Genital-urinary System

Renal System Part 2

Behavioral Objectives• Identify and describe the etiology, pathophysiology, clinical manifestations, nursing management and

patient education for the following:– Urinary retention– Urinary incontinence– Urinary suppression– Residual urine

• Discuss common pharmacological interventions appropriate in treatment of patient with GU disorders• Describe general nursing consideration and intervention in pre and post-operative care of patients

undergoing urological surgery• Describe etiology, pathophysiology, clinical manifestations, nursing management and patient education

for the following GU disorders:– Pyelonephritis– Cystitis– Urinary tract infections (UTI)– Urethritis– Nephritic syndrome– Hydronephrosis– Renal calculi– Renal neoplasm’s

Dysfunctional Voiding Patterns

• Urinal Incontinence• Pathophysiology

– Unplanned loss of urine that is sufficient to be considered a problem

– Continence requires intact urinary, neurologic and muscular-skeletal systems

– Any break in communication between these systems can lean to incontinence (or residual)

Types of Incontinence

• Stress Incontinence– Involuntary loss of urine through an intact

urethra due to a sudden in intra-abd. pressure– Treatment-mild: Biofeedback & bladder drills– Treatment-moderate to severe: surgery

• Pelvic Floor Training and the role of Biofeedback: Health Care Professionals usually advise Pelvic Floor Training as a first line treatment or an adjunct therapy for urine leakage that occurs during coughing, laughing or on exertion. Pelvic floor exercises are effective, but only if carried out regularly and diligently. The lack of feedback on progress may lead to frustration and the discontinuation of an exercise routine, hence, it is prudent to choose devices/exercisers with biofeedback function, such as Peritron Perineometer and PFX range of pelvic floor exercisers with pressure biofeedback. The challenge is to motivate and encourage the workout and simultaneously ensure exercising of the correct muscles. Appropriate feedback will stimulate discipline and step-wise progress. PFX is available in 2 versions - vaginal for women only and anal that can used by both men and women. PFX and Peritron Perineometer products can help people, who wish to monitor the effectiveness of their exercising efforts, because of the valuable biofeedback that they generate. Pelvic floor exercises should become routine events in women's lives, but especially before and after

childbirth, hysterectomy and the menopause.

Types of Incontinence

• Urge Incontinence– Involuntary loss of urine associated with a

strong urge to void that cannot be suppressed. – Treatment-• Biofeedback• Pelvic floor nerve stimulation• Bladder drill• Anticholinergics

anticholinergic

• An anticholinergic agent blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system.

• An example dicyclomine. • Decreased the effects mediated by

acetylcholine on acetylcholine receptors

Types of Incontinence

• Reflux incontinence– Involuntary loss of urine due to Hyperreflexia in

the absence of normal sensation– Associated with spinal cord injuries

Types of Incontinence

• Overflow incontinence– Involuntary loss of urine due to over-distention

of the bladder• Bladder is unable to empty normally • over distended • frequent urination (just over flow) • Incontinence

– Treatment:• Catheterization

Behavior Therapy Management

• Fluid Management– Increase fluid– Decrease fluid– WATER!!!!

• Standardized voiding frequency• Timed voiding• Bladder retraining

Behavior Therapy Management

• Pelvic Muscle Exercises– Kegel exercises

• Goal – strengthen

voluntary muscles

Behavior Therapy Management

• Pharmacological Therapy– Anticholinergic agents• Oxybutynin/Ditropan

– Action: Inhibits bladder contractions– Indications for use: urge incontinence

Surgical management

• Involve lifting and stabilizing the bladder or urethra

Nursing Management• fluids• No diuretics after 4PM• Avoid bladder irritants– Caffeine– Alcohol– Aspartame (nutrasweet)

• High fiber meals• Void regularly• Enc pelvic floor exercises• Stop smoking

Urinary Retention• Pathophysiology

– Urinary Retention • The inability to empty the bladder completely

– Residual urine• urine that remains in the bladder after voiding

– Assoc. with• post-op d/t reflux spasm of sphincters• Diabetes• Prostatic enlargement• Urethral pathology• Trauma• Pregnancy• Neurologic disorders

Urinary Retention

• Assessment– Measure post void

residual urine• Portable bladder

scanner

Urinary Retention

• Complications– Chronic infections – Pyelonephritis – Sepsis – Kidney failure– Deathmosis

Urinary Retention• Nursing Management– Promoting normal urinary eliminations

• Provide privacy• Commode• Male stand• Sitz bath• Hot tea• Water faucet on• Tapping pubic area• Dipping hand in warm water

– Promoting urinary elimination• Catheterization

Neurogenic Bladder

• A dysfunction d/t a lesion of the nervous system • Two types of neurogenic bladder– Spastic bladder / reflex bladder

