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Faculty of Nursing
Ainshams University
M-S Nursing Department
Assessment, care, and management of chronic ill
patient urology
Prepared by
Hagar Ali Ali
Heba Abd-Alazeem
2nd Semester Doctorate Degree
Under supervision of
Prof. Dr Tahany El Senousy
Professor/ Medical Surgical Nursing Department
Faculty of Nursing
Ainshams University
2010
Outlines
 Introduction
 Specific terminology related to urology disorders
 Anatomy and physiology of urinary tract system
 Functions of the urinary system
 Structures of the urinary system
 blood circulation of urinary system
 steps of urine formation
 General Assessment of urinary tract system
 Types of chronic disorders of urinary tract system
1. upper urinary tract disorders
2. lower urinary tract disorders
 Apply nursing care plan for urology disorders
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Learning objectives
At the end of this lecture the student will be able to:
 Introduction
 Define Specific terminology related to urological disorders
 Identify structure of the urinary system
 Explain Anatomy and physiology of urinary tract system
 Identify Functions of the urinary system
 Explain blood circulation of kidneys
 Explain steps of urine formation
 Explain General Assessment of urinary tract system
 List types of chronic disorders of urinary tract system
 Identify (definition – causes – clinical manifestation –
complications – medical management – surgical management) for
every disorder)
 Apply nursing care plan for urology disorders
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Introduction
Proper function of the urinary system is essential to life. Dysfunction of
the kidneys and lower urinary tract is common and may occur at any age
and with varying levels of severity. Assessment of upper and lower
urinary tract function is part of every health examination and necessitates
an understanding of the anatomy and physiology of the urinary system as
well as of the effect of changes in the system on other physiologic
functions.
Disorders of the lower and upper urinary tracts range from easily treated
infections to life-threatening disorders that necessitate organ replacement
or
long-term
treatment
with
dialysis.
Recent
advances
in
phamacotherapeutics and technology have improved the diagnostic and
treatment possibilities for these disorders. Additionally, many disorders
that once required surgical intervention and prolonged recuperation can
now be treated with noninvasive, nonsurgical techniques. (Bruner, 2009)
Specific terminology:
 Uremia: is a syndrome of kidney failure characterized by elevated
blood urea nitrogen (BUN) and creatinin levels
 Azotemia: is defined as increase in serum urea and creatinin levels
 Frequency : voiding more frequently than every 3 hours
 Urgency: The need to void immediately
 Hesistancy : Difficulty initiating voiding
 Oliguria: Urine output < 400ml/24hr
 Anuria: Urine output < 100ml/24hr

urethrovesical reflux: backward flow of urine from the urethra
into the bladder
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 Nephrotic syndrome: Is a set of clinical manifestations caused by
protein wasting secondary to diffuse glomeruolar damage
manifestation include (proteinuria , hypoalbunemia, and edema)
 Nephritic syndrome: refers to set of clinical manifestations that
include hematuria and at least one of the following: oliguria,
hypertension, elevated BUN or decreased GFR.
 urinary casts: protein plugs secreted by damaged kidney tubules
 specific gravity: reflects the weight of particles dissolved in the
urine; expression of the degree of concentration of the urine
I. Structure of the urinary system
1. Upper urinary tract that involves kidneys and ureters
2. Lower urinary tract involves the bladder and urethra
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II. Anatomy and physiology of the urinary system
 An over view about anatomy and physiology of kidney
 The kidneys are bean shaped organ about the size of a fist
they are located at the bottom of the rib cage at the back
of the body "retroperitoneally".
 Represent about 0-5 of total weight of the body.
 Most people have two kidneys, but some people have
only one it is possible to lead totally normal healthy life
with just one kidney.
 Kidney receive 20-25% of total arterial blood pumped by
heart.
 Each kidney is enclosed as fibrous capsule and is
embedded in fatty tissue. It consist approximately 13millions nephrons. The kidney is anatomically divide
into outer dark red portion called the cortex and inner
height coloured section lying between cortex and pelvic.
The medullary tissue is arranged in conical or pyramidal
masses.
 The nephron: The nephron is a tube closed at one end, open at the
other it consist of:
 Glomerulus: A capillary net work within the Bowman's
capsule blood the glomerulus passes into second
capillary network.
 Bowman's capsule: located at the closed end the wall
of the nephron is pushed forming a double walled
chamber.
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 Proximal convoluted tubule: Coiled and lined with
microvilli and staffed with mitochondria.
 Loop of renle: It makes a hair pin and returns to DCT.
 Distal convoluted tubule: Which is also highly coiled
and surrounded by capillaries.
 Collecting tubule: It leads to the pelvic of the kidney
from where urine flows to the bladder and periodically
on to outside the body.
 Renal pelvis: When the ureter joins the kidney it expands to form
a funnel shaped receiving basin for ht eurine delivered by
collecting tubules, it has projecting pouches "calyces".
 Blood supply:
Renal artery to each kidney arises from the
abdominal aorta. When the artery enter the kidney it progressively
subdivides to become afferent arterioles. Each afferent arteriole
enters nephrone to form glomerulus.
The glomerular capillaries unite to form the efferent arterioles the
blood is then collected into venules and eventually into renal veins that
carries to inferior vena cava.
Large volume of blood continuously circulated through the kidneys
it is estimated that renal blood flow average about 100-1200 L per
minutes about 23% from cardiac output.
2. Function of the kidney
1. Control of body fluid osmolarity to maintain the normal intra cellular
fluid "ICF" and extracellular fluid volume "ECF including the blood
volume.
2. Regulation of electrolyte balance K+ and Na+.
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3. Regulation of acid base balance and blood PH.
4. Excretion of waste products, urea, uric acid and creatinine.
5. Excretion of drugs, chemicals. Toxins.
6. Secretion of hormones.
a. Enythropoietin
b. Renin
c. Vitamin D3
d. Prostaglandins
Ureters
 The ureters are two slender tubes that run from the sides of the
kidneys to the bladder. Their function is to transport urine from the
kidneys to the bladder.
 Peristalsis movement in ureters to propel urine from kidneys to
bladder.
Bladder
The bladder is a muscular organ and serves as a reservoir for urine.
Located just behind the pubic bone, it can extend well up into the
abdominal cavity when full. Near the outlet of the bladder is a small
muscle called the internal sphincter, which contract involuntarily to
prevent the emptying of the bladder
Urethra
 The urethra is a tube that extends from the bladder to the outside
world. It is through this tube that urine is eliminated from the body
 The male urethra is about 20 cm long , but female urethra is 4 cm
long
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Prostate gland:
 Is a male reproductive gland
 Numerous prostatic ducts empty into urethra
III. Functions of the urinary system
The function of the urinary system is to: (1) removes waste products
from the blood (2) eliminate them from the body. The principal waste
products being eliminated are water, carbon dioxide and nitrogenous
wastes including urea, uric acid and creatinine. Other functions of the
urinary system include (3) regulation of the volume of body fluids (4)
balance of pH and the electrolyte composition of these fluids
Steps of urine formation
 Filtration occurs in Bowman's capsule
 Resorption occurs in the tubules and collecting duct
 Secretion occurs in the tubules and collecting duct
Ultrafilteration:
 Is the process by which the fluid part of the urine is formed.
 Blood passes through the capillary bed of the glomerrulus, the
pressure of plasma forces fluid across the semi permeable membrane
(basement membrane) of the glomerulus into Bowman's capsule.
 Water and small molecules begins to be filtered out into Bowman's
capsule through tiny pres in the capillary wall
 Blood cells and proteins are too large but urea is the correct size ti be
filtered
 The volume of this glomerular filtrate approximates 180 L/Day.
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 99% Of This Total Volume Is Reabsorbed And Only 1% Is Secreted
 Clinically GFR is the amount of glomerular filtrate formed in 1
minute approximately(125ml/min) ( 7.5 L/ hr)
 Urine formation begins when blood enters the afferent arteriole of
the nephron. it is in Bowman's capsule and the tubules that the
ulrafilterate begins to be transformed into urine
Resorption and secretion:
 The proximal convoluted tubules resorb 85% to 90% of the water in
the ultrfilterate up to 80% of filtered sodium and most of the filtered
potassium , bicarbonate , chloride, phosphate, glucose, and amino
acids
o The distal convoluted tubules and collecting tubule produce
the final urine
o Another mechanism that prevents water and electrolyte
depletion is endocrine or hormonal response ADH or
vasopressin is produced by the hypothalamus and stored and
released by the pituitary glad in response to changes in
plasma osmolarity
o In both descending and ascending loops of the Henle the
ultrafiilterate is further refined as more sodium , and water is
desorbed and magnesium is reclaimed from the tubules
o Final urine composition is made in the distal nephron which
include distal convoluted tubules and collecting ducts
o The final urine becomes concentrated and acidic as it moves
from the proximal to the distal tubules and finally into the
collecting duct
o The average urine output in adult is 1-2 L/Day
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Renal circulation:
The renal circulation receives around 20% of the cardiac output. It
branches from the abdominal aorta and returns blood to the ascending
vena cava. It is the blood supply to the kidney, and contains many
specialized blood vessels.
General Assessment of the urinary system
Assessment of the urinary system begins with
1. Health History
2. Physical examination
3. Diagnostic tests
I. Health History:
Health history focus on
1. assessment of predisposing factors of disorders
2. signs and symptoms of disorder
3. family history and surgical history
When obtain health history about patient with urological disorders
it's important to obtain information about:
1. Assess voiding pattern if thee is frequency , dysuria, hematuria
urgency
2. Asses weight gain (fluid retention )
3. History of nausea and vomiting
4. Assess if there is flank pain (lateral pain = loin pain) onset,
duration , frequency , aggravating factors , if response to analgesic
or not , associated signs and symptoms (nausea , vomiting )
5. Assess if muscle weakness indicator to disturbance of calcium
level
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6. Assess level of consciousness indicator of ammonia accumulation
and NH3 increased
7. Assess medication take , allergy
8. History of chronic illness (hypertension , DM liver disease, heart
disease) indicator for prerenal causes of ARF
9. Assess if patient smoker or not
10.Assess drug abuse , alcoholism indicator to intrarenal causes of
ARF
11.Change in bowel habits
12.Assess if there is family history of renal disorders
13.History of lethargy or fatigue
14.Assess surgical history if exposure to surgery and anesthesia
II. Physical examination includes the following (inspection,
auscultation, percussion, palpation)
 Obtaining clean catch urine specimen
 Inspect urine for color, odor, and clarity before sending it to the
laboratory for analysis
 Obtain vital signs
 Inspect skin color and condition including looking for evidence of
excessive dry skin or excoriation
 Inspect the face especially the periorbital area
 Palpate lower extremities for evidence of edema
 Expose the abdomen , and assess its contour and symmetry
 Auscultate bowel sounds
 palpate abdomen for tenderness including suprabupic region
 Peruses the kidney for tenderness
 Inspect the genital area and urinary meatus for redness swelling
discharge or ulceration.
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III. Diagnostic tests include the following:
1.
Blood tests
2.
Urine tests
3.
Imaging studies
1. Blood tests include the following:
Blood teste
Renal Concentration Tests
Specific gravity( 1.010–1.025)
Urine osmolality(300–900 mOsm/kg/24 h, 50–1,200 mOsm/kg
random s)
24-Hour Urine Test
Creatinine clearance
Measured in mL/minute/1.73 m2
Age Male Female
Under 30 88–146 81–134
30–40 82–140 75–128
40–50 75–133 69–122
50–60 68–126 64–116
60–70 61–120 58–110
70–80 55–113 52–105
Serum Tests
Creatinine level( 0.6–1.2 mg/dL (50–110 μmol/L)
Urea nitrogen (blood urea nitrogen 7–18 mg/dL
BUN to creatinine ratioAbout( 10_1)
3. Imaging studies include the following :
 An abdominal X-rays (KBU) (Kidney , Ureter, And Bladder )
 Intravenous pyelogram (IVP)to reveal renal arteries and blood
circulation to kidney
 Retrograde pyelogram (used as an alternative to IVP)
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 Computed tomography (CT Scan)
 MRI (Magnetic resonance imaging) useful in kidney tumor or cancer
to clear visualization of soft tissue
 Renal angiography is similar to IVP
 Ultrasound examination to determine size and texture of kidney and
bladder
 Electromyography (EMG) involves the placement of electrodes in
the pelvic floor musculature or over the area of the anal sphincter to
evaluate the neuromuscular function of the lower tract. It is usually
performed simultaneously with the CMG
 Nuclear scans require injection of a radioisotope (technetium 99m–labeled compound or iodine-131 hippurate) into the circulatory
system; the isotope is then monitored as it moves
 through the blood vessels of the kidneys. A scintillation camera is
 placed behind the kidney with the patient in a supine, prone, or
seated position. Nuclear scans are used to evaluate acute and chronic
renal failure,renal masses, and blood flow before and after kidney
transplantation.
 A cystometrogram (CMG) is a graphic recording of the pressures in
the bladder during bladder filling and emptying. It is the major
diagnostic portion of urodynamic testing. During the test, the amount
of fluid instilled into the bladder and the patient’s sensations of
bladder fullness and urge to void are recorded. These are then
compared with the pressures measured in the bladder during bladder
emptying
 Uroflowmetry (flow rate) is the record of the volume of urinepassing
through the urethra per time unit (milliliters per second).The flow
rate reflects the combined activity of the detrusor muscle And the
bladder neck and the degree of relaxation of the urethral sphincter.
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 Urethral Pressure Profile measures the amount of urethral pressure
along the length of the urethra needed to maintain continence. Gas or
fluid is instilled through a catheter that is withdrawn while the
pressures along the urethral wall are obtained.
Types of chronic disorders in urinary system:
1-UPPER URINARY TRACT DISORDERS
 CHRONIC PYELONEPHRITIS
 CHRONIC GLOMERULONEPHRITIS
 NEPHROTIC SYNDROME
 CHRONIC RENAL FAILURE
 KIDENY CANCER
 POLYCYSTIC KIDENY
1-UPPER URINARY TRACT DISORDERS
 CHRONIC PYELONEPHRITIS
Definition:
Pyelonephritis is a serious bacterial infection of the kidney that can be
acute or chronic. Chronic pyelonephritis is renal injury induced by
recurrent or persistent renal infection.
Causes:
 Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis
Signs and Symptoms:
 no symptoms
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 Noticeable signs and symptoms may include fatigue, headache, poor
appetite, polyuria, excessive thirst, and weight loss.
Treatment:
Treatment of chronic pyelonephritis requires correction of the underlying
disorder as follow.
The choice of antimicrobial agent is based on which pathogenis identified
through urine culture. Impaired renal function alters the excretion of
antimicrobial agents and necessitates careful monitoring of renal
function, especially if the medications are potentially toxic to the kidneys.
Complications
 ESRD (from progressive loss of nephrons secondary to chronic
inflammation
 hypertension,
 formation
 kidney stones
CHRONIC GLOMERULONEPHRITIS
Definition: Chronic glomerulonephritis is the advanced stage of a group
of kidney disorders, resulting in inflammation and slowly worsening
destruction of internal kidney structures called glomeruli.
Causes:






repeated episodes of acute glomerulonephritis
hypertensive
nephrosclerosis
hyperlipidemia,
chronic tubulointerstitial
glomerular sclerosis.
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Symptoms
The symptoms of chronic glomerulonephritis vary. Some patients
with severe disease have no symptoms at all for many years.The first
indication of disease may be a sudden, severe nosebleed, a stroke, or a
seizure. Many patients report that their feet are slightly swollen at night.
Most patients also have general symptoms, such as loss of weight and
strength, increasing irritability, and an increased need to urinate at night
(nocturia). Headaches, dizziness, and digestive disturbances are common.
signs and symptoms of renal insufficiency and chronic renal failure may
develop. The patient appears poorly nourished, with a yellow-gray
pigmentation of the skin and periorbital and peripheral (dependent)
edema. Blood pressure may be normal or severely elevated. Retinal
findings include hemorrhage, exudate, narrowed tortuous arterioles, and
papilledema. Mucous membranes are pale because of anemia.
Cardiomegaly, a gallop rhythm, distended neck veins, and other signs and
symptoms of heart failure may be present. Crackles can be heard in the
lungs. Peripheral neuropathy with diminished deep tendon reflexes and
neurosensory changes occurs late in the disease. The patient becomes
confused and demonstrates a limited attention span. Anadditional late
finding includes evidence of pericarditis with a pericardial friction rub
and pulsus paradoxus (difference in blood pressure during inspiration and
expiration of greater than 10 mm Hg).
Medical Management
Symptomatic treatment as follow:
 The blood pressure is reduced with sodium and water restriction.
 Antihypertensive agents.
 Weight is monitored daily.
 Diuretic medications are prescribed
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 Proteins of high biologic value (dairy products, eggs, meats) are
provided to promote good nutritional status.
 Adequate calories are also important to spare protein for tissue
growth and repair.
 UTIs must be treated promptly to prevent further renal damage.
 Initiation of dialysis is considered early in the course of the disease
to keep the patient in optimal physical condition
 Prevent fluid and electrolyte imbalances.
 Minimize the risk of complications of renal failure.
NEPHROTIC SYNDROME
Nephrotic syndrome is a primary glomerular disease characterized by
the following:
• Marked increase in protein in the urine (proteinuria)
• Decrease in albumin in the blood (hypoalbuminemia)
• Edema
• High serum cholesterol and low-density lipoproteins (hyperlipidemia)
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Pathophysiology of nephrotic syndrome
Medical Management
i.
The objective of management is to preserve renal function.
ii.
Diuretic agents may be prescribed for the patient with severe
edema;
iii.
angiotensin-converting enzyme (ACE) inhibitors in combination
with diuretics often reduces the degree of proteinuria but may take
4 to 6 weeks to be effective.
iv.
antineoplastic agents (cyclophosphamide [Cytoxan])
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v.
immunosuppressant medications (azathioprine [Imuran],
chlorambucil
vi.
The patient may be placed on a low-sodium, liberal-potassium diet
to enhance the sodium/potassium pump mechanism, thereby
assisting in elimination of sodium to reduce edema.
vii.
Protein intake should be about 0.8 g/kg/day, with emphasis on
high biologic proteins (dairy products, eggs, meats), and the diet
should.
CHRONIC RENAL FAILURE
Chronic renal failure, or ESRD, is a progressive, irreversible deterioration
in renal function in which the body’s ability to maintain metabolic and
fluid and electrolyte balance fails, resulting in uremia or azotemia
(retention of urea and other nitrogenous wastes in the blood).
Causes and risk factors:
 systemic diseases, such as diabetes mellitus hypertension; chronic
glomerulonephritis; pyelonephritis; obstruction of the urinary tract;
hereditary lesions, as in polycystic kidney disease; vascular
disorders; infections;
 medications or toxic agents.
 Autosomal dominant polycystic kidney disease accounts
 Environmental and occupational agents include lead, cadmium,
mercury, and chromium.
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Signs and symptoms:
Causes
Signs and
symptoms
Assessment
parameter
1. Hematological system
 Decreases erythropoietin
 Decreased survival time of
RBCs
 Blood loss during dialysis
 Anemia
 Fatigue
 Defects in
platelets
functions
 Decreased
hamatocrit
1. . Haematocrit
2. . Hemoglobin
3. .
Bleeding
time
2. Cardiovascular system
 Fluid overload
 Chronic hypertension
 Rennin angiogenesis
mechanism




