GU Flashcards
1
Q
Functions of the Kidneys
A
- Remove metabolic waste from blood in the form of urine
- Regulate electrolytes and acid-base balance
- Control of blood pressure
- Regulates RBC production
- Synthesis of vitamin D to active form
2
Q
Glomerulus
A
Network of capillaries that act as filter for filtrate to proximal tubules
3
Q
Bowman’s capsule
A
Contains the glomerulus and acts as filter for urine
4
Q
Proximal tubule
A
Site of reabsorption
5
Q
Loop of Henle
A
U-shaped nephron tubule, site for further concentration of filtrate through reabsorption. This is where loop diuretics work (Lasix)
6
Q
Distal tubule
A
Site where filtrate enters collecting tubule
7
Q
Collecting tubule
A
Releases urine
8
Q
Risk Factors for GU disorders
A
- Strep disorders => chronic renal failure
- Increased age => UTI’s, BPH
- Invasive procedures (cysto, foley) => UTI’s
- Immobilization => stones
- Diabetes => renal failure, neurogenic bladder
- Hypertension => renal failure
- Multiparous women => stress urinary incontinence
- Neurologic Disorders => MS, Parkinson’s
9
Q
S/Sx of Urinary Tract Disease
A
- Pain
- Changes in voiding
- GI symptoms
10
Q
What kind of pain can there be in a urinary tract disease?
A
- Kidney
- Ureteral
- Bladder
- Urethral
- Prostatic
11
Q
Describe kidney pain
A
Dull ache in costovertebral angle (CVA) radiates to umbilicus
12
Q
Describe ureteral pain
A
Pain in costovertebral angle (CVA) and/or flank which can radiate to abdomen, thigh, and genital area
13
Q
Describe bladder pain
A
Pain in lower abdomen and suprapubic area
14
Q
Describe prostatic pain
A
Pain in perineum and rectum
15
Q
Urinary Frequency
A
Voiding more often, associated with infection, disease, diuretics
16
Q
Urinary Urgency
A
Strong desire to void, associated with prostate, infection
17
Q
Dysuria
A
Pain or difficulty voiding
18
Q
Nocturia
A
Excessive urination at night (usually getting up more than twice a night)
19
Q
Urinary Retention
A
Inability to empty the bladder
20
Q
Urinary Incontinence
A
Involuntary loss of urine
21
Q
Urinary Hesistancy
A
Delay in voiding
22
Q
Enuresis
A
Involuntary voiding during sleep
23
Q
Hematuria
A
Blood in the urine
24
Q
Proteinuria
A
Proteins in the urine
25
Bacteriuria
Bacteria in the urine
26
Normal urine output per hour
30 mL per hour
27
Anuria
Output is less than 50 mL in 24 hours
| *Hemodialysis patients
28
Oliguria
Output is less than 400 mL per 24 hours
29
Polyuria
Output is more than 2500 mL per 24 hours
| *DKA and CHF patients
30
What kind of GI symptoms can one have if there is urinary tract disease present?
1. N/V
2. Abdominal discomfort or distention
3. Diarrhea
* GI symptoms occur because the GI tract and urinary tract have shared autonomic and sensory innervations and reflexes
31
Physical examination of the kidneys
1. Inspect the skin for edema, skin turgor, hydration, and pallor
2. Attempt to palpate but you shouldn't be able to due to costovertebral angle tenderness
3. Listen for bruits (renal artery stenosis)
32
Physical examination of bladder
Palpate for fullness and location of bladder (usually can only do this if it is distended)
33
Physical examination of the meatus
Inspection for edema, redness, and drainage
34
Physical examination of prostate
Digital rectal exam (done by MD); done to detect hyperplasia of prostate in older men
35
Urinalysis
Analysis of urine. Analysis is used to identify abnormalities. Clean catch or mid-stream specimen may be used - want it clean as possible
36
Urine C & S
Identify if bacteria are present and treat with appropriate antibiotics
37
Normal urine specific gravity
1.005 - 1.030
38
A decrease in specific gravity can indicate what?
1. Diabetes insipidus
2. Glomerulonephritis
3. Renal failure
39
An increase in urine specific gravity can indicate what?
1. CHF
2. Hepatic disorders
3. Dehydration
40
Normal osmolality of urine
250 - 900
| *Tells diluting and concentrating ability of kidneys
41
Normal pH of urine
5.0 - 8.0
42
A urine pH greater than 7.0 can indicate what?
1. UTI
2. Alkaline diet
3. Alkalosis
4. Medications
43
A urine pH less than 5.0 can indicate what?
1. High protein diet
2. Fever
3. Acidosis
44
If glucose, ketones, and/or proteins are positive in the urinalysis what can this indicate?
1. Severe infection
2. Renal disease
3. Diabetes
45
If RBCs and WBCs are present in the urinalysis what can this indicate?
