Genital-urinary System

1
Genital-urinary System

• Renal System
• Part 2

2
Behavioral Objectives

• Identify and describe the etiology,
  pathophysiology, clinical manifestations, nursing
  management and patient education for the
  following
• Urinary retention
• Urinary incontinence
• Urinary suppression
• Residual urine
• Discuss common pharmacological interventions
  appropriate in treatment of patient with GU
  disorders
• Describe general nursing consideration and
  intervention in pre and post-operative care of
  patients undergoing urological surgery
• Describe etiology, pathophysiology, clinical
  manifestations, nursing management and patient
  education for the following GU disorders
• Pyelonephritis
• Cystitis
• Urinary tract infections (UTI)
• Urethritis
• Nephritic syndrome
• Hydronephrosis
• Renal calculi
• Renal neoplasms

3
Dysfunctional Voiding Patterns

• Urinal Incontinence
• Pathophysiology
• Unplanned loss of urine that is sufficient to be
  considered a problem
• Continence requires intact urinary, neurologic
  and muscular-skeletal systems
• Any break in communication between these systems
  can lean to incontinence (or residual)

4
Types of Incontinence

• Stress Incontinence
• Involuntary loss of urine through an intact
  urethra due to a sudden h in intra-abd. pressure
• Treatment-mild Biofeedback bladder drills
• Treatment-moderate to severe surgery

5

• Pelvic Floor Training and the role of
  Biofeedback  Health Care Professionals usually
  advise Pelvic Floor Training as a first line
  treatment or an adjunct therapy for urine leakage
  that occurs during coughing, laughing or on
  exertion. Pelvic floor exercises are effective,
  but only if carried out regularly and diligently.
  The lack of feedback on progress may lead to
  frustration and the discontinuation of an
  exercise routine, hence, it is prudent to choose
  devices/exercisers with biofeedback function,
  such as Peritron Perineometer and PFX range of
  pelvic floor exercisers with pressure
  biofeedback. The challenge is to motivate and
  encourage the workout and simultaneously ensure
  exercising of the correct muscles. Appropriate
  feedback will stimulate discipline and step-wise
  progress. PFX is available in 2 versions -
  vaginal for women only and anal that can used by
  both men and women. PFX and Peritron Perineometer
  products can help people, who wish to monitor the
  effectiveness of their exercising efforts,
  because of the valuable biofeedback that they
  generate. Pelvic floor exercises should become
  routine events in women's lives, but especially
  before and after childbirth, hysterectomy and the
  menopause.

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Types of Incontinence

• Urge Incontinence
• Involuntary loss of urine associated with a
  strong urge to void that cannot be suppressed.
• Treatment-
• Biofeedback
• Pelvic floor nerve stimulation
• Bladder drill
• Anticholinergics

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anticholinergic

• An anticholinergic agent blocks the
  neurotransmitter acetylcholine in the central and
  the peripheral nervous system.
• An example dicyclomine.
• Decreased the effects mediated by acetylcholine
  on acetylcholine receptors

8
Types of Incontinence

• Reflux incontinence
• Involuntary loss of urine due to Hyperreflexia in
  the absence of normal sensation
• Associated with spinal cord injuries

9
Types of Incontinence

• Overflow incontinence
• Involuntary loss of urine due to over-distention
  of the bladder
• Bladder is unable to empty normally ?
• over distended ?
• frequent urination (just over flow) ?
• Incontinence
• Treatment
• Catheterization

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Behavior Therapy Management

• Fluid Management
• Increase fluid
• Decrease fluid
• WATER!!!!
• Standardized voiding frequency
• Timed voiding
• Bladder retraining

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Behavior Therapy Management

• Pelvic Muscle Exercises
• Kegel exercises
• Goal
• strengthen voluntary muscles

12
Behavior Therapy Management

• Pharmacological Therapy
• Anticholinergic agents
• Oxybutynin/Ditropan
• Action Inhibits bladder contractions
• Indications for use urge incontinence

13
Surgical management

• Involve lifting and stabilizing the bladder or
  urethra

14
Nursing Management

• h fluids
• No diuretics after 4PM
• Avoid bladder irritants
• Caffeine
• Alcohol
• Aspartame (nutrasweet)
• High fiber meals
• Void regularly
• Enc pelvic floor exercises
• Stop smoking

15
Urinary Retention

• Pathophysiology
• Urinary Retention
• The inability to empty the bladder completely
• Residual urine
• urine that remains in the bladder after voiding
• Assoc. with
• post-op d/t reflux spasm of sphincters
• Diabetes
• Prostatic enlargement
• Urethral pathology
• Trauma
• Pregnancy
• Neurologic disorders

16
Urinary Retention

• Assessment
• Measure post void residual urine
• Portable bladder scanner

17
Urinary Retention

• Complications
• Chronic infections ?
• Pyelonephritis ?
• Sepsis ?
• Kidney failure
• Deathmosis

18
Urinary Retention

• Nursing Management
• Promoting normal urinary eliminations
• Provide privacy
• Commode
• Male stand
• Sitz bath
• Hot tea
• Water faucet on
• Tapping pubic area
• Dipping hand in warm water
• Promoting urinary elimination
• Catheterization

19
Neurogenic Bladder

• A dysfunction d/t a lesion of the nervous system
• Two types of neurogenic bladder
• Spastic bladder / reflex bladder
• Empties on reflex
• Flaccid bladder
• Bladder becomes distended ?
• Overflow incontinence ?
• Bladder does not contract ?
• Can not feel discomfort

20
Neurogenic Bladder Management

• Catheterization
• Obstruction
• Post-op
• Monitor output with critical
• Neurogenic bladder or urinary retention
• Stage III or IV decubitus ulcers
• Indwelling devices
• Drainage bag below the level of the bladder
• Tubing not kinked and no too long
• Increase fluids
• Suprapubic catheterization

21
Urological Surgery

• Drainage tubes
• Nephrostomy drainage
• Tube inserted directly into the kidney

22
Nephrostomy drainage

• Nursing management
• Assess for complications
• Bleeding
• Infection
• Skin
• Ensure unobstruction
• Never clamp
• Irrigate
• Encourage fluids
• Aseptic technique
• Measure IO

23
Urethral Stent

• A tubular device that maintains position
  patency of the urethra

24
Nursing Process post-op urinary surgery

• Ineffective airway clearance r/t the surgical
  incision
• Ineffective breathing pattern r/t to surgical
  incision general anesthesia
• Assess resp status
• Auscultation
• Admin analgesics
• Splint
• Change position frequently
• Incentive spirometer
• Amb.

25
Test Question!

• Which of the following is appropriate nursing
  interventions for a patient with a nursing
  diagnosis of ineffective breathing patterns
  following renal surgery?
• Have the patient lay on affected side most of the
  time
• Encourage short breaths so not to strain incision
  site
• Bed rest
• Administer analgesics
• None of the above

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Nursing Process post-op urinary surgery

• Acute pain
• Assess pain level
• Assess abd. distention
• Admin analgesics
• Moist heat
• Massage
• Splint
• Exercise

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Nursing Process post-op urinary surgery

• Urine retention r/t pain, immobility and
  anesthesia
• Asses I0
• Assess drainage drainage system
• Aseptic technique
• Maintain closed system
• Irrigate?
• Enc pt to move assist to move
• Anchor cath
• Fluids

28
Nursing Process post-op urinary surgery

• Potential complications
• Bleeding
• Pneumonia
• Infection
• Fluid disturbances
• Deep vein thrombosis

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Urinary tract infections (UTI)

• Describe etiology, Pathophysiology, clinical
  manifestations, nursing management and patient
  education for Urinary tract infections (UTI)
• Pathophysiology
• UTIs are caused by pathogenic micro-organisms in
  the urinary tract
• Bacteria in bladder ? attach to the bladder ?
  colonizes in the epithelium
• E. Coli

