic disease in the world, affecting 600,000 in US, 12.5/world!!the world, affecting 600,000 in US, 12.5/world!!

Accounts for 10-15% of chronic kidney disease.Accounts for 10-15% of chronic kidney disease. 2 forms (childhood (rare), adult). Adult: 2 forms (childhood (rare), adult). Adult:

autosomal disorder, involves both kidneys, cysts autosomal disorder, involves both kidneys, cysts destroy surrounding tissue, filled with blood, pus. destroy surrounding tissue, filled with blood, pus.

Clinical manifestations-hypertension, hematuria, Clinical manifestations-hypertension, hematuria, feeling of heaviness in back, may have uti, feeling of heaviness in back, may have uti, chronic pain, palpable kidneys, effects other chronic pain, palpable kidneys, effects other organsorgans


PKDPKD

Diagnosis based on hx, IVP, ultrasound, CT. Diagnosis based on hx, IVP, ultrasound, CT. Usually progresses to end-stage renal failure.Usually progresses to end-stage renal failure.

Collaborative care; no specific tx. Major aim Collaborative care; no specific tx. Major aim is to prevent infections and symptoms. is to prevent infections and symptoms. Kidney transplant is only cure.Kidney transplant is only cure.

Nursing interventions: management of end-Nursing interventions: management of end-stage renal disease.stage renal disease.


Fig. 46-7


Fig. 46-8


InstrumentationInstrumentation

Urethral catheterizationUrethral catheterization Ureteral cathetersUreteral catheters Suprapubic cathetersSuprapubic catheters Nephrostomy tubesNephrostomy tubes Intermittent catheterizationIntermittent catheterization


Fig. 46-11


Surgery ofSurgery ofthe Urinary Tractthe Urinary Tract


Renal and Ureteral SurgeryRenal and Ureteral Surgery

Preoperative managementPreoperative management Postoperative managementPostoperative management

Urine outputUrine output Respiratory statusRespiratory status Abdominal distentionAbdominal distention

Laparoscopic nephrectomyLaparoscopic nephrectomy


Urinary DiversionUrinary Diversion

Incontinent urinary diversionIncontinent urinary diversion Continent urinary diversionsContinent urinary diversions Orthotopic bladder substitutionOrthotopic bladder substitution


Fig. 46-12


Fig. 46-13


Fig. 46-14


Nursing ManagementNursing ManagementUrinary DiversionUrinary Diversion

Preoperative managementPreoperative management Postoperative managementPostoperative management


Fig. 46-15


Fig. 46-16

Documents

Chapter 46 Nursing Management Renal and Urologic Problems S. Buckley, RN, MS Mosby pp Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier