Smeltzer Textbook of Medical Surgical Nursing

NU 230 Adult Health 1ALTERATIONS IN URINARY ELIMINATION

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Class Outline Care of the Patient:Undergoing diagnostic testingWith a lower urinary tract infectionWith urinary incontinenceWith urinary retentionWith urolithiasisExperiencing urinary diversionsUndergoing prostate surgery

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***Tables & Charts***Think about:Whos at risk?Why & So What?Preventive interventionsAssmt/Planning/Implementation/EvaluationStudy Tables & Charts3

Chapter 53

Assessment of Kidney and Urinary Function

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins4

Kidney and Urinary SystemsRegulates fluid and electrolytes, removing wastes and providing hormones involved in red blood cell production, bone metabolism, and control of blood pressureStructuresKidneysUretersBladderUrethra

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsKidneys, Ureters, and Bladder

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsAssessment (pgs.1514-1517)Requires excellent communication skillsRisk factorsChief complaint/Effect on quality of lifeSymptoms Pain (Table 53-2)Changes in voiding (Table 53-3)GI symptomsGero considerations (see p. 1513)

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Diagnostic Studies (pgs 1518-1524)Urinalysis and urine cultureRenal function tests:refer to Table 53-5UltrasonographyCT and MRINuclear scansEndoscopic procedures

BiopsiesIV urography Retrograde pyelographyCystographyRenal angiographyRefer to Chart 53-4

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsUrinalysis Whats normal/what isnt/what does it mean? - and then what?

Color (Table 53-4)Clarity & odorSpecific gravity (normal range 1.010-1.025)pH (nl @ 6)Protein, glucose, ketone bodies, nitrites

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Other Urine Tests Urine for culture and sensitivity

Composite urine collections (24 hr)Creatinine clearancebest indication of overall kidney function (approximation of GFR)Urine osmolality (300-900 mOsm/kg/24h)

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Lab Assessment of Renal FunctionSerum creatinine (will not increase unless 50% of kidney function is lost)BUN (can elevate from high protein diet, tissue damage, infection, stress, dehydration)Serum creatinine more reliable SC = 0.6-1.2 mg/dlBUN = 7-18mg/dl

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Risks and Nursing Interventions in Evaluations of Urinary SystemAll tests consider general principlesWhat position is needed?Patient EducationInformed Consent if riskBefore and after careCommon nursing diagnoses/etiology: (Chart 53-4)Deficient knowledgeAcute painFear and anxietySpecial considerationse.g. urodynamic testing, imaging, cystoscopy, biopsy12

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Intravenous UrographyIVP StudyIVP= Intravenous PyelographyWhat used for- assess gross kidney size or obstructionIV dye given then X-rays taken Requires bowel prep so bowel contents will not block pictureNormal to feel hot, flushed feeling when dye injectedNot used as often secondary to multiple risks and newer tests

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IVPRisks and Nursing Interventions Dye Studies Risks: Allergy, Nephrotoxic Pre: assess iodine, contrast, shellfish allergy, NPO to concentrate dyePost: Monitor fever, wheeze, rash, nausea, vomiting, rehydrate, monitor renal function and I/O, serum Creat., may give acetylcysteine or IV sodium bicarb to prevent renal damage

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CaseGeorge Wright, 63 years of age, is admitted in same day surgery for a renal angiogram for the diagnosis of renal artery stenosis. 15

QuestionsWhat patient education should the nurse provide to the patient?What preparation should the nurse provide for the patient who is going for a renal angiogram?

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Renal Arteriography:Catheter is inserted in femoral artery at groin, to renal artery, dye injected, x-ray picturesUsed to monitor for vascular problems

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Renal Arteriography Risks and Nursing InterventionsRisk: Bleeding: Prior to procedure monitor PT/PTT,discontinue anticoagulantsPost: Pressure to catheter insertion siteManual, ice and sand bag X 15 minutesBed-rest- 6 hours, then stand to void or bedside commode x24hrsVital Sx q 15 minx4 etc, H+HMonitor for hematoma

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Arteriography Risks and Interventions: Risk: Embolus Pre: Assess pulses, pedal pulsesPost: monitor for occlusion of femoral artery: 6 Ps, monitor distal pulses, notify MDRisk: Infection : insertion of catheter / sterile procedurePost- temp q4hx48 to 72 h, monitor for chills, malaise, WBCRisk: renal failure secondary to dye19