30
Urinary tract infections

• Reflux
• Backward flow of urine from the urethra to the
  bladder
• Cough ?
• increase bladder pressure ?
• urine forced into urethra ?
• stop coughing ?
• decreased pressure ?
• urine flows back into bladder

31
Urinary tract infections

• Types of UTIs
• Cystitis
• Inflammation of the bladder
• Prostatitis
• Inflamation of the prostate gland
• Urethritis
• Inflammation of the urethra
• Pyelonephritis
• Inflammation of the renal pelvis parenchyma
• Interstitial nephritis
• Inflammation of the kidney

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Defense Mechanism

• Physical barrier
• Urine flow
• Enzymes
• Antibodies

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Defense Mechanism

• Who is more likely to get a UTI
• Male
• Female
• Why?
• Shorter urethra

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Predisposing factors to UTI

• Factors increasing urinary stasis
• Foreign bodies
• Anatomic factors
• Factors compromising immune system
• Functional disorders

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Clinical Manifestations Lower UTI

• Dysuria
• Burning
• Frequency
• Urgency
• Nocturia
• Incontinence
• Pelvic pain
• Hematuria
• Cloudy urine
• Back pain

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Clinical Manifestations Upper UTI

• Fever Chills
• Back pain (flank)
• N/V
• H/A
• Malaise
• Dysuria

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Gerontologic considerations

• Few SS
• Fatigue
• Alt cognitive function
• Slight drop in temp

38
Assessment Dx findings

• UA
• Culture

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Medical management/pharmacological therapy

• Antibiotic
• Cephalosporin
• Bactrim/Septra
• Urinary analgesic
• Phenazopyridine (Pyridium)
• Urine ? orange

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Nursing Process UTI

• Assessment
• SS
• Voiding patterns
• Sexual intercourse
• Urine

41
Nursing Process UTI

• Diagnosis
• Acute pain related to inflammation of the urinary
  tract
• Assess pain
• Admin. Analgesics
• Tell pt ? orange
• Teach non-Rx
• Heating pad
• Warm showers
• Admin antispasmodics

42
Nursing Process UTI

• Diagnosis
• Deficient knowledge detection, preventions and
  recurrence and meds
• Hygiene
• Fluid intake
• Voiding habits

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Nursing Process UTI

• Nursing Interventions Hygiene
• Shower not bath
• Front to back
• Wash after BM w/soap water
• No harsh soaps

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Nursing Process UTI

• Nursing Interventions Fluid Intake
• Increased
• Water
• Avoid irritants
• Coffee
• Tea
• Citrus
• Spices
• Cola
• Alcohol

45
Nursing Process UTI

• Nursing Interventions Voiding habits
• 2-3 hrs
• Empty completely
• Before after intercourse

46
Pyelonephritis

• Bacterial infection of the renal pelvis, tubules
  and interstitial tissue of one or both kidneys.
• Pathophysiology
• Lower ascends up
• Reflux
• Obstruction
• ? enlarged kidney

47
Pyelonephritis

• Clinical manifestations
• Acutely ill
• Fever Chills
• Pyuria
• Flank pain
• Bacteriuria

48
Pyelonephritis

• Assessment Dx
• Ultrasound
• CT
• UA
• Pyuria
• Bacteriuria
• Hematuria
• WBC

49
Pyelonephritis

• Medical Management
• Outpatient
• Dehydration

50
Pyelonephritis

• Rx
• 2 week antibiotics
• IV

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Pyelonephritis

• Complications
• End Stage Renal Disease
• Hypertension
• Kidney stones
• Urosepsis

52
Urethritis

• Pathophysiology
• Inflammation of the urethra
• Usually ascending infection
• STD

53
Urethritis

• Clinical manifestations Men
• Prostatitis
• Epididymitis
• Urethral stricture
• Sterility
• Clinical Manifestations - Women
• Asymptomatic

54
Urethritis

• Treatment
• Tetracycline
• Partners

55
Nephrotic syndrome

• Pathophysiology
• Primary glomerular disease characterized by
• Marked increase in protein in the urine
• (proteinuria)
• Decrease in albumin in the blood
• (hypoalbuminemia)
• Edema
• High serum cholesterol and low-density
  lipoprotein

