GenitoURINARY SYSTEM DISORDERS
Things you have to think about when thinking about the kidneys:
- Acid base: Ph 7.35-7.45, paO2 75-100, paCO2 35-45, HCO3- 22-28
- Fluids and electrolytes, specific gravity, metabolic wastes (creat, BUN), medication excretion
- RAAS
- Erythropoietin
- Calcitriol
- Minimum output 0.5 ml/kg/hr
In general labs:
specific gravity: 1.010-1.030
urinalysis should be the first void of the day, examine within 1 hour of coid.
creat clearance for GFR requires 24 hour specimen. GFR >90 normal.
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BUN 10-20
Creat 0.6-1.2
Prostate specific antigen >10 = significant risk of prostate cancer
Radiological tests
**WHENEVER DYE IS INVOLVED, CHECK FOR ALLERGIES and CREATININE LEVELS. ANY TIME DYE IS INVOLVED THE PATIENT MAY FEEL FLUSHING**
IVpyelography c contrast: to visualize urinary tract (kidneys, ureters, bladder)
Nurse's responsibility:
pre procedural: check creatinine (for proper clearance), check allergies, NPO 8hrs pre
administer laxatives, enema, fluids as ordered.
Renal angiography c contrast : visualize the blood vessels of the renals
Nurse's responsibility:
pre-procedural: check creatinine (for proper clearance), check allergies, locate and mark peripheral pulses, have patient void.
post-procedural: check for hematoma/hemorrhage c bed rest for 8 hrs, check peripheral pulses
Cystoscopy: considered an invasive procedure, scope passed to view interior of urinary tract,
used to clear calculi from utethra, bladder, ureters
used to treat lesions in bladder, urethra, prostate
pink or tea-colored urine is ok post procedure
bright red urine or clots NOT OK
Nurse's responsibility:
pre-procedural: NPO, DO NOT INFUSE FLUIDS if complete block by calculi, give cathartics, pain RX/deep breathing exercises to relieve bladder spasms.
post-procedural: assess for leg, back, abdominal pain. Push fluids, flush, sitz.
Renal biopsy: major hemorrhage potential
Nurse's responsibility, preprocedure:
- clotting (norm: 2-6 minutes)/PT (11-14 seconds norm, 17-28 seconds altered)
- prebiopsy x-rays of kidney for baseline
- IVF, NPO 8hr pre preprocedure
- confirm consent
post procedure:
- pressure to puncture site for 20 min
- maintain supine bed rest for 24 hr
- VS q 15 min for 4 hr
- fluids, pain medicine, I&O, Hgb/hct 8 hrs post procedure
- No heavy lifting for 2 weeks
Indwelling urinary catheterization: a sterile procedure in the hospital. A clean procedure at home b/c bacteria is the same as bacteria already present in patient. Necessary for irrigation of the bladder or to bypass an obstruction.
Disorders
Cystitis: risk factors are incorrect wiping, prolonged bath with excessive soap, BPH, not voiding after sex, not wearing cotton underwear/wearing thongs
s/s include:
- frequency with small volume & urgency, hematuria,
- suprapubic tenderness/flank pain
- fever, malaise, chills c cloudy, foul-smelling urine
Nursing responsibilities: clean catch urine sample for C&S, push 3,000 mL/day, cranberry juice, heat perineum for comfort
Medication:
- ABX--sulfonamides or sulfa/bactrim, if allergic to sulfa then give nitrofurantoin
- analgesics--phenazopyridine (will turn urine orange)
- antispasmodic--hyoscyamine
Acute (post streptococcal) glomerulonephritis: acute disease of the renal glomeruli of both kidneys due to antigen/antibody reaction 3 weeks after an acute strep infection, tonsillitis, or pharyngitis, especially in children. The best way to treat APSGN is to have early treatment of strep infection with completion of abx.
s/s include:
- cola/tea colored urine with flank/abdominal pain
- proteinuria, oliguria, anuria, azotemia, anemia
- edema/ascites/hypertension
- ESR>1-13
- dipstick urinalysis = significant erythrocytes /erythrocyte casts
Nursing responsibilities: SYMPTOMATIC RELIEF + treat infection if present. Maintain bed rest, restrict fluids, increase calories (with reduced protein and sodium). Daily weights.
