Download Care of the patient with Urinary Problems The components of the

Care of the patient with Urinary Problems
The components of the urinary system are the ureters, bladder, and urethra.
With problems in the urinary system, homeostasis of fluids, electrolytes, nitrogenous wastes,
storage or elimination of urine, and blood pressure is disrupted.
Although life-threatening complications are rare, patients may have significant functional,
physical, and psychosocial changes that reduce quality of life.
Nursing interventions are directed toward prevention, detection, and management.
INFECTIOUS DISORDERS
Infections of the lower urinary tract and kidneys are common, especially among women.
Urinary tract infections are described by their location in the tract.
Acute infections in the lower urinary tract include urethritis, cystitis, and prostatitis, while acute
pyelonephritis is an upper urinary tract infection.
The site of infection and type of bacteria or other organism determines treatment.
CYSTITIS
Cystitis is an inflammation of the bladder caused by irritation or, more commonly, by infection
from bacteria, viruses, fungi, or parasites.
Noninfectious cystitis is caused by irritation from chemicals or radiation.
Interstitial cystitis is an inflammatory disease that has no known cause.
Infectious cystitis can lead to complications, including pyelonephritis and sepsis.
Changes in fluid intake patterns, urinary elimination patterns, and hygiene patterns can help
prevent or reduce cystitis in the general population.
Frequency, urgency, and dysuria are the common manifestations of a urinary tract infection, but
cloudy, foul smelling, or blood tinged urine may occur.
The diagnosis of cystitis is based on history, physical exam, and laboratory data.
Urography, abdominal sonography, or computed tomography may be needed to locate the site of
an obstruction or the presence of calculi.
Laboratory assessment for a UTI is a urinalysis performed on a clean-catch midstream specimen
with testing for leukocyte esterase and nitrate.
A urine culture confirms the type of organism and the number of colonies and is indicated when
the UTI is complicated or does not respond to usual therapy.
Drugs used to treat bacteriuria and promote patient comfort include urinary antiseptics or
antibiotics, analgesics, and antispasmodics.
Common Nursing Dx:
Most important nursing interventions/teaching?
URETHRITIS
Urethritis is an inflammation of the urethra that causes symptoms similar to UTI.
In men, manifestations of urethritis are burning or difficulty with urination and a discharge from
the urethral meatus, usually caused by sexually transmitted diseases.
In women, urethritis causes manifestations similar to those of bacterial cystitis.
URETHRAL STRICTURES
 Urethral strictures are narrowed areas that are idiopathic or caused by an STD or from trauma
during catheterization, urologic procedures, or childbirth.
 The most common symptom of urethral stricture is obstruction of urine flow.

URINARY INCONTINENCE
Continence is a learned behavior to control the time and place of urination and is unique to
humans and some domestic animals.
Efficient bladder emptying from coordination between bladder contraction and urethral
relaxation is needed for continence.
Incontinence is involuntary loss of urine causing social or hygienic problems.
Assess the abdomen to estimate bladder fullness, to rule out palpable hard stool, and to evaluate
bowel sounds.
With a physician’s order, determine the amount of residual urine by portable ultrasound or
catheterizing the patient immediately after voiding.
In women, inspect external genitalia to determine whether there is apparent urethral or uterine
prolapse, cystocele, or rectocele with pelvic floor muscle weakness.
Imaging is rarely needed unless surgery is being considered.
Initial interventions for stress incontinence include keeping a diary, behavioral interventions,
such as diet and exercise, and drugs or surgery as a last resort.
Other interventions for stress incontinence include behavior modification, psychotherapy, and
electrical stimulation devices to strengthen urethral contractions.
Stress incontinence may be corrected by vaginal, abdominal, or retropubic surgeries with varying
success rates.
Interventions for patients with urge incontinence or overactive bladder include behavioral
interventions and drugs; surgery is not recommended.
Interventions for the patient with reflex or overflow incontinence caused by obstruction of the
bladder outlet may include surgery to relieve the obstruction.
Causes of functional or chronic intractable incontinence vary greatly, so the focus of intervention
is treatment of reversible causes.
Follow these general guidelines when caring for patients with urinary problems.
Use sterile technique when inserting a catheter or any other instrument.
Use contact precautions with drainage from the genitourinary tract.
Teach patients to clean the perineal area after voiding, having a bowel movement, or after sexual
intercourse.
