Chapter 46: Renal and Urologic Problems Flashcards
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
Urinary Tract Infection (UTI)
Dx of UTI
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
UTI Tx
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
UTI prevention
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.
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.
Acute pyelonephritis
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).
Dx of UTIs
Tx of UTIs
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
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
Urosepsis
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.
Chronic pyelonephritis
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
d) A 72 y/o woman hospitalized with a stroke who has a urinary catheter b/c of urinary incontinence
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.
Urethritis
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
Urethral stricture
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.
Interstitial Cystitis
Tx of interstitial cystitis
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)
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
Glomerulonephritis
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
Acute post-streptococcal glomerulonephritis (APSGN)
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
Goodpasture syndrome
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
Nephrotic syndrome
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
Obstructive uropathies
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).
Urinary tract calculi
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.
Nephrolithiasis (Kidney stones)
Reduce dietary oxalate (green veggies, tomatoes, beets, nuts, chocolate, cocoa, tea); give diuretics; reduce sodium intake
Calcium oxalate or phosphate
Usually in women. Always associated with UTI. Give ABX. Acetohydroxamic acid, remove stone with surgery, acidify urine
Struvite (magnesium ammonium phosphate)
Usually in men, alkalinize urine, give allopurinol, reduce dietary purines (red meats, shellfish, fish)
Uric acid
Genetic defect, increase hydration, give potassium citrate to alkalinize urine
Cystine
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
Kidney stones
Tx of kidney stone
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
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
Lithotripsy
Prevention of future kidney stones
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
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
d) Drink 2000 to 3000 mL of fluid a day
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
Ureteral stricture
Blunt trauma is most common. Suspect in any abdominal trauma.
Renal trauma
Renal vascular problems
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
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
Polycystic kidney disease (PKD)
Hereditary disease- requires genetic counseling. Cysts in the medulla. Kidneys are scarred and can’t concentrate urine.
Medullary cystic disease
Inherited disease that affects the glomeruli. Can have deafness and eye problems. Hematuria, proteinuria, edema, HTN. Does not recur after transplant
Alport syndrome
Renal involvement in metabolic and connective tissue diseases
Manage the primary disorder. Prevent ESRD. Diabetic neuropathy (1* cause of ESRD). Gout.. Amyloidosis. SLE. Scleroderma.
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
Kidney cancer
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
Bladder cancer
Bladder cancer post-op care
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
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
Intravesical Chemo
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.
Urinary incontinence
Urinary incontinence nursing care
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
