Module 7: Renal and Urologic Problems Flashcards

Question

Urinary Stone Management

Answer 1

2 concurrent approaches: 1. Manage acute attack * Pain, infection, and/or obstruction  Opioids, NSAIDS, -adrenergic blockers 2. Evaluate cause of stone formation and prevent further development * Family history; geographic residence; nutrition assessment; fluid intake; vitamins A, C, and D; activity pattern * History of prolonged illness, GI or GU disease or surgery, previous stones, prescribed and OTC meds, diet supplements Treatment and patient teaching  Adequate hydration  Sodium restriction  Diet changes  Drugs * Alter pH of urine, prevent excess urinary secretion of a substance, or correct primary disease  Struvite stones: antibiotics and acetohydroxamic acid; surgery Stones of 4 mm or less may pass spontaneously (may take weeks)  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 Or if:  The patient can’t be treated medically or only has one kidney

Answer 2

 Cystoscopy—remove stone in bladder  Cystolitholapaxy—large stones broken up with lithotrite (stone crusher)  Cystoscopic lithotripsy—ultrasonic waves break stones  Complications of above procedures: Hemorrhage, retained stone fragments, and infection Ultrasonic, laser or electrohydraulic lithotripsy—used to break stones during:  Flexible ureteroscopes—remove stones from renal pelvis and upper urinary tract  Percutaneous nephrolithotomy—nephroscope inserted through skin into pelvis of kidney; stone fragmented and removed, followed by irrigation. May place nephrostomy tube. * Complications: bleeding, injury to adjacent structures, and infection

Answer 3

Procedure to eliminate stones from urinary tract:  Laser lithotripsy  Extracorporeal shock-wave lithotripsy (ESWL)  Percutaneous ultrasonic lithotripsy  Electrohydraulic lithotripsy * Ureteral stent placed to facilitate passage of sand; removed in 2 weeks * Postprocedure: hematuria; prophylactic antibiotics  Encourage fluids to dilute urine and reduce pain * Complications (rare): hemorrhage, infection, obstruction

Answer 4

Primary indications for surgery:  Pain, infection, and obstruction Type of surgery depends on location of stone  Nephrolithotomy—kidney  Pyelolithotomy—renal pelvis  Ureterolithotomy—ureter  Cystotomy—bladder  Postop complication: hemorrhage

Answer 5

Obstructing stone  Adequate fluids to avoid dehydration * Forcing fluids not recommended; increased pain After urolithiasis  High intake (~3 L/day) to produce 2.5 L urine/day  Water is best!  Prevents supersaturation of minerals  Reduce risk of dehydration  Limit colas, coffee, and tea—increased stone formation  Low-sodium diet  Diet restrictions according to type of stone * Purine, calcium, oxalate Prevention of recurrence  Lifestyle changes  Diet changes * Adequate fluid intake (3 L/day) if no CV or renal compromise; produce 2.5 L urine/day; increase if very active * Diet restrictions  Immobile/bed rest patients  Medications; patient teaching

Answer 6

Can affect entire length of ureter from UPJ to UVJ and alter kidney function  Causes: congenital, adhesions or scar formation, or large tumor in peritoneal cavity  Clinical Manifestations: mild to moderate colic, flank pain, and CVAT  Treatments: * Bypass with stent or nephrostomy tube placement; balloon or catheter dilation * Surgery: endoureterotomy, ureteroureterostomy, or ureteroneocystostomy Fibrosis or inflammation of urethral lumen leads to narrowing and compromised opening and closing with bladder filling and voiding  Causes: trauma, urethritis, surgical intervention or repeated catheterizations, congenital defect, idiopathic Manifestations  Straining to void  Urine stream: diminished, sprayed, or split  Postvoid dribbling  Incomplete bladder emptying, frequency, and nocturia  Severe obstruction—urinary retention Diagnostic studies  Retrograde urethrography (RUG), ultrasound urethrography, cystourethrogram, and VCUG Treatment  Dilation with metal instruments or stents of increasing size; stenosis may occur  Self-catheterization every few days  Endoscopic or surgical procedure * Urethroplasty * Resection and re-anastomosis or urethra

Answer 7

Blunt—most common  Causes: abdominal, flank, or back injury; sports injuries, MVAs, and falls  Penetrating—violence (e.g., gunshot, stabbing)  Clinical manifestation: Hematuria  Diagnostic studies: urinalysis, ultrasound, CT, MRI, renal arteriogram Treatments—depend on severity  Bed rest, fluids, analgesia  Exploratory surgery and repair  Nephrectomy  Nursing care  Assess CV status; monitor for shock  Adequate intake; monitor I & O  Pain management  Monitor for hematuria and myoglobinuria

