Exam 2 (Ch. 49, 50, & 51) PPT Flashcards
Health History
What type of questions would you ask the client about their urinary elimination history?
Questions to establish general patterns and any changes.
For Female Clients:
Have you had any pregnancies? (Pregnancy can affect bladder control and pelvic floor muscles.)
Have you experienced any changes in your urinary habits after menopause? (Hormonal changes can affect urinary function.)
For Male Clients:
Have you noticed any changes in your urinary stream or frequency? (Changes in urinary habits can be a sign of prostate problems.)
See PPT for more specific question examples
Health History
Which of the following questions would be MOST important to include when obtaining a urinary elimination history? (Select all that apply.)
A. “How many times do you urinate during the day?”
B. “Have you noticed any changes in the color or odor of your urine?”
C. “Do you experience any pain or burning when you urinate?”
D. “Have you had any recent changes in your fluid intake?”
E. “Do you ever leak urine when you cough, sneeze, or laugh?”
F. “Have you ever had a urinary tract infection?”
G. “Are you taking any medications, including over-the-counter drugs or supplements?”
H. “Have you noticed any swelling in your feet or ankles?”
A, B, C, D, E, F, G
Rationale: All of these questions are relevant to a comprehensive urinary elimination history. They cover frequency, changes in urine characteristics, pain, incontinence, fluid intake, past UTIs, and medication use, all of which can affect urinary function. While ankle swelling (H) can be related to fluid balance, it’s not directly part of the urinary elimination history itself, but rather a broader assessment of fluid status.
Health History
The patient reports urinary frequency and urgency. Which of the following follow-up questions would be MOST important to ask to further explore these specific symptoms? (Highlight the correct answers.)
A. “How long have you been experiencing this?”
B. “Do you have any difficulty starting your urine stream?”
C. “Do you feel like your bladder is completely empty after you urinate?”
D. “Do you drink a lot of caffeinated beverages?”
E. “Have you noticed any blood in your urine?”
F. “Do you ever have accidents where you don’t make it to the bathroom in time?”
A, D, F
Rationale: These questions directly relate to frequency and urgency.
A helps determine the duration of the problem.
D explores potential contributing factors (caffeine is a diuretic).
F assesses urge incontinence (leakage due to urgency). The other questions are important but not the most directly related to frequency and urgency.
A patient reports urinary frequency, urgency, and dysuria. Which action by the nurse is the PRIORITY?
A. Obtain a urine specimen for analysis.
B. Educate the patient on Kegel exercises.
C. Encourage the patient to increase fluid intake.
D. Ask the patient about their typical daily fluid intake.
A. Obtain a urine specimen for analysis.
Rationale: With dysuria (painful urination), the priority is to assess for a urinary tract infection, making a urine specimen crucial for diagnosis. The other actions are important but secondary to ruling out an infection.
Assessment Abnormalities
What does anuria mean?
Absence of urine production.
This is a serious condition often indicating kidney failure.
(24-h urine output <100 mL)
Possible Etiology and Significance
Acute kidney injury, end-stage renal disease (ESRD), bilateral ureteral obstruction
Assessment Abnormalities
What might buring on uriniation mean?
A common symptom of urinary tract infection (UTI) or other inflammation of the urinary tract.
Stinging pain in urethral area
Possible Etiology and Significance
Urethral irritation, UTI, urethral stones
Assessment Abnormalities
What is dysuria?
Painful or difficult urination.
Possible Etiology and Significance
UTI, interstitial cystitis, urethral stones, and wide variety of pathologic conditions
Assessment Abnormalities
What is enuresis?
Involuntary nocturnal urination
Involuntary urination, especially at night (bedwetting). Can be normal in young children but may indicate a problem in older individuals.
Possible Etiology and Significance
Lower urinary tract disorder
Assessment Abnormalities
What is frequency?
The need to urinate more often than usual, but with normal or small volumes of urine per void.
↑ Incidence of urination
Possible Etiology and Significance
Acutely inflamed bladder, retention with overflow, excess fluid intake, intake of bladder irritants, urethral stones
Assessment Abnormalities
What is hematuria?
Terms Related to Urine Components/Characteristics:
Blood in the urine. Can be visible (gross hematuria) or microscopic (microscopic hematuria).
Possible Etiology and Significance
Cancer of genitourinary tract, blood dyscrasias, kidney disease, UTI, stones in kidney or ureter, anticoagulants
Assessment Abnormalities
What does hesitancy mean?
Delay or difficulty in initiating urination
Possible Etiology and Significance
Partial urethral obstruction, BPH
Assessment Abnormalities
What is incontinence?
Inability to control urination, leading to involuntary leakage.
Possible Etiology and Significance
Neurogenic bladder, bladder infection, injury to external sphincter
Assessment Abnormalities
What is nocturia?
Excessive urination at night, waking the person from sleep.
Possible Etiology and Significance
Kidney disease with impaired concentrating ability, bladder obstruction, heart failure, diabetes, post renal transplant, excess evening and nighttime fluid intake
Assessment Abnormalities
What is oliguria?
Decreased urine output compared to normal.
↓ Amount of urine in a time period (24-hr urine output of 100–400 mL)
Possible Etiology and Significance
Severe dehydration, shock, transfusion reaction, kidney disease, ESRD
Assessment Abnormalities
What might pain with urination indicate?
Pain associated with urination or in the flank, suprapubic region, or lower back may indicate a UTI, kidney stones, or other urinary tract issues.
Suprapubic pain (related to bladder), urethral pain (irritation of bladder neck), flank pain, CVA tenderness
Possible Etiology and Significance
Infection, urinary retention, foreign body in urinary tract, urethritis, pyelonephritis, renal colic, stones
Assessment Abnormalities
What is pneumaturia?
Terms Related to Urine Components/Characteristics:
Passage of urine containing gas
Gas in the urine. Usually indicates a fistula (abnormal connection) between the urinary tract and the bowel.
Possible Etiology and Significance
Fistula connections between bowel and bladder, gas-forming UTI
Assessment Abnormalities
What is polyuria?
Excessive urination, producing large volumes of urine.
Large volume of urine in a time period
Possible Etiology and Significance
Diabetes, diabetes insipidus, chronic kidney disease, diuretics, excess fluid intake, obstructive sleep apnea
Assessment Abnormalities
What is retention?
Inability to urinate even though bladder contains excess amount of urine
Possible Etiology and Significance
Finding after pelvic surgery, childbirth, catheter removal, anesthesia; urethral stricture or obstruction; neurogenic bladder
Assessment Abnormalities
What is stress incontinence?
Leakage of urine with increased abdominal pressure, such as coughing, sneezing, or laughing.
Involuntary urination with ↑ pressure (sneezing or coughing)
Possible Etiology and Significance
Weakness of sphincter control, lack of estrogen, urinary retention
Urinary Elimination Findings
How would you document urinary elimination findings?
- General Information:
Frequency, Amount, Color, & Odor - Specific Symptoms:
Dysuria, Hematuria, Frequency, Urgency, Hesitancy, Incontinence, Nocturia, Polyuria, Oliguria, Anuria, & Cloudy urine - Associated Factors:
Fluid intake & Medications - Diagnostic Tests and Results:
Urinalysis, Urine culture, & Bladder scan
Diagnostic Studies
What are general urinalysis for?
What should be done before, during, & after the study
General examination of urine to establish baseline information or provide data to establish a tentative diagnosis and determine if further studies are needed.
Before: Wash perineal area before collecting specimen.
During: Try to obtain first urinated morning specimen.
After: Ensure specimen is examined within 1 hr of urinating.
Diagnostic Studies
What is a urine culture and what does it reveal?
What it is: A test to identify and grow bacteria in urine.
What it reveals: The specific type of bacteria causing a urinary tract infection (UTI) and which antibiotics are effective against it (sensitivity testing).
Diagnostic Studies
What is the nurses responsibility during a creatinine clearance test?
During: Collect 24-hr urine specimen. Discard 1st urination when test is started. Save urine from all subsequent urinations for 24 hr. Have patient urinate at end of 24 hr and add specimen to collection. Measure serum creatinine during 24-hr period.
Clearance of creatinine by kidney approximates the GFR.
Calculated as follows:
Reference interval: (Book)
Male: 107–139 mL/min/1.73 m2
Female: 87–107 mL/min/1.73 m2 (corrected for body surface area).
PPT: Normal GFR is about 125 mL/min
Diagnostic Studies
What is a cystoscopy, and what is it used for?
