Chapter 46: Renal and Urologic Problems

Question 1

Very common, especially in women. Escherichia coli most common pathogen. Upper urinary tract: renal parenchyma, pelvis, and ureters
Lower urinary tract: usually no systemic manifestations; dysuria, frequency, urgency, hematuria, cloudy urine. Examples: cystitis, urethritis.
Elderly have weird sx- diffuse abdominal pain, cognitive impairment
Can develop into urosepsis and septic shock.
Uncomplicated: occurs in otherwise normal urinary tract
Complicated: coexists with presence of obstruction, stones, catheters, diabetes/neurologic disease, pregnancy- induced changes, recurrent infection

Answer 1

Urinary Tract Infection (UTI)

Question 2

Dx of UTI

Answer 2

UA by dipstick: look for nitrites, WBCs, leukocyte esterase
Urine C&S: specimen by catheterization or suprapubic needle aspiration more accurate. Determine bacteria susceptibility to ABX
CT urography or US when obstruction suspected

Question 3

UTI Tx

Answer 3

Complicated: short course (1-3 days) of ABX
Complicated: longer term (7-14 days)
TMP/SMX (Bactrim) bid: increased incidence of E.coli resistance to TMP-SMX
Nitrofurantoin (macrodantin) rid or aid: long-acting, Microbic, bid. Avoid sunlight, use sunscreen, wear protective clothing
Ampicillin, amoxicillin, cephalosporins
Perineum is better than Tylenol for pain (turns urine red-orange)
May take low-dose ABX daily or a single dose before event that provokes a UTI (i.e. intercourse).
Fluoroquinolones: treat cx UTIs. ex, Cipro
Antifungals for UTIS d/t fungi: amphotericin or fluconazole

Question 4

UTI prevention

Answer 4

Empty bladder regularly and completely (every 3-4 hours)
Evacuate bowel regularly.
Wipe from front to back
Drink adequate amounts of liquid (2000 mL)
Daily cranberry juice or cranberry essence tabs
Take all ABX as prescribed
Empty bladder before and after intercourse
No douches, soaps, powders, sprays, bubble baths
Avoid caffeine, alcohol, citrus juices, chocolate, highly spiced foods/beverages
Local heat or warm bath/shower
Temporarily stop using a diaphragm
Hospital Acquired Infections (HAIs): Avoid unnecessary catheterization. Remove catheters as soon as possible. Wash hands well. Wear gloves when handling catheter. Through perineal hygiene. Maintain sterile closed system.

Question 5

Usually starts with a lower tract infection and a preexisting factor. Most commonly c/b bacteria. Recurring infections can cause scarring, kidney malfunction, and chronic pyelonephritis.
S/S: mild fatigue, chills, fever, vomiting, malaise, flank pain, dysuria, urgency, frequency, CVA tenderness.

Answer 5

Acute pyelonephritis

Question 6

Lab studies: UA- pyuria (+WBCs), bacteriuria (+bacteria), hematuria (+blood), WBC casts, positive urine culture. Urine C&S. CBC (shifts to the left, leukocytosis), Blood cultures if bacteremia is suspected.
Radiology: renal ultrasound, CT urography, do NOT do an IVP (can spread infection).

Answer 6

Dx of UTIs

Question 7

Tx of UTIs

Answer 7

severe with cx: hospitalization
Mild- treat as an outpatient. ABX for 14-21 days (expect sx to improve within 2-3 days).
If relapse, another 6 week course of ABX
Re-infection: treat as individual episodes
Prophylaxis with low dose ABX to prevent recurrence
Fluids, rest, risk of septic shock

Question 8

Systemic infection from urologic source (close observation and VS monitoring). Prompt dx and tx critical. Can lead to septic shock and death. Septic shock- outcome of unresolved bacteremia involving gram-negative organism

Answer 8

Urosepsis

Question 9

Kidneys become small, atrophic, shrunken and lose function d/t scarring or fibrosis. C/b recurring infections. Dx by imaging, not by sx. Often progresses to end-stage renal disease esp. if both kidneys are involved.