1. UTI
| 2. Stones
46
Normal GFR
125 mL/min (varies per age)
47
Glomerular Filtration Rate (GFR)
Rate at which glomeruli filter blood. Most accurate measure of GFR is creatinine clearance - that is because creatinine filtered by glomeruli but is not reabsorbed by tubules
48
Creatinine Clearance
Most accurate measure of glomerular filtration. Do a 24 hour urine collection and check the volume of urine and the urine creatinine level. Also do a serum creatinine halfway through the test.
49
Serum Creatinine
Endogenous waste product of skeletal muscle
1. Reflects balance between production and filtration by glomerulus
2. Best serum indicator of renal function. If elevated, indicates a decrease in GFR
50
Normal serum creatinine
0.7 - 1.4 mg/dL
51
Blood Urea Nitrogen (BUN)
Urea is nitrogenous end product of protein metabolism; test the ability of kidneys to excrete nitrogenous wastes; it's an estimate of GFR
1. Can be affected by medications and dehydration
2. Can also be affected by protein intake, tissue breakdown, and fluid volume changes
52
Normal BUN
10 - 20 mg/dL
| For patient over 60 (8 -20 mg/dL)
53
Types of X-ray/Imaging of GU system
1. KUB
2. Ultrasonography
3. Bladder U/S
4. CT/MRI
5. Nuclear Scans
54
KUB X-ray
(Kidney, Ureter, Bladder)
X-ray shows kidney, ureters, and bladder size, position, and shape of structure. May show calculi or lesions. Limited purposes
55
Ultrasonography
Noninvasive, uses high frequency sounds and reveals depth of a structure below the skin. Usually done with a full bladder for better visualization. No special care afterwards.
56
Bladder U/S
Noninvasive, measures urine volume in bladder
57
CT/MRI
Provides cross sectional views of kidney and urinary tract, can use oral or IV contrast
58
Nuclear Scans
Injection of radioisotope, shows kidney perfusion, encouraged increase fluids to promote excretion of isotope
59
Intravenous Pyelogram (IVP)
Visualizes the entire urinary tract. Will show calculi, size and shape of structures, tumors, and pyelonephritis
60
Nursing Implications of Intravenous Pyelogram
1. Check for allergies because of contrast
2. Give laxative the night before
3. NPO 8 hours or clear liquids
4. May feel flushed, warm with salty taste when dye is injected
61
Voiding Cystourethrography
Urinary catheter allows instillation of contrast into the bladder, X-rays are taken while client is voiding. Shows stricture, ureteral reflux
62
Renal Angiogram
Catheter is advanced up femoral-iliac arteries and dye is injected. Can detect tumors or cysts. Femoral stick so check for bleeding and color, pulse, temp of extremities, frequent VS
63
Cystoscopy
Cystoscope with a lens is inserted into the urethra up to the bladder. Magnifies a view of the urethra, bladder, and orifices
64
Nursing Implications of cystoscopy
1. NPO after midnight
2. Monitor for UTI
3. May have slight pink-tinged urine post procedure
4. Relieve discomfort with warm, moist heat. Sitz bath
5. Observe for complications: bleeding, infection, and pain with urination
6. Urinary retention
65
Ureteroscopy
Scope through ureter; general anesthesia
66
Percutaneous Renal Biopsy
MD uses needle to excise tissue. Used to diagnose presence or progression of disease. Not done as much now because of CT and ultrasound tests.
67
Nursing Implications for Percutaneous Renal Bx
1. NPO after midnight
2. Post-op VS
3. Prone immediately after procedure and then bedrest for 8 hours
4. Need IVF after to prevent clots
5. Post-op pain/responsive to analgesics
6. Assess s/sx bleeding and inspect urine
7. Avoid strenuous activity for 2 weeks
8. Report backache, flank pain radiating to groin (clot in ureter)
68
Renal and ureteral brush biopsy
Provides specific info when abnormal xray findings of the ureter or renal pelvis is detected
*Cystoscope/ureteral catheter introduced and brush biopsy done
69
Risk Factor for Chronic Kidney Disease
1. CAD
2. DM
3. HTN
4. Obesity
70
Causes of Chronic Kidney Disease
1. DM
2. HTN
3. Glomerulonephritis/pyelonephritis
4. Hereditary or congenital disorders
5. Renal cancer
71
Clinical Manifestations of Chronic Kidney Disease
1. Increased creatinine
2. Anemia
3. Metabolic acidosis
4. Calcium and phosphorus imbalances
5. Fluid retention
6. As the disease progresses abnormalities in electrolytes occur, heart failure worsens, and hypertension becomes more difficult to control
72
What is nephrosclerosis?
Hardening of renal arteries - most often due to HTN, DM
73
Treatment of nephrosclerosis
Control of BP and BG, renal replacement therapy
74
What is acute glomerulonephritis (AGN)?