Hypervolemia
Hypertension
Tachycardia
Dysrrythmias
Congestive
heart failure
1. Vital signs – body
weight
2. ECG
3. Heart sounds
4.Monitor
electrolytes
3. Respiratory system
 Compensatory mechanism
of metabolic acidosis
 Uremic toxemia
 Fluid overload
Tachypnea
Pain with
coughing
Elevated
temperature
Pulmonary
edema




1. Respiratory
assessment
2. ABGs
3. Vital signs
4. Pulse oximeter
4. GIT system
 Change in platelets
activity
 Serum uremic toxins
 Electrolyte imbalance
 Anorexia
 Abdominal
distension
 GIT Bleeding
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1. Monitor intake ,
output
2. Hematocrit
3. Hemoglobin
 Nausea ,
vomiting
1.
Assess abdominal
pain , quality of
stools
5. Neurological system
 Uremic toxins
 Electrolyte imbalance
 Cerebra swelling from
fluid shifting
 Confusion
 Convulsions
 Muscle
irritability
 Sleep
disturbance
1. Assess level of
consciousness
2. Assess reflexes
3. - Electrolyte
levels
6. Skeletal system
 Decreased calcium
absorption
 Decreased phosphate
excretion
 Joint pain
 Muscle pain
 Retarded
growth
1. Serum
phosphors
2. Serum calcium
3. - Parathyroid
hormone level
7. Skin




Anemia
Pigmented retained
Dry skin
Decreased size of sweat
glands
8. Genitourinary system
 Damaged nephrons
 Pallor


Pigmentation
Pruritis
 Decreased
urine output
 Proteinuria
 Casts and
cells in urine
- Assess color of skin
- Assess integrity of
skin
- Observe for
bruising
- Monitor intake ,
output
- Serum creatinin ,
BUN
- Urine electrolytes
- Serum electrolytes
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Stages of chronic renal failure:
Stage 1
Reduced renal reserve, characterized by a 40% to 75% loss of nephron
function. The patient usually does not have symptoms because the
remaining nephrons are able to carry out the normal functions of the
kidney.
Stage 2
Renal insufficiency occurs when 75% to 90% of nephron function
is lost. At this point, the serum creatinine and blood urea nitrogen rise, the
kidney loses its ability to concentrate urine and anemia develops. The
patient may report polyuria and nocturia.
Stage 3
End-stage renal disease (ESRD), the final stage of chronic renal failure,
occurs when there is less than 10% nephron function remaining. All of
the normal regulatory, excretory, and hormonal functions of the kidney
are severely impaired. ESRD is evidenced by elevated
creatinine and blood urea nitrogen levels as well as electrolyte
imbalances. Once the patient reaches this point, dialysis is usually
indicated. Many of the symptoms of uremia are reversible with dialysis.
Complications of Chronic Renal failure:
 Hyperkalemia due to decreased excretion, metabolic acidosis,
catabolism, and excessive intake (diet, medications, fluids)
 Pericarditis, pericardial effusion, and pericardial tamponade due to
retention of uremic waste products and inadequate dialysis
 Hypertension due to sodium and water retention and malfunction of
the renin–angiotensin–aldosterone system
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 Anemia due to decreased erythropoietin production, decreased RBC
life span, bleeding in the GI tract from irritating toxins, and blood
loss during hemodialysis
 Bone disease and metastatic calcifications due to retention of
phosphorus, low serum calcium levels, abnormal vitamin
 metabolism, and elevated aluminum levels
Medical Management:
Medical Management
The goal of management is to maintain kidney function and homeostasis
for as long as possible through: Pharmacological therapy
 diet therapy
 dialysis
PHARMACOLOGIC THERAPY
Complications can be prevented or delayed by administering
prescribed antihypertensives, erythropoietin (Epogen), iron supplements,
phosphate-binding agents, and calcium supplements.
DIET THERPAY
Dietary intervention is necessary and includes
 careful regulation of protein intake. Protein is restricted
 sodium intake to balance sodium losses and some restriction of
potassium.
 caloric intake and vitamin supplementation must be ensured.
 the fluid allowance is 500 to 600 mL more than the previous day’s
24-hour urine output.
 Calories are supplied by carbohydrates and fat to prevent wasting.
Vitamin supplementation is necessary because a protein-restricted
diet does not provide the necessary complement of vitamins
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Type of dialysis
a) Introduction
- In UK, approximately half on dialysis are treated by haemodialysis
and other half by peritoneal dialysis. Both method are effective and in
fact many patient with experience both types of dialysis during their
life with kidney failure.
- Your clinical condition may determine which treatment will be the
most suitable, but often you have choice.
- This choice is an important one find out as much as you can about the
different treatment options and discuss them with your renal health
care team and with your family.
Dialysis:
Is an artificial process which replace some of work of the kidneys.
It clears the waste products from the blood and removes excess water.
Dialysis thus performs the two main functions of the kidneys. Toxins
clearance and maintaining fluid balance.
b) Purposes of dialysis
1. Remove waste products of proteins metabolism
2. Remove toxins from blood
3. remove excess water
4. Maintain proper level of electrolytes
5. Maintain acid base balance.
c) How dialysis work
 Waste products are cleared from the blood by process
diffusion.
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called
 Excess water is removed from the blood by process called ultrafiltration.
 Wastes and water pass into special liquid called the dialysis fluid or
dialysate for removal from the body.
 A thin layer of tissue or plastic, known as the dialysis membrane.
5. Haemodialysis
 Haemo is a greek word for blood and dialysis mean a filtrating
process. Therefore haemodialysis refer to the process of filtrating
blood.
 With haemodialysis, the dialysis process takes place out side the
body in machine. The dialysis membrane is an artificial one,
called dialyser the dialyser removes the extra. Fluid and waste
from the blood. The clean blood is then returned to the body.
Definition: An extracorporeal flow of the patients blood is separated
from specifically dialysate membrane. Water and some solutes may move
to or from the blood.
Purpose from haemodialysis
 Haemodialysis cleans and filters your blood using machine to
temporary rid your blood of harmful wastes, extrawater,
haemodialysis helps control blood pressure and help your body
keep balance of important chemicals such s potassium, sodium,
calcium and bicarbonate.
 Haemodialysis is the more efficient method of dialysis but is
more complex procedure. Then peritoneal dialysis and requires
more sophisticated equipment.
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 In haemodialysis, the blood from an artery is directed
extracorporeally. Through an exchange unit and is returned to
vein.
 The components of the exchange unit include porous
tube
through which. The blood flows and a compartment containing a
dialysiate.
 A second essential unit is the dialysate supply system which
mixes and delivers the solutions to exchange unit.
 The membrane like tube which transports the blood requires
priming with blood or prescribed intervenous solution to exclude
all air before being connected to the patient artery and vein.
 Heparine is added to the blood as it enters.
 The dialysis machine to prevent coagulation.
Dialyzing fluid (DF)
Concentration of Na+, Cl- in the DF are equal their conc. In normal
plasma.
Concentration of waste products of metabolism, urea, creatinine,
uric acid, phosphate and phosphate are zero in the DF (to help rapid
transfere of these substances from plasma of the patient to DF).
Concentration of Hco-3, Ca2+ and glucose are higher in the DF than
in uremic their levels in the patient's plasma.
Dialyzing period: usually 3-6 hours, 3 times a weak.
Advantages and disadvantages of haemodialysis
Advantages
Disadvantage
Rapid fluid removal
Vascular access problems
Rapid removal of urea and creatinine
Dietary and fluid restrictions
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Heparinization may e necessary
Effective potassium removal
Extensive equipment necessary
Less protein loss
Hypotension during dialysis
Lowering of serum triglycerides
Added blood loss that contributes tot
anemia
Home dialysis possible
Specially trained personnel necessary
Temporary access can be placed at
Surgery for permanent access placement
bedside
Self-image problems with permanent
access
Vascular access
Before beginning of hemodialysis treatment, a person need an
access to their blood stream called vascular access. The access allows the
patient's blood to travel to and from the dialysis machine at long volume
and high speed so that toxins, waste and extra-fluid can be removed from
the body.
- Types of vascular access.
- There are three types of vascular access
a) Arteriovenous fistula "AV fistula"
b) Arteriovenous graft "AV graft"
c) Control venous catheter or internal port device.
 Each access is created surgically.
 There are limited number of places of body where an access can be
placed (arm-neck-eg-chest).
 Fistula and graft are considered to permanent accesses because they
are placed under the skin with plants use them for many years.
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 When patient find out they are in advanced stags of chronic kidney
disease and will besterting dialysis in the future, their nephrologists
will advice them to get fistula or graft.
 When the patient suddenly discover they have kidney fistula a catheter
may be placed to allow for mediate dialysis treatment.
 The catheter will be used until fistula or graft has time to mature.
1. AV fistula: is created by directly connecting person's artery and vein.
Usually in arm.
 This procedure performed as an outpatient operating using local
anesthetic, blood flows to the vein from the newly connected artery
the vein grow longer and stronger. It can provide good blood flow for
many years of haemodialysis.
 Research studies have proven patients with fistula have the fewest
complications, such as infection or clotting compared to all other
access choice.
 The fistula is considered the "gold standard" access because it:
 Has a lower risk of infection than other access type.
 Has lower risk of forming clots than other access type.
 Performs better than other accesses.
 Allow for greater blood flow
 Lasts longer than other access type
 Can last many years even decades, when well we is cared for.
 Some issues people may have with fistulas includes:
1. The appearance of bulging veins at the access site.
2. Taking several month for new one to mature.
3. not maturing at all in some case.
 Not every one may be able to have fistula due to weak arteries.
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2. AV graft
o AV graft is similar to fistula in that also under the skin of an artery
and vein, except that with graft a man made tubing connects the artery
and vein the soft plastic like tube is about one half inch in diameter
and is mad from Teflon material. Transplanted human vessel may also
be used as grafts to connect an artery and vein.
o Graft don't require as much time to mature as fistula because the graft
does not need time to enlarge before using in most cases a graft can
be used two to six weeks after placement.
o AV graft have more problems then fistulas due to clotting and
infections graft may not last as long as fistula and could need to be
repaired or replaced each year.
Caring for fistula or graft
Taking good care for fistula or graft will help keep it working
properly. There are a few things you can do to help prevent infection,
clotting and damage to your access.
a) Cleanliness is important to keep out infections.
- Keep your access area clean and free of any trauma.
- Look for signs of infection including pain, tenderness swelling or
redness around your access area.
- Also a ware of any fever and flu-like symptoms if patients have sign
of infection proper antibiotic should be used.
b) Protect your access form any restriction or trauma by:
6
- Avoiding tight clothes, jewelry or any thing that may put pressure on
your access .
- Not sleeping on top of or resting on your access area.
- Don't carries, bags or heavy items across your access area.
- Always requesting that blood be drown from your access area.
- Always measuring blood pressure from non access area.
- Learn patient to feel of thrill or vibration.
c) Good needle sticks cannulation help keep access working well
3. Catheters and internal port devices
 Catheter: is narrow tube that is placed into large central vein, usually
in patient's neck, chest or groin. Placement of the catheter usually
takes less then a half hour. Usually two tubes, extend out of the body
from the catheter one allows blood out of the body and one allows
blood back to the body.
 Internal port devices are special access systems which are placed
under the skin and connected to very large venous
catheters to
provide access to remove blood out of the body for cleaning and then
back into the body.
 Catheter and internal port devices can be used for dialysis
immediately after placement.
Care for catheter and internal port devices
- Cleanliness helps prevent infections
- We should always keep it clean and dry especially during showers
keep in healed catheter exit sit wet.
- You will be taught importance of making sure your catheter clamps
are clamped and end caps are on securely.
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- Check site of catheter for sign of infection as redness, swelling, pain,
pus or fever,
Complications of haemodialysis
 The cannula can fall out the client might bleed to death. More severe
bleeding also can occur because the cannula is heparinized.
 The membrane within the dialysis machine can rupture, causing
hemorrhage.
 If the chemical agents used are the wrong ones or if the chemistry
workup is incorrect, the client's electrolyte balance will be disrupted
even further.
 Because most clients on dialysis have high blood pressure (caused by
renal damage), they may go into shock when connected to the
machine.
 The blood in the machine must be warm, or the client can suffer
cardiac arrest from the shock of cold blood.
 Infection or septicemia is always a possibility. Because this client has
especially low resistance, infection can be dangerous.
 Blood can clot in the cannula and cause phlebitis.
 Male clients often become impotent, although this problem may
correct itself as the condition is stabilized.
 Excesses in alcohol or food intake will not be excreted between
dialysis runs.
Nursing intervention in haemodialysis patient
a) Pre dialysis
6
 Patient and family receive a simple explanation of the purpose of
dialysis and what to expect during the procedures.
 Using prepared brochures and audiovisual programs to provide
information and reinforce verbal explanations and instructions.
 Position the patient comfortably in bed or reclining chair with limb
with the AV fistula or graft exposed and supported.
 Measures and record for patient weight and vital signs.
 Blood specimens are obtained when the needles are introduced for
laboratory determinations of haematocrit, electrolytes (Na+, K+), blood
urea and creatinine levels and clotting time.
 The vascular access site is examined for signs of a haematoma or
infection.
 Observations are made of the patient colour and condition of skin
(dryness, turgor, abrasions) and for oedema.

