Class 4 Renal/Urinary elimination adult Flashcards
Define: Anuria
Failure of kidney to produce urine
Define: Oliguria
Small amount of urine production (less than 400mL/24 hour)
Define: Polyuria
Passing abnormal large amount of urine (over 3L/24 hour)
Define: Frequency
Voiding more than 8x during waking hours (the feeling of having to void all the time)
Define: Urgency
Sudden need to urinate
Define: Dysuria
Pain with urination
Define: Hesitancy
decrease in force of urine or difficulty starting flow
Define: incontinence
involuntary loss of urine
Retention
ACUTE?
CHRONIC?
Acute: suddenly unable to void when bladder is full
Chronic: bladder does not empty completely
Define: proteinura
excess of protein in urine
Define: glycosuria
excreation of glucose in urine
Define: Hematuria
Blood in urine
Define: Pyuria
Pus or WBC in urine
Define: Calculi
Stones in urine
Define: casts
Tube shape particles containing WBC, RBC, kidney cells or substances such as protein or fat
Define: CCMS
Clean catch midstream sample. patient must clean perineal area, start to void, then collect urine sample during voiding stream
Define: C&S
Culture (identify the pathogen) and Sensitivity (identify which antibiotic will work)
Define: UA
Urinalysis, to get a baseline, diagnosis, and whether the therapy is working.
Define: PVR
Post Void residual. <50mL is considered residual after voiding
24 hour urine collection
Patient voids at 7am and dumps 1st void. Collects all voids for remaining 24 hours, put on ice. If one void is not collected during that 24 hours the process must start over
Urinalysis info, color, appearance etc
Color: light straw to amber Appearance: clear odor: aromatic pH: 4.5-8 spec. gravity: 1.005-1.030 Protein: 0-5mg/dL Glucose: neg Ketones: neg Nitrites: neg RBC: rare WBC: 3-4 Casts: occasional hyaline
What could be the cause of ketones in the urine?
high protein diet
What could be the cause of RBC in the urine?
Kidney stones
What could be the cause of WBC in the urine?
UTI, fever
What could be the cause of casts in the urine?
fever, heart failure
what would cause the pH to be under 4.5
metabolic or respiratory acidosis
What would cause the pH to be over 8
Bacteria, UTI
What would cause the specific gravity to be under 1.005
Diabetes insidious, over hydration
What would cause the specific gravity to be over 1.030
Dehydration, vomiting, fever
Urine diagnostic Tests
What is PSA (blood)
Prostate-specific antigen
protein produced by prostate and released into blood
Increases with prostate cancer
Urine diagnostic Tests
What is KUB?
Xray of the anteroposterior film of kidneys, ureters and bladder
Looks for urinary calculi and masses
Urine diagnostic Tests
What is IVP
Intravenous phylogram
Xrays after IV injection of contrast.
Looks for stones, masses, hematuria, obstruction
**ask pt is they are allergic to seafood, iodine or contrast
**done before KUB if both are ordered
Pre-procedure: bowel prep, NPO 8 hr (water ok)
Post-procedure: V/S, when to contact provider
Blood test
BUN (10-20 norm): increased= impaired renal function, sepsis, increased protein intake, starvation, dehydration, heart failure
Creatinine (0.6-1.2 norm): increased= impaired renal function
GFR (>60) or (90-100): <15 is considered end stage renal failure
Urine diagnostic Tests
Radiology: retrograde pyelogram
Used for clients who are allergic to iodine-based contrast
Contrast admin directly into urinary tract during cystoscopy.
Evaluates: Ureters, renal pelvis, calyces
Urine diagnostic Tests
Radiology: Cystogram
Contrast instilled into bladder via catheter.
Evaluates: UTI’s, reflux, hematuria, trauma, surgical healing, stress incontinence
Urine diagnostic Tests
Radiography: voiding cystogram
Similar to cystogram but films taken while client is voiding.
Evaluates urethral stricture, fistula, trauma, diverticulum or tumor
CT scan, MRI, Renal angiography
Urine diagnostic Tests
Ultrasonography
Evaluates: kidneys, ureters, bladder, prostate, testes and penis.