56
Nephrotic syndrome

• Clinical Manifestation
• 1 edema
• Malaise
• H/A
• Irritability
• Fatigue

57
Nephrotic syndrome

• Assessment and diagnostic findings
• Proteinuria
• Hyperlipidemia
• Hypoalbuminemia

58
Nephrotic syndrome

• Complications
• Infections
• Thromboembolism
• Pulm. Emboli
• Renal Failure

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Nephrotic syndrome

• Medical Management
• Diuretic
• NSAID
• Diet
• i Sodium
• h K
• h protein
• i Fat

60
Nephrotic syndrome

• Nursing Management - Edema
• qD weight
• IO
• Abd. Girth
• Clean skin
• Avoid people with infections

61
Hydronephrosis

• Pathophysiology
• Dilation of the renal pelvis and calyces of one
  or both kidneys due to an obstruction

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Hydronephrosis

• Clinical Manifestations
• Aching flank
• Dysuria
• Chills fever
• Tenderness
• Pyuria

63
Hydronephrosis

• Medical Management
• Remove obstruction

64
Renal calculi or nephrolithiasis

• Pathophysiology
• Stones are formed in the urinary tract when
  urinary concentrations of the substances such as
  calcium oxalate, calcium phosphate and uric acid
  increase
• Calculus Stone
• Lithiasis Stone formation

65
Renal calculi or nephrolithiasis

• Certain factors favor the formation of stones
• Infection
• Urinary stasis
• Immobility
• Dehydration

66
Renal calculi or nephrolithiasis

• Clinical Manifestations
• Pain
• Abd / flank
• Severe
• NV
• Hematuria

67
Renal calculi or nephrolithiasis

• Assessment and diagnostic findings
• X-ray
• Ultrasonography
• 24-hour urine test
• Cystoscopy
• IVP

68
Renal calculi or nephrolithiasis

• Cystoscopy
• Lighted scope to inspect bladder
• Gen anesthesia
• Nrs Management
• Force fluids
• Expect burning
• Pink tinged
• Frequency
• Orthostatic hypotension

69
Renal calculi or nephrolithiasis

• IVP
• intravenous pyelogram
• X-ray IV dye
• Assess for allergies to dye
• After ? push fluids

70
Renal calculi or nephrolithiasis

• Medical management
• Opioid analgesic
• Antibiotics
• NSAIDs
• Diet
• Calcium OK
• Fluids
• i protein
• i Sodium

71
Renal calculi or nephrolithiasis

• Surgical Management
• If gt 4mm will not pass through ureter
• If not pass spontaneously or if complications ?
  surgery

72
Renal calculi or nephrolithiasis

• Surgical Management
• Ureteroscopy
• First visualize the stone
• Destroy the stone
• Laser
• Electrohydraulic lithotriptos
• Ultrasound

73
Renal calculi or nephrolithiasis

• ESWL - Extracorporeal shock wave lithotripsy
• Gen / spinal
• Shock waves ? water ? stone breaks up

74
Renal calculi or nephrolithiasis

• Nursing Process
• Diagnosis
• Acute pain
• Deficient knowledge to prevent recurrence of
  renal stone

75
Renal calculi or nephrolithiasis

• Nursing Interventions
• Admin opioid agents
• NSAIDS
• Position of comfort
• Amb.
• Heat to flank
• h fluids
• Assess urine
• IO
• Strain urine gauze
• Avoid dehydration

76
Renal neoplasms

• Pathophysiology
• Tobacco leading cause of all UT Ca
• Metastasize early
• Liver
• Lungs
• Bone
• Brain
• 1/3 have metastasis at time of diagnosis

77
Renal neoplasms

• Clinical Manifestations
• Asymptomatic
• Painless hematuria

78
Renal neoplasms

• Medical treatment
• Goal
• Eradicate before metastasis
• Nephrorectomy
• Chemotherapy