Involves inserting a scope into the urethra to visualize the bladder and urethra. Useful for diagnosing bladder cancer, stones, or other abnormalities. Can be used to insert ureteral catheters, remove stones, obtain biopsy specimens of bladder lesions, treat bleeding lesions.
Diagnostic Studies
What is a nurses responsibilty before and after a cystoscopy?
Before: Give IV fluids if general anesthesia is to be used. Ensure consent form is signed. Explain procedure to patient. Give preoperative medication.
After: Explain that burning on urination, pink-tinged urine, and urinary frequency are expected effects. Observe for bright red bleeding, which is not normal. Help with ambulation because orthostatic hypotension may occur. Offer warm sitz baths, heat, mild analgesics to relieve discomfort.
Diagnostic Studies
What is does a cystogram do and what is it for?
Visualizes bladder and evaluates vesicoureteral reflux. Evaluates patients with neurogenic bladder and recurrent UTIs. Can delineate abnormalities of bladder (e.g., diverticula, stones, tumors). Contrast media instilled into bladder via cystoscope or catheter.
Diagnostic Studies
What is a nurses responsibilty before and during a cystogram?
Before: Explain procedure to patient.
During: If done via cystoscope, follow nursing care related to cystoscopy.
Diagnostic Studies
What is a KUB X-Ray and what is it for?
KUB (Kidneys, Ureters and Bladder)
X-ray examination of abdomen and pelvis. Delineates size, shape, and position of kidneys, ureter, and bladder. Can see radiopaque stones and foreign bodies.
Diagnostic Studies
What is a renal ultrasound?
Can visualize the structures and identify abnormalities like kidney stones, tumors, or blockages.
Detects renal or perirenal masses (tumors, cysts) and obstructions. Computer interprets tissue density based on sound waves and displays it in picture form. Safe for patients with renal failure.
Diagnostic Studies
What is a nurses responsibilty before and during a renal ultrasound?
Before: Explain procedure to patient. No bowel preparation needed.
During: Because radiation exposure is avoided, can obtain repeated images over a brief period.
Diagnostic Studies
What is a renal biopsy?
also known as a kidney biopsy
A procedure in which a small sample of kidney tissue is removed and examined under a microscope.
Usually done as a skin (percutaneous) biopsy through needle insertion into lower lobe of kidney under CT or ultrasound guidance.
Diagnostic Studies
What is the purpose of a renal biopsy?
- Diagnose kidney disease
- Evaluate the severity of kidney damage
- Monitor the progression of kidney disease
- Assess the function of a transplanted kidney
- Investigate unexplained kidney problems
Obtains renal tissue for examination to determine type of kidney disease or to follow progress of kidney disease.
Absolute contraindications are bleeding disorders, single kidney, and uncontrolled hypertension.
Relative contraindications include suspected renal infection, hydronephrosis, and possible vascular lesions.
Diagnostic Studies
What is the nursing responsibility before and after the procedure?
Before: Type and crossmatch patient for blood. Ensure consent form is signed. Assess coagulation status through patient history, medication history, CBC, hematocrit, prothrombin time, and bleeding and clotting time. Patient should not be taking aspirin or warfarin.
After: Apply pressure dressing and keep patient on affected side for 30–60 min. Bed rest for 24 hr. Vital signs every 5–10 min, first hour. Assess for flank pain, hypotension, decreasing hematocrit, fever, chills, urinary frequency, dysuria, and gross or microscopic hematuria. Inspect biopsy site for bleeding. Teach patient to avoid lifting heavy objects for 5–7 days and to not take anticoagulant drugs until allowed by HCP
Nursing Management: UTI
What are the key problems with UTI nusing management?
Imparied Urinary System Function
- Assessment: Monitor for changes in urinary frequency, urgency, hesitancy, dysuria (painful urination), hematuria (blood in urine), or cloudy/foul-smelling urine. Assess for bladder distention.
Acute Pain
- Assessment: Assess pain level using a pain scale. Note location, character, and duration of pain.
Knowledge Deficit
- Assessment: Assess the patient’s understanding of UTIs, risk factors, treatment, and prevention strategies.
Nursing Management: UTI
What are the goals of UTI nusing management?
Relief from bothersome symptoms
- Assessment: Identify specific symptoms (dysuria, frequency, urgency, nocturia, hematuria, etc.) Assess their severity and impact on the patient’s quality of life.
No upper urinary tract involvement
- Assessment: Monitor for signs and symptoms of upper UTI (fever, chills, flank pain, nausea, vomiting). Assess urine for casts (indicating kidney involvement).
Non recurrence
- Assessment: Identify risk factors for recurrent UTIs (female sex, history of UTIs, sexual activity, urinary retention, etc.).
Follow-up: Encourage regular follow-up appointments with the healthcare provider to monitor for recurrence and address any concerns.
A 25-year-old female patient is diagnosed with a urinary tract infection (UTI). Which of the following interventions is MOST important in preventing the recurrence of UTIs?
A) Advising the patient to drink cranberry juice daily.
B) Educating the patient about the importance of completing the prescribed antibiotic course.
C) Instructing the patient to take a prophylactic antibiotic after sexual intercourse, if prescribed.
D) Recommending the patient to use scented feminine hygiene products.
C
Rationale: While options A and B are helpful in managing and preventing UTIs, option C directly addresses a known risk factor for recurrent UTIs in some women – sexual activity. If a healthcare provider deems it appropriate, post-coital antibiotic prophylaxis can be a very effective strategy in preventing recurrences. Option D is incorrect as scented feminine hygiene products can irritate the urethra and increase the risk of UTIs.
Prioritizing Actions (Select All That Apply)
A 25-year-old female patient presents to the clinic with complaints of dysuria, frequency, and urgency.
Which of the following actions should the nurse prioritize when caring for this patient? (Select all that apply.)
A. Obtain a urine specimen for culture and sensitivity.
B. Administer phenazopyridine (Pyridium) for pain relief.
C. Encourage the patient to increase fluid intake.
D. Educate the patient on preventive measures for UTIs.
E. Assess for flank pain and costovertebral angle (CVA) tenderness.
F. Administer antibiotics as prescribed.
A, C, E
Rationale: Obtaining a urine specimen (A) is essential for diagnosis. Assessing for flank pain/CVA tenderness (E) helps determine if the infection has spread to the kidneys. Increasing fluid intake (C) helps dilute the urine and flush out bacteria. While pain relief (B) and patient education (D) are important, they are not the immediate priorities. Antibiotics (F) are essential but cannot be administered until a culture is obtained (unless it is a standing order for suspected UTI).
Which statements by the patient indicate a need for further teaching regarding UTI prevention?
A. “I should wipe from front to back after using the toilet.”
B. “I should drink at least 8 glasses of water a day.”
C. “I should avoid using scented feminine products.”
D. “I should empty my bladder as soon as I feel the urge to go.”
E. “I should take a cranberry supplement daily, even if I don’t have a UTI.”
F. “I should douche regularly to maintain vaginal hygiene.”
F
Rationale: Douching disrupts the natural flora of the vagina and can increase the risk of UTIs.
Gerontologic Considerations
What are some renal structural and functional changes seen with age?
These factors specifically increase the risk of UTIs in older adults
Gerontologic Considerations
What risk is associated with the incomplete emptying of bladder, urinary stasis, decreased nerve innervations commonly seen in older adults?
These factors specifically increase the risk of UTIs in older adults
Gerontologic Considerations
Why does the decrease in drug clearance increase drug-drug interactions?
Aging kidneys process and eliminate drugs more slowly. This can lead to higher drug levels in the body, increasing the risk of side effects and toxicity.
Older adults often take multiple medications for various conditions. Reduced kidney function can exacerbate the risk of interactions between these drugs, potentially leading to serious adverse events.
Gerontologic Considerations
What is a common mistconspection about the urinary system and aging?
That urinary incontinence is a normal part of aging.
While some older adults experience incontinence, it is not an inevitable consequence of aging.
It often results from underlying medical conditions, such as:
- Urinary tract infections
- Weak pelvic floor muscles
- Enlarged prostate (in men)
- Neurological disorders
- Medications
Which of the following factors increase this patient’s risk for a UTI? (Select all that apply.)
A. Age
B. Hypertension
C. Female sex
D. Osteoarthritis
E. Mild cognitive impairment
A & C
Rationale: Age and female sex are significant risk factors for UTIs. While hypertension and osteoarthritis are medical conditions, they are not directly linked to increased UTI risk. Cognitive impairment might indirectly contribute if it affects hygiene or fluid intake, but age and sex are the primary risk factors here.
