Obstructive disorders of the Urinary system

Medical Management -Diagnostic Tests: KUB, Renal Ultrasound, blood chemistries, endoscopy -Establish urinary drainage Indwelling catheter Suprapubic Cystostomy Ureterostomy Nephrostomy Stent Insertion Relieve pain- narcotics, anticholinergics Ureterostomy-ilieal conduit Nephrostomy-percutaneous puncture, incision in the back Stent insertion-cystoscopy Anticholinergics-Atropine to dec. smooth muscle motility, anti-spasmodic effect

Nursing Interventions - observe for signs of hematuria - aseptic care of the surgical site -note restoration of urinary function -provide safe environment to prevent injury or infection

Etiology/pathophysiology -Causes: Kinks, cysts, tumors, calculi, prostatic hypertrophy -May lead to infection that thrives due to urine stasis -May lead to ischemia due to compression or atrophy of renal tissue -Clinical Manifestations/Assessment -Continuous need to void -Voiding small amounts frequently -Pain -Nausea

Etiology/Pathophysiology: Hydronephrosis Etiology/Pathophysiology: -Dilation of the renal pelvis-can be congenital or develop at any time -Unilateral or bilateral -Due to the obstruction of the urinary tract -The obstruction builds up pressure from the accumulation of urine that can’t flow past it -The pressure may cause functional and anatomical damage to the renal system. -- The renal pelvis and ureters dilate --Pressure causes fibrosis and loss of function of affected nephrons causing kidney obstruction _

-Dull flank pain (slow onset) A degree of pain will depend on the Clinical Manifestations: -Dull flank pain (slow onset) A degree of pain will depend on the stretching of the urinary tract structures -Severe stabbing pain (sudden onset) -Nausea/Vomiting -Frequency, dribbling, burning and difficulty starting urination

Medical Management -Diagnostic Tests: UA, Renal function studies (BUN, Creatinine), cystoscopy, IVP, KUB, CT, US -Surgery to relieve obstruction -Nephrectomy- if kidney is severely damaged -Antibiotics -Narcotics/antispasmodics

Nursing interventions -Assessment: Subjective-pain, voiding pattern, history of obstructive disorders -Objective-vomiting, hematuria, edema, urine output, abdominal mass, bladder distention, tenderness over kidneys/bladder -Administer meds as ordered, I & O, observe for signs of infection, vital signs, pain assessment, encourage intake of 2L/day unless restricted, anchor drainage tubes, catheter care -if surgery is done: incision observation, care and dressing changes as ordered -Patient and family teaching

Urolithiasis (kidney stone) Etiology/Pathophysiology -Calculi develop from minerals that have precipitated out of solution and adhere, forming stones that vary in size and shape -Why do these stones form? Not sure! -Contributing factors: predisposed, diet, meds -Identified according to location: nephrolithiasis, ureterolithiasis, cystolithiasis Nutrition and Diet Tx- Box 21-3

Clinical Manifestations/Assessments -Flank or pelvic pain -Nausea/vomiting -Hematuria Medical management -Diagnostic tests: KUB, IVP, US, Cystoscopy, UA, etc. -Medication: antibiotics, analgesics -Fluids -Ambulation (if possible) -Surgical procedures: cystoscopy, ureterolithotomy, nephrolithotomy

-Lithotripsy- “ extracorporeal shock wave” -Pt is submerged in a special tank of water -Ultrasonic shock waves are used to pulverize the stone -Urine still must be strained -Pt. may still experience renal colic as the stone fragments pass.

Nursing Interventions -Assessment Subjective-pt Nursing Interventions -Assessment Subjective-pt.’s pain description Objective-presence of hematuria, nausea, vomiting, restlessness - Strain all urine and observe characteristics -Daily fluid intake of 2L (unless contraindicated) -Medication: drug therapy will be specific to the stone composition -Administer analgesics -Monitor lab and diagnostic test results, especially BUN and Creatinine -Pt. and family teaching- hydration, dietary modifications, medication administration, exercise, keep follow up appointments with MD and when to contact the MD.