Inflammation of kidney that affects the capillary bundles in glomeruli. Changes the permeability of glomeruli. Onset usually follows URI (strep), impetigo, mumps, hepatitis B, HIV infections, varicella
*Strep infection 2-3 weeks before glomerulonephritis. The strep product acts as an antigen and stimulates antibodies and results in deposits of molecules in glomeruli which injures the kidney
75
S/Sx of acute glomerulonephritis
1. Hematuria (urine may be cola colored because of RBC's)
2. Edema
3. Azotemia
4. Proteinuria
5. Malaise
6. Also decreased output, CVA tenderness and flank pain
76
Diagnostic Tests for acute glomerulonephritis
1. UA
2. CBC (may have low H/H from blood loss)
3. Strep titer
4. May need renal bx
77
Potential Complications of Acute Glomerulonephritis
1. End stage renal disease (ESRD)
2. Hypertensive encephalopathy
3. HF
4. Pulmonary edema
5. Elderly patients - circulatory overload with dyspnea, cardiomegaly, pulmonary edema, atypical neuro changes
78
Medical Management of acute glomerulonephritis
1. Antibiotics - if residual strep infection, PCN unless allergic - erythromycin
2. Bed Rest - during acute phase until hematuria and proteinuria subside
3. Steroids - May be given to decrease inflammation
4. Diet - low protein, low sodium, high calories, high carbs, fluids may be restricted
5. Diuretics may be given if HTN
6. May have to go on dialysis or may recover
79
Nursing Management of Acute Glomerulonephritis
1. Ensure carbs given liberally for energy and reduce catabolism of protein
2. I and O
3. Fluids as ordered
4. Education
80
Patient Education of Acute Glomerulonephritis
1. Fluid and diet restrictions
2. Notify HCP for s/sx of renal failure (fatigue, N/V, decreased urine output)
3. Notify HCP for s/sx of infection
4. F/U labs
81
What is Chronic Glomerulonephritis?
May present first time with chronic from hypertension, hyperlipidemia, or diabetic nephrosclerosis. Kidney tissue becomes fibrous and shrinks to 1/5th normal size. Renal arteries thicken.
*Acute may progress to chronic
82
S/Sx of chronic glomerulonephritis
1. HTN
2. Edema
3. Weight loss
4. Nocturia
5. Headache, dizziness
6. Increased BUN and creatinine
7. Retinal changes
8. Peripheral neuropathy and confusion late in the disease
83
Laboratory Abnormalities of chronic glomerulonephritis
1. Hyperkalemia
2. Metabolic acidosis
3. Anemia
4. Hypoalbuminemia
5. Increased phosphorus
6. Decreased calcium
84
Nursing Interventions of Chronic GLomerulonephritis
1. Monitor weight daily
2. HBV (High Biological Value)proteins (dairy products, eggs, meats)
3. Adequate calories to spare protein
4. Detection of UTI promptly
5. Patient teaching = diet
85
Discharge Teaching for Chronic Glomerulonephritis
1. F/U appointments
2. BP control
3. Teaching about long-term dialysis, care for access site, dietary and fluid restrictions
4. Report s/sx, N/V, decrease urine output, hematuria, edema
5. Compliance with medications
86
What is nephrotic syndrome?
Not a specific syndrome, but a cluster of clinical findings.
87
Causes of nephrotic syndrome
1. Chronic glomerulonephritis
2. DM
3. Lupus
4. Multiple myeloma
5. Renal vein thrombosis
88
S/Sx of nephrotic syndrome
1. Proteinuria (primary symptom) may be tea/coke color > 3.5 g/d hallmark of diagnosis
2. Hypoalbuminemia
3. Pitting edema (major manifestation) commonly periorbital
4. Hyperlipidemia
89
Diagnostic Test for nephrotic syndrome
Needle bx of kidney
90
Medical Management of nephrotic syndrome
GOAL = reserve renal function
1. Diuretics
2. ACE inhibitors
3. Steroids
4. Treatment of hyperlipidemia controversial (dietary modifications of protein and cholesterol)
91
S/Sx of renal trauma
1. Pain
2. Hematuria (most common manifestation)
3. Mass swelling in flank
4. Ecchymosis or wounds to abdomen or flank
5. S/Sx of shock or hemorrhage (70% of patients in shock when admitted)
92
Medical Management of renal trauma
1. Control hemorrhage (H/H frequently), pain, and infection
2. Surgery if bleeding - must treat quickly
3. Bed rest if gross hematuria or a minor laceration; stay on bedrest till hematuria clears
93
How can bladder injuries occur?
May occur with pelvic fractures and multiple trauma or blow to lower abdomen when bladder is full
94
Complications of bladder injuries
1. Hemorrhage
2. Shock
3. Sepsis
95
Medical Management of bladder injuries
Surgery and repair of laceration
96
Urinary Tract Infection
Caused by pathogenic microorganisms in the urinary tract. Most common site is bladder (cystitis) but urethra (urethritis), prostate (prostatitis) and kidney (pyelonephritis) also possible. Normal urinary tract is sterile above the urethra
97
How are UTI's classified?
