Download Renal Failure Acute and Chronic

Chapter 45
Management of Patients with
Urinary Disorders
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Lower Urinary Tract Infections
Cystitis (inflammation of the urinary
bladder),
Prostatitis (inflammation of the prostate
gland), and
Urethritis (inflammation of the urethra).
Upper UTI; Pylonephritis (inflammation of
the renal pelvis), interstitial nephritis
(inflammation of the kidney), and renal
abscesses
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Lower Urinary Tract Infections
mechanisms maintain the sterility of the
bladder:
the physical barrier of the urethra,
urine flow,
ureterovesical junction competence,
various antibacterial enzymes and
antibodies, and antiadherent effects
mediated by the mucosal cells of the
bladder.
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Risk Factors for UTI
Inability or failure to empty the bladder completely
Obstructed urinary flow
Decreased natural host defenses or
immunosuppression
Instrumentation of the urinary tract (eg,
catheterization, cystoscopic procedures)
Inflammation or abrasion of the urethral mucosa
Contributing conditions: DM, Pregnancy,
neurogenic disorders, Gout, and altered states
caused by incomplete emptying of the bladder and
urinary stasis
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Pathophysiology
Bacteria gain access to the bladder, attach
to and colonize the epithelium of the
urinary tract to avoid being washed out
with voiding, evade host defense
mechanisms, and initiate inflammation.
Many UTIs result from fecal organisms
that ascend from the perineum to the
urethra and the bladder and then adhere
to the mucosal surfaces.
Escherichia coli is the most common agent
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Urethrovesical reflux: With
coughing and straining, bladder
pressure rises, which may force
urine from the bladder into the
urethra. (A) When bladder
pressure returns to normal, the
urine flows back to the bladder
(B), which introduces bacteria
from the urethra to the bladder.
Ureterovesical reflux: With
failure of the ureterovesical
valve, urine moves up the
ureters during voiding (C) and
flows into the bladder when
voiding stops (D). This prevents
complete emptying of the
bladder. It also leads to urinary
stasis and contamination of the
ureters with bacteria-laden urine.
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Routes of Infection
transurethral route (ascending
infection),
through the bloodstream
(hematogenous spread), or
by means of a fistula from the intestine
(direct extension)
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Clinical Manifestations
About half of all patients with
bacteriuria have no symptoms.
dysuria (painful or difficult urination),
burning on urination, frequency
(voiding more than every 3 hours),
urgency, nocturia, incontinence, and
suprapubic or pelvic pain. Hematuria
and back pain may also be present
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Gerontologic Considerations
High incidence of chronic illness
Frequent use of antimicrobial agents
Presence of infected pressure ulcers
Immunocompromise
Cognitive impairment
Immobility and incomplete emptying of
bladder
Use of a bedpan rather than a
commode or toilet
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Diagnosis
UA: puss cells > 4, ? hematouria
C&S.
WBCs
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Medical Management
Pharmacological agents according to C&S
Patient should be instructed to complete
the antibiotic course
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UTIs – Nursing Care
Assessment
Impaired Urinary Elimination
Readiness for Enhanced Self Health
Management
Teaching
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Acute Pyelonephritis
Clinical Manifestations
Chills, fever, leukocytosis, bacteriuria and
pyuria.
Low back pain, flank pain, nausea and
vomiting, headache, malaise, and painful
urination are common findings.
Pain and tenderness in the area of the
costovertebral angle
Symptoms of lower UTI
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Medical managmenet
On out patient basis: AB for 2 weeks
Good oral hydration
If there is a relapse, AB for 6 weeks
If there is N&V > admission, IV Fluids
and IV AB
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Chronic Pyelonephritis
Clinical Manifestations
Usually asymptomatic unless an acute
exacerbation occurs.
Noticeable S&S may include fatigue,
headache, poor appetite, polyuria,
excessive thirst, and weight loss.