Renal tumors Etiology/Pathophysiology -Mostly adenocarcinomas -Usually develop unilaterally -Renal cell carcinomas, as a primary malignant tumor, arise from cells of the proximal convoluted tubules Risk factors -Smoking -Family history -Pre-existing renal disorders, such as polycystic kidney disease and renal cystic disease secondary to renal failure -Transitional cell tumors of the renal pelvis cause hematuria and can be confirmed by cytological study.

Clinical manifestations -Early- intermittent painless hematuria -Late- weight loss, dull flank pain, palpable mass in flank area, gross hematuria Medical management -Radical Nephrectomy -Radiation -Chemotherapy

Nursing Interventions -Assessment Subjective-Inquire about blood in the urine, pain, weight loss, fatigue Objective-Physical assessment, hematuria -Adequate hydration to reduce the discomfort when voiding -Administer analgesia -Encourage active/ passive ROM exercises -Pt./family teaching: community resources, support groups, home health care, importance of follow-up care

Renal Cysts Etiology/Pathophysiology -A single cyst may not matter, but multiple cysts interfere with kidney function -The most significant problem arise with polycystic kidney disease (PKD) -Cysts form in the kidney and can cause pressure on the kidney structure and compromise function -A patient with a long standing renal insufficiency or a dialysis pt. may develop PKD

Clinical Manifestations -Determined by the degree of kidney structure involved -Abdominal and flank pain -Voiding disturbances - Recurrent UTIs -Hematuria -Hypertension

Medical management -Diagnostic Tests: Radiographic imaging, blood work -No specific treatment -Pain relief -Heat (unless bleeding) -Analgesics -Antibiotics -Antihypertensives -Dialysis -Renal transplant

Nursing Interventions -Assessment- Subjective: Abdominal/flank pain, headaches, GI complaints, voiding disturbances, history of recurrent UTIs Objective: Monitor BP, check for hematuria, note the pt.’s complaints and response to treatment. -Patient/family information about genetic counseling -Severity of the disease and patient complaints will determine the nursing intervention

Tumors of the Urinary Bladder Etiology/Pathophysiology -Most common site of cancer in the urinary tract -Ranges from benign papilloma to invasive carcinoma Clinical Manifestations -Painless intermittent hematuria -Changes in voiding pattern

Medial management -Localized tumor: remove by burning (fulguration) -Invasive lesion- partial or total cystectomy (Surgery will include diversion such as an ileal conduit) Nursing Interventions -Assess voiding patterns -Observe characteristics of urine -Importance of follow-up care

Conditions affecting the prostate gland BPH- Benign Prostatic Hypertrophy Etiology/Pathophysiology -enlargement of the prostate gland which encircles the urethra at the base of the bladder -pressure on the urethra prevents complete emptying of the bladder -function of the prostate gland is to secrete an alkaline fluid that helps to neutralize seminal fluid and increase sperm motility -common in men over 50 years old

Clinical manifestations -Frequent urination -Difficulty starting urination -Dysuria -Frequent UTIs -Hematuria -Oliguria -Nocturia

Medical management -Diagnostic Test: blood chemistries, measuring residual urine by cystoscopy, IVP, rectal exam, cytological evaluation -Relieve obstruction- foley catheter -Medication to shrink prostate gland -Prostatectomy -Post-Operative: TURP- bladder irrigations -urine will be pink to red colored -Suprapubic/abdominal catheter: assess drainage

Transurethral Resection of the Prostate (TURP)

Nursing Interventions -Assessment Subjective- inquire about urine stream, difficulty starting, frequency, nocturia Objective-voiding pattern -Insertion of a foley catheter as ordered, avoid a rapid decompression (after 1000 ml is drained, wait 5 minutes before proceeding to drain more) -Post-op TURP: maintain patency of foley catheter and bladder irrigation system, vital signs, close monitoring of urine for signs of hemorrhaging -Medicate for pain and bladder spasms -Patient/family education