1. Lower (bladder)
| 2. Upper (kidney)
98
Diagnostic Tests for UTI
1. UA and C/S (clean catch or cath specimen)
| 2. May test for STD - urethritis frequently from STD
99
Urethrovesical Reflux
Can also be from reflux of urine. Coughing, sneezing, etc. increases pressure in bladder forcing urine into urethra. When pressure returns to normal then urine flows back into bladder taking bacteria with it
100
Risk Factors for UTI's
1. Inability to empty bladder completely
2. Decreased natural host defenses or immunosuppression
3. Indwelling catheterization or urinary tract instrumentation
4. Urine stasis and residual > 100 mL
5. Bladder distention or obstruction
6. Metabolic disorders such as diabetes or gout
7. Neurologic disorders, cognitive impairment
8. Pregnancy
9. Risk increases with age
101
Prevention of UTI's
1. Void every 2-3 hours
2. Wipe back to front
3. Take shower instead of bath
4. Avoid bubble baths - cause irritation
5. Wear cotton underpants
6. Pericare before sexual intercourse and void immediately after
7. Drink lots of fluids - avoid UT irritants (coffee, tea, cola, alcohol). Acidify urine with vitamin C and cranberry juice
102
Cystitis (lower UTI)
Bladder infection. Usually caused by ascending infection from urethra. May be caused by urine flowing back from urethra into the bladder (urethrovesical reflux), fecal contamination, or catheter
103
S/Sx of cystitis
1. Frequency and urgency
2. Burning and pain on urination - hesitancy
3. Nocturia
4. Suprapubic pain
5. Hematuria
6. Pyuria
7. N/V
104
Medical Management of cystitis
1. Antibiotics (Co-trimoxazole and Nitrofurantoin); uncomplicated UTIs can be treated with one-time dose, 3-4 day regimen or 7-10 day regimen; chronic UTI may require treatment for months
2. Fluid intake
3. Preventative measures
105
What is urethritis?
Inflammation of urethra. In males usually caused by gonorrhea. Non-gonorrheal usually caused by chylamydia
106
S/Sx of urethritis
Males - inflammation, purulent drainage and burning on urination
Females - may not have symptoms. May have discharge. Frequently not diagnosed and sterility may occur.
107
Treatment of urethritis
Antibiotics and follow up care to ensure infection gone
| All sexual partners must be tested
108
What is acute pyelonephritis?
Infection of renal pelvis, tubule, interstitial tissue of kidney
Frequently secondary to urine back up or obstruction
109
Causes of acute pyelonephritis
1. Bacterial infection of the kidney
2. Obstruction or renal disease
* Most common organism is E. coli but can also be from proteus, pseudomonas, staph, or strep
110
S/Sx of acute pyelonephritis
1. Flank or back pain
2. CVA tenderness
3. Fever, chills
4. Dysuria, frequency, and urgency
5. Malaise
6. Pus, bacteria and white cells in urine
111
Diagnostic Tests for acute pyelonephritis
1. US
2. CT scan
3. Urine C/S
4. Gallium scan
112
What is chronic pyelonephritis
Persistent kidney inflammation. Usually asymptomatic except for vague/intermittent flank pain, fatigue, headache, occasional fever, and bacteriuria. Can lead to chronic renal failure
113
Medical Management for Acute and Chronic Pyelonephritis
1. Antibiotics for 2 weeks up to 6 months
2. Antiemetics to control N/V
3. Fluids to prevent dehydration and increase urine output
4. Pain meds and urine antiseptics to relieve discomfort
5. Bed rest needed to promote healing
114
Nursing interventions for acute and chronic pyelonephritis
1. Administer meds - antibiotics, antiemetics, analgesics, and antiseptics as ordered
2. Explain to patient that they must continue antibiotics and keep F/U appointments
3. Explain cause, effect etc. of disorder
4. Encourage bed rest and gradual increase activity with frequent rest periods
115
Diet for all UTI's
1. Acid diet - cranberry, prune, plums, vitamin C, breads, meat, eggs
2. At least 3000 mL fluid per day
116
Urolithiasis
Bladder stones
117
Nephrolithiasis
**Kidney Stones
Calculi stones that form in the urinary tract, most common site is the kidney, where they can cause ischemia, altered elimination and UTI due to stasis. Can lead to kidney damage or failure.
*More common in men than women and rare in blacks and children
*Most common cause of urinary obstruction
118
Factors that favor stone formation
1. Fluid volume status
2. Diet
3. Immobility
4. Obstruction
5. Foreign Body (stones forming on a Foley)
6. Metabolic factors
7. Inflammatory bowel disease
8. Family history
9. Medications
119
How does fluid volume status affect stone formation?