Answer 8

 Sclerosis of small arteries and arterioles of the kidney causes reduced blood flow, ischemia, interstitial fibrosis, and necrosis  Benign nephrosclerosis—age-related (more than 60 years old) changes due to HTN and atherosclerosis  Accelerated (malignant) nephrosclerosis—medical emergency due to severe HTN  SBP greater than or equal to 180 mm Hg and/or DBP greater than or equal to 120 mm Hg  Treatment: antihypertensive drugs

Answer 9

Partial occlusion of one or both renal arteries and major branches  Causes: atherosclerosis or fibromuscular hyperplasia  Manifestations: sudden HTN * Ages less than 30 and more than 50 years  Diagnostic studies: renal duplex Doppler ultrasound, CT or MRI angiography, and renal arteriogram Treatment goals  Control BP and restore renal perfusion  Treatments  Percutaneous transluminal renal angioplasty  Surgical revascularization  Nephrectomy (if one kidney involved

Answer 10

May be unilateral or bilateral  Causes: trauma, extrinsic compression, renal cell cancer, pregnancy, contraceptive use, and nephrotic syndrome  Manifestations: flank pain, hematuria, or nephrotic syndrome Treatments  Anticoagulation  Corticosteroids  Surgical thrombectomy

Answer 11

Developmental abnormalities of renal parenchyma  Cystic in nature  Rule out other causes and tumors

Answer 12

One of the most common life-threatening genetic diseases in the world  In United States 600,000 people  Fourth leading cause of ESRD  Genetic link: 2 hereditary forms  Adult—autosomal dominant (90% of cases)  Child—autosomal recessive Adult PKD Affects both kidneys in men and women  Cortex and medulla filled with thin-walled cysts that destroy surrounding tissue by compression  Cysts are filled with fluid; may have blood or pus  Signs and symptoms develop at 30 to 40 years of age  Clinical manifestations (initial): HTN; hematuria; pain or heavy feeling in back, side or abdomen; UTI or urinary stones; may be asymptomatic  Most common problem: chronic, severe pain Kidneys are enlarged; may be palpable  Affects other structures: liver, heart, blood vessels, intestines, and brain  Diagnostic studies: ultrasound or CT scan  Also consider: clinical findings and family history Treatment: no cure  Prevent or treat UTI  Nephrectomy  Dialysis and kidney transplant  Nursing: management for ESRD; genetic counseling

Answer 13

Hereditary disorder of older adults  Kidneys with cysts in medulla are asymmetric and scarred; unable to concentrate urine  Clinical manifestations: polyuria, HTN, progressive renal failure, severe anemia, and metabolic acidosis  Treatment: as with ESRD  Genetic counseling

Answer 14

Chronic hereditary nephritis  Males earlier and more severe than females  Gene mutation for collagen resulting in altered synthesis of glomerular basement membrane 3 genetic types  Sex-linked (most common) * See: hematuria, progressive hearing loss, and deformities in lens  Autosomal recessive—hematuria  Autosomal dominant—hematuria  Treatment: management of ESRD is kidney transplant

Answer 15

In United States 63,340 new cases/year; 14,970 die  Renal cell carcinoma (adenocarcinoma)—most common (Fig. 50.8 in the textbook)  Males more than females; average age 64 years old  Risk factors: cigarette smoking, ACKD, obesity, HTN, exposure to asbestos, cadmium, and gasoline  Increased incidence—First-degree relatives Early stage: asymptomatic; often incidental finding for unrelated condition  25% have metastasis when diagnosed * Renal vein, vena cava, lungs, liver, and long bones  Common manifestations: hematuria, flank pain, palpable mass in flank or abdomen  Other: weight loss, fever, HTN, anemia  Diagnostic Studies: CT scan, ultrasound, angiography, biopsy, MRI; radionuclide isotope scan

Answer 16

Most common urinary system cancer  81,900 new cases/year; 17,240 deaths/year  Older adults more than 55 = 90% cases  Men more than women; whites > blacks or Hispanics  Transitional cell cancer—most frequent  Most are papillomatous growths  Risk factors: cigarette smoking  Other: industrial exposure to dyes; cervical cancer treated with radiation or chemotherapy; prolonged indwelling catheters, chronic, recurrent urinary tract stones, and chronic UTIs Clinical Manifestations/Studies Most common manifestation: microscopic or gross, painless hematuria  Other: dysuria, frequency, and urgency  Diagnostic studies  Urine specimens for cancer or atypical cells, and bladder tumor antigens  CT scan, ultrasound, or MRI  Cystoscopy and biopsy—confirm cancer Cancer is graded and staged (I to V) before treatment; most diagnosed early  Staging determined by depth of invasion of bladder and surrounding tissue  Treatments include:  Surgery  Radiation  Chemotherapy  Intravesical therapy