Which of the following assessment findings would be MOST concerning in this older adult patient with a suspected UTI? (Highlight the concerning findings.)
A. Temperature of 99°F (37.2°C)
B. Reports of dysuria and frequency
C. New onset of confusion
D. Urine with a cloudy appearance
E. Mild tenderness upon palpation of the suprapubic area
F. Increased falls within the past 24 hours
C, F
Rationale: Older adults may not present with classic UTI symptoms like high fever. New-onset confusion (C) and increased falls (F) can be subtle signs of a UTI in this age group and are more concerning than a low-grade fever.
Urinary Retention
What might the following statement be associated with?
“Inability to empty bladder with voiding or the accumulation of urine because of inability to void”
May be associated with leakage or post void dribbling—overflow UI
- Overflow incontinence can occur with urinary retention. Because the bladder is full, urine can leak out involuntarily.
Urinary Retention
What is acute urinary retention?
What is the #1 intervention?
A sudden inability to urinate. It’s a medical emergency because it can cause significant discomfort and potentially lead to bladder damage or kidney problems.
Intervention: Bladder Scan
- A non-invasive ultrasound that measures the amount of urine in the bladder. It’s crucial for diagnosing urinary retention and guiding further treatment.
Urinary Retention
What is chronic urinary retention?
Incomplete emptying of the bladder despite voiding. It may or may not be symptomatic.
Urinary Retention
What is post void residual (PVR), include range?
PVR refers to the amount of urine left in the bladder after urination. A small amount is normal (50 to 75 mL)
More than 100 mL - repeat or further evaluation with UTIs: A More than 100 mL is considered abnormal. It may warrant repeating the measurement or investigating for urinary tract infections (UTIs), as retained urine can increase the risk of infection.
More than 200 mL - Requires further evaluation to determine the cause and appropriate treatment.
Assessment (Select All That Apply)
A 65-year-old male patient presents to the clinic reporting difficulty urinating, a weak urine stream, and a feeling that his bladder is not completely empty after voiding.
Which of the following assessments would be MOST important for the nurse to perform? (Select all that apply.)
A. Palpate the abdomen for bladder distention.
B. Auscultate for bowel sounds.
C. Assess the patient’s perineal area for skin breakdown.
D. Inquire about the patient’s fluid intake patterns.
E. Measure the patient’s blood pressure and heart rate.
F. Ask the patient about any history of urinary tract infections.
A, C, D, F
Rationale: Palpating for bladder distention (A) directly assesses for urine retention. Checking the perineal area (C) identifies potential skin breakdown from leakage or prolonged wetness. Fluid intake (D) is relevant to urine production and elimination. A history of UTIs (F) can contribute to recurrent retention. While bowel sounds (B) and vital signs (E) are part of a general assessment, they are not the most directly related to urinary retention.
Urinary Catheterization
What are some reasons for an indwelling catheterization?
- Relief of urinary retention
- Bladder decompression preop or postop
- Facilitate surgery
- Facilitate healing
- Accurate I & O—critical care
- Stage III or IV pressure ulcer
- Terminal illness—comfort
Urinary Catheterization
What are some reasons for an intermittent catheterization?
- Relief of urinary retention
- Diagnostic study
- Urodynamic testing
- Sterile specimen
- Medication instillation
- Measure PVR
Urinary Catheterization
What are soem nursing considerations for catheterization?
Sterile Technique: Prevent UTIs
Proper Insertion Technique: To minimize trauma to the urethra.
Catheter Care: Prevent infection.
Monitoring Urine Output: Regularly checking the amount, color, and characteristics of urine.
Patient Comfort: Ensuring the catheter is secure and not causing discomfort.
Removal: Minimize discomfort and trauma.
Documentation: Accurate recording of the procedure, including the type and size of catheter inserted, the amount and characteristics of urine drained, and the patient’s response.
Urinary Catheterization
What are some potential complications of catheterization?
Catheter Associated Urinary Tract Infection (CAUTI): The most common complication.
Bladder Spasms: Can cause discomfort or pain.
Periurethral abscess: Occurs around the urethra, often due to infection introduced by the catheter. It can cause pain, swelling, and discharge.
Chronic pyelonephritis: A long-term kidney infection
Urosepsis: A severe, life-threatening infection of the urinary tract that has spread to the bloodstream.
Urethral trauma or erosion: The catheter can irritate and damage the urethra, especially with long-term use. This can lead to inflammation, erosion (wearing away of tissue), and pain.
Fistula: An abnormal connection between two body parts
Stricture formation: A narrowing of the urethra
Stones: Urinary catheters can increase the risk of urinary stones forming. This is because they can introduce bacteria and create a surface for minerals in the urine to deposit on.
Catheter Obstruction: Due to sediment or blood clots.
Long-term catheterization carries significant risks. It’s crucial to use catheters only when necessary and for the shortest duration possible to minimize these complications. Proper catheter care and hygiene are also essential.
Place the following steps for inserting an indwelling urinary catheter in the correct order:
* Inflate the catheter balloon.
* Cleanse the perineal area with antiseptic solution.
* Insert the catheter through the urethra into the bladder.
* Lubricate the catheter tip.
* Don sterile gloves.
- Don sterile gloves.
- Lubricate the catheter tip.
- Cleanse the perineal area with antiseptic solution.
- Insert the catheter through the urethra into the bladder.
- Inflate the catheter balloon.
Rationale: Sterile technique is paramount. Lubrication facilitates insertion. Cleansing reduces infection risk. Insertion precedes balloon inflation to secure the catheter.
Which of the following findings would be MOST concerning and require immediate intervention after urinary catheterization? (Highlight the concerning findings.)
A. Urine output of 20 mL/hour
B. Blood in the urine
C. Patient reports discomfort at the insertion site
D. Leakage around the catheter
E. Fever and chills
A, E
Rationale: Urine output less than 30 mL/hr can indicate kidney issues or catheter obstruction and requires prompt attention. Fever and chills are signs of a potential UTI, a common complication of catheterization. Blood in the urine and discomfort are possible but not as immediately concerning as low urine output and signs of infection. Leakage might indicate a catheter issue but is not as urgent as infection or kidney compromise.
Preventing CAUTI
What are 3 major methods to prevent CAUTIs?
- Use sterile technique if need to open system; consider triple-lumen catheter for continuous irrigations
- Catheter change not necessary if less than 2 weeks; for long-term, determine necessity based on assessment, not routine
- Use catheter sampling port for urine culture; prepare puncture site with antiseptic solution
Preventing CAUTI
What are some ways to prevent CAUTIs involving Unlicensed Assistive Personnel (UAP)?
Ensure UAP:
- Maintains unobstructed downhill flow of urine
- Empties collecting bag regularly; records output
- Provides perineal care 1 to 2 x/day and PRN
- Does not use lotion or powder near catheter
- Uses a securement device to prevent catheter movement and urethral tension
Urinary Obstruction
What is an urinary obstruction?
Anatomic or functional condition that blocks or impedes the flow of urine
Can be congential or acquired
Urinary Obstruction
What is the difference between congenital or acquired urnary obstructions?
Congenital: The obstruction is present at birth. This usually involves a structural abnormality in the urinary tract’s development.
Acquired: The obstruction develops sometime after birth. This is caused by factors like those listed in the “anatomic” section above (kidney stones, tumors, etc.).
Scenario: A 55-year-old male patient with a history of benign prostatic hyperplasia (BPH) presents to the clinic with complaints of increasing urinary frequency, nocturia, and a weak urine stream.
Which of the following assessments would be MOST important for the nurse to perform? (Select all that apply.)
A. Palpate the abdomen for bladder distention.
B. Auscultate for bowel sounds.
C. Assess the patient’s perineal area for skin breakdown.
D. Inquire about the patient’s fluid intake patterns.
E. Measure the patient’s blood pressure and heart rate.
F. Ask the patient about any history of urinary tract infections.
A, C, D, F
Rationale: Palpating for bladder distention (A) directly assesses for urine retention. Checking the perineal area (C) identifies potential skin breakdown from leakage or prolonged wetness. Fluid intake (D) is relevant to urine production and elimination. A history of UTIs (F) can contribute to recurrent retention. While bowel sounds (B) and vital signs (E) are part of a general assessment, they are not the most directly related to urinary retention due to suspected BPH.
