1. Medical-Surgical Nursing: Concepts & Practice
3rd edition
Chapter 34
Care of Patients with Disorders of the Urinary System
Copyright © 2017, Elsevier Inc. All rights reserved.

2. Cystitis Female urethra and cystitis—Escherichia coli
“Honeymoon” cystitis
Older adult considerations

3. Cystitis (Cont.) Signs, symptoms, and diagnosis
Painful urination, frequent and urgent urination, and low back pain
Tendency to recur—less acute symptoms such as fatigue, anorexia, and constant feeling of bladder pressure between flare-ups
Older adults and confusion—cloudy urine, hematuria, and signs of infection
Urinalysis and urine cultures

4. Cystitis (Cont.) Treatment and nursing management Antibiotics
Topical estrogen and postmenopausal women
Encourage fluids (8-12 large glasses unless contraindicated)
Cranberry and altered pH
Sitz bath and hot water bottles
Preventing urinary tract infections (UTIs)
Vitamin C

5. Urethritis Etiology and pathophysiology Signs and symptoms
Gonococcus and herpes virus
Nonspecific urethritis
Childbirth and urethritis
Chemical irritation
Signs and symptoms
Burning, itching, frequency in voiding, and painful urination
Discharge—purulent if gonorrhea is present

6. Diagnosis
Diagnosis of urethritis is based on the presence of symptoms and a patient history that includes possible exposure to sexually transmitted infections (STIs).
Culture and sensitivity of urine are obtained to identify causative organisms, and culture specimens are used to rule out STIs.

7. Treatment and Nursing Management
The treatment and nursing management for urethritis are similar to cystitis.
The nurse should be especially aware of the possibility of a gonorrheal infection (until a definite diagnosis has been established) and should carry out the necessary teaching to prevent spread of the infection to the eyes.

8. Pyelonephritis Etiology and pathophysiology Signs and symptoms
Acute pyelonephritis and stasis of urine
Chronic infection and scar tissues
Signs and symptoms
Acute state: fever, chills, headache, malaise, nausea and vomiting, and flank pain radiating to the thigh and genitalia
Chronic state: subtle and gradual scarring—weight loss, low-grade fever, and weakness

9. Diagnosis Manifestations and physical assessment
Urine culture and sensitivity
Kidneys, ureter, and bladder (KUB) radiography and intravenous pyelogram (IVP) —obstruction

10. Treatment Prompt treatment and prevention of recurrence
Correct obstruction—stone removal and formation prevention
Bed rest, analgesics, and antipyretics
Antibiotics

11. Acute Glomerulonephritis
Etiology and pathophysiology
Beta-hemolytic streptococcal infection
Immune: antigen-antibody reaction
Signs, symptoms, and diagnosis
Sudden fever, chills, flank pain, edema, puffiness about the eyes and visual disturbances, and marked hypertension
UA, creatinine and blood urea nitrogen (BUN), and complete blood count (CBC)
Urine: smoky, +red blood cells, +protein, and increased specific gravity

13. Treatment Sodium-restricted diet and fluid therapy
Low-protein, high-carbohydrate
Plasmapheresis and autoimmune disorders

14. Nursing Management Clinical history
Edema—cardiac failure and pulmonary edema
Bed rest until hematuria, proteinuria, and hypertension subside

15. Nursing Management (Cont.)
Sodium restriction
Antihypertensives and diuretics
Plasmapheresis and corticosteroids
Shunt assessment and care
Monitor for complications

16. Chronic Glomerulonephritis
Etiology and pathophysiology
Rapidly develop or progress slowly
Kidney atrophy—decreased functional nephrons and eventual renal failure
Signs and symptoms
Generalized edema, headache associated with hypertension, fatigue, dyspnea, weight loss, loss of strength, increasing irritability, and nocturia
Proteinuria, hematuria, and kidney failure
Acute exacerbations

17. Diagnosis Routine examination: retinal hemorrhage
Urinalysis (UA), creatinine, BUN, CBC, and electrolytes
Proteinuria, urinary casts, elevated BUN and creatinine, anemia, hyperkalemia, hypermagnesemia, increased phosphorous, decreased serum calcium, and decreased albumin

18. Treatment Latent stage: symptomatic treatment Dialysis
Kidney transplant

19. Nephrotic Syndrome Signs, symptoms, and diagnosis
Proteinuria, hyperlipidemia, hypoalbuminemia, and severe edema
Facial edema and periorbital edema may be present in the morning; lower extremity edema is more evident at the end of the day
Irritable, tired, or lethargic

20. Diagnostic Tests Urinalysis and serum tests for protein and lipids
Renal biopsy

21. Treatment
Adequate protein; low-fat, low-sodium diet; supplemental multiple vitamins and minerals
Diuretics, antibiotics, cortisone, and cyclophosphamide

22. Nursing Management Monitor intake and output. Record daily weight.
Encourage rest.
Provide skin care.
Encourage compliance with dietary and medication regimen.

