Nursing II Kathleen C. Ashton

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Nursing IIKathleen C. Ashton

• The Client With Alterations in Urinary
  Elimination

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Assessment

• Renal system consists of kidneys, ureters,
  bladder, and urethra (KUB x-ray of these 3)
• Most have 2 kidneys, some born with 1 or 3
• Person with 3 kidneys may be unaware until x-ray
  done for some other purpose
• Kidney is main excretory organ of body (1-2L/day)
• Very vascular - receives about 25 of cardiac
  output
• Kidneys separated from abdominal cavity by
  membrane, protected by posterior rib cage
• Liver displaces right kidney downward, prone to
  injury

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Kidney Structure

• Cortex
• glomeruli
• proximal and distal tubules of the nephrons
• filtering mechanism
• Medulla
• loops of Henle, collecting ducts of nephrons
• collect and concentrate urine
• Calyx - canal for urine
• Ureter - fibromuscular tube, goes to bladder
• Bladder - sac with about 500 ml capacity
• Urethra - to outside of body

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Effects of aging

• Kidneys decrease in size, bladder loses its
  capacity
• Result urgency, frequency, retention, dysuria
• Incontinence is not a normal part of aging.
  Consult a Clinical Nurse Specialist
• Kegel exercises useful for women of any age

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Screening

• Good history from client and family. Begin with
  chief complaint in clients own words
• Nature of pain
• Past medical history
• Family history specific diseases and vague
  symptoms
• Dietary and fluid patterns and preferences
• Cultural and educational background (teach)

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3 Manifestations of Kidney Disease

• 1. Pain May be absent in renal disease, most
  always seen in acute conditions. May be in back,
  flank, abdomen, labia, testes, thigh or
  suprapubic region. Renal colic severe pain
• 2. Change in voiding Normal 1200 to 1500ml
  urine/24 hours. May see urgency,
  frequency(gt5-6x/day), burning on urination,
  dysuria, hesitancy, nocturia, stress
  incontinence, enuresis, polyuria, oliguria,
  hematuria, incontinence, proteinuria

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Manifestations, cont

• 3. GI symptoms nausea, vomiting, diarrhea,
  abdominal discomfort, paralytic ileus,
  gastrointestinal hemorrhage. Due to the
  proximity of kidneys to the gi tract and areas of
  shared innervation

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Diagnostic Tests of Urine

• Lab- urine specimens - careful collection
• Clean catch - goal is to minimize contamination
• Catheter specimen for culture - never use urine
  from bottom of a Foley bag
• 24 hour collection use 1 large container, put up
  alerts, may need preservative
• Creatinine Clearance measures glomerular
  filtration rate (kidneys excrete creatinine in
  urine, as they fail the serum creatinine rises)

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Other Diagnostics

• KUB x-ray
• IVP uses contrast medium. Check for allergy to
  iodine
• CAT scan and angiography
• Ultrasound non-invasive
• Cystoscopy used for direct inspection,
  collecting urine from each kidney, measuring
  bladder capacity, biopsy
• BUNgt100 usually dialysis, seizures common

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Infections

• Ascending infections - according to location
• Usually the result of stasis of urine from
• congenital anomaly
• stone or calculi
• Can be spread from elsewhere, such as the throat
• E. coli is the most common cause -
• careful catheter insertion technique and care
• females must wipe front to back

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Inflammations that can lead to infections

• Urethritis inflammation of urethra
• May be secondary to vaginal infection
• Gonorrhea is common cause
• Thick purulent discharge characteristic of GC
  infection
• SS
• discomfort or burning on urination
• usually no fever if no infection
• Treatment antibiotics, increase fluids,
  analgesics, good nutrition, rest, attention to
  cleanliness

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Other infections

• Cystitis inflammation of bladder
• Body usually wards it off - natural protection of
  bladder lining and pH
• May result from unsterile catheterization
• SS urgency, 3 cardinal signs
• frequency, dysuria, hematuria
• if bacteremia - then chills and fever
• Dx patient history, physical exam, urine for CS
• Treatment identify and correct contributing
  factors, bed rest, force fluids, antibiotics -
  Cipro, Bactrim, cranberry juice, stents to keep
  open

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Pylonephritis

• Infection of renal parenchyma and lining of
  collecting system. Acute and chronic forms
• Acute very ill
• SS kidney pain, chills, fever, malaise, nausea,
  pyuria (pus in urine), frequency and burning in
  bladder (also infected), often occurs with
  pregnancy and diabetes. May have elevated WBCs.
  Most people have no symptoms
• Chronic worse. Re-infection. Kidneys
  irreversibly damaged. Prevent further damage. May
  need transplant. Complications uremia, anemia,
  HPT from renal ischemia, calculi in infected
  kidney

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Treatment

• Acute Fluids (3-4 L/day), antipyretics, full
  course of antibiotics. Teach proper nutrition
  fluids, urinate regularly especially after
  intercourse. Follow up urine CS 2 weeks after
  end of antibiotics.
• Chronic IV antibiotics, fluids, monitoring of
  renal function with nephrotoxic medications, may
  be on bedrest. Treat infections promptly.