Answer 9

Chronic pyelonephritis

Question 10

The nurse identifies which pt as having the greatest risk for a UTI?

a) A 37 y/o man with renal colic associated with kidney stones
b) A 26 y/o pregnant woman who has a hx of UTIs
c) A 69 y/o man who has urinary retention c/b benign prostatic hyperplasia
d) A 72 y/o woman hospitalized with a stroke who has a urinary catheter b/c of urinary incontinence

Answer 10

d) A 72 y/o woman hospitalized with a stroke who has a urinary catheter b/c of urinary incontinence

Question 11

Most common cause in men is sexually transmitted disease (gonococcal if purulent discharge; can cause distress). Hard to dx in women. Tx: Bactrim, Macrodantin, other ABX as specific for the infection. Important to avoid intercourse until sx subside and treat sexual partners from last 60 days.

Answer 11

Urethritis

Question 12

Usually result of fibrosis or inflammation from trauma, gonococcal urethritis, surgery or frequent cats, congenital defects, BPH.
S/S: diminished force of urine stream, straining to void, spraying stream, post-void dribbling, split urine stream, incomplete bladder emptying, frequency, nocturia.
Risk of acute urinary retention (EMERGENCY)
Dx: retrograde urethrography, VCUG
Tx: dilation (usually have recurrence), if recurrent can have pt self-acth few days to dilate

Answer 12

Urethral stricture

Question 13

S/S: bladder pain, urgency, frequency, pain during intercourse
Pain is worsened by bladder filling, postponing urination, physical exertion, pressure against suprapubic area, eating certain foods, stress.
Pain is temporarily relieved by urination.
Dx of exclusion (looks like a UTI but no bacteriuria or pyuria, negative urine culture)
UTI is a cx.

Answer 13

Interstitial Cystitis

Question 14

Tx of interstitial cystitis

Answer 14

Avoid bladder irritants (i.e. coffee, OJ, multivitamins, see others on UTI slide). Prelief (OTC med) to alkalinize the urine. Alluvial or nortriptyline for burning pain. No drugs provide immediate relief so may need opioids. Can give meds directly into the bladder through a small catheter (i.e. DMSO, heparin, hyaluronic acid, lidocaine, BCG). Avoid clothing that creates pressure (i.e. tight waistbands, tight belts)

Question 15

Immune disorder c/b antibody-induced injury or deposition of immune complexes.
S/S: hematuria, proteinuria, urinary excretion of RBCs, WBCs, casts, elevated BUN and creatinine; swollen face, blood in the urine, decreased urine output, increased BP
Oftentimes have a hx of drug exposure, infections, immune disorders
Most commonly associated withs strep

Answer 15

Glomerulonephritis

Question 16

Develops 5-21 days after strep throat infection.
S/S: body edema (eyes first), HTN, smoky or rust-colored urine, proteinuria, oliguria, abdominal/flank pain (no UTI sx).
Dx: positive ASO titers; erythrocyte casts.
Do a renal biopsy.
Tx: rest, restricted sodium and fluid intake, diuretics, antihypertensives, may restrict protein, only give ABC if strep infection is still present
95% recover completely

Answer 16

Acute post-streptococcal glomerulonephritis (APSGN)

Question 17

Rare autoimmune disease seen mostly in young, male smokers.
S/S: flu-like sx with pulmonary sx, hematuria, weakness, pallor, anemia
Dx: serum anti-GBM antibodies, low Hgb/Hct, elevated BUN and creatinine
Tx: corticosteroids, plasmapheresis, immunosuppressants, dialysis, renal transplant

Answer 17

Goodpasture syndrome

Question 18

Glomerulus is excessively permeable to protein causing proteinuria that leads to low plasma albumin and tissue edema.
S/S: edema (anasarca), HTN, massive proteinuria, hyperlipidemia, hypoalbuminemia, weight gain, decreased serum protein
Tx: sx control, low-sodium diet, low to moderate protein diet, corticosteroids

Answer 18

Nephrotic syndrome

Question 19

Any anatomic or functional condition that blocks urine flow. Congenital or acquired. Infection increases risk of irreversible damage. Can lead to reflux, hydrometer, hydronephrosis. Tx: relieve blockage

Answer 19

Obstructive uropathies

Question 20

More common in men. Increased incidence: white persons, family hx of stone formation, previous hx (recur in up to 50% of pts), summer months (suggests dehydration as a cause).