Bladder scan
Prostate scan: performed transrectally, pre-procedure prep: enema
Diagnostic Tests
Surgical: Endoscopy
Cystourethroscopy and Urethroscopy
Preop: UA, permits, IV fluids
Intra-op: anesthesia, lithotomy position
Post-op education: increase fluids, assess bleeding, monitor for infection, warm baths, NSAIDS’s, cath for retention, B&O (Belladonna and opioids) for bladder spams
Diagnostic Tests
Surgical: Endoscopy
Ureteroscopy, Nephroscopy, Ureterorenoscopy
Preop: UA, antibiotics, NPO, permits
Intra-op: anesthesia, Trendelenburg position
Postop: observation for perforation and urinary extravasation into abdomen, infection, renal colic, bleeding.
Unilateral stents may be left in for at least 48 hours
increase fluids
continue antibiotics
Diagnostic Tests
Surgical: Biopsy
Transurethral bladder
Transrectal Prostate
Percutaneous and Open Renal
Obstructive Disorders
Bladder cancer: surgical treatment
What is TUR?
Transurethral resection. used to diagnose cancer and remove cancerous tissue from bladder
- for low grade superficial tumors
- palliative for inoperable tumors
- often followed with intravesical BCG (bacillus Calmette-Guérin) or chemo
Obstructive Disorders
Bladder cancer: surgical treatment
What is Fulguration?
Uses heat from electricity current to destroy abnormal tissue
- for low grade superficial tumors
- palliative for inoperable tumors
- often followed with intravesical BCG or chemo
What is partial Cystectomy?
Partial bladder removal
- clients who can’t tolerate a radical cystectomy
- isolated tumors that can’t be treated with TUR
Obstructive Disorders
Bladder cancer: surgical treatment
What is radical cystectomy and urinary Diversion?
Requires urinary diversion
Also done for Neurogenic Bladder, Radiation Induced Cystitis and Congenital defects
Used for when tumors have invaded the bladder wall
Obstructive Disorders
Bladder cancer: Urinary Diversion
What is Ileal Conduit?
ureteroileostomy, ileal bladder or Bricker’s procedure
- portion of intestine used to form stoma
- ureters implanted into this portion of intestine
- continuous urine flow
- incontinent diversion
Obstructive Disorders
Bladder cancer: Urinary Diversion
What is Cutaneous Ureterostomy?
- each ureter brought to surface of ab to form a stoma
- continuous drainage
- incontinent diversion
Obstructive Disorders
Bladder cancer: Urinary Diversion
What is Indiana Pouch?
- improved/larger version of Kock Pouch
- reservoir created from ascending colon and terminal ileum
- ureters implanted into side of diversion
- special nipple valve, used to attach reservoir to skin
- internal storage 800mL
- no drainage devise needed
- must be drained every 3-4 hours
- continent diversion
Obstructive Disorders
Bladder cancer: Urinary Diversion
Guidelines for patients for Indiana Pouch?
- > 2 years of life expectancy
- 1-3 hours surgery
- creatinine 2.5 or less
- fine motor skills needed
- electrolyte re-absorption is minimal if urine is drained regularly
- no severe bowel history
Obstructive Disorders
Bladder cancer: Urinary Diversion
Orthotopic neobladder?
Must have normal liver/renal function Good motor skills 1-2 years life expectancy May need to cath but might be able to void normally May have incontinence
Obstructive Disorders
Bladder cancer: Urinary Diversion
Total Cystectomy with Urinary Diversion Pre op
- bowel prep (clear liquids 1-3 days, laxatives/enemas night before, antibiotics, NPO night before)
- Enterostomal nurse visitation
- potential sexual dysfunction
- informed consent
Obstructive Disorders
Bladder cancer: Urinary Diversion
Total cystectomy with Urinary diversion Post op
- usual post op assessments
- assess stoma (q 2hr x 24 hr, q 4hr x 48-72 hrs, q 8hr for color and patency) report if dusky color, could be necrosis.
- NPO until peristalsis resumes or bowel sounds
- I/O q 1 hour
- assess urine
- monitor for complications
What is minimum urine output per hour?
30mL/hr x 24 hour OR 720mL a day
Obstructive Disorders
Ureteral Tumors info
Primary tumors are rare
Gross hematuria is usually 1st symptom
Treatment: surgical incision and resection
Obstructive Disorders:
What is Urolithiasis?
Etiology?
Pathophysiology?
Urinary Calculi
Etiology: 2 primary causes, Urinary stasis or supersaturation of urine with poorly soluble crystalloids r/t fluid depletion or increased solutes, family history
Pathophysiology:
Types of calculi:
calcium phosphorus or oxalate (most common)
uric acid
struvite (stones), cystine (genetic defect)
Obstructive Disorders:
urolithiasis potential damage?