23. Hydronephrosis Etiology and pathophysiology
Dilation of the renal pelvis and ureters due to obstruction
Compensatory hypertrophy
Signs, symptoms, and diagnosis
Severe pain and signs of kidney failure
Urologic examination and detailed radiographs

24. Treatment
Nephrostomy tube or ureteral stent
See Box 32-1 on p. 739.

25. Nursing Management Postoperative care Hemorrhage and dressing
Positioning, coughing, and deep breathing

26. Polycystic kidney disease
A congenital disorder where clusters of fluid-filled cysts develop in the nephrons
Hereditary; caused by genetic mutation
Can be present at birth (autosomal recessive) or develop at about age 30 (autosomal dominant)

27. Expected findings Family history Abdominal and flank pain
Increased abdominal girth
Headaches
Hypertension
Constipation
Bloody or cloudy urine
Progressive kidney failure

28. Diagnostics Urinalysis Gradual increase of serum creatinine
Hematuria, proteinuria
Ultrasound CT
MRI

29. Nursing care Hypertension control Pain management Infection prevention
Constipation prevention

30. Renal Stenosis Blocked or narrowed renal artery
Hypertension and chronic renal failure
Magnetic resonance imaging (MRI), computed tomography (CT) scan, or ultrasonography—decreased kidney size
Antihypertensives
Balloon angioplasty or stent placement

31. Renal Stones Renal staghorn calculus
Variations in composition and environment (acidic or alkaline)
Major types, including hereditary type
Identify the type and cause
Preventive measures based on type
Appropriate method of treatment

32. Causative Factors
Supersaturation of the urine with crystalloids that do not readily dissolve (e.g., calcium, uric acid, and cystine)
Urinary infections, which can produce bacteria and other debris that form a core for stone formation
Inadequate fluid intake, which results in concentrated urine and inadequate flushing of the urinary tract

33. Causative Factors (Cont.)
Sluggish flow of urine, as may occur with bed rest or immobility
Certain substances in the urine (e.g., urate, a salt of uric acid), which encourage the formation of crystals of calcium oxalate or calcium phosphate

34. Renal Staghorn Calculus
See Figure 34-1 on p. 791.
From Lewis SL, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed. 9, St. Louis, 2014, Mosby.

35. Stone Types Calcium oxalate (most common) Calcium phosphate Uric acid
Struvite (more common in women)
Cystine
See Table 34-2 on p. 792.

37. Etiology and Pathophysiology
Calcium stones and parathyroid tumor
Males > females
Family history of stones
History of intestinal bypass surgery for obesity
Immobility
History of recurrent UTI

38. Prevention Adequate flow of dilute urine through the kidney
Prevent UTI
Urinary pH modification—ascorbic acid or dietary modifications

39. Signs and Symptoms
Severe pain—stones that are small enough to move along
Flank pain radiates downward to genitalia and inner thigh. This causes obstruction and swelling of the ureter.
Nausea and vomiting

40. Diagnosis UA and KUB IVP
Serum levels of calcium, uric acid, and cystine

41. Treatment Flushing the stone—oral intake or intravenous infusion
Pain management—opioids, nonsteroidal anti-inflammatory drugs, and antispasmodics
Antibiotics
Irrigation via ureteral catheter or percutaneous nephrostomy

42. Treatment (Cont.) Stent Extracorporeal shockwave lithotripsy (ESWL)
Cystoscopy and surgery
Nephrolithotomy
Pyelonephrolithotomy

43. Nursing Management Pain management Fluid intake of 3000 to 4000 mL
Early ambulation
Adjunctive therapy for ESWL: corticosteroids, calcium channel blockers, alpha agonists
Percussion, diuresis, and inversion (PDI) therapy

44. Nursing Management (Cont.)
Cystoscopy or surgery
Nephrolithotomy, pyelolithotomy, and ureterolithotomy
Monitor: infection, hemorrhage, and leakage of fluid
Initial assessment: changes in urinary output, characteristics of the urine, risk factors and history, and other assessment data
Straining of urine

45. Common Catheters and Tubes Used for Urologic Disorders
Urethral catheter
Foley catheter
Suprapubic catheter
Ureteral catheter
Ureteral stent
Nephrostomy tube
See Table 34-3 on p. 794.