Answer 20

Urinary tract calculi

Question 21

More common with urinary diversions, long-term catheters, neurogenic bladder, urinary retention. Can get infected. Calculus- the stone. Lithiasis- stone formation. Calcium stones are the most common type. Keep urine dilute and free-flowing.

Answer 21

Nephrolithiasis (Kidney stones)

Question 22

Reduce dietary oxalate (green veggies, tomatoes, beets, nuts, chocolate, cocoa, tea); give diuretics; reduce sodium intake

Answer 22

Calcium oxalate or phosphate

Question 23

Usually in women. Always associated with UTI. Give ABX. Acetohydroxamic acid, remove stone with surgery, acidify urine

Answer 23

Struvite (magnesium ammonium phosphate)

Question 24

Usually in men, alkalinize urine, give allopurinol, reduce dietary purines (red meats, shellfish, fish)

Answer 24

Uric acid

Question 25

Genetic defect, increase hydration, give potassium citrate to alkalinize urine

Answer 25

Cystine

Question 26

S/S: severe abdominal/flank pain, hematuria, n/v, mild shock with cool/moist skin, may have UTI sx
Dx: UA, urine culture, CT, IVP (if NO renal failure), retrograde pyelogram, US, cystoscopy
Very important to retrieve and analyze the stone to dx the underlying problem that led to stone formation.
Labs: calcium, phosphorus, Na, K+, HCO3-, uric acid, BUN, creatinine, urine pH
If they have recurrent stones, get 24 hour urine for above plus magnesium, oxalate, citrate and sulfate

Answer 26

Kidney stones

Question 27

Tx of kidney stone

Answer 27

Treat the acute attack and then find out the cause of the stones to prevent it from happening again.
Acute- opioids, ureteral stent for stones >44mm, forcing fluids with an active stone can increase pain
Strain all urine to retrieve all stones
Surgery or procedure to remove stones is done when stones are too large to pass, associated with infection, impairing renal function, causing persistent pain/nausea/ileus, pt only has one kidney

Question 28

Insertion of a scope into the bladder or kidney pelvis and fragment the stone with ultrasound, electrohydraulic, laser, or extracorporeal shock wave lithotripsy.
Often give anesthesia. Stone is shattered and broken into fine sand that is suctioned or irrigated out.
Post-procedure: common to have flank pain, bruising, hematuria
May leave a ureteral stent to prevent obstruction; don’t let it get obstructed. Never clamp it

Answer 28

Lithotripsy

Question 29

Prevention of future kidney stones

Answer 29

Assess family hx, activity patient, hx of GI/GU disease or surgery.
After stone has passed, increase fluids to 3000 mL/day (water; no cola, coffee, or tea).
No calcium restrictions in diet, but do restrict sodium.
Limit oxalate-rich foods (i.e. spinach, asparagus, tomatoes, beets, nuts, chocolate, coffee, tea).
Increase activity.
Prevent dehydration
Self-monitor urinary pH
Measure urine output

Question 30

What does the nurse teach a 64 y/o woman to do to prevent the recurrence of renal calculi?

a) Use a filter to strain all urine.
b) Avoid dietary sources of calcium
c) Choose diuretic fluids such as coffee
d) Drink 2000 to 3000 mL of fluid a day

Answer 30

d) Drink 2000 to 3000 mL of fluid a day

Question 31

Usually an unintended result of surgical intervention d/t scars or adhesions.
S/S: colicky pain increased by consuming large volumes of fluid over short period of time, rare to have an infection.
Tx: temporary stent by endoscopy or diversion of urine via nephrostomy tube in the renal pelvis, definitive correction is dilation with a balloon catheter

Answer 31

Ureteral stricture

Question 32

Blunt trauma is most common. Suspect in any abdominal trauma.