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Oscopy ( cystoscopy, ureteroscopy)Insertion of a scope into cavity to visualize or treat.Used for bladder wall problems or obstructionsInterventionsNPO, laxative or fleets to remove stool from the lower colonPain: Post: General or local anesthesiaMonitoring , mild discomfort20

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Cystoscopic Examination

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsOscopy ( cystoscopy, ureteroscopy Infection-sterile procedurePost- temp q4h -72h, monitor etcLocal trauma- assess bleeding- pink tinged urine is normal, gross hematuria is not, assess function (leaking, retention)If catheter in place- clots can obstruct it. May need irrigation 22

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Biopsy- Insert needle into kidneyUsed for unexplained renal problems or renal CA dxPre- assess ability to lie +breathe in prone, NPOPre- patient is sedatedProne position 30-45 minhold breath on request 15-30 secondsInfection- sterile procedure -- same as above23

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Biopsy RisksPost: Bleed Risk- BR, supine with back roll( putting pressure on puncture site). At least 6 hrs, then limited BRP if no bleedingCan elevate HOB if back roll stays monitor: VS, H+H, assess bleeding, pink tinge ok, - no bloodmonitor for hemorrhaging- pain, decr BP Post - hematuriaPost- painPost- Infection- sterile procedure - same as above

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Chapter 55

Management of Patients With Urinary Disorders

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

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26Why does this patient need a NURSE?

Case Sue Meade, 22 years of age, presents to the clinic with complaints of burning, pain, and urgency when urinating. The patient has a fever of 100F. The urine is strong in odor and cloudy with sediments.27

Questionsa. What questions should the nurse ask during the assessment to gain more information about the possible causes of the urinary tract infection?b. What patient education should be provided?

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Urinary Tract InfectionsMost common reason health careCommon site of acquired infectionLower UTICystitisProstatitisUrethritisUpper UTIPyelonephritis: acute and chronicInterstitial nephritisRenal abscess and perirenal abscess

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsFactors Contributing to UTIFunction of glycosaminoglycan (GAG)Urethrovesical refluxUretherovesical refluxUropathogenic bacteriaShorter urethra in women Risk factors

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsRisk Factors for UTI (see Chart 55-2)Incomplete bladder emptyingObstructionImmunosuppressionInstrumentationInflammation of urethraContributing conditionse.g. DM, neurologic disorders

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Bladder Infection: Long-Term Catheterization

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patient With a UTIAssessmentPain, burning upon urination, frequency, nocturia, incontinence, hematuriaAbout half are asymptomaticAssociation of symptoms with sexual intercourse, contraceptive practices, and personal hygieneGerontologic considerationsAssessment of urine, urinalysis, and urine culturesOther diagnostic tests

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patient With a UTIDiagnosisAcute painDeficient knowledgePredisposing factors: infectionRecurrenceDetectionPreventionPharmacologic therapy

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsCollaborative Problems and Potential ComplicationsSepsisRenal failure

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patient With a UTIPlanningMajor goals may include relief of pain and discomfort, increased knowledge of preventive measures and treatment modalities, and absence of complications.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsInterventionsPersonal hygiene: wipe front to backMedications as prescribed: antibiotics, analgesics, and antispasmodics Application of heat to the perineum to relieve pain and spasmIncreased fluid intakeAvoidance of urinary tract irritants such as coffee, tea, citrus, spices, cola, and alcoholFrequent voiding Patient education

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestionIs the following statement true or false?

Older adult patients often lack the typical symptoms of UTI and sepsis.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswerTrue

Older adult patients often lack the typical symptoms of UTI and sepsis.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsUrinary IncontinenceAn underdiagnosed and underreported problem that can have significant impact on the quality of life and decrease independence, which may lead to compromise of the upper urinary systemUrinary incontinence is not a normal consequence of agingRisk factors: refer to chart 55-6

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsUrinary Incontinence/AssessmentHistory and observationPhysicalPsychosocial

UI in Hospitalized Older AdultsMore than 25 million 35% admitted to hospitalWhat are risk factors and complications?See consultgerirn.org reading

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Types of Urinary IncontinenceStressUrgeReflexOverflowFunctionalIatrogenicMixed incontinence

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsUrinary Incontinence/ stressNursing DX- stress incontinenceLeakage of