Nephrolithiasis
What is nephrolithiasis?
Nephrolithiasis is the formation and presence of kidney stones (calculi) in the urinary system.
Nephrolithiasis
What are some risk factors of nephrolithiasis (kidney stones)?
Metabolic: Conditions like hyperparathyroidism, renal tubular acidosis, cystinuria, and others can alter the composition of urine and increase stone formation risk.
Climate: Hot climates can lead to dehydration, concentrating urine and increasing the risk.
Dietary: High sodium, high protein, high oxalate (spinach, rhubarb), and excessive sugar intake can contribute. Inadequate fluid intake is a major risk factor.
Genetic: Family history can increase the risk of developing kidney stones.
Lifestyle: Sedentary lifestyle, obesity, and certain medications can also increase risk.
Nephrolithiasis
How are nephrolithiasis formed? How can they be prevented?
Formation: Kidney stones form when the concentration of dissolved substances (crystals) in the urine becomes too high. These crystals precipitate (come out of solution) and clump together, forming a stone.
Prevention: The key to preventing kidney stones is to keep the urine dilute (by drinking plenty of fluids) and free-flowing (preventing stasis).
Nephrolithiasis
What are some clinical manifestations of kidney stones?
First symptom—sudden, severe pain (renal colic)
* Flank area, back, or lower abdomen
* Ureter stretches, dilates, and spasms
* May see nausea and vomiting; “kidney stone dance;” dysuria, fever, chills; moist, cool skin
Nephrolithiasis
What are some common sites of obstruction
for kidney stones?
Ureteropelvic Junction (UPJ): Obstruction at the UPJ (where the ureter joins the kidney) typically causes dull costovertebral (flank) pain or renal colic.
Ureterovesical Junction (UVJ): Obstruction at the UVJ (where the ureter joins the bladder) often causes lower abdominal pain, and the pain may radiate to the testicles or labia.
A client with a kidney stone is experiencing severe flank pain, nausea, and vomiting. Which of the following nursing interventions is the highest priority?
A. Administering antiemetics to relieve nausea and vomiting.
B. Administering pain medication as prescribed.
C. Monitoring urine output and straining urine.
D. Encouraging oral fluid intake as tolerated.
C
Rationale: While managing pain and nausea are important, the highest priority is to monitor urine output and strain the urine. This is crucial to assess for complete obstruction and to retrieve the stone for analysis if it passes.
A client is diagnosed with a kidney stone and is scheduled for shock wave lithotripsy (SWL). Which of the following pre-procedure instructions is most important for the nurse to provide to the client?
A. “You will need to fast for 8 hours before the procedure.”
B. “You may experience some bruising on your back after the procedure.”
C. “You will be given general anesthesia for the procedure.”
D. “You will need to drink plenty of fluids after the procedure.”
D
Rationale: While all instructions are important, emphasizing post-procedure hydration is the most critical. Adequate fluid intake helps to flush out the fragmented stone particles and prevent further stone formation. Bruising is common but not the most crucial instruction. SWL typically does not require fasting or general anesthesia (it’s usually done under conscious sedation).
Nephrolithiasis-Interprofessional Care
Endourologic, lithotripsy, or open surgical stone removal may be considered if stones
- Are too large (more than 7 mm) to pass spontaneously
- Are associated with bacteriuria or symptomatic infection
- Impair renal function
- Cause persistent pain, nausea, or paralytic ileus
- The pt can’t be treated medically or only has one kidney
Stones less than/equal to 4 mm may pass spontaneously (may take weeks)
Nephrolithiasis-Interprofessional Care
What are endourologic procedures & lithotripsy?
Endourologic procedures: These are minimally invasive procedures that involve inserting instruments into the urinary tract to remove or break up the stone. Examples include:
* Ureteroscopy: A thin scope is passed through the urethra, bladder, and into the ureter to visualize and remove or fragment the stone.
* Percutaneous nephrolithotomy (PCNL): A small incision is made in the back, and a needle is inserted into the kidney. The stone is then removed or broken up using instruments. This is typically used for larger stones in the kidney.
Lithotripsy: This is a non-invasive procedure that uses shock waves to break the stone into smaller pieces that can then be passed in the urine. The most common type is extracorporeal shock wave lithotripsy (ESWL).
Nephrolithiasis- Surgical Therapy
What are the 3 primary indications for surgery?
Surgery is not the first-line treatment for kidney stones. It’s reserved for specific situations.
- Pain: intractable pain that is not relieved by conservative measures.
- Infection: If a patient develops a kidney infection (pyelonephritis) in conjunction with a kidney stone, and the infection is severe or doesn’t respond to antibiotics, surgery may be needed to remove the stone and drain any abscesses. This is particularly true if the infection is threatening kidney function or spreading to the bloodstream (sepsis).
- Obstruction: If the obstruction is severe or prolonged, surgery may be required to remove the stone and restore urine flow. This is an emergency if both kidneys are obstructed.
Nephrolithiasis- Surgical Therapy
What are some types of kidney stone surgeries?
Type of surgery depends on location of stone
Nephrolithotomy—kidney (involves making an incision into the kidney to remove a stone located within the kidney itself.)
Pyelolithotomy—renal pelvis (involves making an incision into the renal pelvis to remove a stone that is lodged there.)
Ureterolithotomy—ureter (involves making an incision into the ureter to remove a stone that is stuck in the ureter.)
Cystotomy—bladder (involves making an incision into the bladder to remove a stone that has passed from the ureter and is lodged in the bladder.)
Nephrolithiasis- Surgical Therapy
What is the main postop complication of nephrolithiasis surgical therapy?
Hemorrhage
The patient is 2 hours post-ureterolithotomy. Place the following nursing assessments in order of priority:
Assess the incision site for bleeding and signs of infection.
Monitor urine output and characteristics.
Administer pain medication as needed.
Encourage oral fluid intake.
- Monitor urine output and characteristics.
- Assess the incision site for bleeding and signs of infection.
- Administer pain medication as needed.
- Encourage oral fluid intake.
Rationale: Urine output is the MOST critical immediate assessment to ensure kidney function and identify potential complications like obstruction or bleeding. Assessing the incision site is next to check for local complications. Pain management follows assessment, and fluids are important but not the immediate priority.
Which of the following signs or symptoms would be MOST concerning and require immediate intervention in the postoperative period? (Highlight the correct answer.)
A. Small amount of bloody drainage from the incision site.
B. Urine output of 15 mL per hour.
C. Pain at the incision site.
D. Nausea and vomiting.
B
Rationale: Urine output of 15 mL/hr indicates potential kidney compromise and requires immediate intervention. Some bloody drainage (A) and pain (C) are expected initially. Nausea/vomiting (D) are possible post-operatively but not as immediately life-threatening as low urine output.
Nutritional Therapy
What are some nutritional methods for obstructing stones?
Adequate fluids to avoid dehydration
- Facilitate stone passage: More dilute urine can help flush the stone down the urinary tract.
- Reduce the risk of further stone growth: Diluted urine is less likely to become supersaturated with minerals, reducing the chance of the existing stone growing or new stones forming.
Forcing fluids not recommended; increased pain
Nutritional Therapy
What are some diet/fluids changes pt. should make after having kidney stones?
High intake (~3 L/day) to produce 2.5 L urine/day: This is the cornerstone of prevention. Increasing fluid intake dilutes your urine. When your urine is dilute, minerals are less likely to clump together and form stones.
* Water is best!
* Prevents supersaturation of minerals
* Reduce risk of dehydration
* Limit colas, coffee, and tea—increased stone formation
Low-sodium diet: High sodium intake can increase calcium excretion in the urine, which can contribute to calcium-based stones.
Dietary restrictions according to the type of stone
* Oxalate: Found in foods like spinach, rhubarb, almonds, and chocolate.
* Purine: Found in red meat, organ meats, and some seafood.
* Calcium: While calcium is important for bone health, excessive calcium intake can be a factor in some cases.
Kidney Cancer
What is the most common type of kidney cancer? What are some risk factors?
Renal cell carcinoma
Risk factors: cigarette smoking, ACKD, obesity, HTN, exposure to asbestos, cadmium, and gasoline
Increased incidence—First-degree relatives
Males more than females; average age 64 years old
Kidney Cancer
Where does kidney cancer often metastasis to?
Early stage: asymptomatic; often incidental finding for unrelated condition
25% have metastasis when diagnosed
Renal vein, vena cava, lungs, liver, and long bones
Kidney Cancer
What are some common manifestations of kidney cancer?
