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TEXT STEP #1 Build a solid foundation. Urinary System Function, Data Collection, and Therapeutic Measures Urinary System Function, Data Collection, and Therapeutic Measures • When teaching females self-catheterization, have them stand with one foot on the toilet, if able, during the catheterization.
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PRACTICE ANALYSIS TIP Linking NCLEX-PN® to Practice The LPN/LVN will:
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Gerontological Issues boxes prepare you to provide quality care to older adults. Key Points • The urinary system consists of two kidneys and two ureters, the urinary bladder, and the urethra. The kidneys form urine and the rest of the system eliminates urine. Consequently, dehydration, common in older adults, and changes in renal function are a serious consideration for individuals in this age group who need medication therapy. The risk of adverse medication reactions, such as toxicity and overdose, increases. It can be important to monitor kidney function (such as serum creatinine and blood urea nitrogen [BUN] levels) in an older adult receiving medication therapy. Home Health Hints • Secure pets in another room when performing sterile procedures such as urinary catheter changes. When inserting a urinary catheter, use a flashlight as needed. Have an extra catheter kit and a sterile specimen con- tainer available. owing in part to arteriosclerosis and diminished renal blood flow. The urinary bladder decreases in size, and the tone of the detrusor muscle decreases. These changes may result in the need to urinate more often or in residual urine in the bladder after voiding. Older adults often experience more infections of the urinary tract. Gerontological Issues Age-Related Renal Changes These changes typically occur in the renal system as people age: • Decreased filtration efficiency of the kidneys affects the body’s ability to eliminate drugs • Decreased renal function slows the excretion of certain medications, so they remain in the body longer • Collect specimen for diagnostic testing (e.g., urine). • Check for urinary retention (bladder scan, ultrasound, palpation). • Insert, maintain, and remove urinary catheter. • Provide care to client with bladder management protocol. • Reinforce teaching to the patient and caregiver to keep water to drink next to the patient to maintain hydration. TV commercials can be a reminder to take sips. • Reinforce teaching for the nurse to be notified if the cath- eter becomes plugged as well as how to take the catheter out if it becomes plugged and the nurse is not readily available. Leave a syringe to deflate the balloon with instructions not to cut the balloon valve stem.
URINARY SYSTEM DATA COLLECTION • Reinforce teaching to patient or caregiver on how to switch drainage bags from a large bag to a leg bag if desired for ambulation. When unattached to the urinary drainage system, an extra drainage bag should be cleansed with a solution of 1 part white vinegar and 3 parts water (1/4 cup vinegar, 3/4 cup water) or a solu- tion of 1 part bleach to 10 parts water (1/4 cup bleach, 21/2 cups water). Be Safe! boxes help you remember concepts essential to safe care. Health History If the patient has impaired kidney function, head-to-toe data collection is needed because kidney disease can affect every system of the body. Table 36.2 describes sample questions to ask for a health history to use along with the WHAT’S UP? format (see Chapter 1) for symptoms. Physical Examination Table 36.3 lists objective data to collect on all body systems. Many disease states may precipitate kidney disease such as diabetes, gout, hypertension, and neoplasms. Other factors include excessive use of over-the-counter analgesics, infec- tions, or manipulation of the urinary tract during procedures. Key signs and symptoms include costovertebral angle pain, flank pain, dysuria , and back and leg pain. The patient may have peripheral edema and periorbital edema in the morning. The skin may be pale, itchy, and dry. Electrolyte abnormal- ities may cause arrhythmias or seizures. The patient’s level of consciousness may be altered, ranging from lethargy to coma. High-frequency deafness may occur with hereditary nephritis. Cardiovascular friction rubs may be heard in ure- mic patients. The lungs may fill with fluid and crackles heard in the lungs. BE SAFE! AVOID FAILURE TO RESCUE! After an uncircumcised male is catheterized, the foreskin must be properly repositioned over the glans penis. It cannot be left retracted, as this can cause injury. If left retracted, subsequent swelling may make it impossible to pull the foreskin over the glans penis later. This can cause ischemia of the glans penis, a medical emergency. The HCP must be notified immediately. An emergency circumcision may be needed if the foreskin cannot be properly positioned. Always ensure that the foreskin is positioned properly after catheterization or perineal care.