A lower fluid intake increases concentration of stone forming substances in the urine. Changes in urine pH favor stone formation
120
How does diet affect stone formation?
1. High intake of calcium
2. Oxalates
3. Purines
121
Foods high in oxalate
1. Spinach
2. Beets
3. Potato chips
4. French fries
5. Nuts
6. Nut butters
122
Foods high in purines
1. Organ meat
2. Game meat
3. Anchovies
4. Beer
5. Bacon
123
How does immobility affect stone formation?
Immobility allows calcium to be released into circulation from bones and filtered by kidneys promoting stone formation. Also slows renal drainage.
124
How does obstruction affect stone formation?
Urine stasis allows stone forming substances to collect and form stones. Obstruction also encourages infection which compounds the problem
125
How do metabolic factors affect stone formation?
1. Hyperparathyroidism
2. Elevated uric acid
3. Oxalate metabolism problems
4. Genetic defect in cystine metabolism
5. Excess intake of calcium/vitamin D
126
How does inflammatory bowel disease affect stone formation?
Patients with IBD, ileostomy, or bowel resection absorb more oxalate.
127
What medications encourage stone formation?
1. Laxatives
2. Antacids
3. High doses ASA
4. Diamox
5. Vitamin D
128
Types of Stones
1. Calcium
2. Oxalate
3. Struvite
4. Uric Acid
5. Cystine
129
Clinical Manifestations of Stones in Renal Pelvis
Intense deep ache in CVA can radiate down toward the bladder; N/V (renal colic)
130
Clinical Manifestations of Stones in Ureter
Acute, wave-like flank pain radiates down thigh and to genitalia. May have the urge to void but little urine passed and usually contains blood - (ureteral colic)
131
Clinical Manifestations of Stones in the Bladder
1. UTI
2. Hematuria
3. Retention if stone obstructs the bladder neck
132
General S/Sx of stone formation
1. Diaphoresis
2. Restlessness
3. Pain
4. GI (N/V/D)
133
Diagnostic Tests to confirm GU stones
1. UA
2. KUB and/or IVP
3. Serum chemistries
4. CT
5. Cystoscopy
134
Potential Complications of Stone Formation
1. Obstruction
2. Pyelonephritis
3. Tissue irritation leads to renal abscess and can contribute to cancer
4. Urosepsis
135
Ways to relieve pain in patients with GU stones
1. Narcotics
2. Heating pad
3. Hot bath
4. Report increases in severity promptly
5. Positions of comfort
136
Teaching for patients with GU stones
1. Restrict protein 60 g per day
2. Na 3-4 g per day
3. Avoid intake of oxalate high foods
4. Generally don't want to limit calcium intake because it could lead to osteoporosis
5. High fluids every 1-2 hours, 2 glasses of water at bedtime, every time upon awakening, 2 L/day
6. Avoid dehydration
7. Strain urine at home
8. Notify MD any sudden increase in pain may indicate obstruction
9. Contact HCP at first sign of UTI
137
Surgical Procedures for patients with GU stones
1. Extracorporeal Shock Wave Lithotripsy (ESWL)
2. Ureteroscopy or cystoscopy
3. Percutaneous Nephrostomy or nephrolithotomy
138
Extracorporeal Shock Wave Lithotripsy (ESWL) (Stones)
Shock waves directed at location to crush stones (patient may be submerged in large bath of warm water). Stones are then passed in the urine in a few days. Client needs to increase fluid intake to facilitate passage
139
Ureteroscopy or cystoscopy (Stones)
Visualize stone through ureteroscope and then destroy stone with a laser, lithotriptor, or U/S wave device. May remove stone with basket. Stent may be inserted for a few days to keep ureter patent (observed for obstruction/infection). May have hematuria until stent removed. Strain all urine after.
140
Percutaneous Nephrostomy or Nephrolithotomy (Stones)
Percutaneous tract to kidney through which nephroscope is introduced. Stone may be extracted or ultrasonic waves may be used to pulverize the stone
141
Diet and Medication Treatment for Calcium Stones
1. No longer recommend calcium restriction unless true hypercalcemia
2. High fluid intake
3. Restrict protein
4. Restrict sodium
5. Acid diet
6. Medications (cellulose sodium phosphate, thiazide diuretics, lithostat)
7. Avoid antacids that contain calcium
142
Diet and Medications Uric Acid Stones
1. Avoid foods high in purine
2. Other proteins may be limited
3. Teach client to avoid alcohol, fasting and crash diets - may increase uric acid
4. Alkaline diet
5. Avoid high purine foods
6. Medications (allopurinol)
143
Recommended Diet for Oxalate Stones
1. High fluid intake
| 2. Avoid these high oxalate foods
144
Recommended Diet for Cystine Stones
1. Low protein
| 2. Alkaline diet
145
Alkaline Diet
1. Milk
2. Vegetables
3. Rhubarb
4. Most fruit including citrus
146
Acid Diet
1. Cranberries
2. Prunes
3. Plums
4. Eggs
5. Bread
6. Meat
147
What is a urethral stricture?