Hematuria, flank pain, palpable mass in flank or abdomen
Other: weight loss, fever, HTN, anemia
Kidney Cancer
What are some comon diagnostic studies for kidney cancer?
CT scan: Provides detailed images of the kidneys and surrounding structures.
Ultrasound: Can help visualize kidney masses.
Angiography: Examines the blood vessels supplying the kidneys.
Biopsy: A tissue sample is taken for examination under a microscope to confirm the diagnosis.
MRI: May be used for further evaluation or staging.
Radionuclide isotope scan: Can help detect metastasis to the bones.
The patient is scheduled for a nephrectomy (kidney removal). Place the following actions in the order of priority:
* Administer pain medication as ordered.
* Monitor for signs and symptoms of bleeding.
* Encourage deep breathing and coughing exercises.
* Assess the patient’s understanding of the surgical procedure.
- Assess the patient’s understanding of the surgical procedure.
- Monitor for signs and symptoms of bleeding.
- Administer pain medication as ordered.
- Encourage deep breathing and coughing exercises.
Rationale: Understanding (teaching) should ideally come before the procedure. Monitoring for bleeding is the priority post-op concern. Pain management and respiratory exercises are important but secondary to identifying potential hemorrhage.
What are the 3 main indications for nephrectomy?
- Kidney Cancer
- Diseased Kidney
- Kidney Transplantation
What is a nephrectomy?
The surgical removal of a kidney
Which of the following are potential advantages of a partial nephrectomy compared to a radical nephrectomy (removal of the entire kidney)? (Select all that apply.)
A. Reduced risk of chronic kidney disease.
B. Shorter hospital stay.
C. Decreased need for post-operative pain medication.
D. Lower risk of complications.
E. Preservation of renal function.
F. Faster recovery time.
A, E
Rationale: Partial nephrectomy aims to preserve as much kidney function as possible (E), thus reducing the long-term risk of chronic kidney disease (A). While some patients may experience shorter stays or faster recovery, this is not guaranteed and depends on individual factors. Pain management needs are similar, and complication risks can vary.
Which of the following are potential complications specific to a partial nephrectomy? (Highlight all that apply.)
A. Urine leak
B. Bleeding
C. Infection
D. Pneumonia
E. Decreased overall kidney function
F. Hypertension
A, E
Rationale: Urine leak (A) is a risk due to the surgical manipulation of the kidney’s collecting system. Decreased overall kidney function (E) can occur if a significant portion of the kidney is removed. Bleeding (B) and infection (C) are general surgical risks. Pneumonia (D) is a risk for any surgery, not specific to partial nephrectomy. Hypertension (F) is more associated with chronic kidney disease, not specifically partial nephrectomy.
The patient asks, “Will I need dialysis after part of my kidney is removed?” How should the nurse respond?
“Most patients do not need dialysis after a partial nephrectomy, as the remaining kidney portion should be able to function adequately. However, we will closely monitor your kidney function after surgery, and long-term follow-up is essential.”
Rationale: This provides reassurance and emphasizes the importance of ongoing monitoring.
What is polycystic kidney disease?
A hereditary disorder characterized by the growth of numerous cysts in the kidneys.
What are some common manifestations of polycystic kidney disease?
Abdominal and flank pain: The enlarged, cyst-filled kidneys can cause pain in the abdomen and flank (side/back).
Hematuria: Blood in the urine, which can be caused by cyst rupture or bleeding from the enlarged kidneys.
Hypertension: High blood pressure is a common complication of PKD, often due to the disrupted kidney function.
Frequent UTI: Urinary tract infections are more common in people with PKD, possibly due to the structural changes in the kidneys and the presence of cysts.
Kidney stones: The altered kidney structure and urine flow can increase the risk of kidney stone formation.
Enlarged kidneys: The kidneys become enlarged due to the numerous cysts, which can sometimes be felt during a physical exam.
What are some complications associated with polycystic kidney disease?
End-stage renal disease (ESRD): This is a serious complication. Over time, the cysts progressively damage the kidneys, leading to kidney failure. Many people with PKD will eventually require dialysis or a kidney transplant.
Liver cysts: As mentioned earlier, cysts can also develop in the liver. While usually not as problematic as kidney cysts, they can sometimes cause pain or other symptoms.
Cerebral aneurysms: These are weak spots in the blood vessels of the brain that can bulge out and potentially rupture, causing bleeding. People with PKD have an increased risk of cerebral aneurysms.
Mitral valve prolapse: A heart valve problem that can sometimes occur in people with PKD.
What are some ways PKD is diagnosed?
Polycystic Kidney Disease (PKD)
CT scan or MRI: These imaging studies provide detailed pictures of the kidneys and can reveal the presence of cysts.
Ultrasound: A less invasive imaging technique that can also detect kidney cysts.
Genetic testing: Can be used to confirm the diagnosis of PKD, especially in individuals with a family history of the disease.
Kidney Transplant
What is a live donor nephrectomy?
The surgical removal of a kidney from a living donor for transplantation
Donor’s surgery begins 1-2 hrs prior to recipient’s surgery
- Ensure the kidney is ready for immediate transplantation once the recipient’s surgery is underway.
Kidney Transplant
How long are the kidney preserved for a deceased donor nephrectomy?
Donor usually suffered brain death or cardiac death
Kidneys are preserved up to 72 hours prior to transplant surgery
Kidney Transplant
What does cold ischemic time refer to?
This refers to the time the kidney is without a blood supply (outside the donor’s body and before it’s transplanted into the recipient). Minimizing cold ischemic time is important for good graft function (how well the kidney works after transplant).
Kidney Transplant
What kind of values are usually monitored following a kidney transplant?
Urine output: Tracking urine output is essential. Initially, there might be a large volume of urine as the kidney starts functioning.
Lab values: Monitoring BUN (Blood Urea Nitrogen) and creatinine levels to assess kidney function.
Electrolytes: Monitoring and managing electrolyte balance, as the new kidney may take time to regulate them effectively.
You may see a large increase of urine output due to the kidney being re-established and will normalize once BUN and Creatine return to normal
- A sudden decrease in urine output is a cause of concern (leak, obstruction or rejection
What is the best treatment for ESRD (End-Stage Renal Disease)?
Kidney Transplant
Reverse’s pathophysiology of ESRD
What is true about kidney transplants and dialysis?
Eliminates dialysis (and dietary & lifestyle restrictions)
Less expensive than dialysis after first year
Kidney Transplant Nursing Management
What are some nursing management skills for preoperative care of kidney transplant?
Emotional and physical preparation
- Stress that dialysis may be required
- Review need for immunosuppressive drugs and prevention of infection
ECG, Chest x-ray, lab studies, possibly dialysis
Preoperative care focuses on preparing the patient emotionally and physically for the transplant, including education and necessary testing.
Kidney Transplant Nursing Management
What are some nursing management skills for postoperative care of kidney transplant?
Kidney transplant recipient
* Maintenance of fluid and electrolyte balance is first priority
* Immunosuppressant therapy to prevent rejection
* Meticulous infection control practices
Postoperative care prioritizes maintaining fluid and electrolyte balance, preventing rejection and infection, and ongoing patient education.
Which of the following nursing assessments are MOST crucial in the immediate postoperative period for a kidney transplant recipient? (Select all that apply.)
A. Monitoring urine output and characteristics.
B. Assessing the surgical incision for signs of infection.
C. Auscultating lung sounds for respiratory complications.
D. Administering pain medication as ordered.
E. Monitoring for signs and symptoms of organ rejection.
F. Educating the patient on long-term medication management.
A, B, E
Rationale: Urine output (A) is paramount to assess graft function. Incision site (B) checks for local complications. Monitoring for rejection (E) is critical due to the risk of transplant failure. Lung sounds (C) and pain management (D) are important, but less immediate than graft function and rejection. Long-term education (F) is important but not the immediate priority.
Which of the following are potential complications specific to kidney transplantation that the nurse should monitor for? (Highlight all that apply.)
A. Acute rejection
B. Hyperkalemia
C. Infection
D. Hypertension
E. Diabetes Mellitus
F. Delayed graft function
A,C, & F
Kidney Transplant Complications
What are some kidney transplant complications?