Answer 32

Renal trauma

Question 33

Renal vascular problems

Answer 33

Nephrosclerosis- usually caused by HTN and atherosclerosis, treat with antihypertensives
Renal artery stenosis- consider when HTN develops abruptly in pts 50. Diagnose with renal ateriogram. Tx: renal angioplasty, surgical revascularization
Renal vein thrombosis- can occur with trauma, cancer, pregnancy, BCP use, nephrotic syndrome. S/S: flank pain, hematuria, fever. Tx: anticoagulation to prevent PE, surgical thrombectomy

Question 34

Most common life-threatening genetic disease. Childhood form progresses rapidly.
S/S: none early, HTN, hematuria, feeling of heaviness in back/side/abdomen, UTI, stones, chronic pain, kidneys may be palpable
Dx: family hx, IVP, US, CT
Tx: genetic counseling, prevent infections, nephrectomy, dialysis, kidney transplant
Cx: ESRD, liver, heart, blood vessel, intestinal problems, cerebral aneurysm

Answer 34

Polycystic kidney disease (PKD)

Question 35

Hereditary disease- requires genetic counseling. Cysts in the medulla. Kidneys are scarred and can’t concentrate urine.

Answer 35

Medullary cystic disease

Question 36

Inherited disease that affects the glomeruli. Can have deafness and eye problems. Hematuria, proteinuria, edema, HTN. Does not recur after transplant

Answer 36

Alport syndrome

Question 37

Renal involvement in metabolic and connective tissue diseases

Answer 37

Manage the primary disorder. Prevent ESRD. Diabetic neuropathy (1* cause of ESRD). Gout.. Amyloidosis. SLE. Scleroderma.

Question 38

Cigarette smoking is the biggest risk factor.
S/S: no early signs, hematuria, flank pain, palpable mass in flank or abdomen, weight loss, fever, HTN, anemia
Dx: CT, US, needle aspiration, MRI, IVP
Tx: radical nephrectomy, radiation for palliation, cry oblation or radio frequency ablation if surgery is not an option, chemo for metastasis

Answer 38

Kidney cancer

Question 39

More common in men. Risks include cigarette smoking, exposure to dyes, chronic kidney stones, chronic lower UTIs.
S/S: painless hematuria, bladder irritability with dysuria, frequency, urgency.
Dx: urine cytology, CT, US, MRI, cystoscopy with biopsy
Tx: intravesical chemo, TURBT
Very high incidence of recurrence

Answer 39

Bladder cancer

Question 40

Bladder cancer post-op care

Answer 40

Drink large volumes of fluid, no alcohol.
Watch for bright red blood and clots
Expect pink urine for a few days (dark red flecks 7-10 days after from scabs)
Give opioids and stool softeners
Take 2-3 sit baths/day
Need follow up cystoscopies every 3-6 months for 3 years and then yearly
May have radiation and chemo

Question 41

Instillation of chemo into the bladder by catheter (can also give BCG or interferon).
Done weekly, retained for 2 hours.
Must empty bladder before instillation and change position every 15 minutes.
No systemic effects (i.e. hair loss, n/v, stomatitis), but can cause hemorrhagic cystitis
Increase daily fluid intake, stop smoking, watch for UTIs, must have routine urologic follow ups

Answer 41

Intravesical Chemo

Question 42

Uncontrolled leakage of urine (multiple types. Stress, urge [overactive bladder], overflow, functional).
Dx: hx, voiding log, careful exam, UA, PVR, urodynamic testing
Tx: 80% can be fixed. Stress- kegel exercises, biofeedback. Urge-bladder training, meds (alpha-adrenergic agonists [Cardura, Hytrin, Flomax], anticholinergics [detrol, ditropan, vesicare]).
Surgery to reposition the urethra or support the bladder.

Answer 42

Urinary incontinence

Question 43

Urinary incontinence nursing care

Answer 43

Ensure adequate fluid volume. Reduce bladder irritants. Toiling every 2-3 hours during the day. Quit smoking. Prevent constipation. Kegel exercises. Don’t use feminine hygiene pads-use specific