The Aging Renal and Urinary Systems edema, fever, chills, itchy dry skin, changes in level of consciousness, and alterations in voiding pattern. • Weight is the best indicator of fluid balance in the body. Weigh the patient at the same time each day, in the same or similar clothing, and with the same scale. Look for Pelvic floor muscles weaken Kidneys trends in weight gain or loss related to fluid balance. • Intake and output should be carefully measured. Intake includes oral, IV, irrigation, tube feeding, and other CRITICAL THINKING Mrs. Bohke is a 64-year-old female patient admitted to the hospital with a diagnosis of pneumonia. During her stay, she tells the nurse she has trouble getting to the bathroom in time and often dribbles before she can get there. Males Females 1. What type of urinary incontinence does Mrs. Bohke have? 2. When caring for a patient with incontinence, is it helpful GFR decreases • Several blood and urine tests reflect kidney function. If the kidneys are not filtering adequately, the serum test values, such as the creatinine and blood urea nitrogen, will be elevated. A renal biopsy diagnoses or provides information about kidney disease. • Contrast media used in diagnostic testing and procedures can be nephrotoxic and cause contrast-induced acute kidney injury within 48 hours. • Urinary incontinence is defined as the involuntary Nephrons decrease fluids. Output includes urine, emesis, nasogastric effluent, wound drainage if it is copious, and any other drainage. • A urinalysis is a commonly performed diagnostic test for the urinary system, kidney disease, and systemic diseases that may affect the kidneys. Decreased ability to concentrate urine to decrease fluid intake? Why or why not? Suggested answers are a the end of the chapter. Prone to bladder infections, urinary incontinence, and urethral irritation Difficulty voiding Urine retention Increased risk from Urine retention Prostate enlarges
• The purpose of urine formation is the removal of potentially toxic waste products from the blood. The kidneys regulate blood pressure, electrolyte balance, acid–base balance, formation of erythropoietin, and activation of vitamin D. Critical Thinking Exercises throughout each chapter help connect what you read to what you will see and do in the clinical setting, and include suggested answers at the end of the chapter to check your understanding.
Urinary bladder
Dysuria • With age, the number of nephrons in the kidneys decreases, often to half the original number by age 70 or 80. The glomerular filtration rate also decreases. The urinary bladder decreases in size, and the tone of the detrusor muscle decreases. This may result in the need to urinate more often or in residual urine in the bladder after voiding. Older adults are also more subject to infections of the urinary tract. • Hypertension and diabetes are the most common causes of renal problems. Urinary frequency • If the patient has impaired kidney function, head-to-toe data collection is needed because kidney disease can affect every system of the body. • Common symptoms of kidney disease include dull ache
Decreased bladder size and tone of detrusor muscle
electrolyte balance. The result is accumulation of nitroge- nous waste products in the blood and uremia . CKD affects each body system (Table 37.6).
Evidence-Based Practice Clinical Question
What is the cumulative impact of social determinants of health on mortality in U.S. adults with CKD and diabetes? Evidence This study analyzed data from the 2005 through 2014 National Health and Nutrition Examination Surveys for 1,376 adults who had diabetes and CKD to look at the effect that social determinants of health had on mortality. Social determinates of health relate to socioeconomic; psychosocial; neighborhood environment; and political, cultural, and economic factors that people experience during their lifetime. This analysis looked at family income to poverty ratio, food insecurity, and depression. It was found that these social determinants had a cumulative effect on mortality that increased by 41% for each addi- tional social determinant. Depression was independently associated with mortality (Ozieh et al, 2021). Implications for Nursing Practice
ostic
Evidence-Based Practice boxes feature an in-depth look at research that supports the best care and describe how that knowledge applies in practice.
Chapter 12
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and the type of surgery performed can predict postoperative urinary retention (Abdul-Muhsin et al, 2020). After outpatient surgery, patients may be required to void before discharge.