Answer 17

Transurethral resection of the bladder tumor (TURBT)—superficial lesions removed with cystoscope  Fulguration (burns base of the tumor) or high energy laser (kills cancer cells)  Used to control bleeding in high risk patients or with advanced tumors  Disadvantage: re-occurrence, scarring, or inability to hold urine (repeated TURBTs Segmental (partial) cystectomy—remove large tumors in 1 area of bladder wall and margin of normal tissue  Radical cystectomy—invasive tumors or trigone area but no metastasis beyond pelvic area; must have urinary diversion  Men—bladder, prostate, and seminal vesicles  Women—bladder, uterus, cervix, urethra, anterior vagina, and ovaries Post Op Care Postoperative care  Drink large volume of fluid for 1 week  Patient teaching:  Monitor color and consistency of urine  Pink for several days; not bright red or with clots  May have dark red or rust-colored flecks for 7 to 10 days  Opioid analgesics and stool softeners; coping; and follow-up care (regular cystoscopies)

Answer 18

Local instillation of immunotherapy or chemotherapy by urethral catheter  Retained for 2 hours; change position every 15 minutes  Weekly intervals for 6 to 12 weeks  Induction and maintenance therapy  Post procedure: irritative voiding and hemorrhagic cystitis—increased fluids

Answer 19

Involuntary leakage of urine  More prevalent with older adults (women more than men) but not a natural consequence of aging  Gender differences * Men—common with BPH or prostate cancer; overflow incontinence from urinary retention * Women—stress and urge incontinence

Answer 20

Bladder pressure greater than urethral closure pressure  Interference with bladder or sphincter control DRIP  D: delirium, dehydration, depression  R: restricted mobility, rectal impaction  I: infection, inflammation, impaction  P: polyuria, polypharmacy

Answer 21

 Stress  Urge **Combined stress + urge = mixed incontinence  Overflow  Reflex  Incontinence after trauma or surgery  Functional incontinence  May have more than 1 type

Answer 22

Many can be cured or improved  Treat transient, reversible factors first  Interventions depend on type  Individualized to patient preference, type and severity, and anatomic defects * Lifestyle modifications * Scheduled voiding regimens * Pelvic floor muscle rehabilitation * Antiincontinence devices * Containment devices Drug therapy  Surgical therapy -Depends of type of UI * Urinary structural support/repositioning * Increased urethral resistance of internal sphincter and intraabdominal pressure reception * Retropubic colposuspension and pubovaginal sling * Suburethral sling * Bulking agent injection * Artificial sphincter surgery

Answer 23

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  Acute urinary retention—inability to pass urine; medical emergency  Chronic urinary retention—incomplete emptying despite urination  Post void residual (PVR)—normal 50 to 75 mL * More than 100 mL—repeat or further evaluation with UTIs * More than 200 mL—further evaluation

Answer 24

Bladder outlet obstruction—bladder can’t empty due to severe blockage  Men—enlarged prostate  Deficient detrusor contraction—muscle can’t contract with enough force or time to empty bladder  Neurologic diseases involving sacral 2, 3, and 4; diabetes; overdistention; chronic alcohol use; and anticholinergic drugs

Answer 25

Diagnostic studies (Same as UI)  Urinalysis, post void residual, urodynamic studies, ultrasound  Interprofessional care  Behavioral therapies (as with UI)  Scheduled toileting and double voiding  Catheterization: intermittent or indwelling  Drug therapy

Answer 26

Surgical therapy—obstruction  Transurethral or open techniques for: * Prostate enlargement or cancer * Bladder neck contracture * Urethral strictures * Dyssynergia of bladder neck  Abdominal or transvaginal approach for: * Pelvic organ prolapse  Surgical therapy—deficient detrusor contraction * Sacral neuromodulation * Intraurethral valve pump

Answer 27

Acute urinary retention—emergency  Insert catheter —consider indwelling  Patient teaching to minimize risk: * Drink small amounts throughout the day * Be warm when trying to void * Avoid excess alcohol  Patient teaching if unable to void: * Drink caffeinated coffee or tea to increase urgency * Warm bath/shower * Seek medical care

Answer 28

Chronic urinary retention  Behavioral methods * Scheduled toileting; every 3 to 4 hours  Catheterization  Surgery  Drugs

Answer 29

Indications for indwelling  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

Answer 30

Indications for intermittent  Relief of urinary retention  Diagnostic study  Urodynamic testing  Sterile specimen  Medication instillation  Measure PVR

Answer 31

Unacceptable reasons for catheterization  Routine urine specimen  Convenience for nurse or patient’s family  Complications of long-term use (more than 30 days)  CAUTI—most common HAI  Other: bladder spasms, periurethral abscess, chronic pyelonephritis, urosepsis, urethral trauma or erosion, fistula or stricture formation, and stones Complications of long-term use (more than 30 days)  CAUTI—most common HAI  Other: bladder spasms, periurethral abscess, chronic pyelonephritis, urosepsis, urethral trauma or erosion, fistula or stricture formation, and stones