46. Trauma to Kidney and Ureters
Blunt trauma—motor vehicle accident, sports, or occupation
Penetrating injuries and ureteral trauma
Minor contusion, severe hemorrhage, and hypovolemic shock

47. Signs, Symptoms, and Diagnosis
Massive hemorrhage, hematuria, abdominal or flank pain, and possibly enlarged mass
Urinalysis, hemoglobin and hematocrit, and electrolytes
BUN and creatinine
Radiologic studies: KUB, IVP, or CT scan
Rhabdomyolysis and ARF

48. Treatment
Bleeding
Lacerations and contusions without renal function interruption—bed rest
Severe kidney damage—nephrectomy

49. Nursing Management Preoperative care Postoperative care
Monitor for hypovolemic shock, cardiovascular changes, urinary output, and size of flank mass.
Grey Turner sign—bruising over the flank or lower back suggestive of retroperitoneal bleeding
Monitor urinary output and indwelling urinary catheter.
Postoperative care

50. Trauma to the Bladder Etiology and pathophysiology Signs and symptoms
Violent blow or crushing injury
Bladder perforation or rupture
Bladder trauma and fullness
Signs and symptoms
Painful hematuria and inability to void
Marked tenderness and spasm in the suprapubic areas
Large mass

51. Diagnosis and Treatment
Gross hematuria, suprapubic pain, and difficulty voiding
Retrograde or CT cystography
Suprapubic cystostomy

52. Nursing Management Meticulous attention to drains and dressings
Cold applications
Postoperative shock and massive hemorrhage

53. Cancer of the Bladder Etiology and pathophysiology
Smokers and risk for bladder cancer
Urban living
Occupational exposure to nitrates, dyes, rubber, or leather processing
Bladder papilloma tumors—highly invasive and metastasis

54. Signs, Symptoms, and Diagnosis
Hematuria
Frequency, urgency, or dysuria
IVP, cystoscopy, or biopsy of tumor
Complementary and alternative therapy: healthy bladder

55. Treatment Surgery, chemotherapy, radiation Photodynamic therapy
Cystectomy or transurethral resection of the bladder tumor
Intravesical chemotherapy
Bacille Calmette-Guerin (BCG) instillations
Photodynamic therapy

56. Surgery for Urinary Diversion
Minor surgery and major surgery
Urinary diversion and bladder removal
Ileal conduit or ileal loop
Cutaneous ureterostomy
Vesicostomy
Ureterosigmoidoscopy or sigmoid conduit
Ileal reservoir (Kock, Indiana, Mainz, or Florida patch)
Orthotic bladder substitutes

57. Surgery for Urinary Diversion (Cont.)
See Figure 34-2 on p Ureterostomies divert urine directly to the skin surface through a ureteral skin opening (stoma). After ureterostomy, the patient must wear a pouch.
From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 7, Philadelphia, 2010, Saunders.)

58. Surgery for Urinary Diversion (Cont.)
See Figure 34-2 on p Conduits collect urine in a portion of the intestine, which is then opened onto the skin surface as a stoma. After the creation of a conduit, the patient must wear a pouch.
From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 7, Philadelphia, 2010, Saunders.)

59. Surgery for Urinary Diversion (Cont.)
See Figure 34-2 on p Sigmoidostomies divert urine to the large intestine, so no stoma is required. The patient excretes urine with bowel movements, and bowel incontinence may result.
From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 7, Philadelphia, 2010, Saunders.)

60. Surgery for Urinary Diversion (Cont.)
See Figure 34-2 on p Ileal reservoirs divert urine into a surgically created pouch, or pocket, which functions as a bladder. The stoma is continent, and the patient removes urine by regular self-catheterization.
From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 7, Philadelphia, 2010, Saunders.)