• Empties on reflex– Flaccid bladder

• Bladder becomes distended • Overflow incontinence • Bladder does not contract • Can not feel discomfort

Neurogenic Bladder: Management

• Catheterization – Obstruction– Post-op– Monitor output with critical– Neurogenic bladder or urinary retention– Stage III or IV decubitus ulcers

• Indwelling devices– Drainage bag below the level of the bladder– Tubing not kinked and no too long– Increase fluids

• Suprapubic catheterization

Urological Surgery

• Drainage tubes• Nephrostomy drainage– Tube inserted directly into the kidney

Nephrostomy drainage• Nursing management– Assess for complications

• Bleeding• Infection• Skin

– Ensure unobstruction– Never clamp– Irrigate– Encourage fluids– Aseptic technique– Measure I&O

Urethral Stent

• A tubular device that maintains position & patency of the urethra

Nursing Process: post-op urinary surgery

• Ineffective airway clearance r/t the surgical incision• Ineffective breathing pattern r/t to surgical incision &

general anesthesia– Assess resp status– Auscultation– Admin analgesics– Splint– Change position frequently– Incentive spirometer– Amb.

Test Question!

– Which of the following is appropriate nursing interventions for a patient with a nursing diagnosis of ineffective breathing patterns following renal surgery?

A. Have the patient lay on affected side most of the timeB. Encourage short breaths so not to strain incision siteC. Bed restD. Administer analgesicsE. None of the above

Nursing Process: post-op urinary surgery

• Acute pain– Assess pain level– Assess abd. distention– Admin analgesics– Moist heat– Massage– Splint– Exercise

Nursing Process: post-op urinary surgery

• Urine retention r/t pain, immobility and anesthesia– Asses I&0– Assess drainage & drainage system– Aseptic technique– Maintain closed system– Irrigate?– Enc pt to move – assist to move– Anchor cath– Fluids

Nursing Process: post-op urinary surgery

• Potential complications– Bleeding– Pneumonia– Infection– Fluid disturbances– Deep vein thrombosis

Urinary tract infections (UTI)

• Describe etiology, Pathophysiology, clinical manifestations, nursing management and patient education for Urinary tract infections (UTI)

– Pathophysiology• UTI’s are caused by pathogenic micro-organisms in the urinary

tract• Bacteria in bladder attach to the bladder colonizes in the

epithelium

• E. Coli

Urinary tract infections

• Reflux– Backward flow of urine from the urethra to the

bladder• Cough • increase bladder pressure • urine forced into urethra • stop coughing • decreased pressure • urine flows back into bladder

Urinary tract infections• Types of UTI’s– Cystitis –

• Inflammation of the bladder– Prostatitis –

• Inflamation of the prostate gland– Urethritis –

• Inflammation of the urethra – Pyelonephritis –

• Inflammation of the renal pelvis parenchyma– Interstitial nephritis –

• Inflammation of the kidney

Defense Mechanism

• Physical barrier• Urine flow• Enzymes• Antibodies

Defense Mechanism

• Who is more likely to get a UTI– Male– Female

• Why?– Shorter urethra

Predisposing factors to UTI

• Factors increasing urinary stasis• Foreign bodies• Anatomic factors• Factors compromising immune system• Functional disorders

Clinical Manifestations: Lower UTI

• Dysuria• Burning• Frequency• Urgency– Nocturia– Incontinence– Pelvic pain– Hematuria– Cloudy urine– Back pain

Clinical Manifestations: Upper UTI

• Fever & Chills• Back pain (flank)• N/V• H/A• Malaise• Dysuria

Gerontologic considerations

• Few S&S• Fatigue• Alt cognitive function• Slight drop in temp

Assessment & Dx findings

• UA• Culture

Medical management/pharmacological therapy

• Antibiotic– Cephalosporin– Bactrim/Septra

• Urinary analgesic– Phenazopyridine

(Pyridium)• Urine orange

Nursing Process: UTI

• Assessment– S&S– Voiding patterns– Sexual intercourse– Urine

Nursing Process: UTI

• Diagnosis– Acute pain related to inflammation of the urinary tract– Assess pain– Admin. Analgesics

• Tell pt orange– Teach non-Rx

• Heating pad• Warm showers

– Admin antispasmodics

Nursing Process: UTI

• Diagnosis– Deficient knowledge detection, preventions and

recurrence and meds• Hygiene • Fluid intake• Voiding habits

Nursing Process: UTI

• Nursing Interventions: Hygiene– Shower not bath– Front to back– Wash after BM w/soap & water– No harsh soaps

Nursing Process: UTI

• Nursing Interventions: Fluid Intake– Increased– Water– Avoid irritants

• Coffee• Tea• Citrus• Spices• Cola• Alcohol

Nursing Process: UTI

• Nursing Interventions: Voiding habits– 2-3 hrs– Empty completely– Before & after intercourse

Pyelonephritis

• Bacterial infection of the renal pelvis, tubules and interstitial tissue of one or both kidneys.