Compare for patient his weight and his weight in last dialysis
sessions, and difference in weight.
During dialysis
- During dialysis the patient is monitored continuously for indications
of the effectiveness of treatment and signs of complications.
- Observing and recording for vital signs on schedule manner.
- Monitoring for temperature of dialysate, heparinization and blood
clotting time.
- Observing for signs of dehydration or overhydration.
- Blood analysis for potassium and sodium levels may be repeated.
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-
The first dialysis should be short (2+-3 hours) to allow gentele
clearance of nitrogen waste. This prevents complication of cerebral
oedema associated with disequilibrium syndrome (disorientation or
convulsion)
- Fluid are given, often in excess of dialysis allowance.
To give the patient a little more freedom and extra fluid may
removed through out the dialysis.
- Allow patient free diet at least for first two hours of dialysis. This still
adequate time for metabolites to be dialyzed out safely before the end
of dialysis.
- The temperature of dialysate is monitored and automatically
controlled.
-
The dialyzer has alarm to alert attending staff of malfunction
- The length of time the patient is kept on dialyser varies with patient
condition. Average range is (4-6 hours).
C) Post dialysis
1. The arterial line is clamped after completion
2. Try as possible blood in dialyzing circuit lines is returned to the
patient.
3. Dressing is applied and area observed until ether is no evidence of
bleeding.
4. Apply pressure for brief period.
5. The patient weight, blood pressure, lying and standing pulse and
temperature are taken sudden change in blood pressure, rapid work,
pulse, headache, disorientations and disrobed level of conscious.
6. Inspection for possible leakage around tube.
7. Mild abdominal discomfort may be alleviated by slowing the rate
of inflow.
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8. Restriction for food and fluid.
9. Put patient in his comfortable position.
10. Activity is encouraged as much as possible
Post dialysis
1. We must record the following
a. Times that the flow is commenced and completed
b. Coloure and volume of the fluid (negative and positive
balance).
c. Patient weight on completion of dialysis
2. The catheter is cupped and an antiseptic or sterile occlusive
dressing may be applied.
3. Check patient vital signs.
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6. Peritoneal Dialysis
Uses a natural membrane inside the body called peritoneal
membrane for dialysis this membrane has tiny boles in it and act as filter
allowing waste products and fluid from the blood to pass across
peritoneal dialysis may be used for most patient with symptomatic renal
failure and have a healthy peritoneal surface area.
How peritoneal dialysis occur?
- Dialysate is introduced into peritoneal cavity. The peritoneum consist
of two membranes, the parietal and visceral potential space between
this two layer form peritoneal cavity normally this cavity normally
small amount of serous fluid.
- Transfer of solutes and fluid across these layers take space by
diffusion and osmosis.
Peritoneal catheter
- A permanent peritoneal catheter used with patient who has chronic
renal failure. Catheter with several openings in the tip such as tenck
off catheter or modifications of it. Is inserted into peritoneal cavity.
- Tissue cell fibroblasts
subcutaneous section of
grow into the two dacrom cuffs on the
catheter in 2-3 weeks. Stabilizing the
catheter position and decrease the incidence of infection and escape
of fluid.
- The procedure is done in operating theater and local or general
anaesthetic.
Dialysis solution: are available commercially in one or two liters in
plastic bag and provide various options of glucose concentrations of
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1.5%-2.5% and 4.25%s. the plasma composition is similar to that of
plasma.
Phases of peritoneal dialysis
a) Inflow phase: Prescribed amount of solution 2 liter, is
infused through an established catheter over about 10
minutes after solution has been infused. The inflow clamp is
closed before air enters tube.
b) Dwell phase: Equilibration: during this phase diffusion and
osmosis occur between the patient's blood and peritoneal
cavity. This phase last about 20-30 minutes.
c) Drain phase: drain for solution it takes about 15-30 minutes
and may be facilitated gently by massaging the abdomen or
changing position.
Methods of peritoneal dialysis
a) Automated peritoneal dialysis
An automated device called a cycler is used to delive the dialysate
for APD. The automated cycler times and controls the fill dwell and drain
phases. The machine cycles four or more exchange per night 1-2 hour per
exchange. The patient disconnect from machine in morning and usually
leaves fluid in the abdomen during the day. One to two manual exchange
may be also prescribed to ensure adequate dialysis.
b) Continuous ambulatory peritoneal dialysis (CAPD)
Continuous because the process does not end constantly cleans the
blood as long as there is dialysis fluid in peritoneal cavity. With CAPD,
dialysis is taking place 24 hours a day 7 day per week.
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Ambulatory: ambulate means to walk because patient not attached
to machine. The dialysis is happening all the time day and night during
activities and while the patient sleeps.
CAPD: Involves performing an exchange of dialysis fluid
exchange are usually carried out by patient themselves.
CAPD can be performed in any clean and convenient place at
home, at work at school or an holiday
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Advantages and disadvantages of PD
Advantages
Disadvantages
Immediate initiation in almost any
Bacterial or chemical peritonitis
hospital
Protein loss into dialysate
Exit site and tunnel infections
Less complicated than hemodialysis
Self-image problems with catheter
placement
Fewer dietary restrictions
Hyperglycemia
Relatively short training time
Aggravated hypyerlipidemia
Usable in the patient with vascular access
Surgery for catheter placement
problems
Contraindication in the patient with
Less cardiovascular stress
multiple abdominal surgeries, trauma,
Home dialysis possible
unrepaired hernia
Specially trained personnel needed
Preferable for the diabetic patient
Catheter can migrate
Complications of PD
1. Peritonitis: This is a major complication of peritoneal dialysis due
to sudden increase of organism by contamination of equipment or
dialysate fluid.
2. Catheter complications as follow: Leakage around the catheter
obstruction of catheter.
3. Pain: This may be due to the tip of catheter pressing on viscra or
overheating from dialysate.
4. Protein catabolism and anorexia: break down of tissue protein
may occur due to loss of protein in dialysate. Anorexia may occur
due to feeling of fullness.
5. Electrolytes imbalance.
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6. Disequilibrium syndrome: Rapid removal of nitrogenous wastes
from blood can produce a complication in which cerebral oedema
develops causing seven headache restlessness and disorientation
"very rare complication nursing care for patient with peritoneal
dialysis
Nursing care for patient with peritoneal dialysis
Predialysis
1. Preparation of the patient by:
a. Evaluation the patient understanding of dialysis
b. Explanation of procedure and patient purpose.
2. Assessment for patient include
a. Vital signs (temp. pulse, Bl. p, respiratory).
b. Laboratory investigation and serum electrolytes, blood urea
nitrogen, serum creatinine.
c. Assess for signs of over load, respiratory distress and
dehydration.
3. Examination for abdominal distention and tenderness, observe for
area around the catheter for redness, drainage and infection.
During dialysis
1. Apply aseptic technique during handling the catheter tubing and
dialysate.
2. Warming for dialysate solution.
3. Record for amount, type of dialysate and its time for instillation.
4. Observation for patient psychological and physiological reactions.
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5. Observing for unwanted sign and symptoms, such as abdominal
pain, nausea vomiting.
7. General Care for the Client Receiving Dialysis
 Always wear gloves (rationale: you will be exposed directly to the
client's blood. Many people double glove).
 Check the shunt every 2 to 4 hours for vibration (thrill), which you
can feel. Listen with a stethoscope for the whooshing sound of blood
moving through the shunt (bruit). Record the sound as follows: RAG
(right arm gortex)++. (The ++ indicates that you can both feel and
hear the blood movement.
 Notify the physician immediately if you detect a change in the
intensity of these sounds or sensations or if they are absent (rationale:
this could be life threatening).