Narrowing of urethra that can be conginital or acquired. Urine flow outside bladder restricted and dilation of system proximal to stricture occurs
148
Causes of urethral strictures
1. Injury (could be from Foley, surgical instruments, or straddle injury)
2. Untreated gonorrhea urethritis
3. Congenital abnormalities
149
S/Sx of urethral stricture
1. Decreased force or volume of stream
2. Retention
3. Hesitancy, straining
4. Overflow incontinence
150
Potential Complications Urethral Strictures
Hydronephritis
151
Diagnostic Tests
1. UA, C/S
2. IVP - intravenal pyelogram
3. Voiding cysto
4. Urethroscopy
152
Medical Management of Urethral Stricture
1. Dilation - begin with smaller and progress
| 2. Surgical removal
153
Hydronephrosis
Distention of renal pelvis and calices by obstruction of urine flow. Urine is trapped proximal to obstruction. Renal tissue is destroyed, uremia results. Permanent damage may occur.
154
Causes of hydronephrosis
1. Stones
2. Tumor
3. Scar tissue
4. Urethral stricture or ureter stricture
5. BPH
155
S/Sx of hydronephrosis
If gradual may be none, otherwise acute flank pain. If infection will have will have s/sx of UTI (pain, fever, chills, tenderness, pyuria, decreased output) may have hematuria
156
Medical Management of Hydronephrosis
Identify and correct the cause - antibiotics, remove obstruction
May need urinary diversion
157
Risk Factors for Bladder Cancer
1. Caucasian men (4X more than women), age > 55
2. Smoking
3. Chemicals (environment)
4. Recurrent or chronic UTI's
5. High urinary pH
6. High cholesterol intake
7. Pelvic radiation therapy
8. Metastasis from prostate, colon, rectum
158
S/Sx of bladder cancer
Painless hematuria is usually only symptom
| Any alteration in voiding needs to be investigated especially if have risk factors
159
Diagnostic Tests
1. UA - cytology to see what kind of cells are present
2. IVP - assess bladder and surrounding structures
3. Cystoscopy - direct visualization of tumor
160
Medical Management of Bladder Cancer
1. Radiation
2. Medication - Bacillus Calmette Guerin
3. Surgery - local resection or total cystectomy
161
Urinary Diversions
Performed to divert urine from bladder to new exit site
162
Two types of urinary diversions
1. Cutaneous
| 2. Continent
163
Pre-Op Preparation for Urinary Diversions
1. Bowel cleaning
2. Low residue diet
3. Antibiotics for bowel disinfection
4. Hydration
5. May need hyperalimentation (TPN)
6. ET (stoma nurse) for pre-op teaching and to mark stoma location
164
Ileal Conduit
Oldest type of diversion, transplant ureters to an isolated section of the terminal ileum (intestine) and bring one end to the abdominal wall as an ileostomy
165
Complications of Ileal Conduit
1. Infection
2. Dehiscence
3. Urinary leakage
4. Ureteral obstruction
5. Small bowel obstruction
6. Stomal gangrene
* Not normal to see stool in drainage
166
How to assess and manage diversion
1. Change appliance early a.m. decrease urine output
2. Skin barrier essential
3. Avoid moisturizing soaps
4. Avoid foods with strong odors
5. Liquid deodorizer, diluted white vinegar into bottom of pouch, ascorbic acid PO
6. No ASA in pouch/will ulcerate stoma
7. Change pouch regularly
8. Empty when 1/3 full
167
Ureterosigmoidostomy
Implant ureters into sigmoid colon. Urine excreted during bowel movements. Voiding is through rectum. This procedure usually done for patient who has had pelvic radiation, previous small bowel resection or small bowel disease
168
Nursing Implications for ureterosigmoidostomy
1. May require adjustment of lifestyle b/c frequency
2. Bowel incontinence may occur. May have frequency (q2h). Will be like watery diarrhea - some degree of nocturia
3. Anal sphincter training will help patient gain control and learn to differentiate between need to void and need to defecate
4. F/E imbalances - large areas of bowel are exposed to urine and electrolyte reabsorption - so imbalances may occur
5. May have catheter in rectum, can irrigate but never force, danger of introducing bacteria into newly implanted ureters
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Cutaneous Ureterostomy
Ureter brought through abdominal wall and attached to opening. Used for patients with ureteral obstruction such as pelvic cancer, for poor risk patients because requires less extensive surgery than others procedures. May also used for patients who have had previous abdominal radiation
170
Cutaneous Ureterostomy Nursing Implications
1. Appliance to collect urine needed
| 2. Stoma usually flush with skin or retracted
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Vesicostomy
Bladder sutured to abdominal wall and stoma created for urine drainage
*Appliance to collect urine needed
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Nephrostomy
Catheter inserted into renal pelvis via incision in flank. Do not clamp nephrostomy tubes
*Appliance is needed
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Continent Ileal Urinary Reservoir (Indiana Pouch)
Most common continent diversion. Uses segment of ileum and cecum to form reservoir. Ureters tunneled and anastomosed. Reservoir made by narrowing part of the ileum and sewing terminal ileum to SQ tissue. Pouch is sewn to abdominal wall around a cecostomy tube.