Rejection
Infection
Cardiovascular disease
- Transplant recipients have increased incidence of atherosclerotic vascular disease
- Immunosuppressants can worsen hypertension and hyperlipidemia
- Patients need to adhere to antihypertensive regimen
Cancer: Immunosuppression increases the risk of certain cancers
Recurrence of original kidney disease
Which of the following signs or symptoms could indicate a potential complication in this kidney transplant recipient? (Select all that apply.)
A. Sudden weight gain of 5 lbs in 2 days.
B. Fever and chills.
C. Increased energy levels and improved appetite.
D. Pain or tenderness at the transplant site.
E. Urine output of 30 mL/hour.
F. Blood pressure consistently above 160/90 mm Hg.
A, B, D, F
Rationale: Sudden weight gain (A) can indicate fluid retention, a sign of rejection or other issues. Fever/chills (B) suggest infection. Pain at the transplant site (D) is concerning for rejection or other problems. High blood pressure (F) can be a sign of graft dysfunction or medication side effects. Increased energy/appetite (C) are positive signs. Urine output of 30 mL/hr (E) is within normal limits.
Which of the following manifestations are MOST suggestive of acute rejection rather than infection in a kidney transplant patient? (Highlight all that apply.)
A. Fever
B. Decreased urine output
C. Hypertension
D. Weight gain
E. Pain at the transplant site
F. Elevated white blood cell count
B, D, E
Rationale: Decreased urine output (B), weight gain (D), and transplant site pain (E) are more indicative of rejection. Fever (A) and elevated WBC (F) can occur in both rejection and infection. Hypertension (C) is less specific and can have multiple causes.
What is the most common cancer of the urinary system?
Bladder Cancer
- More common in men than women
Bladder Cancer
What are some risk factors of bladder cancer?
About 1/2 related to cigarette smoking
Other risk factors
- Exposure to dyes used in rubber and other industries
- Indwelling catheters use for a long period of time
- Chronic recurrent urinary tract stones (often in the bladder) and chronic UTIs
- Women treated with radiation for cervical cancer
- Patients who receive cyclophosphamide, docetaxel, or gemcitabine: These are chemotherapy drugs that, while used to treat cancer, can increase the risk of bladder cancer as a side effect
Bladder Cancer
What is the most common sign of bladder cancer?
Hematuria
Bladder Cancer
What procedures is considered the GOLD STANDARD for diagnosing bladder cancer?
Cystoscopy with biopsy
Cystoscopy with biopsy allows direct visualization and tissue sampling for definitive diagnosis.
Bladder Cancer: Surgical Therapy
What is Transurethral resection of the bladder tumor (TURBT)?
This procedure targets superficial lesions within the bladder. It utilizes a cystoscope, a thin tube inserted into the urethra, to visualize and remove the tumor. This is a minimally invasive approach often used for early-stage cancers.
Bladder Cancer: Surgical Therapy
What is Segmental (partial) cystectomy?
This involves the surgical removal of a portion of the bladder wall affected by cancer. It is employed for larger tumors confined to a single area of the bladder. A margin of healthy tissue surrounding the tumor is also removed to ensure complete eradication of cancerous cells.
Bladder Cancer: Surgical Therapy
What is radical cystectomy?
This is a more extensive surgery involving the complete removal of the bladder. It is typically recommended for invasive cancers or those located in the trigone area (the base of the bladder near the urethra) but no metastasis beyond pelvic area. Because the bladder is removed, a urinary diversion procedure is necessary to create a new pathway for urine elimination. Radical cystectomy is appropriate when there is no metastasis beyond the pelvic area.
In men, it may also involve removal of the prostate and seminal vesicles, while in women, it may include removal of the uterus, ovaries, and part of the vagina.
The patient develops a fever, redness at the incision site, and purulent drainage on postoperative day 3. What complication is suspected?
Surgical site infection (SSI)
Bladder Cancer Management
What are some surgical therapy for bladder cancer management?
Transurethral resection with fulguration
- Transurethral resection means a surgical procedure done through the urethra (the tube that carries urine out of the body) without the need for an external incision.
- Fulguration refers to the use of an electric current to destroy tissue, often used to stop bleeding or remove small growths.
Laser photocoagulation: Can be used to treat superficial bladder tumors. The laser energy is delivered through a cystoscope (a thin tube inserted into the urethra) to destroy the tumor cells while minimizing damage to surrounding healthy tissue.
Open loop resection with fulguration
- Open Loop Resection: This indicates a surgical procedure where a loop-shaped instrument is used to cut away tissue. The term “open” suggests it might involve a traditional surgical incision, although it can also refer to techniques using scopes where the loop is manipulated externally.
- Fulguration: As discussed earlier, this is the use of an electric current to destroy tissue (often to stop bleeding or remove small growths).
Cystectomy (segmental, partial, or radical) (Surgical removal of the bladder.)
- Segmental Cystectomy: Removal of a portion of the bladder wall.
- Partial Cystectomy: Removal of a larger portion of the bladder, but not the entire organ.
- Radical Cystectomy: Removal of the entire bladder, as well as surrounding tissues and organs. In men, this often includes the prostate and seminal vesicles. In women, it may involve removal of the uterus, ovaries, and part of the vagina. Lymph nodes in the pelvis are also usually removed during a radical cystectomy.
Bladder Cancer Management
What are 2 forms of intravesical immunotherapy for bladder cancer management?
Bacille Calmette-Guérin (BCG)
α-interferon (Intron A)
Bladder Cancer Management
What are some forms of intravesical chemotherapy for bladder cancer?
doxorubicin
epirubicin
gemcitabine
mitomycin
thiotepa
valrubicin (Valstar)
A patient is scheduled to receive intravesical chemotherapy with gemcitabine. Which of the following actions by the nurse is most important prior to the instillation of the medication?
A. Administer an antiemetic medication.
B. Ensure the patient has adequate hydration.
C. Assess the patient for signs of urinary tract infection.
D. Explain the potential for hair loss to the patient.
C. Assess the patient for signs of urinary tract infection.
Rationale: Intravesical chemotherapy can irritate the bladder lining. Administering it in the presence of a UTI could worsen the infection.
A patient undergoing intravesical chemotherapy asks the nurse why the medication is not given through a vein like other chemotherapy drugs. What is the nurse’s best response?
A. “Intravesical chemotherapy is less toxic than traditional chemotherapy.”
B. “This method delivers the medication directly to the bladder cancer cells, reducing side effects to the rest of your body.”
C. “This type of chemotherapy is only effective for early-stage bladder cancer.”
D. “Giving chemotherapy through a vein is too painful for bladder cancer patients.”
B. “This method delivers the medication directly to the bladder cancer cells, reducing side effects to the rest of your body.”
Rationale: This response provides an accurate and patient-centered explanation for the use of intravesical chemotherapy.
CBI Nursing Management
What is the purpose of CBI?
CBI: Continuous Bladder Irrigation
Continuous bladder irrigation is used to flush out blood clots and debris from the bladder, often after urologic surgery (e.g., transurethral resection of the prostate - TURP) or in cases of hematuria (blood in the urine).
CBI Nursing Management
What are some key nursing managements for CBI?
Assess Bleeding and Clots (Some bleeding is expected after certain procedures, but it should gradually decrease)
Assess Catheter Patency:
- Intake and Output (I&O)
- Bladder Spasms
Manual Irrigation
Medication Administration: Administer antispasmodics (to reduce bladder spasms) and analgesics (for pain) as needed and as prescribed.
Monitor Catheter Drainage: Monitor for increased blood clots
Discontinue CBI and Notify HCP: If obstruction occurs and cannot be resolved with manual irrigation, stop the CBI and immediately notify the healthcare provider (HCP).
Post-Catheter Removal Care: Teach patients Kegel exercises after the catheter is removed to strengthen the pelvic floor muscles and improve urinary control.
Discharge Instructions: Provide thorough care instructions to patients discharged with an indwelling catheter, including catheter care, signs of infection, and when to seek medical attention.
Which of the following nursing actions are essential when managing a patient receiving continuous bladder irrigation (CBI)? (Select all that apply.)
A. Assessing the urine for blood and clots.
B. Monitoring intake and output.
C. Administering antipyretics (for fever).
D. Manually irrigating the catheter if outflow decreases.
E. Encouraging the patient to perform Valsalva maneuver.
F. Teaching Kegel exercises after catheter removal.
A, B, D, F
Rationale: These are all key nursing responsibilities in CBI management. Antipyretics are for fever, which is not directly related to CBI. Valsalva maneuver is contraindicated as it can increase intra-abdominal pressure and lead to bleeding after certain procedures.