urologica urinary c such as o • Recogniz frequentl dribbles m emptying bladder s need for complica • Assist pa and provi male pati voiding. • Use techn unable to running w patient’s catheteri • Have pati pelvic mu • Notify th distended timefram EVALUATIO patient is a or complic
17/03/22 5:14 PM 1. You verify that the IV controller pump is set at what rate? 2. How many milliliters do you record as Mrs. Owens’s total intake for the last 12 hours? • Intake for 12 hours: • 8 oz coffee Cue Recognition exercises provide practice in identifying actions to take when presented with patient cues or data. • 4 oz orange juice • 6 oz tomato soup with the PCA pump, what action will you take? 6. Which team members do you collaborate with? 7. What action do you take to support the needs of the patient and family? Suggested answers are at the end of the chapter. CLINICAL JUDGMENT Mrs. Owens returned from a bowel resection 2 days ago. She is receiving 1,000 mL of 0.9% normal saline solution over 10 hours on an IV controller pump. Chapter 12 CLINICAL JUDGMENT Mrs. Wood, age 42, returns to the surgical unit after a hysterectomy. Her postoperative vital signs and data collection findings are normal. Mrs. Wood rates her pain level at 9 out of 10, and the nurse notes that she moans occasionally, repeatedly moves her legs, and pulls at her covers near her abdominal incision. She is drowsy but repeatedly says it hurts. In the PACU, a PCA pump was started. The last dose of medication was delivered 45 minutes ago. Her family is at her bedside trying to talk to her about her experience. 1. What nonverbal pain cues do you find Mrs. Wood is displaying? 2. How do you document Mrs. Wood’s pain? 3. What action do you take to relieve Mrs. Wood’s pain? 4. When will you next monitor Mrs. Wood’s pain level? 5. If Mrs. Wood indicates that her pain remains unrelieved
vention ns and ve care lectro- passing urine cement er elec- similar inuous uid and patients ate the RT pro- ic fluid can be
• WORD • BUILDING • hemodialysis: hemo—blood + dialysis—passage of a solute through a membrane uremia: ur—urea + emia—in the blood Clinical Judgment case studies and questions help you practice and think about what you are learning, and then apply the learning to clinical decision-making. An awareness of social determinants of health, and screen- ing for them as well as for depression in CKD patients, to plan interventions or make referrals (e.g., for Meals on Wheels or mental health services) may help reduce mortal- ity for CKD patients. Reference: Ozieh, M. N., Garacci, E., Walker, R. J., Palatnik, A., & Egede, L. E. (2021). The cumulative impact of social determinants of health factors on mortality in adults with diabetes and chronic kidney disease. BMC Nephrology, 22 (1), 76. https://doi.org/10.1186/s12882-021-02277-2
Nursing Care of Patients Having Surge
Traditionally, after GI surgery, bowel sounds were moni- tored by the nurse. The patient was kept NPO until flatus and bowel sounds returned. It is now known that bowel sounds are not correlated with bowel motility and the patient’s abil- ity to safely drink and eat postoperatively. In fact, patients can be hydrated and fed early, which promotes healing and faster recovery. Follow your institutions’ policy if monitor- ing bowel sounds is required. CUE RECOGNITION 12.3 The surgeon’s orders for a patient who had a colectomy are NPO with IV fluids and an NG tube to low intermittent suction to be irrigated prn. The patient reports stomach pressure and nausea with a need to vomit. What action do you take? Suggested answers are at the end of the chapter.
move in bed, to get out of bed, and to walk. Mon els that may interfere with movement. Observe tolerance for activity.
Nutrition Notes Nourishing the Postoperative Patient After surgery, 5% glucose in 0.45% normal salin nously is commonly prescribed. This is done to catabolism (muscle protein being used for ener a patient is fasting. However, this prevention do long. One liter of this solution contains 170 calo nourished adults may tolerate not eating for up but malnourished adults should be fed early to impacting their recovery. Advocate for a nutritio your patients following surgery. Patients usually progress from clear liquids t diet as soon as possible. Offer water first, then c to see patient’s tolerance. If “diet as tolerated” is the patient should be asked, “What sounds goo Offering a full dinner when the patient doesn’t may “turn off” the appetite. soft, bow bladder d 10. He is r hands du really hur 1. What a 2. What a sympto CLINIC Mr. McDo laparosco report yo normal pa analgesic 20 mL at 1 light dinn McDonald three ban abdomen
• 3/4 cup gelatin • 2 cups of water • 1,200 mL of 0.9% normal saline solution IV • Output for 12 hours: • 1,700 mL of urine Suggested answers are at the end of the chapter.
NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION
Imbalanced Nutrition: Less Than Body Requirements related to NPO, pain, and nausea
NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION
LEARN
STEP #2 Make the connections to key topics.