Medication:
abx--PCN
corticosteroids
antihypertensives
Chronic glomerulonephritis: end stage of chronic glomerulonephritis (etiology unknown, suspected to be inherited e.g. Alport syndrome), that develops over time. Patient is unaware until there is severe kidney impairment (GFR<30). Often there is simultaneous drug use, microbial infections, viral infections, immune disorders. May require renal biopsy. Renal failure is inevitable in 2-30 years.
s/s
- hematuria with casts, uremia.
- Elevated BUN>20, serum creat >1.2
- fatigue
Treatment is supportive and symptomatic, in line with tx for chronic renal disease.
-----------------------Detour to Renal Failure & Dialysis
Chronic renal failure: leading cause is DM, then HTN, kidney diseases (chronic glomerulonephritis, pyelonephritis, congenital kidney disease polycystic kidney disease).
s/s include:
- GFR:
Normal: l >90
stage 2: 60-90
stage 3: 30-60
stage 4: 15-30
End stage: <15
- elevated BUN, creat
- anemia (remember erythropoietin), hypocalcemia (remember calcitriol), hyperkalemia (K+ and diabetes may exacerbate metabolic acidosis)
- fluid volume overload: h/a, hypertension, n/v/d/irritability
- pruritus/uremic frost
Nurse's responsibility:
- balance electrolytes
- renal diet (low protein, low potassium, low sodium, low phosphate--no phosphate enemas, no magnesium antacids, high carb, calcium supplements)
- I&O, weights
- watch for bleeding
TX:
- diuretics in early stage
- phosphate binders: aluminum hydroxide gel, calcium acetate (Phoslo), sevelamer
- erythropoeitin alpfa
- dialysis: remove urea, creatinine, balance hyperkalemia and hypocalcemia, reduce excess fluid.
Nurse's responsibility with dialysis:
- hold am RX
- weigh the client before and after procedure
- monitor BP continuously during procedure
- provide fistula care (remember: "you *feel* a thrill, and hear a bruit")
- no BP or blood work on fistula side
- instruct patient to alert you of muscle cramps, HA, N/V during procedure
- with peritoneal dialysis: warm dialysate to prevent cold shock (dialysate is stored in the refrigerator when not used), allow flow by gravity--5-10 minutes inflow, close clamp, 30 minutes of equilibration, 10-30 min of drainage (should be pale yellow and clear)
- with continuous ambulatory peritoneal dialysis, infuse 1.5-3 liters by gravity, 4-8 hours equilibration, drain in 20-40 min, of 4-5 exchanges daily 7 days a week. For any peritoneal dialysis be sure to monitor for bowel perforation, peritonitis (rebound tenderness, fever, cloudy outflow).
Acute renal failure: results from trauma, allergic reactions, drug overdose, kidney stones, shock.
Identify if:
- prerenal cause (hypovolemia, HF, burn injury, anaphylaxis)
- renal cause (trauma, APSGN, hemolytic uremic syndrome from E.coli in children, substance abuse)
- postrenal cause (kidney stones, BPH, tumors, strictures)
Acute renal failure occurs in 4 stages:
- Stage 1) onset hours to days. Dialysis.
- Stage 2) oliguric for 1-3 weeks with <400 ML in 24, edema, elevated BUN, creat, hyperkalemia (watch for dysrhythmias) increased specific gravity, acidosis, heart failure. Diet: (low protein, low potassium, high carb, restricted fluids). Bed rest. Begin dialysis. Assess for pericarditis.
- Stage 3) diuresis of 4,000-5,000 ml/day=this indicates nephrons are recovering--watch for hypotension, decreased specific gravity, and electrolyte imbalances.
- Stage 4) recovery takes 1 year.
Nurse's responsibility:
- assist in eliminating/preventing cause (radiologic tests, cystoscopy, urolithotripsy)
- correct hyperkalemia: insulin D50W, kayexalate, calcium IV or sodium bicarbonate.