61. Nursing Management
Clarify orders regarding irrigation of tubes, drains, and stomas.
Postoperative care
Observe for pain, abdominal rigidity, fever, and bleeding.
Urine should never stop flowing regardless of surgical procedure.
Urine color and characteristics
Stoma assessment and skin irritation
Reduce odor of urine.
Psychological care

62. Cancer of the Kidney Etiology and pathophysiology
Risk factors: smoking and exposure to lead or phosphate
Signs, symptoms, and diagnosis
Hematuria, palpable abdominal or flank mass, and flank pain
Fever, fatigue, weight loss, decreased appetite, and hypertension
Renal angiogram, arteriogram, CT, MRI, and ultrasonography

63. Treatment and Nursing Management
Surgical removal of the affected kidney (nephrectomy) before metastasis occurs
The patient usually does not have severe symptoms until metastases have occurred.
Chemotherapy with a variety of drug regimens is used for metastatic cancer.
Immunotherapy is sometimes attempted for recurrent tumors.
Sunitinib (Sutent) and sorafenib tosylate (Nexavar) are drugs for advanced kidney cancer. They act to deprive the tumor cells of blood and nutrients. Temsirolimus (Torisel) and newly approved everolimus (Afinitor) inhibit tumor cell growth and proliferation; these drugs are available to patients who failed to respond to sunitinib or sorafenib. In October 2009, the Food and Drug Administration announced approval of another new drug, pazopanib (Votrient) which interferes with the growth of new blood vessels which would supply the tumor.
Nursing care of the patient is the same as that for patients after nephrectomy (see Chapter 8 for care of patients with cancer).

64. Acute Renal Failure Etiology
Sudden onset—physical injury, infection, inflammation, or damage from toxic chemicals
Renal ischemia—circulatory collapse, severe dehydration, and prolonged hypotension

65. Pathophysiology
Prerenal ARF: decreased blood flow such as hypovolemic shock or decreased cardiac output
Intrarenal ARF: glomerular damage, acute tubular necrosis (ATN), caused by ischemia, toxins, or vascular disease
Postrenal ARF: obstruction of the ureters, bladder, or urethra

66. Signs and Symptoms Changes in urine output and urine results
Electrolyte imbalances
Fluid imbalance
Acid-base imbalance
Gastrointestinal effects
Mental status changes
Anemia and platelet dysfunction
Impaired wound healing and susceptibility to infection

67. Diagnosis
Urinalysis
Creatinine, BUN, CBC, electrolytes, and arterial blood gases
Radiologic studies (e.g., ultrasonography, IVP, CT, or MRI)
Renal biopsy

68. Treatment Correct underlying cause. Prevent or control complications.
Symptomatic treatment
Correct fluid and electrolyte imbalance.
Manage anemia and hypertension.
Hemodialysis or peritoneal dialysis
Address malnutrition, anemia, and potential for infection.
Continuous renal replacement therapies (CRRTs)

72. Nursing Management Monitor for signs of fluid imbalance.
Report urine output of less than 30 mL/hr.
Monitor electrolytes.
Nutritional assessment.
Encourage optimal activities of daily living.
Hand hygiene

73. Pathophysiology of Renal Failure
See Concept Map 34-1 on p. 799.

74. Phases of Acute Tubular Necrosis
Oliguric or nonoliguric phase
Older adult considerations
Diuretic phase
Recovery phase
In the oliguric or nonoliguric phase, the patient puts out either a great deal of or very little urine. Oliguria is a urine output of 100 to 400 mL in 24 hours. This phase usually occurs immediately or within 1 week after an ischemic event and lasts for an average of 10 to 14 days; however, it can go on for weeks to months, and prolonged oliguria worsens the prognosis. BUN and creatinine levels rise. When this occurs, there may be volume overload, which can precipitate heart failure, multiple electrolyte imbalances, metabolic acidosis, catabolism (destructive breakdown of body tissue), and end-stage renal failure (ESRF). At this point, dialysis is needed. Because of the overall decreased kidney function related to aging, an older patient may be experiencing oliguria even though urine volumes are as high as 600 to 700 mL/day. Nonoliguric ATN is often caused by nephrotoxic agents. Urine output is greater, but the kidneys cannot eliminate waste products efficiently, BUN and creatinine levels rise, and electrolyte imbalances occur. Dialysis is needed less often or for shorter periods, and the prognosis is better than for oliguric failure.
The diuretic phase only occurs if dialysis has not been started early and extracellular fluid volume has built up. In this phase, the kidney is unable to concentrate urine, and output can be between 1000 and 2000 mL/day. With this increased output, there is a danger of dehydration, hyponatremia, and hypokalemia. Approximately 25% of deaths related to ARF occur during this phase.
The recovery phase begins as the kidney function begins to normalize. The concentration of urine, urine output, and electrolyte balance begin to recover. There are 1 to 2 weeks of rapid improvement and then a period of slower recovery lasting between 3 and 12 months. About one-third of patients with ARF are left with residual renal insufficiency, and about 5% must continue dialysis.