UNIT NINE Understanding the Urinary System
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Understanding the Urinary System
Formation of Urine Urine formation involves three processes: glomerular filtra- tion, tubular reabsorption, and tubular secretion. Glomerular Filtration In glomerular filtration, blood pressure forces water and small solutes out of the glomeruli and into Bowman capsules. This fluid is called renal filtrate (Fig. 36.3). Tubular Reabsorption and Secretion Exiting the glomerular capsule, renal filtrate enters the renal tubules. Tubular reabsorption is the recovery of useful mate- rials from the renal filtrate and their return to the blood in the peritubular capillaries (Table 36.1). In tubular secretion, substances are actively secreted from the blood in the peritu- bular capillaries into the filtrate in the renal tubules. The Kidneys and Acid–Base Balance Other than exhalation of carbon dioxide by the respiratory system, the kidneys are the organs most responsible for maintaining the normal pH range of blood and tissue fluid. They compensate for the pH changes that are part of normal body metabolism or the result of disease. In acidosis, the kidneys secrete more hydrogen ions into the renal filtrate and return more bicarbonate ions back to the blood. When body fluids become too alkaline, the kidneys return hydrogen ions to the blood and excrete bicarbonate ions in urine.
is an indentation, the hilus, where the renal artery enters and the renal vein and ureter emerge. The ureter carries urine from the kidney to the urinary bladder. Internal Structure of the Kidney A frontal section of the kidney shows three areas: the cortex, medulla, and pelvis (Fig. 36.1). Blood Vessels of the Kidney The pathway of blood flow through the kidney is an essen- tial part of the process of urine formation. Blood enters the kidney from the renal artery and exits through the renal vein. Extensive branching within the kidney eventually leads arte- rial blood to each afferent arteriole. This vessel begins the microcirculation at the nephron , the functional unit of the kidney. The exchanges that take place in the capillaries of the nephrons form urine from blood plasma. Nephrons Urine is formed in the approximately 1 million nephrons per kidney. The two major parts of a nephron are the renal cor- puscle with glomerulus and the renal tubule with peritubular capillaries (Fig. 36.2). These are the two sites of exchange between blood plasma and urinary filtrate within the nephron. All parts of the renal tubule are surrounded by the peritubular capillaries. The capillaries arise from the efferent arteriole and receive the materials reabsorbed by the renal tubules.
CHAPTER 36 Urinary System Function, Data Collection, and Therapeutic Measures Maureen McDonald, Janice L. Bradford
KEY TERMS azotemia (AY-zoh-TEE-me-ah) cystoscopy (sis-TAH-skuh-pee) dysuria (dis-YOO-ree-ah) hematuria (HEE-muh-TOOR-ee-ah)
LEARNING OUTCOMES 1. Identify the normal anatomy of the urinary system. 2. Describe the normal function of the urinary system. 3. Discuss the effects of aging on the urinary system. 4. Explain data to collect when caring for a patient with a disorder of the urinary system. 5. Plan preparation and postprocedure care for patients undergoing diagnostic tests of the urinary system. 6. Plan nursing care for patients with incontinence. 7. Discuss nursing actions to decrease the risk of infection in urinary catheterized patients.
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Urinary and Renal Disorders
incontinence (in-CON-tin-ense) nephrotoxic (NEF-row-TOK-sik) nocturia (knock-TOO-ree-ah) percutaneously (PUR-kyoo-TAY-nee-us-lee)
polyuria (pa-lee-YOO-ree-ah) pyelogram (PIE-eh-loh-gram)
CHAPTER CONCEPTS
NORMAL URINARY SYSTEM ANATOMY AND PHYSIOLOGY
Caring Elimination Teaching and learning
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Urinary and Renal Disorders
The urinary system consists of two kidneys and two ureters, the urinary bladder, and the urethra. The kidneys form urine, and the rest of the system eliminates the urine. The purpose of urine formation is the removal of potentially toxic waste products from the blood; however, the kidneys have other equally important functions as well: • Regulation of blood volume, pressure, and composition by excretion or conservation of water • Regulation of the electrolyte balance of the blood by excretion or conservation of minerals • Regulation of the acid–base balance of the blood by the excretion or conservation of ions such as hydrogen or bicarbonate • Production of erythropoietin, which stimulates erythrocyte production in the bone marrow • Activation of vitamin D, which maintains bone health The process of urine formation helps maintain the normal composi- tion, volume, and pH of blood and tissue fluid. Kidneys The bilateral kidneys are located against the posterior wall of the abdominal cavity. They are retroperitoneal. The superior portions of both kidneys rest on the inferior surface of the diaphragm; these por- tions are protected by the lower rib cage. The kidneys are cushioned by surrounding adipose tissue. This tissue is covered by a fibrous connec- tive membrane, the renal fascia. On the medial surface of each kidney
The renal cortex forms the outer region of the kidney.
Fibrous capsule
The renal medulla forms the inner region.
Extensions from the renal cortex, called renal columns , divide the interior region into cone-shaped sections.