Keep two clamps on the dressing over the external cannula at all
times. (rationale: in case of cannula separation).
 Do not draw blood on the arm with a cannula or fistula. (Rational: to
avoid disturbing the shunt).
 You may need to take the client's blood pressure with an electronic
device. (rationale: you may be unable to hear it with a stethoscope).
 If an arteriovenous fistula bleeds, apply pressure until the bleeding
stops (Rationale: bleeding can be a life threatening emergency).
 Usually, you will not flush the port (Rational: it is not likely to clot
and you want to avoid further possibility of injection).
 Many clients on dialysis are diabetic and require insulin.
 These clients usually will not void (rationale: they do not produce
urine because of lack of kidney functioning).
 Do not give these clients orange juice. Give apple or grape juice
instead. (Rationale: orange juice is high in potassium. Elevated
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potassium is common in these clients and is dangerous. Hyperkalemia
(elevated potassium) can cause fluid overload, shortness of breath, and
irregular hearbeat, which can lead to cardiac arrest).
 Blood for potassium and other electrolyte level tests is usually drawn
daily. (Rational: to determine what should be included in the next
run).
 Follow medication times exactly. (rationale: to maintain therapeutic
blood levels and to avoid overload).
 Measure the client's daily weight (Rationale: to evaluate fluid
retention).
 The client's blood pressure may be elevated (rationale: monitor blood
pressure carefully).

Guaiac all stools is often ordered (rationale: to check for internal
bleeding from the vascular kidney).
 Teach the client and family about care of the cannula or fistula and
other aspects. (Rational: they must understand that disconnection of
these devices is an emergency, requiring immediate attention).
 Carefully and completely document all teaching.
 Assessment also includes careful observation for any indication of
excessive bleeding. Hemorrhage can easily occur after surgery for
renal calculi because the kidneys are so vascular.
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Surgical Management - Kidney transplantation
Definition: Kidney transplantation is a surgical procedure to remove a
healthy, functioning kidney from a living or brain-dead donor and
implant it into a patient with nonfunctioning kidneys
Purpose
Kidney transplantation is performed on patients with chronic kidney
failure, or end-stage renal disease (ESRD).
Description
Kidney transplantation involves surgically attaching a functioning kidney,
or graft, from a brain-dead organ donor (a cadaver transplant) or from a
living donor to a patient with ESRD. Living donors may be related or
unrelated to the patient, but a related donor has a better chance of having
a kidney that is a stronger biological match for the patient.
Preoperative care:
 Emotional support
 Monitor vital signs
 The patient is fasting 6-8 hours
 Increase fluid intake to ensure adequate excretion of waste
products
 Explain the procedure for patient and relative
 Ensure adequate investigation especially kidney functions tests
Postoperative care:
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 A typical hospital stay for a transplant recipient is about five days.
 Both kidney donors and recipients will experience some discomfort
in the area of the incision after surgery.
 Pain relievers are administered following the transplant operation.
Patients may also experience numbness, caused by severed nerves,
near or on the incision.
 A regimen of immunosuppressive, or anti-rejection, medication is
prescribed to prevent the body's immune system from rejecting the
new kidney.
 Common immunosuppressants include cyclosporine, prednisone,
tacrolimus, mycophenolate mofetil, sirolimus, baxsiliximab,
daclizumab, and azathioprine.
 The kidney recipient will be required to take a course of
immunosuppressant drugs for the lifespan of the new kidney.
 Intravenous antibodies may also be administered after transplant
surgery and during rejection episodes.
 Because the patient's immune system is suppressed, he or she is at
an increased risk for infection. The incision area should be kept
clean, and the transplant recipient should avoid contact with people
who have colds, viruses, or similar illnesses. If the patient has pets,
he or she should not handle animal waste. The transplant team will
provide detailed instructions on what should be avoided posttransplant. After recovery, the patient will still have to be vigilant
about exposure to viruses and other environmental dangers.
 Transplant recipients may need to adjust their dietary habits.
 Certain immunosuppressive medications cause increased appetite
or sodium and protein retention, and the patient may have to adjust
his or her intake of calories, salt, and protein to compensate.
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Complications:
1. Infection and bleeding (hemorrhage).
2. A transplanted kidney may be rejected by the patient
3. Atelectasis
4. Pneumonia
5. Thromboembolism
Normal results
The new kidney may start functioning immediately, or may take several
weeks to begin producing urine. Living donor kidneys are more likely to
begin functioning earlier than cadaver kidneys, which frequently suffer
some reversible damage during the kidney transplant and storage
procedure. Patients may have to undergo dialysis for several weeks while
their new kidney establishes an acceptable level of functioning.
Studies have shown that after they recover from surgery, kidney donors
typically have no long-term complications from the loss of one kidney,
and their remaining kidney will increase its functioning to compensate for
the loss of the other.
Morbidity and mortality rates
A new study describes the psychological profile of adolescents who have
received kidney transplants and compares them to those of healthy peers.
The findings reveal a significantly higher prevalence of psychiatric
conditions (depression, phobia, ADHD), educational impairment and
social isolation among adolescents who had undergone a transplant.
(Science Daily, 2009)
Chronic kidney tumor
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Definition: It is formation of tumor in the kidney
Causes and risk factors
1. The cause of kidney cancer is unknown
2. Gender affects men more than women
3. Tobacco use - Occupational exposure to industrial chemicals
such as petroleum products , heavy metals, asbestos
4. Obesity - Unopposed estrogen therapy
5. Polycystic kidney disease
Pathophysisology
 Because the kidneys are deeply protected in the body tumors can become
quit large before causing symptoms
 As the tumor enlarges it occupies space extending into adjacent renal
structures and interfering with urine flow.
 Tumor cells tend to metastases by way of the renal vein and vena cava to
the lungs, bones lymph nodes, liver, and brain.
 The majority of renal cell carcinoma starts in the proximal convoluted
tubules
 There are five cell types (clear cell, papillary, chromophobe, collecting
duct, unclassified clear cell type )
 Renal cell carcinoma is staged using the TMN system or the Robson
system
TMN T = tumor- M = metastasis - N= Lymph nodes nvolvement
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The Robson system includes the following:

Stage I: The Tumor Is Well Defined Encapsulated , Compress On
The Renal Parenchyma

Stage II: Tumor Invade the Fat Surrounding Kidney

Stage III: Local metastases through direct extension or vein or
lymph nodes

Stage IV: Distant metastases I the lung, liver , spleen
Treatment: Radiation therapy - Chemotherapy - Immunotherapy
Surgical therapy (open nephrectomy – laparoscopic procedure) )
1. Open nephrectomy
The surgical procedure to remove a kidney from a living donor is called a
nephrectomy.
2. Laparoscopic nephrectomy: Laparoscopic nephrectomy is a form of
minimally invasive surgery using instruments on long, narrow rods to
view, cut, and remove the donor kidney
Outcome of the nephrectomy or heminephrectomy
1. Reduce pain and haematuria caused by the tumor
2. The hospital stay is typically 4-6 days
3. Return to the work within 4-8 days
4. With laparoscopic surgery (fewer analgesic- early dischargedearly rerun to work- )
Polycystic kidney
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Definition: It is formation of one or more fluid- filled cavities within the
kidneys.
Causes: Hereditary causes - Acquired after birth
Signs & symptoms
Abdominal and flank pain – Haematuria - Infection due to rupture of
cysts - Chronic renal failure - Hypertension in 50% of patients
Management:
1. health history
2. Ultrasound
3. CT – MRI
4. Hypertension should be controlled
5. Diets limited in protein
6. Antibiotics to control infection
7. Analgesics to control pain
8. Patient Is Instructed Signs and Symptoms Of Infection To Avoid
Incidence Of CKD
Surgical Management: Surgical aspiration - laparoscopic decompression
of cysts
2.LOWER URINARY TRACT DISORDERS
1. Bladder cancer
2. Ureteral stricture
3. Urethral stricture
4. voiding disorders
1. Bladder Cancer
6
Definition: Cancer that forms in tissues of the bladder
Types of bladder cancer:
There are three types of bladder cancer that begin in cells in the lining of
the bladder. These cancers are named for the type of cells that become
malignant (cancerous):
1. Transitional cell carcinoma: Cancer that begins in cells in the
innermost tissue layer of the bladder. These cells are able to stretch
when the bladder is full and shrink when it is emptied. Most
bladder cancers begin in the transitional cells.
2. Squamous cell carcinoma: Cancer that begins in squamous cells,
which are thin, flat cells that may form in the bladder after longterm infection or irritation.
3. Adenocarcinoma: Cancer that begins in glandular (secretory) cells
that may form in the bladder after long-term irritation and
inflammation.
NB: Cancer that is confined to the lining of the bladder is called
superficial bladder cancer (papillary lesions). Cancer that begins in the
transitional cells may spread through the lining of the bladder and invade
the muscle wall of the bladder or spread to nearby organs and lymph
nodes; this is called invasive bladder cancer (non-papillary lesions).
Causes: Cause of bladder cancer is unknown cause
Risk factors:
 Smoking.
 Being exposed to certain substances at work, such as rubber,
certain dyes and textiles, paint, and hairdressing supplies.
 A diet high in fried meats and fat
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 Being older, male
 Having an infection caused by a certain parasite.
 Certain drugs such as cyclophosphamide and phenacetin are known
to predispose to bladder Transitional cell carcinoma (TCC)
 Family history
Signs and symptoms
 Painless haematuria. this may be visible to the naked eye (frank
hematuria) or detectable only by microscope (microscopic
hematuria)
 pain during urination,
 frequent urination (Polyuria)
 Feeling the need to urinate without results.
 Fatigue
 Shortness of breathing
 Anemia
Stages of bladder cancer:
The following stages are used to classify the location, size, and spread of
the cancer, according to the TNM (tumor, lymph node, and metastasis)
staging system:

Stage 0: Cancer cells are found only on the inner lining of the
bladder.

Stage I: Cancer cells have proliferated to the layer beyond the
inner lining of the urinary bladder but not to the muscles of the
urinary bladder.
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
Stage II: Cancer cells have proliferated to the muscles in the
bladder wall but not to the fatty tissue that surrounds the urinary
bladder.

Stage III: Cancer cells have proliferated to the fatty tissue
surrounding the urinary bladder and to the prostate gland, vagina,
or uterus, but not to the lymph nodes or other organs.

Stage IV: Cancer cells have proliferated to the lymph nodes, pelvic
or abdominal wall, and/or other organs.

Recurrent: Cancer has recurred in the urinary bladder or in
another nearby organ after having been treated.
Diagnosis:
1. (CAT scan): A procedure that makes a series of detailed pictures of
areas inside the body, taken from different angles. The pictures are
made by a computer linked to an x-ray machine. A dye may be
injected into a vein or swallowed to help the organs or tissues show
up more clearly. This procedure is also called computed
tomography, computerized tomography, or computerized axial
tomography.
2. Urinalysis: A test to check the color of urine and its contents, such
as sugar, protein, red blood cells, and white blood cells.
3. Internal exam: An exam of the vagina and/or rectum. The doctor
inserts gloved fingers into the vagina and/or rectum to feel for
lumps.
4. Intravenous pyelogram (IVP): A series of x-rays of the kidneys,
ureters, and bladder to find out if cancer is present in these organs.
A contrast dye is injected into a vein. As the contrast dye moves
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through the kidneys, ureters, and bladder, x-rays are taken to see if
there are any blockages.
5. Cystoscopy: A procedure to look inside the bladder and urethra to
check for abnormal areas. A cystoscope is inserted through the
urethra into the bladder. A cystoscope is a thin, tube-like
instrument with a light and a lens for viewing. It may also have a
tool to remove tissue samples, which are checked under a
microscope for signs of cancer.
6. Biopsy: The removal of cells or tissues so they can be viewed
under a microscope by a pathologist to check for signs of cancer. A
biopsy for bladder cancer is usually done during cystoscopy. It may
be possible to remove the entire tumor during biopsy.
7. Urine cytology: Examination of urine under a microscope to check
for abnormal cells.
Medical management:
The treatment of bladder cancer depends on how deep the tumor
invades into the bladder wall:
1. Superficial tumors : by elecrocautary – and cystoscopy
2. Immunotherapy as BCG anti-inflammatory and prevent recurrence
of superficial tumors
3. Chemotherapy as alternative of BCG
4. Radiation therapy
Surgical management:

Determine type of surgery according to stage of cancer

Radical Cystectomy by urinary diversion in late stage of tumor
Nursing implications for bladder cancer surgeries:
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Procedure
1. Transurethral
resection of bladder
tumor(TURBT)
Description
Tumor removal via
cystoscope inserted
into urethra
Nursing
considerations
- Maintain continuous
bladder irrigations
ordered
- Ensure catheter
patency
- Monitor for excessive
bleeding
- Encourage fluids up
to 2.500- 3.000 ml/day
2. Partial cystectomy
3.Complete or radical
cystectomy
- Give stool softeners
to prevent straining
Resection of the tumor - Maintain urethral and
and a portion of the
suprapubic catheter
bladder wall
patency to reduce
pressure on suture
lines
Removal of the entire
urinary bladder and
surrounding tissues
- Monitor for excessive
bleeding
- Permanent urinary
diversion required
- Maintain stent
position and patency
4. Cutanous
ureterostomy
One or both ureters
brought to abdominal
wall urine drains via
stoma
- May have urethral
catheter to drain pelvic
cavity
-Requires urinary
drainage appliance
- Small stoma may
make tight seal
difficult
- Risk for irritation
from direct contact
6
with urine
5.Ileal conduit
6.Continent internal
ileal reservoir or
continent ileal bladder
conduit (Kock`s pouch
)
- Increased risk for
UTI due to direct
access from skin to
kidney
- Continuous urine
drainage requires
appliance
Portion of ileum
formed into pouch
ureters inserted into
pouch and open end is
brought to surface to - Risk for infection is
significant
form stoma
Pouch created from
ileum
- Good skin care is
vital due to constant
contact with urine
Drainage –collection
device is not necessary
2. Ureteral stricture:
Definition: The ureters are tubes that normally carry urine from the
kidneys to the bladder. A ureteral stricture is a narrowing of the ureter
that results in an obstruction in the flow of urine.
Causes and risk factors
1. They may develop after treatment for another urologic condition.
2. Individuals who have undergone ureteroscopic or percutaneous kidney
treatment for stones or tumors
6
3. Pelvic radiation therapy or urinary diversion surgery may develop
ureteral strictures. After these procedures, scar tissue may obstruct the
ureter
4. Gynecologic or vascular surgery procedures.
5. External traumatic injury can cause strictures.
Symptoms and diagnosis
 Include flank and/or abdominal pain, nausea, vomiting, fever,
infection, or sometimes an overall sensation of not feeling well.
 A variety of diagnostic tests to clarify different causes of stricture.
 X-rays, ureteroscopy, retrograde pyelogram or nephrostogram,
ultrasound, CT scan, or MRI.
Treatment:
 After determining the cause and location ureteral stricture, develop
an individualized treatment strategy, we focus on minimally
invasive treatments for ureteral strictures whenever possible.
 For strictures that develop shortly after external injury or after
surgical injury, surgery may be the first choice of treatment.
 During surgery doctor will remove scar tissue and may surgically
reconstruct ureter in a different location and reconnect it to the
kidney. Surgery may be open, laparoscopic or robotic. If the
stricture is extensive, then tissue from another part of the body,
such as the small intestine, may be used to help reconstruct the
ureter.
 For less severe or chronic strictures, endoscopy may be
recommended. Here, a flexible tube is passed through the urethral
6
opening and threaded up through the bladder into the ureters. The
doctor then uses specialized surgical instruments or lasers to cut
through the blockage. In some cases, a balloon may be used to
dilate the ureter. A stent (a hollow tube) may be inserted to keep
the ureter open after treatment for several weeks.
 Because an obstructed ureter may lead to fluid retention in the
kidneys (hydronephrosis), your doctor may need to drain the fluid
through a procedure known as percutaneous nephrostomy, in which
a needle is inserted through the back into the kidney to drain excess
urine. A ureteral stent may also be put in place; this device can
help drain urine directly from the kidney to the bladder, bypassing
the point of obstruction or stricture
3. Urethral stricture:
 A urethral stricture most commonly results from previous infection
or injury. A less forceful urinary stream or a double stream usually
occurs with mild strictures. Severe strictures may completely block
the stream of urine. The buildup of pressure behind the stricture
may cause the formation of passages from the urethra into the
surrounding tissues (diverticula). By decreasing the frequency or
completeness of urination, strictures often lead to urinary tract
infections.
 A urologist diagnoses a stricture by looking directly into the
urethra through a flexible viewing tube (cystoscope) after
administering a lubricant containing a local anesthetic. To widen
the urethra, a urologist may dilate or cut (urethrotomy) the
stricture. Urethral strictures can recur and may require excision of
6
the scar and surgical reconstruction of the urethra, sometimes with
a skin graft
Voiding disorders
Types of voiding disorders
1. Chronic Urine retention
2. Chronic Urine incontinence
Chronic Urine retention:
Urinary retention also known as ischuria is a lack of ability to urinate. It
is a common complication of benign prostatic hypertrophy (also known
as benign prostatic hyperplasia or BPH), although anticholinergics may
also play a role, and requires a catheter or Prostatic stent. Various
medications (e.g. some antidepressants) and recreational use of
amphetamines and opiates are notorious for this.
Signs and symptoms:
Urinary retention is characterised by poor urinary stream with
intermittent flow, straining, Incomplete voiding - hesitancy (a delay
between trying to urinate and the flow actually beginning). -Incontinencenocturia (need to urinate at night) and
Chronic urine retention causes obstruction of the urinary tract:

Bladder stones

Loss of detrusor muscle tone (atonic bladder is an extreme form)

Hydronephrosis (congestion of the kidneys)

Hypertrophy of detrusor muscle

Diverticula in the bladder wall (leads to stones and infection
6
Causes:
In the bladder:

Detrusor sphincter dyssynergia

Neurogenic bladder (commonly saccral nerve damage,
demyelinating diseases or Parkinson's disease)

Iatrogenic scarring of the bladder neck (commonly from removal
of indwelling catheters or cystoscopy operations)

Damage to the bladder
In the prostate

Benign prostatic hyperplasia

Prostate cancer and other pelvic malignancies

Prostatitis
Penile urethra

Congenital urethral valves

Phimosis or pinhole meatus

Circumcision

Obstruction in the urethra, for example a metastasis or a
precipitated pseudogout crystal in the urine

STD lesions (gonorrhoea causes numerous strictures, leading to a
"rosary bead" appearance, whereas chlamydia usually causes a
single stricture)
Others:

Consumption of some psychoactive substances, mainly stimulants,
such as Ecstasy.
6

Use of drugs with anticholinergic properties.