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Nursing Implications for Indiana Pouch
1. Urine collects in pouch until catheter inserted and urine drained
2. Have to be taught self-catheterization = reservoir must be drained at regular intervals to prevent absorption of metabolic waste products from the urine. Also needs to be done to prevent UTI
3. Kock pouch has a nipple with one way valve - the valve prevents leakage of urine and drainage of urine is under patients control
4. In males Kock pouch can be attached to one end of urethra to allow for more normal voiding. Female urethra too short
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Post-Op Interventions for Indiana Pouch
1. Stoma - should be beefy, red, moist
2. Urinary output - monitor hourly < 30 mL/hr dehydration or obstruction
3. Pain - postop pain control
4. Body image - learning to cope with body image change and increase self-esteem. Learn to accept altered urinary function and sexuality
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Potential Complications of Indiana Pouch
1. Respiratory complications - atelectasis
2. Fecal/urine leakage that leads to skin irritation: irritation, bleeding, infections
3. Peritonitis
4. Stoma ischemia
5. Stoma retraction and separation
6. F/E imbalances
7. Ascorbic acid to keep urine pH <6.5 - alkaline incrustation around stoma
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Discharge Planning for Indiana Pouch
1. Provide diet instructions - avoid gas forming foods if diversion into the GI tract
2. Teach care of pouch
3. Self cath if continent pouch
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Risk Factors for Benign Prostatic Hyperplasia (BPH)
1. Smoking
2. Heavy alcohol consumption
3. HTN
4. CV disease
5. DM
6. Increase age
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S/Sx of BPH
1. Frequency
2. Urgency
3. Retention
4. Hesitancy
5. Straining
6. Decrease volume and force of stream
7. Dribbling
8. UTI
9. Nocturia
10. Enlarged prostate on digital rectal exam
11. Chronic urinary retention - azotemia, renal failure
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Diagnostic Tests to confirm BPH
1. Digital exam
2. UA
3. Urodynamics
4. PSA - prostate specific antigen
5. CBC before surgery to correct clotting defects
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Potential Complications of BPH
1. Hydroureter
2. Hydronephrosis
3. Pyelonephritis
4. Renal failure
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Medical Management of BPH
1. Watchful waiting
2. Balloon dilation
3. Suprapubic cystoscopy/suprapubic catheter
4. Medication
5. Transuretheral Needle Ablation
6. Microwave Therapy
7. Transurethral Laser Resection
8. Transurethral Incision of Prostate (TUIP)
9. Transurethral Resection Prostate (TURP)
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Transurethral Needle Ablation
For BPH
| Uses radio frequency to destroy tissue
184
Microwave Therapy
For BPH
| Microwave heat. Tissue sloughs off. Water cooling system used so patient not burned.