The cone-shaped sections are called renal pyramids . Consisting of tubules for transporting urine away from the cortex, the base of each pyramid faces outward toward the cortex. The point of the pyramid, called the renal papilla , faces the hilum.
Urinary and Renal Disorders
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Hilum
The renal papilla extends into a cup called a minor calyx . The calyx collects urine leaving the papilla.
Renal papilla
Two or three minor calyces join together to form a major calyx .
Ureter
The major calyces converge to form the renal pelvis , which receives urine from the major calyces. The renal pelvis continues as the ureter , a tube-like structure that channels urine to the urinary bladder.
FIGURE 36.1 Interior of the kidney.
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Pre-Assessment for Urinary and Renal Disorders
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Question 2 of 6 The health-care provider alerts the nurse that a patient is at risk for chronic kidney disease. Which risk factors should the nurse expect to find in this patient’s chart? Select all that apply. Diabetes mellitus
Urinary calculi Hypertension Autoimmune disease Acute urinary tract infection
Pre-Assessment for Urinary and Renal Disorders
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Urinary and Renal Disorders
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Post-Assessment for Urinary and Renal Disorders
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Question 2 of 6 The nurse manager has taught a new staff nurse about monitoring and caring for arteriovenous access. The staff nurse demonstrates understanding of appropriate care when performing which action? Feeling for a thrill Auscultating carotid pulses Palpating for a bruit Accessing graft for labs
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• Urinary and Renal Disorders • COPD
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Heart Failure Chapter 26 COPD Chapter 31 Cirrhosis Chapter 36 Urinary and Renal Disorders Chapter 37 Diabetes Chapter 40 Seizures Chapter 48
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Urinary and Renal Disorders
Real-world cases mirror the complex clinical challenges you will encounter in a variety of healthcare settings. Each case study begins with a patient photograph and a brief introduction to the scenario.
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Urinary and Renal Disorders
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ASSESS STEP #4 Improve comprehension & retention. High-quality questions , including more difficult question types like select-all-that-apply , assess your understanding and challenge you to think at a higher cognitive level. PLUS! Brand-new Next Gen NCLEX ® stand-alone questions provide you with even more practice answering the new item types and help build your confidence.
Urinary and Renal Disorders
The nurse is caring for a client with chronic kidney disease (CKD). Which of the following can the nurse expect to find? Select all that apply.
Fatigue Pruritis Edema Hypotension Anemia
The nurse is caring for a client with chronic kidney disease (CKD). Which of the following can the nurse expect to find? Select all that apply. Fatigue Rationale: Fatigue is found in clients with CKD. Pruritis Rationale: Pruritis is commonly seen in clients with CKD. Edema Rationale: Edema is common in clients with CKD. Hypotension Rationale: Clients with CKD have hypertension. Anemia Rationale: Anemia is common in clients with CKD.
Content Area Adult Health: Renal and Urinary Coordinated Care
Integrated Processes Caring
Client Need Physiological Integrity Cognitive Level Application (Applying) Question Type Multiple Response
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Urinary and Renal Disorders
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Brief Contents
UNIT ONE: Understanding Health-Care Issues, 1 1 Critical Thinking, Clinical Judgment, and the Nursing Process, 1 2 Evidence-Based Practice, 9 3 Issues in Nursing Practice, 15 4 Cultural Influences on Nursing Care, 31 5 Complementary and Alternative Modalities, 41 UNIT TWO: Understanding Health and Illness, 50 6 Nursing Care of Patients With Fluid, Electrolyte, and Acid–Base Imbalances, 50 7 Nursing Care of Patients Receiving Intravenous Therapy, 69 8 Nursing Care of Patients With Infections, 83 9 Nursing Care of Patients in Shock, 105 10 Nursing Care of Patients in Pain, 118 11 Nursing Care of Patients With Cancer, 140 12 Nursing Care of Patients Having Surgery, 164 13 Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response, 