A patient post-TURP is receiving CBI. The nurse notes that the urine output has significantly decreased, and the patient is complaining of bladder spasms. What is the nurse’s most appropriate initial action?
A. Administer pain medication as prescribed.
B. Manually irrigate the catheter.
C. Notify the healthcare provider immediately.
D. Increase the flow rate of the CBI.
B
Rationale: The decreased output and bladder spasms suggest a potential blockage. Manual irrigation is the first step to attempt to restore patency. If irrigation is unsuccessful, then the HCP should be notified.
Urinary Diversion
What is urinary diversion and what are some common causes that require it?
Urinary diversions are surgical procedures performed when urine flow is blocked or impaired. They reroute urine away from the bladder and out of the body.
Common Causes of Urinary Flow Blockage Requiring Diversion:
Bladder Cancer
Congenital Anomalies (birth defects)
Strictures (narrowing of the urethra or ureters)
Trauma to the Bladder
Chronic Bladder Inflammation
Urinary Diversion
What is the difference between incontinent & continent urinary diversion?
Incontinent Urinary Diversion: Urine drains continuously into a pouch or bag worn outside the body. The patient has no control over urine flow.
Continent Urinary Diversion: A pouch is created inside the body to hold urine. The patient learns to self-catheterize to empty the pouch periodically, or in some cases, can void naturally. This provides more control over urinary elimination.
Incontinent Urinary Diversion
What are some key points to know/teach the pt. about incontinent urinary diversion?
Most common: ileal conduit (ileal loop)
Colon conduit also used
“Diversion to skin; must wear appliance”
“Ureters anastomosed to conduit; bowel brought to abdominal wall to form stoma”
“No valve = no voluntary control”: This emphasizes the lack of continence, meaning the urine flow is continuous and not controlled by the patient.
“Urine drips into external collection device”: Reinforces the need for a pouch to collect the continuously draining urine.
Ileal Conduit
What is an ileal conduit, how it’s created, & why it’s done?
An ileal conduit is an incontinent urinary diversion. This means urine drains continuously from a stoma (an opening) on the abdomen into an external collection bag or pouch.
How it’s created: A piece of the ileum (small intestine) is surgically removed and formed into a tube or channel. The ureters (tubes carrying urine from the kidneys) are attached to this ileal segment. The open end of the ileum is then brought to the surface of the abdomen, creating the stoma.
Why it’s done: It’s performed when the bladder is either removed (cystectomy) due to conditions like bladder cancer, or if it’s not functioning properly.
Ileal Conduit
What are some of the complications associated with ileal conduit?
Stoma complications: Necrosis, retraction, prolapse, stenosis.
Skin irritation: Around the stoma due to urine leakage or pouch adhesive.
Infection: Urinary tract infections or infection at the stoma site.
Obstruction: Blockage of urine flow within the conduit.
Electrolyte imbalances: Due to urine loss.
Continent Urinary Diversion
What is a continent urinary diversion?
Intra-abdominal urinary reservoir that can be catheterized; has internal pouch
- Internal Pouch: A portion of the intestine is used to create a pouch or reservoir inside the abdomen.
- Continence Mechanism: A valve or other mechanism is constructed to prevent urine from leaking involuntarily.
- Self-Catheterization: Patients must regularly catheterize themselves to drain the urine from the internal pouch. This is a crucial aspect of managing this type of diversion.
Continent Urinary Diversion
What are some types of continent urinary diversion?
Kock Pouch: This type of continent diversion involves creating a pouch from a section of the ileum (small intestine). What makes the Kock Pouch unique is the presence of a special valve mechanism. This valve prevents urine from leaking out of the stoma (the opening on the abdomen) until a catheter is inserted to drain the pouch.
Mainz Pouch: Similar to the Kock Pouch, the Mainz Pouch is also constructed from a portion of the ileum. However, the specific configuration and surgical technique may differ slightly. It also features a valve mechanism to ensure continence.
Indiana Pouch: The Indiana Pouch is another type of continent diversion, but in this case, it’s typically made from a combination of the ileum and the ascending colon (part of the large intestine). Like the others, it also has a valve mechanism to prevent leakage.
Florida Pouch: The Florida Pouch is another variation of a continent urinary diversion, and it’s also constructed from a portion of the intestines. The specific design and surgical approach may vary.
Methods of Urinary Diversion
Which of the following assessments are MOST crucial in the immediate postoperative period for a patient with a urinary diversion? (Highlight all that apply.)
A. Monitoring urine output and characteristics.
B. Assessing the surgical incision for signs of infection.
C. Evaluating the function of the diversion (e.g., stoma appearance, drainage).
D. Auscultating bowel sounds.
E. Providing emotional support and addressing concerns.
F. Administering pain medication as ordered.
A, B, C, D
Rationale: Urine output (A) is paramount to ensure kidney function. Incision site (B) checks for complications. Diversion function (C) assesses its patency. Bowel sounds (D) indicate return of function. While emotional support (E) and pain management (F) are important, they are not the immediate priorities.
Types of Catheters
What is a suprapubic catheter and why is it used?
Description: A catheter inserted surgically through an incision in the abdomen directly into the bladder.
Use: Used when urethral catheterization is not possible or appropriate (e.g., urethral injury, prostate enlargement obstructing the urethra). Can be used for long-term bladder drainage.
Types of Catheters
What are nephrostomy tubes and why are they used?
Description: A tube inserted percutaneously (through the skin) into the renal pelvis (part of the kidney where urine collects) and connected to a drainage bag.
Use: Used to drain urine directly from the kidneys when there is a blockage or other issue preventing urine flow from the kidneys to the bladder (e.g., kidney stones, tumors).
Types of Catheters
What is intermittent catheterization (strair catheter) and why is it used?
Description: Insertion of a catheter through the urethra into the bladder to drain urine, followed by immediate removal of the catheter.
Use: Used for patients who are unable to empty their bladder effectively on their own (e.g., due to neurological conditions or spinal cord injury) but do not require continuous drainage. Helps prevent urinary retention and associated complications.
Types of Catheters
What is a standard Foley catheter (indwelling urethral catheter) and why is it used?
Description: A flexible tube inserted through the urethra into the bladder, with a balloon inflated to hold it in place for continuous urine drainage.
Use: Used to continuously drain urine from the bladder when patients are unable to void or when it’s necessary to monitor urine output closely (e.g., after surgery, in critical care).
Nursing Management (Urinary Diversions?)
What are some postoperative complications?
Atelectasis: Collapsed lung tissue, prevented by deep breathing and coughing exercises.
Shock: Related to fluid/blood loss, requiring monitoring of vital signs and fluid replacement.
Thrombophlebitis: Blood clots in veins, prevented by early ambulation and leg exercises.
Small bowel obstruction: Blockage in the small intestine, requiring monitoring of bowel sounds and function.
Paralytic ileus: Temporary loss of bowel function, also requiring monitoring of bowel sounds and function.
UTI (Urinary Tract Infection): Prevented by maintaining catheter patency and hygiene.
Nursing Management- Urinary Diversions
What are some specific considerations for post-urinary diversion?
Prevent stoma injury & maintain urine output
- Mucus in urine is expected
- Encourage high fluid intake
Nurses need to preform stoma assessment
Scenario: A 70-year-old patient is 2 days post-operative from an ileal conduit urinary diversion surgery.
Which of the following actions should the nurse prioritize in the immediate post-operative period? (Select all that apply.)
A. Encourage coughing and deep breathing exercises.
B. Monitor the stoma for color, edema, and drainage.
C. Administer pain medication as ordered.
D. Ensure the urine collection bag is properly attached and draining.
E. Encourage early ambulation.
F. Provide emotional support and education about the ileal conduit.
A, B, D
Rationale: Maintaining pulmonary function (A), stoma viability (B), and ensuring urine drainage (D) are the immediate priorities in the early post-operative period. While pain management (C) and ambulation (E) are important, they are not the highest priorities at this moment. Emotional support (F) is crucial but not in the immediate moment.
Over several shifts, the nurse notes the following trends in urine output:
Day 1: 1200 mL
Day 2: 900 mL
Day 3: 600 mL
Day 4: 400 mL
What is the most concerning interpretation of this trend?
A. The patient is not drinking enough fluids.
B. The patient is developing a urinary tract infection.
C. There may be a blockage in the ileal conduit or ureter.
D. This is a normal variation in urine output.
C. There may be a blockage in the ileal conduit or ureter.
Rationale: A steadily declining urine output suggests a potential obstruction, requiring prompt investigation.