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Calculi

• Causes salts precipitate out and form calculi.
  Most in kidney but can plug urinary system. May
  be from excessive calcium secretion. Infection
  usually present, makes the urine alkaline - may
  cause calcium to precipitate. Acid pH related to
  uric acid deposits. Complication of bed rest,
  dehydration.
• SS hematuria, pyuria, urine retention, dysuria
  if opening from bladder to urethra is blocked
• Classic symptom flank pain and colic - severe
  and may recur until stone is passed. Narcotics
  given
• Smaller the stone, greater the colic. Staghorn
  calculi

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Calculi, cont

• Nursing Implications Strain all urine through
  filter.
• At home use clear glass with cheesecloth lining.
  Force fluids (2500 to 3000ml/day) to flush out
  stone. Increased activity may result in passage
  of stone.
• Treatment X-ray to locate stone. IVP for stones
  that arent radiopague. Lithotripsy may be tried.
  In about 1 to 2 of cases, surgery may be needed.
  May be able to snare stone and remove it during
  cystoscopy.
• Teaching Bring stone to MD for examination.
  Report any hematuria, burning or signs of UTI or
  infection elsewhere - may lead to stone.

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Dietary considerations

• Uric acid stones treated with alkaline ash diet.
  Foods included milk, fruits (except cranberries,
  prunes and plums), vegetables (except beans,
  peas). Sodium bicarbonate or polycitrate may be
  given, 1 to 3 quarts of orange juice /day
  recommended
• Calcium stones treated with acid ash diet. Foods
  included meat, fish, poultry, eggs, cheese,
  grains, fruits (cranberries, prunes, plums).
  Avoid citrus juices and carbonated beverages.
  Sodium acid phosphate may be given.

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Kidney Surgery

• May be indicated for tumors, cancer,
  transplantation, tubes
• Apprehension and misunderstanding common
• Vascular organ problems with circulation
• May need Coumadin reversal or renal artery
  embolization prior to surgery to starve the
  cancer and help reduce blood flow
• Extracorporeal or bench surgery uses hypothermia
  to cool kidney and keep it perfused to reduce
  permanent damage

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Post op Complications

• Hemorrhage
• Shock
• Abdominal distention
• Respiratory embarrassment (anterior incision)
• Paralytic ileus may result from manipulation
  during surgery

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Urinary Diversions

• Performed due to obstruction(tumors) or necrosis
  of tissue
• Kocks pouch-original type, still used
• Two types more commonly used today
• Catheterizable Continent Urinary Reservoir
• Orthotopic Neobladder
• Decision based on capability of patient and stage
  of cancer

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Catheterizable Continent Urinary Reservoir

• Bowel segments anastomosed to ureters with a
  one-way valve leading to stoma on abdomen.
  Requires
• Long, complex surgical procedure
• Life expectancy beyond 1 year
• Adequate renal function
• Able to self catheterize
• Healthy bowel to form diversion
• May experience metabolic alterations and
  electrolyte imbalances

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Orthotopic Neobladder

• Allows normal voiding without any visible sign of
  a stoma or appliance
• Ileum anastomosed to urethra or bladder neck
• Requires lengthy surgery and recovery phase, plus
  one who will be compliant with follow-up care
• May develop metabolic acidosis and bone
  demineralization

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Nursing Implications with Diversions

• Patient and family teaching for back-up support
• Technique for self catheterization must be
  learned
• Exercises to strengthen the pelvic floor muscles
  such as Kegels need to be learned and performed
  by both men and women to maintain continence. A
  reconstructed bladder depends on pelvic floor
  contraction for continence.
• Fluid intake of at least 2L/day
• Watch for signs of UTI may indicate pouchitis
  or pyelonephritis

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Ureteroileostomy or ileal conduit

• Ureter removed and small section of ileum used
  instead - brought out on abdomen
• Good skin care is critical
• Psychological support
• Check output - if less than 30 ml/hour, may be
  obstruction
• Check for good circulation to stoma
• Increase fluids
• Some are using Florida pouch on the inside of
  abdominal wall

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Nephrostomy Tubes

• Tube inserted into kidney
• Anchor to prevent dislodgement!
• Temporary if used to divert urine while ureters
  are repaired and allowed to heal. Permanent if
  ureters are removed or blocked due to inoperable
  cancer.

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Nursing Care

• Use good aseptic technique
• Assess for bleeding, patency, or obstruction
• Never clamp! (will lead to infection)
• Prevent dislodgement (requires immediate
  re-insertion by MD)

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Ureteral Stent

• Allows urine flow from blocked ureters
• Double J more easily lodged in place
• Measure output
• Observe for bleeding

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Tumors

• Renal cancer fairly rare
• Affects more men than women
• Long term dialysis is a risk factor - more cysts
  and tumors form
• Most renal tumors are adenocarcinomas and
  metastasize early to opposite kidney, brain,
  liver, bone and lungs.
• SS usually painless. 3 classic signs (occur
  late) hematuria, pain, mass in flank.

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Tumors cont

• Management Must remove entire kidney with the
  tumor
• Nursing Implications
• Pain management
• Support client and family
• Annual check-ups
• Know family history