Encourage all patients to maintain an adequate fluid intake, a minimum of 1.5 to 2.5 L daily
unless another health problem requires fluid restriction.
Instruct women who have stress incontinence the proper way to perform pelvic floor
strengthening exercises.
Teach patients who come into contact with chemicals in their workplaces or with leisure time
activities, to avoid direct skin or mucous membrane contact.
Use a nonjudgmental approach in caring for patients with urinary incontinence.
Avoid referring to protective pads or pants as “diapers.”
Recognize the need for the patient undergoing cystectomy and urinary diversion to grieve about
the body image change.
Assess comfort in discussing issues related to elimination and the urogenital area.
Use language and terminology during assessment that patients are comfortable with.
Report immediately any condition that obstructs urine flow.
Instruct patients with UTI to complete all prescribed antibiotic therapy even when symptoms of
infection are absent.
Evaluate daily the indications for maintaining indwelling catheters and discontinue their use as
soon as possible.
Teach patients the expected side effects and adverse reactions to prescribed drugs.
Assess the patient’s manual dexterity and cognitive awareness before teaching a regimen of
intermittent self-catheterization.
Common Nursing Dx:
Most important nursing interventions/teaching?
Care of the patient with Bowel Elimination Problems
STRUCTURES AND FUNCTIONS
The main function of the gastrointestinal (GI) system is to supply nutrients to body cells.
The GI tract is innervated by the autonomic nervous system. The parasympathetic system is
mainly excitatory, and the sympathetic system is mainly inhibitory.
The two types of movement of the GI tract are mixing (segmentation) and propulsion
(peristalsis).
The secretions of the GI system consist of enzymes and hormones for digestion, mucus to
provide protection and lubrication, water, and electrolytes.
Mouth:
The mouth consists of the lips and oral (buccal) cavity.
The main function of saliva is to lubricate and soften the food mass, thus facilitating
swallowing.
Pharynx:
A musculomembranous tube that is divided into the nasopharynx, oropharynx, and
laryngeal pharynx.
Esophagus:
A hollow, muscular tube that receives food from the pharynx and moves it to the stomach
by peristaltic contractions.
Lower esophageal sphincter (LES) at the distal end remains contracted except during
swallowing, belching, or vomiting.
Stomach:
The functions are to store food, mix the food with gastric secretions, and empty contents
into the small intestine at a rate at which digestion can occur.
The secretion of HCl acid makes gastric juice acidic.
Intrinsic factor promotes cobalamin absorption in the small intestine.
Small intestine: two primary functions are digestion and absorption.
Large intestine:
The four parts are (1) the cecum and appendix; (2) the colon (ascending, transverse,
descending, sigmoid colon); (3) the rectum; and (4) the anus.
The most important function of the large intestine is the absorption of water and
electrolytes.
Liver:
Hepatocytes are the functional unit of the liver.
Is essential for life. It functions in the manufacture, storage, transformation, and excretion
of a number of substances involved in metabolism.
Biliary tract:
Consists of the gallbladder and the duct system.
Bile is produced in the liver and stored in the gallbladder. Bile consists of bilirubin,
water, cholesterol, bile salts, electrolytes, and phospholipids.
Pancreas:
The exocrine function of the pancreas contributes to digestion.
The endocrine function occurs in the islets of Langerhans, whose beta cells secrete
insulin; alpha cells secrete glucagon; and delta cells secrete somatostatin.
GERONTOLOGIC CONSIDERATIONS
Aging causes changes in the functional ability of the GI system.
Xerostomia (decreased saliva production) or dry mouth is common.
Taste buds decrease, the sense of smell diminishes, and salivary secretions diminish, which can
lead to a decrease in appetite.
Although constipation is a common complaint of elderly patients, age-related changes in colonic
secretion or motility have not been consistently shown.
The liver size decreases after 50 years of age, but liver function tests remain within normal
ranges. There is decreased ability to metabolize drugs and hormones.
ASSESSMENT
Subjective data:
Important health information: the patient is asked about abdominal pain, nausea and
vomiting, diarrhea, constipation, abdominal distention, jaundice, anemia, heartburn,
dyspepsia, changes in appetite, hematemesis, food intolerance or allergies, excessive gas,
bloating, melena, hemorrhoids, or rectal bleeding.