Persistent and recurring infection may
produce progressive scarring of the
kidney resulting in renal failure
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Urinary Incontinence
Involuntary urination
Causes of Transient Incontinence: DIAPPERS
Delirium
Infection of urinary tract
Atrophic vaginitis, urethritis
Pharmacologic agents (anticholinergics, sedatives,
analgesics, diuretics, muscle relaxants, adrenergic
Psychological factors (depression, regression)
Excessive urine production (increased intake, diabetes
insipidus, diabetic ketoacidosis)
Restricted activity
Stool impaction
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Types
Urinary Incontinence
Stress
Urge
Overflow
Reflex
Functional
Iatrogenic incontinence
mixed incontinence
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Urinary Incontinence - Treatment
Medications
Anticholinergic agents
alpha-adrenergic
Estrogen therapy
Surgery
Bladder neck suspension
Prostatectomy
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Urinary Incontinence - Treatment
Behavioral modification
Kegal exercise
Fluid management
Timed voiding (? Every 2 hours)
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Urinary Retention
Occurs when bladder cannot empty
May be caused by obstructive or
functional problem
Benign prostatic hypertrophy
Surgery
Drugs
Neurologic diseases
Trauma
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Urinary Retention Manifestations
Manifestations
Overflow voiding (dribbling, frequency)
Incontinence
S & S of UTI
hematuria, urgency, frequency, nocturia, and
dysuria
Firm, distended bladder
May be displaced
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Urinary Retention
Complications
Hydronephrosis
Acute renal failure
Urinary tract infection which may lead to
urolithiasis or nephrolithiasis
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Suprapubic Catheters
Is a temporary measure
to divert the flow of
urine from the urethra
when the urethral route
is impassable
Inserting a catheter into
the bladder through a
suprapubic incision or
puncture.
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Hydronephrosis, Hydroureter,
and Urethral Stricture
Outflow obstruction
Urethral stricture
Causes bladder distention and progresses to the ureters
and the kidneys
Hydronephrosis –
Kidney enlarges as urine collects in the pelvis and kidney
tissue due to obstruction in the outflow tract
Over a few hours this enlargement can damage the
blood vessels and the tubules
Hydroureter
Effects are similar, but occurs lower in the ureter
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Causes of Obstruction
Tumor
Stones
Congenital structural defects
Fibrosis
Treatment with radiation in pelvis
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Complication of Obstruction
If untreated, permanent damage can
occur within 48 hours
Renal failure
Retention of
Nitrogenous wastes (urea, creatinine, uric acid)
Electrolytes (K, Na, Cl, and Phosphorus)
Acid base balance impaired
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Renal Calculi
Called nephrolithiasis
or urolithiasis
Most commonly
develop in the renal
pelvis but can be
anywhere in the
urinary tract
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Renal Calculi
Vary in size –from very large to tiny
Can be 1 stone or many stones
May stay in kidney or travel into the
ureter
Can damage the urinary tract
May cause hydronephrosis
More common in white males 30-50
years of age
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Renal Calculi
Predisposing factors
Dehydration
Prolonged immobilization
Infection
Obstruction
Anything which causes the urine to be alkaline
Metabolic factors
Excessive intake of calcium, calcium based antacids or
Vit D
Hyperthyroidism
Elevated uric acid
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Renal Calculi
Subjective symptoms
Sever pain in the flank area, suprapubic area,
pelvis or external genitalia
May radiate anteriorly and downward toward the
bladder in females and toward the testis in males.
If in ureter, may have spasms called “renal colic”
Urgency, frequency of urination
N/V
Chills
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Renal Calculi
Objective symptoms
Increased temperature
Pallor
Hematuria
Abdominal distention
Pyuria
Anuria
May have UTI on urinalysis
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Renal Calculi- Manifestations
Kidney/Pelvis
May be asymptomatic
Dull, aching flank pain
Ureter
Acute severe flank pain, may radiate
Nausea/vomiting
Pallor
Hematuria
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Renal Calculi- Manifestations
Bladder
May be asymptomatic
Dull suprapubic pain
Hematuria
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Renal Calculi
Diagnostic procedures
Urinalysis with C & S
KUB
IVP
Renal CT
Kidney ultrasound
Cystoscopy with retrograde pyleogram
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Renal Calculi
Treatment
Most (> 1 cm) are passed without
intervention
May need cystospy-- with basket retrieval
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Lithotripsy :
Extracorporeal shock
wave lithotripsy
(ESWL) is the noninvasive treatment
of urinary calculosis
and biliary calculi to
fragment the stone
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Renal Calculi-Treatement
Lasertripsy: stone and is destroyed by the
laser
Lithotomy: surgical removal of stone
Pylelolithotomy – removal from renal
pelvis
Urolithotomy – removal from the ureter
Nephrolithotomy – removal from kidney
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Nutritional Therapy
Calcium Stones
? Restrict Ca, protein, and Na. liberal
amount of water.