75. Chronic Renal Failure Etiology Progressive loss of kidney function
All causes of ARF may also cause CRF.
Hypertension, diabetes mellitus, sickle cell disease, glomerulonephritis, nephrotic syndrome, lupus erythematosus, heart failure, and liver cirrhosis
Diabetes mellitus and Healthy People 2020
Most common causes: glomerulonephritis and nephrosclerosis

76. Stages of Chronic Renal Failure
Azotemia—accumulation of nitrogenous waste products such as urea nitrogen and creatinine
Stage 1: diminished renal reserve
Stage 2: renal insufficiency
Stage 3: end-stage renal disease
Azotemia is the accumulation of nitrogenous products, which is signaled by an increase in BUN and serum creatinine. The patient may experience nausea and vomiting and changes in mental awareness and levels of consciousness. The kidney is not able to excrete potassium; therefore, be alert for high levels of serum potassium (5 to 7 mEq/L), which can adversely affect the heart, causing dysrhythmia and cardiac arrest.
Three stages of CRF:
In stage 1, there is diminished renal reserve but no accumulation of metabolic wastes. The healthier kidney works harder. Urine concentration is decreased, and polyuria and nocturia occur.
Stage 2 is renal insufficiency and is signaled by a rise in circulating metabolic wastes; therefore, BUN and serum creatinine levels begin to rise. The glomerular filtration rate (GFR) falls, and oliguria and edema occur.
Stage 3 is ESRD. Circulating metabolic wastes accumulate in the blood, homeostasis cannot be maintained, electrolyte and fluid imbalances are serious, and dialysis or kidney transplant is necessary to maintain life.

77. Systemic Effects of Uremia
See Figure 34-3 on p. 803.
From Lewis SL, Dirksen SR, Heitkemper MM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed. 9, St. Louis, 2014, Mosby.

78. Signs and Symptoms
Earliest sign of renal impairment is the inability of the kidneys to concentrate urine—polyuria and nocturia
Renal insufficiency: oliguria and eventual anuria
Uremia or uremic syndrome
Uremic frost
Electrolyte imbalances, nutritional deficiency, and effects
Uremia or uremic syndrome includes the clinical signs and symptoms that affect the entire body during ESRD. Uremia signs generally appear when BUN concentration passes 100 mg/dL. The presence of uremic signs is the absolute indicator for initiating dialysis. The goals are to maintain BUN below 100 mg/dL and creatinine below 8 mg/dL.

79. Diagnosis Creatinine and creatinine clearance
Urinalysis with culture and sensitivity
Hematocrit and hemoglobin
Renal ultrasound, renal scan, CT scan, and renal biopsy
Creatinine is a stable byproduct of skeletal muscle activity, which is excreted completely by the kidneys; therefore, creatinine clearance (CC) is a good measure of GFR. CC depends on the amount of blood passing through the kidney; narrowing of the renal arterioles, shock, or dehydration decreases the volume that is available to the kidney for filtration. CC is also affected by the functional abilities of the glomeruli. Urine is collected for a 24-hour period.

80. Treatment and Nursing Management
Correct fluid and electrolyte imbalance.
Medications
Renal dialysis
Hemodialysis
Peritoneal dialysis
Kidney transplant
Nursing management

81. Peritoneal Dialysis Through Abdominal Catheter
See Figure 34-6 on p. 807
From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 7, Philadelphia, 2010, Saunders.)

82. Kidney Transplantation
Benefits and special problems
See Figure 34-7 on p. 808.
From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed. 8, Philadelphia, 2009, Saunders.

83. Community Care Community education Outpatient clinics Home care
Long-term care facilities
Dialysis centers