The patient is asked about (1) history or existence of diseases such as gastritis, hepatitis,
colitis, gallbladder disease, peptic ulcer, cancer, or hernias; (2) weight history; (3) past
and current use of medications and prior hospitalizations for GI problems.
Many chemicals and drugs are potentially hepatotoxic and result in significant patient
harm unless monitored closely.
Objective data:
Anthropometric measurements (height, weight, skinfold thickness) and blood studies
(e.g., serum protein, albumin, hemoglobin) may be performed.
Physical examination
Mouth. The lips are inspected for symmetry, color, and size. The lips, tongue, and
buccal mucosa are observed for lesions, ulcers, fissures, and pigmentation.
Abdomen. The skin is assessed for changes (color, texture, scars, striae, dilated
veins, rashes, lesions), symmetry, contour, observable masses, and movement.
Auscultation of the four quadrants of the abdomen includes listening for increased
or decreased bowel sounds and vascular sounds.
Percussion of the abdomen is done to determine the presence of distention, fluid,
and masses. The nurse lightly percusses all four quadrants of the abdomen.
Light palpation is used to detect tenderness or cutaneous hypersensitivity,
muscular resistance, masses, and swelling.
Deep palpation is used to delineate abdominal organs and masses. Rebound
tenderness indicates peritoneal inflammation.
During inspiration the liver edge should feel firm, sharp, and smooth. The surface
and contour and any tenderness are described.
The spleen is normally not palpable. If palpable, manual compression of an
enlarged spleen may cause it to rupture.
The perianal and anal areas should be inspected for color, texture, lumps, rashes,
scars, erythema, fissures, and external hemorrhoids.
DIAGNOSTIC STUDIES
Many of the diagnostic procedures of the GI system require measures to cleanse the GI tract, as
well as the use of a contrast medium or a radiopaque tracer.
An upper GI series with small bowel follow-through provides visualization of the esophagus,
stomach, and small intestine.
Virtual colonoscopy combines computed tomography (CT) scanning or magnetic
resonance imaging (MRI).
Endoscopy refers to the direct visualization of a body structure through a lighted
fiberoptic instrument.
INTESTINAL OBSTRUCTION
Intestinal obstruction is a common and serious disorder caused by a variety of conditions and is
associated with significant morbidity.
Obstructions can be partial or complete and are classified as mechanical or nonmechanical.
Since x-ray findings are often normal when a strangulated obstruction actually exists in the small
intestine, obstruction cannot be ruled out on the basis of x-ray findings.
Obstruction of the large intestine often shows gas distention of the colon on abdominal x-rays
and free air indicates a perforated intestine.
An abdominal ultrasound, endoscopy, or barium enema studies help to determine the cause of the
obstruction.
A computed tomography scan is useful in uncovering the cause and location of the obstruction
and may be the diagnostic tool of choice in some cases.
If the obstruction is partial and there is no evidence of strangulation, nonsurgical management is
the treatment of choice.
Paralytic ileus responds well to nonsurgical methods of relieving obstruction.
Remember to assess the patient’s nasogastric tube for proper placement, patency, and output at
least every 4 hours.
In patients with complete mechanical obstruction and in some cases of incomplete mechanical
obstruction, surgical intervention is necessary to relieve the obstruction.
A strangulated obstruction is complete and surgical intervention is always required.
MEDICATIONS
Antidiarrheals may be given to control frequent watery stool. However, the cause of the diarrhea
should be identified and treated as well.
Antidiarrheals primarily act by decreasing the hypermotility of the intestinal tract. Constipation
is a side effect of most antidiarrheals.
The nurse should assess the client beginning antidiarrheal therapy for liver disease, glaucoma, or
previous narcotic dependence. A client with prolonged diarrhea should also be assessed for
dehydration.
Laxatives are given to clients experiencing constipation when nonpharmacologic methods are
not effective.
The nurse should encourage clients with constipation to increase fiber and fluids in the daily diet.
These clients should also be educated regarding possible fluid and electrolyte imbalances that
may occur with laxative overuse.
Diarrhea
Diarrhea is most commonly defined as an increase in stool frequency or volume, and an
increase in the looseness of stool.
Diarrhea can result from alterations in gastrointestinal motility, increased secretion, and
decreased absorption.
All cases of acute diarrhea should be considered infectious until the cause is known.