Stones or metastases can theoretically appear anywhere along the
urinary tract, but vary in frequency depending on anatomy
Diagnostic tests:
Urine flow tests may aid in establishing the type of micturition
abnormality. Common findings include a slow rate of flow, intermittent
flow and a large post void residual, determined by ultrasound of the
bladder. In chronic retention, ultrasound of the bladder may show
massive increase in bladder capacity (normal capacity being 400-600 ml).
Determination of the serum prostate-specific antigen (PSA) may aid in
diagnosing or ruling out prostate cancer, though this is also raised in BPH
and prostatitis. A TRUS biopsy of the prostate (trans-rectal ultra-sound
guided) can distinguish between these prostate conditions. Serum urea
and creatinine determinations may be necessary to rule out backflow
kidney damage. Cystoscopy may be needed to explore the urinary passage
and rule out blockages
Treatment:
In acute urinary retention, urinary catheterization, placement of a
Prostatic stent or suprapubic cystostomy instantly relieves the retention.
In the longer term, treatment depends on the cause. Benign prostatic
hypertrophy may respond to alpha blocker and 5-alpha-reductase
inhibitor therapy, or surgically with prostatectomy or transurethral
resection of the prostate (TURP).
6
Chronic Urinary incontinence
Definition: Urinary incontinence — the loss of bladder control — is a
common and often embarrassing problem. The severity of urinary
incontinence ranges from occasionally leaking urine when you cough or
sneeze to having sudden, unpredictable episodes of strong urinary
urgency.
Symptoms: Urinary incontinence is the inability to control the release of
urine from your bladder. The problem has varying degrees of severity.
Some people experience only occasional, minor leaks — or dribbles — of
urine. Others wet their clothes frequently. For a few, incontinence means
both urinary and fecal incontinence — the uncontrollable loss of stools.
Types of urinary incontinence include:

Stress incontinence. This is loss of urine when you exert
pressure — stress — on your bladder by coughing, sneezing,
laughing, exercising or lifting something heavy

Urge incontinence. This is a sudden, intense urge to urinate,
followed by an involuntary loss of urine. Your bladder muscle
contracts and may give you a warning of only a few seconds to a
minute to reach a toilet. With urge incontinence, you may also
need to urinate often.

Overflow incontinence. If you frequently or constantly dribble
urine, you may have overflow incontinence. This is an inability to
empty your bladder, leading to overflow. With overflow
incontinence, sometimes you may feel as if you never completely
empty your bladder.
6

Mixed incontinence. If you experience symptoms of more than
one type of urinary incontinence, such as stress incontinence and
urge incontinence, you have mixed incontinence.

Functional incontinence. Many older adults, especially people in
nursing homes, experience incontinence simply because a physical
or mental impairment keeps them from making it to the toilet in
time. For example, a person with severe arthritis may not be able
to unbutton his or her pants quickly enough. Someone with
Alzheimer's disease may not plan well enough to make a timely
trip to the toilet. This type of incontinence is called functional
incontinence.

Gross total incontinence. This term is sometimes used to
describe continuous leaking of urine, day and night, or periodic
large volumes of urine and uncontrollable leaking. The bladder has
no storage capacity. Some people have this type of incontinence
because they were born with an anatomical defect. It can be caused
by a spinal cord injury or by injury to the urinary system from
surgery.
Causes:
Causes of persistent urinary incontinence
Urinary incontinence can also be a persistent condition caused by some
underlying physical problem — weakened pelvic floor or bladder
muscles, neurological diseases, or an obstruction in your urinary tract.
Factors that can lead to chronic incontinence include:

Pregnancy and childbirth. Pregnant women may experience
stress incontinence because of hormonal changes and the increased
6
weight of an enlarging uterus. In addition, the stress of a vaginal
delivery can weaken the pelvic floor muscles and the ring of
muscles that surrounds the urethra (urinary sphincter).

Changes with aging. Aging of the bladder muscle affects both
men and women, leading to a decrease in the bladder's capacity to
store urine and an increase in overactive bladder symptoms.
Women produce less of the hormone estrogen after menopause, a
decrease that can contribute to incontinence. Estrogen helps keep
the lining of the bladder and urethra healthy. With less estrogen,
these tissues lose some of their ability to close — meaning that
your urethra can't hold back urine as easily as before.

Hysterectomy. In women, the bladder and uterus (womb) lie
close to one another and are supported by the same muscles and
ligaments. Any surgery that involves a woman's reproductive
system — for example, removal of the uterus (hysterectomy) —
runs the risk of damaging the supporting pelvic floor muscles,
which can lead to incontinence.

Painful bladder syndrome (interstitial cystitis). This rare,
chronic condition can be associated with an inflammation of the
bladder wall. It occasionally causes urinary incontinence, as well
as painful and frequent urination. Interstitial cystitis affects women
more often than men, and its cause isn't clear.

Prostatitis. Loss of bladder control isn't a typical sign of
prostatitis, or inflammation of the prostate gland — a walnut-sized
organ located just below the male bladder. Even so, urinary
incontinence sometimes occurs with this extremely common
6
condition. The prostate actually surrounds the urethra, so
inflammation of the prostate occasionally swells and constricts the
urethra, blocking normal urine flow and leading to urinary urgency
and frequency. Rarely, this also causes incontinence.

Enlarged prostate. In older men, incontinence often stems from
enlargement of the prostate gland, a condition also known as
benign prostatic hyperplasia (BPH). The prostate begins to enlarge
in many men after about age 40. As the gland enlarges, it can
constrict the urethra and block the flow of urine. For some men,
this problem results in urge or overflow incontinence.

Prostate cancer. In men, stress incontinence or urge incontinence
can be associated with untreated prostate cancer. However, more
often, incontinence is a side effect of treatments — surgery or
radiation — for prostate cancer.

Bladder cancer or bladder stones. Incontinence, urinary
urgency and burning with urination can be signs and symptoms of
bladder cancer and also of bladder stones. Other signs and
symptoms include blood in the urine and pelvic pain.

Neurological disorders. Multiple sclerosis, Parkinson's disease,
stroke, a brain tumor or a spinal injury can interfere with nerve
signals involved in bladder control, causing urinary incontinence.

Obstruction. A tumor anywhere along your urinary tract can
obstruct the normal flow of urine and cause incontinence, usually
overflow incontinence. Urinary stones — hard, stone-like masses
that can form in the bladder — may be to blame for urine leakage.
Urinary obstruction can also occur after overcorrection during a
6
surgical procedure to correct urinary incontinence, leading to more
urine leakage.
Diagnostic tests:
Complete medical exam.
A complete physical examination, focusing on your abdomen and
genitals, also may give clues to your incontinence. Your doctor will look
for reasons for your incontinence, such as a urinary tract infection, mass
or compacted stool. If the cause of your incontinence is harder to find,
your doctor may want to do some tests.
Common tests:
Common tests for urinary incontinence include:

Bladder diary. Your doctor may go over a bladder diary that he
or she has asked you to complete at home over several days. You
record how much you drink, when you urinate, the amount of urine
you produce, whether you had an urge to urinate and the number
of incontinence episodes. To measure your urine, your doctor may
give you a pan that fits over your toilet rim. The pan has markings
like a measuring cup. Keeping a bladder diary can be tedious, but
it gives your doctor important information.

Urinalysis. A sample of your urine is sent to a laboratory, where
it's checked for signs of infection, traces of blood or other
abnormalities. For the sample to be collected, you're asked to
urinate into a container. A urine culture is a lab test that
specifically checks for signs of infection in your urine. A urine
cytology involves a check of your urine for cancer cells.
6

Blood test. Your doctor may have a sample of your blood drawn
and sent to a laboratory for analysis. Your blood is checked for
various
chemicals
and
substances
related
to
causes
of
incontinence.
Specialized tests:
If further testing is needed, you'll likely be referred to a doctor who
specializes in urinary disorders (urologist). Women might be referred to a
doctor who focuses on urological problems in women (urogynecologist).
At the specialist's office, you may undergo additional testing such as:

Postvoid residual (PVR) measurement. This test helps your
doctor determine whether you have difficulty emptying your
bladder. For the procedure, you're asked to urinate (void) into a
funnel-like container that allows your doctor to measure your urine
output. Then your doctor checks the amount of residual urine in
your bladder using a catheter — a thin, soft tube that's inserted into
your urethra and bladder to drain any remaining urine — or an
ultrasound device. For the ultrasound test, a wand-like device is
placed over your abdomen. The device sends sound waves through
your pelvic area. A computer transforms these sound waves into an
image of your bladder, so your doctor can see how full or empty it
is. A large amount of leftover (residual) urine in your bladder may
mean that you have an obstruction in your urinary tract or a
problem with your bladder nerves or muscles.

Pelvic ultrasound. Ultrasound also may be used to view other
parts of your urinary tract or genitals to check for abnormalities.