Postoperative Management
What are some post-op nursing managements for ileal conduit?
Meticulous skin care: Essential to prevent complications related to urine contact with the skin.
Avoid: alkaline encrustations with dermatitis and yeast infections, product allergies, and shearing effect excoriations
Changing appliances: See Table 45-22 in the textbook
Continent diversion
Patient teaching
* How to catheterize: Clean technique, catheter insertion and removal.
* When to catheterize: Frequency, how to recognize fullness.
* How to irrigate: Maintaining patency of the reservoir.
Body Image: emotional impact, provide support
What is an orthotopic bladder?
A surgically constructed neobladder, created from a section of the intestine, that is connected to the urethra, allowing the patient to void through their urethra.
Postoperative Management
What are some post-op nursing managements for orthotopic bladder?
Catheterize for postoperative urinary retention
Bladder control may take up to 6 months
Empty bladder every 2 to 4 hours by relaxing outlet sphincter and bearing down with abdominal muscles; does not feel need to void
Follow-up pouchogram in 3 to 4 weeks
Postoperative Management
What are some discharge teachings for ileal conduit?
Symptoms of obstruction or infection
- Obstruction (e.g., decreased urine output, abdominal pain).
- Infection (e.g., fever, chills, cloudy urine, back pain).
Ostomy care
- Stoma Changes: Explain that the stoma may shrink in size as it heals.
- Skin Care: Teach how to keep the peristomal skin clean and healthy.
Appliances
- Components: Faceplate (skin barrier), pouch, drainage opening.
- Proper Fit: Emphasize the importance of a proper fit to prevent leaks and skin irritation.
- Changing: Provide detailed instructions on how to change the appliance.
Need to know: where to buy supplies, emergency contact numbers, location of ostomy clubs
Follow-up visits with WOCN (Wound, Ostomy, Continence Nurse) and HCP
The patient reports feeling nauseous and has not had a bowel movement in 2 days. His ostomy output has significantly decreased and the urine appears darker than usual. What complication is the patient MOST likely experiencing?
A. Dehydration.
B. Urinary tract infection.
C. Bowel obstruction.
D. Stoma necrosis.
C. Bowel obstruction.
Rationale: Nausea, lack of bowel movement, decreased ostomy output, and darker urine are concerning signs of a potential bowel obstruction.
Kidney (Renal) Failure
What is kidney (renal) failure? What are some common causes?
Partial or complete impairment of kidney function that results in inability to excrete metabolic waste products and water
- Affects all body systems
- Treatment & dietary changes are challenging
- Impacts lifestyle, occupation, family relationships, and self-image
Causes: Common causes of CKD include diabetes, high blood pressure, glomerulonephritis (kidney inflammation), and polycystic kidney disease.
Which of the following is a key diagnostic indicator of kidney function? (Highlight the correct answer.)
A. Blood urea nitrogen (BUN) level
B. Serum creatinine level
C. Glomerular filtration rate (GFR)
D. Urinalysis
C
Rationale: GFR is the BEST indicator as it directly measures kidney’s filtering capacity. While BUN and creatinine are also indicators, they are less specific than GFR. Urinalysis provides information about the urine but not the filtration rate.
Comparison of AKI and CKD
What are the following criteria of AKI?
Onset:
Most common causes:
Diagnostic criteria:
Reversibility:
Cause of death:
Onset: Sudden
Most common causes: Acute tubular necrosis
Diagnostic criteria: Acute reducation in urine output and/or elevation in serum creatinine
Reversibility: Potentially
Cause of death: Infection
Comparison of AKI and CKD
What are the following criteria of CKD?
Onset:
Most common causes:
Diagnostic criteria:
Reversibility:
Cause of death:
Onset: Gradual, over years
Most common causes: Diabetic nephropathy
Diagnostic criteria: GFR <60 mL/min/1.73 m2 for >3 months
AND/OR Kidney damage >3 months
Reversibility: Progressive and irreversible
Cause of death: Cardiovascular disease
Dialysis
What are some usages of dialysis?
Used to correct fluid and electrolyte imbalances and removes waste products in kidney failure
Can be used to treat drug overdoses
Dialysis
What are the 2 methods of dialysis available?
Peritoneal Dialysis (PD): This method uses the lining of the abdomen (peritoneum) as a natural filter. A solution is instilled into the abdomen, and waste products and excess fluids pass from the blood into the solution. The solution is then drained from the abdomen.
Hemodialysis (HD): This is the more common type. Blood is pumped out of the body through tubes to a dialysis machine, where it’s filtered through a special membrane (dialyzer) to remove waste and excess fluids. The cleaned blood is then returned to the body.
Dialysis
When is dialysis started?
GFR < __
Started when patient’s uremia (buildup of waste products in the blood) can no longer be adequately treated conservatively; GFR < 15 mL/min/1.73 m2
Peritoneal Dialysis
How is peritoneal access obtained?
Peritoneal access is obtained by inserting a catheter through anterior abdominal wall
Technique for catheter placement varies; usually done via surgery
PD may start right away or bed delayed until site healed
Aseptic technique important to avoid peritonitis
Peritoneal Dialysis
What is the #1 risk for Peritoneal Dialysis?
Infection
A patient on peritoneal dialysis reports cloudy dialysate (outflow) and abdominal pain. What complication is suspected?
A. Catheter occlusion.
B. Peritonitis.
C. Hyperglycemia.
D. Constipation.
B. Peritonitis.
Rationale: Cloudy dialysate and abdominal pain are classic signs of peritonitis, a serious complication of peritoneal dialysis.
Hemodialysis (HD) Vascular Access Sites
Obtaining vascular access is one of most difficult problems. What are the types of access?
HD requires rapid blood flow and access to a large blood vessel.
Arteriovenous (AV) fistulas and grafts: These are considered the preferred long-term access options.
- Fistula: A surgical connection between an artery and a vein, creating a large, strong vessel for needle insertion. Allows arterial blood flow through vein (becomes arterialized).
- Graft: A synthetic tube is used to connect an artery and a vein if the patient’s own veins are not suitable for a fistula.
Temporary vascular access: This refers to catheters, usually inserted into a large vein in the neck or chest, used for temporary access until a fistula or graft matures or in emergency situations.
Hemodialysis (HD) Vascular Access Sites
What are some risk of HD?
Hypotension
Blood loss
Infection
Arteriovenous Fistulas and Grafts
Where is the preferred access for HD? When is it placed and why?
AV fistulas are considered the “gold standard” for hemodialysis access due to their longevity and lower risk of infection compared to other options.
Forearm or upper arm
↑ vein size and wall thickness
Placed 3 months before HD; needs to mature
“Feel ‘thrill’ or hear ‘bruit’ due to high velocity of blood flow”
Permacath
What is a permacath?
A piece of plastic tubing – very similar to a jugular catheter – and is used inexactly the same way for your haemodialysis.
The permacath has a cuff that holds the catheter in place and acts as a barrier to infection. The cuff is underneath the skin and cannot be seen.
AV Fistulas and Grafts
What are some risk associated with AV Fistulas and Grafts?
Distal ischemia (steal syndrome): Occurs when too much blood is “stolen” from the distal extremity by the fistula or graft, leading to inadequate blood supply to the hand and fingers.
- Pain distal to access site
- Numbness or tingling of fingers
- Poor capillary refill
Aneurysms: Weakening and bulging of the vessel wall, can occur at the access site.
AV Fistulas and Grafts
What are some saftey alerts for AV Fistulas and Grafts?
No BP, venipunctures, or IV lines
- Post signs in room or labeled arm band
Prevent infection and clotting
Vascular Access for HemodialysisArteriovenous Fistula
Why is the AV Fistula Preferred?
Lower Infection Risk (compared to catheters, because they are created using the patient’s own tissue and do not involve a foreign object)
Long-Term Use: With proper care, AV fistulas can last for many years, providing reliable access for hemodialysis.
Better Blood Flow: AV fistulas provide excellent blood flow, which is essential for effective hemodialysis treatments.
Vascular Access for HemodialysisArteriovenous Fistula
What are some challenges with AV Fistualas?
Not Always Possible: Some patients may have damaged or unsuitable veins.
Maturation Time: The waiting period for fistula maturation can be challenging for patients who need immediate dialysis.
Potential Complications: While generally safe, AV fistulas can develop complications such as infection, clotting (thrombosis), narrowing (stenosis), or aneurysm formation.