Patients receiving antibiotics (e.g., clindamycin [Cleocin], ampicillin, amoxicillin,
cephalosporin) are susceptible to Clostridium difficile (C. difficile), which is a serious bacterial
infection.
Fecal Incontinence
Fecal incontinence, the involuntary passage of stool, occurs when the normal structures that
maintain continence are disrupted.
Risk factors include constipation, diarrhea, obstetric trauma, and fecal impaction.
Prevention and treatment of fecal incontinence may be managed by implementing a bowel
training program.
Constipation
Constipation can be defined as a decrease in the frequency of bowel movements from what is
“normal” for the individual; hard, difficult-to-pass stools; a decrease in stool volume; and/or
retention of feces in the rectum.
The overall goals are that the patient with constipation is to increase dietary intake of fiber and
fluids; increase physical activity; have the passage of soft, formed stools; and not have any
complications, such as bleeding hemorrhoids.
An important role of the nurse is teaching the patient the importance of dietary measures to
prevent constipation.
Types of Ostomies
We rarely see a continent urostomy or ileostomy however there are many people who have these
over a pouch to manage effluent. There are other procedures the ostomy patient may go through.
The continent pouches have to be accessed by the patient using a special tube to drain. The continent ileostomy or urostomy consists of a reservoir made from part of the intestine allowing urine
or stool to collect. The patient can sense fullness and empties the pouch through a tube passed
through the stoma opening. The stoma does not allow leaking between emptying. See pictures
below.
The new urostomy typically has two stents coming out of the stoma. The stents are used within
the ureters to keep scar tissue from closing the ureters therefore stopping the kidney from
draining into the conduit which is made up of a portion of the bowel. These stents will stay in
place for 7-14 days. The patient will produce mucus and urine. The mucus is normal, remember
the bowel will con-tinue to produce this for the patient’s lifetime.
The colostomy or ileostomy may be permanent or temporary. When it is temporary, the
colorectal surgeon may place a Hartmann Pouch. This is a sewing over of the distal stump of the
colon, allow-ing the edema reduction and healing to occur. The Hartman Pouch is opened at a
future point and the colon is re-anastomosed.
When the patient and surgeon determine that it the surgical approach to a continent ileostomy
with drainage to be through the rectum, the entire colon is removed leaving the anal vault and
anus (typically for ulcerative colitis). The small intestine is brought to the rectum and looped up
like a J. This is sewn together (see picture) and the septum between the bowel loops is removed
making a reservoir for the stool. A temporary loop ileostomy is placed while the J-Pouch heals.
Once the J- pouch is healed, the loop ileostomy is taken down, and the patient once again stools
rectally. The stool is from the ileum and will be water to tooth paste thickness.
Ostomy Care and Management
Urostomy
This is typically created using a portion of the bowel as the conduit or artificial channel for the
ureters to be planted into allowing passage of the urine through the conduit and into a pouch.
Bladder Cancer is the #1 indication for a urostomy, and smoking increases the risk for bladder
cancer. Chronic irritation of the bladder such as indwell-ing catheters may increase the incidence
causing transitional cell carcinoma. Congenital defects, urinary incontinence, refractory radiation
cystitis and trauma to the bladder are all indications for a urostomy.
Patient Teaching
Remember, the conduit may be made from both large and small intestine.
rt the urologist if a stent comes out before 5th day post op
ch which is different from a fecal pouch
ates open and closure of pouch
Ileostomy
Typical indications for an ileostomy include Crohn’s disease, Ulcerative colitis, colon cancer,
Familial adenomatous polyposis and trauma to the abdomen. The ileostomy can have an end
stoma that is typically perma-nent or be a loop stoma (temporary) that allows the surgeon to
reconnect the stoma easily when ready.
Patient Teaching: The location of the stoma within the small intestine will determine how
watery the stool will be. Mal-absorption can be a problem with an ileostomy
– this is normal
each the
patient
– once identified a
change in the medi-cation is needed for proper absorption
leakage, change the appliance
Colostomy
Indications for a colostomy include diverticulitis, inflammatory bowel disease, trauma, rectal
cancer, birth defects, spinal cord injury and bowel obstruction.
Patient Teaching: The consistency of the colostomy stool depends on the location of the stoma,
ascending colon will have more watery output, transverse colon will have a large stoma with soft
un-formed output, and descending ostomy may have formed stool
stoma has occurred (usually 3 months)
the pouch on for all ostomy types, no shield is necessary