Uric Acid Stones
low-purine diet to reduce urinary excretion
of uric acid (shellfish, mushrooms, and
organ meats), limit protein, Allopurinol.
Avoid food contain oxylate: spinach,
strawberries, chocolate, tea, peanuts, and
wheat bran
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Renal Calculi
Assessment
History and physical exam
Location, severity, and nature of pain
I/O
Vital signs, looking for fever
Palpation of flank area, and abdomen
? N/V
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Renal Calculi
Nursing interventions
Primary is to treat pain – usually with
opioids
Ambulate
Force fluids, may have IV
Watch for fluid overload
Strain urine – send stone to lab if passed
Accurate I/O
Medicate N/V
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Renal Calculi
Surgical removal
Routine pre and post op care
May return with catheter, drains, nephrostomy
tube and ureteral stent – must maintain patency
and may need to irrigate as ordered
Measure drainage from all tubes – need at least
30 cc/hr
Watch site for bleeding
May need frequent dressing changes due to fluid
leakage, or may have collection bag
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Renal Calculi
Discharge and prevention
Continue to force fluids post discharge
May need special diet
Stones are analyzed for calcium or other
minerals
May need to watch products with calcium
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Cancer of the Urinary Tract
Bladder cancer
Kidney tumors
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Bladder Cancer
Bladder cancer is 4th leading cause of
cancer deaths.
More common in men than women
Cancers arising from the prostate, colon,
and rectum in males and from the lower
gynecologic tract in females may
metastasize to the bladder
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Risk factor for bladder cancer
Cigarette smoking: risk increase with number
of years and packs smoked
Exposure to environmental carcinogens: dyes,
rubber, leather, ink, or paint
Recurrent or chronic bacterial infection of the
urinary tract
Bladder stones
High urinary pH
High cholesterol intake
Pelvic radiation therapy
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Bladder Cancer Manifestations
Painless hematuria
Frequency
Urgency
Dysuria
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Bladder Cancer
Diagnostic tests
Bladder ultrasound
Urinalysis
Urine cytology
Cystoscopy
Biopsy
Treatment
Medications
Surgery: remove tumor or bladder,
Urinary Diversions
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Cutaneous Urinary Diversions
A. conventional
ileal conduit,
B. cutaneous
ureterostomy
C. vesicostomy
D. nephrostomy
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continent urinary diversions
A. Indiana
pouch
B. & C the
Kock pouch,
also called a
continent
ileal
diversion
D.
Ureterosigmoidostomy.
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Kidney Tumors
Uncommon
Renal cell carcinoma most common
primary tumor
Can occur anywhere, Often metastasize
Risk factors
Smoking
Obesity
Renal calculi
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Kidney Tumors Manifestations
May be silent
Flank pain
Palpable mass
Fever, fatigue
Weight loss, anemia, polycythemia
Hypercalcemia, hypertension, or
hyperglycemia
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Kidney Tumors –
Interdisciplinary Care
Diagnostic tests
Renal ultrasound
CT scan
Kidney biopsy
Treatment
Radical nephrectomy
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Bladder and Kidney Cancer –
Nursing Care
Assessment
Diagnosing, Planning, and
Implementing
Impaired Urinary Elimination
Risk for Impaired Skin Integrity
Disturbed Body Image
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Bladder and Kidney Tumors –
Nursing Care
Diagnosing, Planning, and
Implementing
Acute Pain
Ineffective Breathing Pattern
Disturbed Body Image
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