– Pathophysiology• Lower ascends up• Reflux• Obstruction• enlarged kidney

Pyelonephritis

• Clinical manifestations– Acutely ill– Fever & Chills– Pyuria– Flank pain– Bacteriuria

Pyelonephritis

• Assessment & Dx:– Ultrasound– CT– UA• Pyuria• Bacteriuria• Hematuria• WBC

Pyelonephritis

• Medical Management– Outpatient– Dehydration

Pyelonephritis

• Rx– 2 week antibiotics– IV

Pyelonephritis

• Complications– End Stage Renal Disease– Hypertension– Kidney stones– Urosepsis

Urethritis

• Pathophysiology– Inflammation of the urethra – Usually ascending infection– STD

Urethritis

• Clinical manifestations – Men– Prostatitis– Epididymitis– Urethral stricture– Sterility

• Clinical Manifestations - Women– Asymptomatic

Urethritis

• Treatment– Tetracycline– Partners

Nephrotic syndrome

• Pathophysiology– Primary glomerular disease characterized by:• Marked increase in protein in the urine

– (proteinuria)• Decrease in albumin in the blood

– (hypoalbuminemia)• Edema

• High serum cholesterol and low-density lipoprotein

Nephrotic syndrome

– Clinical Manifestation• #1 – edema• Malaise• H/A• Irritability• Fatigue

Nephrotic syndrome

• Assessment and diagnostic findings– Proteinuria– Hyperlipidemia – Hypoalbuminemia

Nephrotic syndrome

• Complications– Infections– Thromboembolism– Pulm. Emboli– Renal Failure

Nephrotic syndrome

• Medical Management– Diuretic– NSAID– Diet• Sodium• K+• protein• Fat

Nephrotic syndrome

• Nursing Management - Edema– qD weight– I&O– Abd. Girth– Clean skin– Avoid people with infections

Hydronephrosis

• Pathophysiology– Dilation of the

renal pelvis and calyces of one or both kidneys due to an obstruction

Hydronephrosis

• Clinical Manifestations– Aching flank– Dysuria– Chills & fever– Tenderness– Pyuria

Hydronephrosis

• Medical Management – Remove obstruction

Renal calculi or nephrolithiasis

• Pathophysiology– Stones are formed in the urinary tract when

urinary concentrations of the substances such as calcium oxalate, calcium phosphate and uric acid increase

• Calculus = Stone• Lithiasis = Stone formation

Renal calculi or nephrolithiasis

• Certain factors favor the formation of stones:– Infection– Urinary stasis– Immobility– Dehydration

Renal calculi or nephrolithiasis

• Clinical Manifestations– Pain• Abd / flank• Severe• N&V

– Hematuria

Renal calculi or nephrolithiasis

• Assessment and diagnostic findings– X-ray– Ultrasonography– 24-hour urine test– Cystoscopy– IVP

Renal calculi or nephrolithiasis

• Cystoscopy– Lighted scope to inspect

bladder– Gen anesthesia– Nrs Management

• Force fluids• Expect burning • Pink tinged • Frequency• Orthostatic hypotension

Renal calculi or nephrolithiasis

• IVP– intravenous pyelogram– X-ray + IV dye– Assess for allergies to

dye– After push fluids

Renal calculi or nephrolithiasis

• Medical management– Opioid analgesic– Antibiotics– NSAIDs– Diet• Calcium OK• Fluids• protein• Sodium

Renal calculi or nephrolithiasis

• Surgical Management– If > 4mm will not

pass through ureter– If not pass

spontaneously or if complications surgery

Renal calculi or nephrolithiasis

Surgical Management • Ureteroscopy– First visualize the stone – Destroy the stone

• Laser• Electrohydraulic

lithotriptos• Ultrasound

Renal calculi or nephrolithiasis

• ESWL - Extracorporeal shock wave lithotripsy – Gen / spinal– Shock waves

water stone breaks up

Renal calculi or nephrolithiasis

• Nursing Process – Diagnosis• Acute pain• Deficient knowledge to prevent recurrence of renal

stone

Renal calculi or nephrolithiasis

• Nursing Interventions– Admin opioid agents– NSAIDS– Position of comfort– Amb.– Heat to flank– fluids– Assess urine– I&O– Strain urine – gauze– Avoid dehydration

Renal neoplasm’s

• Pathophysiology– Tobacco leading cause of all UT – Ca– Metastasize early• Liver• Lungs• Bone• Brain

– 1/3 have metastasis at time of diagnosis

Renal neoplasm’s

• Clinical Manifestations– Asymptomatic– Painless hematuria

Renal neoplasm’s

• Medical treatment– Goal:• Eradicate before metastasis• Nephrorectomy• Chemotherapy