Stress test. For this test, you're asked to cough vigorously or bear
down as your doctor examines you and watches for loss of urine.
6

Urodynamic testing. These tests measure pressure in your
bladder both at rest and when filling. A doctor or nurse inserts a
catheter into your urethra and bladder. The catheter is used to fill
your bladder with water while a pressure monitor measures and
records the pressure within your bladder. Normally, pressure
increases by only very small amounts during filling. This test helps
your doctor measure the strength of your bladder muscle and the
health of your urinary sphincter.

Cystogram. In this X-ray of your bladder, a catheter is inserted
into your urethra and bladder. Through the catheter, your doctor
injects a fluid containing a special dye. As you urinate and expel
this fluid, images show up on a series of X-rays. These images
help reveal problems with your urinary tract.

Cystoscopy. In this procedure, a thin tube with a tiny lens
(cystoscope) is inserted into your urethra. With the aid of this
device, your doctor can check for — and potentially remove —
abnormalities in your urinary tract.
Once the tests are complete, your doctor can explain the results and
discuss treatment options with you.
Treatment:
Treatment for urinary incontinence depends on:
1. The type of incontinence,
2. The severity of your problem and the underlying cause.
Treatment options for urinary incontinence fall into four broad categories:
1. behavioral techniques
6
2. medications
3. devices
4. Surgery.
1. Behavioral techniques
Behavioral techniques and lifestyle changes work well for certain types of
urinary incontinence. They may be the only treatment you need.

Pelvic floor muscle exercises. These exercises strengthen your
urinary sphincter and pelvic floor muscles — the muscles that help
control urination. Your doctor may recommend that you do these
exercises frequently to treat your incontinence. They are especially
effective for stress incontinence, but may also help urge
incontinence.
To do pelvic floor muscle exercises (Kegels), imagine that you're
trying to stop your urine flow. Squeeze the muscles you would use
and hold for a count of three. Relax, count to three again, then
repeat. You can do these exercises almost anywhere — while
you're driving, watching television or sitting at your desk at work.
With Kegels, it can be difficult to know whether you're contracting
the right muscles and in the right manner. In general, if you sense a
pulling-up feeling when you squeeze, you're using the right
muscles. Men may feel their penises pull in slightly toward their
bodies. To double-check that you're contracting the right muscles,
try the exercises in front of a mirror. Your abdominal, buttock or
leg muscles shouldn't tighten if you're isolating the muscles of the
pelvic floor. Another way to be sure you're doing Kegels correctly
is a simple finger test. Place a finger in your anus or vagina. Then
6
squeeze around your finger. The muscles you contract are your
pelvic floor muscles.
If you're still not sure whether you're contracting the right muscles,
ask your doctor for help. Your doctor can refer you to a physical
therapist for biofeedback techniques that will help you identify and
contract the right muscles.
After several months of doing pelvic floor muscle exercises
correctly, you should notice improvement in your urinary control.
Contract your pelvic muscles to control leakage when you have an
urge to urinate or when you cough or sneeze.

Bladder training. Your doctor may recommend bladder training
— alone or in combination with other therapies — to control urge
and other types of incontinence. Bladder training involves learning
to delay urination after you get the urge to go. You may start by
trying to hold off for 10 minutes every time you feel an urge to
urinate. Then try increasing the waiting period to 20 minutes. The
goal is to lengthen the time between trips to the toilet until you're
urinating every two to four hours.

Scheduled toilet trips. This means timed urination — going to
the toilet according to the clock rather than waiting for the need to
go. Following this technique, you go to the toilet on a routine,
planned basis — usually every two to four hours.

Scheduled toilet trips In some cases, you can simply modify
your daily habits to regain control of your bladder. You may need
to cut back on or avoid alcohol or caffeine, if either causes you
incontinence. If acidic foods irritate your bladder, cutting back on
6
such triggers may rid you of your problem. For some people,
reducing liquid consumption before bedtime is all that's needed.
Losing weight also may eliminate the problem.
2. Medications
Many times, urinary incontinence can be corrected with the help of
medication. Often, medications are used in conjunction with behavioral
techniques. Drugs commonly used to treat incontinence include:

Anticholinergic (antispasmodic) drugs. These prescription
medications calm an overactive bladder, so they may be helpful for
urge incontinence. As (Detrol),

Antidepressant drugs may occasionally be used in combination
with other medications to treat incontinence.

Antibiotics. If your incontinence is due to a urinary tract
infection or an inflamed prostate gland (prostatitis), your doctor
can successfully treat the problem with antibiotics.

Electrical stimulation
in this procedure, electrodes are temporarily inserted into your
rectum or vagina to stimulate and strengthen pelvic floor muscles.
Gentle electrical stimulation can be effective for stress
incontinence and urge incontinence, but it takes several months
and multiple treatments to work. And it can cause side effects,
such as abdominal cramps, diarrhea and bleeding. Electrical
stimulation is usually reserved for people with severe urge
incontinence who don't respond to behavioral techniques or
medications.
6
3. Medical devices
several medical devices are available to help treat incontinence. They're
designed specifically for women and include:

Urethral inserts. These are small, tampon-like disposable
devices or plugs that a woman inserts into her urethra — the tube
where urine exits the body — to prevent urine from leaking out.
Urethral inserts aren't for everyday use. They work best for women
who have predictable incontinence during certain activities, such
as playing tennis.

Pessary (PES-uh-re). Your doctor may prescribe a pessary — a
stiff ring that you insert into your vagina and wear all day. The
device helps hold up your bladder, which lies near the vagina, to
prevent urine leakage. You need to regularly remove the device to
clean it. You may benefit from a pessary if you have incontinence
due to a dropped (prolapsed) bladder or uterus.
4.
Surgery
If other treatments aren't working, several surgical procedures have been
developed to fix problems that cause urinary incontinence. In men,
surgery may be necessary to remove the obstructive part of an enlarged
prostate gland. If your bladder or uterus has slipped out of position, a
surgeon can put it back in place with a variety of techniques. Rarely,
surgery to treat urinary incontinence may involve enlarging the bladder or
correcting a birth defect. Or surgery may be needed to bolster weakened
urinary sphincter muscles.
Some of the more common procedures include:
6
Artificial urinary sphincter. This small device is particularly

helpful for men who have weakened urinary sphincters from treatment
of prostate cancer or an enlarged prostate gland, and it's used rarely in
women with stress incontinence. Shaped like a doughnut, the device is
implanted around the neck of your bladder. The fluid-filled ring keeps
your urinary sphincter shut tight until you're ready to urinate. To urinate,
you press a valve implanted under your skin that causes the ring to
deflate and allows urine from your bladder to be released. This surgery
is the most effective procedure for male incontinence. Complications
include malfunction of the device — which means the surgery will need
to be repeated — and infection, but both are uncommon.

Bulking material injections. Some women and men with stress
incontinence benefit from urethral injections of bulking agents.
This procedure involves injecting bulking materials — which may
be cow-derived collagen, carbon particle beads or synthetic sugars
— into the tissue surrounding the urethra or the skin next to the
urinary sphincter. The injection tightens the seal of the sphincter
by bulking up the surrounding tissue. The procedure is done with
minimal anesthesia and typically takes about two to three minutes.
It usually needs to be repeated after several months, because the
effect can be lost over time. There is a risk of rejection or
infection.

Sacral nerve stimulator. This small device acts on nerves that
control bladder and pelvic floor contractions. The device, which
resembles a pacemaker, is implanted under the skin in your abdomen.
A wire from the device is connected to a sacral nerve an important
nerve in bladder control that runs from your lower spinal cord to your
bladder. Through the wire, the device emits electrical pulses that
6
stimulate the nerve and help control the bladder. The pulse doesn't
cause pain and provides relief from heavy leaking in many cases.
Possible complications include infection, but the device can be
removed.

Sling procedure. The most popular and common surgery for
women with stress incontinence is the sling procedure. During this
procedure, a surgeon removes a strip of abdominal tissue and places it
under the urethra. Or the surgeon may use a strip of synthetic mesh
material or a strip of tissue from a donor (xenograft) or cadaver. The
strip acts like a hammock, compressing the urethra to prevent leaks
that occur with the activities of daily living. Sling procedures improve
or cure incontinence in most cases. There are varying techniques for
the sling procedure, so talk with your doctor about what procedure is
planned and why.

Bladder neck suspension. In this procedure, your surgeon makes
a 3- to 5-inch incision in your lower abdomen. Through this
incision, he or she places stitches (sutures) in the tissue near the
bladder neck and secures the stitches to a ligament near your pubic
bone (Burch procedure) or in the cartilage of the pubic bone itself
(Marshall-Marchetti-Krantz, or MMK, procedure). This has the
effect of bolstering your urethra and bladder neck so that they don't
sag. The downside of this procedure is that it involves major
abdominal surgery. It's done under general anesthesia and usually
takes about an hour. Recovery takes about six weeks, and you'll
likely need to use a catheter until you can urinate normally.
 Absorbent
pads
and
catheters
If medical treatments can't completely eliminate your incontinence
6
or you need help until a treatment starts to take effect — you can
try products that help ease the discomfort and inconvenience of
leaking urine.
 Pads and protective garments. Various absorbent pads are
available to help you manage urine loss. Most products are no
more bulky than normal underwear, and you can wear them easily
under everyday clothing. Men who have problems with dribbles of
urine can use a drip collector — a small pocket of absorbent
padding that's worn over the penis and held in place by closefitting
underwear.

Catheter. If you're incontinent because your bladder doesn't
empty properly, your doctor may recommend that you learn to
insert a soft tube (catheter) into your urethra several times a day to
drain your bladder (self-intermittent catheterization).
6
APPLYING NURSING CARE PLAN FOR CHROIC UROLOGY PATIENTS
6
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