- obstruction with possible hydronephrosis
- tissue trauma with hemorrhage
- infection
Obstructive Disorders:
Urolithiasis (kidney stones) clinical manifestations and Diagnosis
Manifestation: sharp, severe, sudden pain (renal or ureteral colic)
N/V, pallor, diaphoresis and anxiety
Gross hematuria
Elevated temp and WBC
Diagnosis: UA, KUB, IVP, Cystoscopy used to diagnosis calculi
Obstructive Disorders:
Urolithiasis treatment
Relieve acute manifestations
Facilitate passage of stone
Increase fluids
Decrease pain
Obstructive Disorders:
Urolithiasis preventing stone recurrence
FLUID, MEDICATION, DIETARY
Increase fluids- 2.5-3L per day
Medications:
Calcium and oxalate stone- thiazide diuretic
Uric and cystine stone- potassium citrate
Dietary modifications
Calcium stone- reduce calcium/sodium/protein
Calcium oxalate- reduce spinach, nuts, chocolate, beer, pop, beets
Uric stones- need purine diet of increase organ meats, venison, sardines
Obstructive Disorders:
Urolithiasis Surgical Management
3 types?
Laser Lithotripsy- lasers and ureteroscopy remove or loosen impacted stones
Extracorporeal Shock Wave Lithotripsy (ESWL)- external sound waves break up stones
Percutaneous Nephrolithotomy- guide inserted through skin under fluoroscopy near stone and an ultrasonic wave is used to break up stone
Obstructive Disorders:
Urinary Reflux causes and pathophysiology
-backward flow of urine
-severity ranges from Grade I to Grade V
Causes: congenital abnormality, chronic bladder infections, outlet obstruction in bladder neck
Pathophysiology: continuous presence of residual urine, leads to chronic UTI’s, renal damage and/or pyelonephritis (kidney infection)
Obstructive Disorders:
Urinary Reflux surgical management
- usually involves re-implantation of ureters
- post op: urethral or suprapubic catheter
- advantages of ureteral catheter: splints ureter to facilitate healing, prevents obstruction due to post op/trauma edema, drain urine
Voiding Disorders:
Urinary Retention
- inability of bladder to empty partially or completely
- PVR (post void residual >50 mL)
- patient dribbling (voiding 25-50 mL at a time)
Causes: detrusor muscle failure, decreased sensory input to bladder (anesthesia), BPH (benign prostatic hyperplasia), rectocile (rectal) or enterocele (vaginal) prolaps, poor bladder muscle tone
Urinary Retention Medical treatment
Identify and remove cause
cholinergic medication (increases peristalsis)
urethral dilation
Voiding Disorders:
Urinary Retention Surgical Management
- done if structural defect is found
- removal of enlarged prostate or urethral stricture
- correction of structural abnormality
- bladder neck repair
- suprapubic cystotomy (done when urethral cath is diff, inserted through ab into bladder, used for bladder training
Prostate Disorders:
BPH (benign prostatic hyperplasia)
- abnormal increase in the number of normal cells (hyperplasia) in prostate
- excessive smooth muscle contraction
Prostate Disorders:
BPH (benign prostatic hyperplasia)
clinical manifestations?
- usually develops slowly
- decreases in size and force of urine stream
- hesitancy, urgency, nocturia
- incomplete emptying
- urine leaking
Prostate Disorders:
BPH (benign prostatic hyperplasia)
Medical Management?
- slow prostate growth (Proscar med, takes 6-12 months)
- relax prostate muscle (Flomax)
- relieve retention, catheterization
Prostate Disorders:
BPH (benign prostatic hyperplasia)
Surgical management?
- TURP (transurethral resection of prostate), most common, “gold standard”
- TUIP (transurethral incision of prostate)
- open prostatectomy
Prostate Disorders:
BPH (benign prostatic hyperplasia)
Post Op Care
- Prevention of injury (no straining during defecation, prevent constipation, avoid bladder irritants)
- Monitor for bleeding/bladder irrigation
- Strict I/O
- Pain medication
- Pelvic exercises
- Erectile dysfunction (rare), Viagra, sexual counseling
- Arrange follow-up
Urinary Drainage Systems:
Maintenance
- Uro-meter (little plastic measure on bag)
- I/O for continuous/intermittent bladder irrigation
- *total output - amount of irrigation admin = urine output
What are the 2 highest diseases that cause renal insufficiency/failure?
Diabetes
Hypertension