- phosphate binders: aluminum hydroxide, calcium acetate, sevelamer
----------------End detour
Nephrosis: diffuse glomerular damage secondary to autoimmune disease resulting in protein wasting
s/s:
anasarca, ascites
proteinuria, oliguria
hypoalbuminemia
anorexia/malase/nausea
Nursing responsibilities:
bed rest with severe edema to preserve renal function
low sodium, low potassium, moderate protein, high calorie diet (god help us if the patient is diabetic, also)
I&O, weights, abdominal girth daily
Medications: loop diuretics, prednisone, immunosuppressive agents (cyclophosphamide)
Urolithiasis: Occurs most often with males 20-40 years of age due to execessive purine or oxalate (calcium) intake. Manifests s/s similar to UTI. Could be pain as severe renal colic (indicates block in ureter), or dull aching (block in the kidney) that radiates to the groin. Often accompanied by N/V/D/Constipation, hematuria.
Nurse's responsibilities:
- Force fluids 3,000 mL/day UNLESS complete block.
- give allopurinol if stones are uric
- avoid calcium if stones are calcium
- lithotripsy
- strain all urine
- pain control--opioids, and nsaid ketorolac.
- maintain proper urine pH
Renal and urinary tract surgery
Kidney transplantation: live or cadaver donors
Nurse's responsibility preoperative:
- hemodialysis within 24 hours of transplant
- balancing of metabolics
- administer immunosuppressive therapy (azathioprine --watch for bone marrow depression, cyclosproine, steroids)
postoperative:
- protective isolation
- azathioprine, cyclosporine, steroids--watch for oliguria, edema & s/s of infection systemically and over graft site
- CBC, watch for elevated BUN, creat, hypertension
Urinary diversion: removal of bladder and creation of a nephrostomy or urostomy.
nursing responsibilities:
- hemorrhage and shock (very common)
- stoma infection
- pain control
- paralytic ileus
- adequate fluid
- bloody drainage is expected after surgery BUT SHOULD CLEAR WITHIN 24-48 HOURS.
- never irrigate the surgical implant
- use aseptic technique
GenitoUrinary tract hyperplasia
Benign Prostatic Hyperplasia: enlargement of prostate with age of unknown etiology. Diagnosed with DRE, cystoscopy, and rule out prostate cancer with PSA <10.
s/s
- difficulty starting stream, dribbling/decreased force
- frequent UTI
- nocturia
- hematuria
nursing responsibilities:
- give antibiotics
- alpha-blockers causes vasodilation to promote urinary flow (anything with -sin suffix, e.g., tamsulosin, alfuzosin, terazosin, etc.)
- enzyme inhibitors to decrease the size of the prostate gland (dutasteride, finasteride)
- assist with TURP
TURP: endoscopic cutting out of extra tissue.
- shock, hemorrhage--expect blood, but monitor I&O (account for continuous bladder irrigation) for excessive discrepancies in fluid, which will indicate hemorrhage.
- assess for TURP syndrome: (absorption of irrigation fluids through prostate tissue) hypertension, N/V, visual changes, hyponatremia, confusion, bradycardia.
- insert indwelling foley with flush port, intake >3000 ml/day
- administer ABX, pain meds
- tape catheter to leg, teach Kegels
- do not lift, sit for prolongued periods of time, take stool softeners, fiber, water, ambulate to prevent straining
Prostate cancer: slow growing cancer that occurs in AA men, with elevated testosterone and high fat diet, and 50+ years/or familial history. Dx: PSA>10 is indicative of cancer, or a pea sized, hard nodule in a DRE, accompanied by frequent UTIs, and hematuria. Treatment: radical prostatectomy, radiation, internal radioactive seeds, hormone therapy.
Testicular Cancer: most frequent cancer in males 15-34 y-o. Higher risk in patients with undescended testes or family history.
s/s:
- swelling, painless lump
- possible heaviness or aching in lower abdomen or scrotum
tx: sperm banking + orchiectomy, chemotherapy
Incontinence
Incontinence: Urge--cannot hold when stimulus to void occurs, 2) functional--cannot get to the bathroom due to physical impediment, OR not aware of the stimulus to void (eg. spinal injury), 3) stress--voids with straining or lifting.
tx:
- give anticholinergics (eg tolterodine, and oxybutynin) for urge incontinence
- give tricyclic antidepressants (eg imipramine) for stress incontinence
- adult incontinency devices, maintain toilet schedule, decrease fluid after 6 p.m., perform crede, or cystitis, Kegels, make route of transfer to bathroom clear.
- help to completely void by stimulating relaxation with privacy and warm water (to hands, or thigh, or just turning the water on), positioning the client upright, or as a last resort administering bethanechol chloride (which will stimulate voiding)
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