185
Transurethral Laser Resection
For BPH
Treated tissue vaporizes or becomes necrotic and sloughs off. Body reabsorbs dead tissue. Done as output. Less post-op bleeding than TURP
186
Transurethral Incision of Prostate (TUIP)
For BPH
Electric current/laser beam used to make incisions in prostate to decrease resistance to flow of urine. No tissue removed
187
Transurethral Resection Prostate (TURP)
For BPH
| Scope introduced through the urethra to prostate. Inner portion of prostate removed or entire gland
188
Post-Op Care BPH Surgery
1. Bladder irrigation
2. Assess for bleeding or clot formation
3. Use antispasmodics for bladder spasms
4. Teach perineal exercises to improve bladder control
5. Fluid intake to keep urine clear
6. Teach to watch for bleeding up to 2 weeks after TURP
7. MD should manipulate catheter
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Suprapubic Prostatectomy
For BPH
Remove gland through abdominal incision
1. Change dressings frequently using sterile technique
2. Foley catheter in place
190
Perineal Prostatectomy
For BPH
| Remove the gland through incision in perineum. Used for radical cancer treatment
191
Nursing Implications for perineal prostatectomy
1. Better for very old, frail, and poor surgical risk patient with large prostate
2. Higher risk post-op impotence and incontinence
3. Possible damage to rectum and external sphincter
4. Greater risk for infection
192
Retropubic prostatectomy
Abdominal incision without opening bladder. Approaches the prostate between the pubic arch and bladder. More common than suprapubic
193
Laparoscopic Radical Prostatectomy
Provides better visualization, experience less bleeding, shorter hospital stays, less post-op pain
194
Potential Complications after Prostatectomy
1. Hemorrhage - irrigation
2. Infection - antibiotics
3. DVT - elevate HOB, O2, notify MD, early ambulation
4. Catheter obstruction - irrigation
5. Sexual dysfunction
195
Prostate Cancer
1. Most common cancer in men
2. More prevalent in African American males
3. Growth of prostate gland depends on presence of testosterone
4. Recommended men over 40 have digital rectal exam yearly
196
Risk Factors for Prostate Cancer
1. Family history
2. Diet
3. Chemical exposure
4. Age
5. African American
197
Clinical Manifestations of Prostate Cancer
1. Usually none in early stages
2. Symptoms from obstruction later
3. Blood in urine if invades bladder, painful ejaculation
4. May get symptoms from metastasis late in diagnosis usually to bone or lymph nodes
198
Diagnostic Tests to confirm Prostate Cancer
1. Examine tissue from prostatectomy
2. PSA (normal <4) [remember it could be elevated due to BPH or infection]
3. PAP (prostate acid phosphatase 2.5-3.7) - tells if cancer metastasized. Also tells effectiveness of treatment
4. DRE - advanced lesion is stony hard and fixed
199
Medical Management of Prostate Cancer
1. Surgery - standard treatment
2. Radiation
3. Hormone treatment
200
Radiation (Prostate Cancer)
Can be done if found early enough
1. External (teletherapy) 6-8 weeks of daily radiation
2. Internal (brachytherapy) radioactive seeds implanted; avoid close contact with pregnant women and infants for 2 months; strain urine for seeds and use condom for up to 2 weeks after implant
201
Hormone Treatment (Prostate Cancer)
Prostate cancers are androgen-dependent, used to control not cure - monthly injections of hormone leuprolide prevents progression of disease - very expensive. Or may do orchiectomy (remove testes). May take estrogen, female hormone
202
Epididymitis
Inflammation of epididymis
| Usually unilateral and caused by infection from prostate gland or UTI
203
Complications of Epididymitis
1. Orchitis (infection of testes)
2. Abscess
3. Sterility
204
S/Sx of Epididymitis
1. Severe pain and tenderness in groin and scrotum
2. N/V
3. Fever, chills
4. Dysuria
5. Frequency and urgency
6. Elevated WBC (20,000-30,000)
205
Medical Management of Epididymitis
1. Bedrest, usually for 3-5 days
2. Elevate scrotum
3. Ice packs
4. Analgesics
5. Antipyretics
6. Antibiotics
7. Later - local heat, sitz bath
8. Avoid straining, lifting, sexual stimulation until infection under control
206
Prostatitis
Inflammation of prostate; most commonly carried from urethra, prostate secretes fluid that forms part of seminal fluid
*Can be acute or chronic, bacterial or viral
207
Clinical Manifestations of Prostatitis
1. Burning
2. Urgency
3. Frequency
4. Nocturia
5. Dysuria
6. Pain in perineal and rectal area
7. Pain with or after ejaculation
8. Fever
208
Acute Bacterial Prostatitis S/Sx
1. Sudden fever
2. Chills
3. Perineal, rectal, lower back pain
4. Urinary symptoms
209
Chronic Bacterial Prostatitis
Major cause of recurrent UTI's
| *Fever/temps uncommon
210
Management of Viral Prostatitis
NSAIDs
211
Management of Bacterial Prostatitis
1. Antibiotics (sulfa drugs)
| 2. Chronic - difficult to treat, antibiotics diffuse poorly into prostatic fluid
212
Patient Education for Prostatitis
1. Bed rest
2. Analgesics
3. Sitz baths
4. Complete antibiotics
5. Do not force fluids
6. Avoid diuretics
7. During acute periods avoid sexual activity
8. F/U 6 months to a year
213
Causes of ED
1. Psychogenic - anxiety, fatigue, depression, and pressure to perform
2. Organic - occlusive vascular disease, endocrine disorders, chronic renal failure, GU conditions, hematologic conditions, neurologic conditions, trauma, alcohol, medication, and drug abuse
214
Phimosis
Foreskin cannot be retracted
1. Usually caused by poor hygiene or medical conditions such as DM
2. Glans penis should be cleaned to prevent inflammation
3. Steroid cream to reduce constriction
* May require circumcision after inflammation resolves
215
Paraphimosis
Once retracted, foreskin cannot be returned over glans -> venous congestion, edema, and enlargement of glans
1. Arterial occlusion and necrosis may occur
2. Treated by firmly compressing glans for 5 minutes to reduce edema and size, then moving foreskin forward while pushing glans back
* May require circumcision after inflammation resolves