192 UNIT THREE: Understanding Influences on Health and Illness, 211 14 Developmental Considerations and Chronic Illness in the Nursing Care of Adults, 211 15 Nursing Care of Older Adult Patients, 222 16 Patient Care Settings, 235 17 Nursing Care of Patients at the End of Life, 247 UNIT FOUR: Understanding the Immune System, 263 18 Immune System Function, Data Collection, and Therapeutic Measures, 263 19 Nursing Care of Patients With Immune Disorders, 277 20 Nursing Care of Patients With HIV and AIDS, 297 UNIT FIVE: Understanding the Cardiovascular System, 317 21 Cardiovascular System Function, Data Collection, and Therapeutic Measures, 317 22 Nursing Care of Patients With Hypertension, 342
23 Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders, 353 24 Nursing Care of Patients With Occlusive Cardiovascular Disorders, 377 25 Nursing Care of Patients With Cardiac Arrhythmias, 404 26 Nursing Care of Patients With Heart Failure, 425
UNIT SIX: Understanding the Hematologic and Lymphatic Systems, 448
27 Hematologic and Lymphatic System Function, Data Collection, and Therapeutic Measures, 448 28 Nursing Care of Patients With Hematologic and Lymphatic Disorders, 462 UNIT SEVEN: Understanding the Respiratory System, 486 29 Respiratory System Function, Data Collection, and Therapeutic Measures, 486 30 Nursing Care of Patients With Upper Respiratory Tract Disorders, 518 31 Nursing Care of Patients With Lower Respiratory Tract Disorders, 533 UNIT EIGHT: Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems, 572 32 Gastrointestinal, Hepatobiliary, and Pancreatic Systems Function, Data Collection, and Therapeutic Measures, 572 33 Nursing Care of Patients With Upper Gastrointestinal Disorders, 598 34 Nursing Care of Patients With Lower Gastrointestinal Disorders, 618 35 Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders, 649 UNIT NINE: Understanding the Urinary System, 675 36 Urinary System Function, Data Collection, and Therapeutic Measures, 675 37 Nursing Care of Patients With Disorders of the Urinary System, 695
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CHAPTER 37 Nursing Care of Patients With Disorders of the Urinary System Maureen McDonald
KEY TERMS
LEARNING OUTCOMES 1. Explain the predisposing causes, symptoms, laboratory abnormalities, and treatment of urinary tract infections. 2. Explain the predisposing causes, symptoms, treatment, and teaching for kidney stones. 3. List risk factors and signs and symptoms of cancer of the bladder. 4. List risk factors and signs and symptoms of cancer of the kidneys. 5. Discuss nursing care for a patient with an ileal conduit or continent reservoir. 6. Explain the pathophysiology and nursing care for diabetic nephropathy, nephrosclerosis, hydronephrosis, and glomerulonephritis. 7. Describe the signs and symptoms for patients with acute kidney injury. 8. Describe the signs and symptoms for patients with chronic kidney disease. 9. Plan nursing care for patients with acute kidney injury. 10. Plan nursing care for patients with chronic kidney disease.
anuria (an-YOO-ree-ah) azotemia (AH-zoh-TEE-mee-ah) calculi (KAL-kyoo-lye) cystitis (sis-TY-tis) glomerulonephritis (gloh-MUR-yoo-loh-neh-FRY-tis) hemodialysis (HEE-moh-dy-AH-lih-sis) hydronephrosis (HY-droh-neh-FROH-sis) nephrectomy (neh-FREK-tuh-mee) nephrolithotomy (NEH-froh-lih-THAH-tuh-mee) nephropathy (neh-FROP-uh-thee) nephrosclerosis (NEH-froh-skleh-ROH-sis) nephrostomy (neh-FRAW-stoh-mee) nephrotoxins (NEH-froh-TOK-sins) oliguria (AW-lih-GYOO-ree-ah) peritoneal dialysis (PEAR-ih-toh-NEE-uhl dy-AL-ih-sis) polyuria (PAH-lee-YOOR-ee-ah) pyelonephritis (PY-eh-loh-neh-FRY-tis) stent (STENT) uremia (yoo-REE-mee-ah) urethritis (YOO-reh-THRY-tis) urethroplasty (yoo-REE-throw-PLAS-tee) urosepsis (YOO-roh-SEP-sis)
11. Discuss nursing care for a vascular access site. 12. Plan nursing care for patients on hemodialysis. 13. Plan nursing care for patients on peritoneal dialysis.
Disorders of the urinary tract involve the urethra, bladder, ureters, and kidneys. These disorders include infection, obstruction, cancer, hered- itary disorders, and metabolic, traumatic, or chronic diseases. Some disorders lead to chronic kidney disease (CKD) if not treated.
CHAPTER CONCEPTS
Caring Elimination Fluid and electrolytes Infection Teaching and learning
URINARY TRACT INFECTIONS
The urinary tract is a sterile environment. A urinary tract infection (UTI) is the invasion of the urinary tract by bacteria. UTIs are most often caused by an ascending infection, starting at the external urinary meatus and moving up toward the bladder and kidneys. Most UTIs are caused by the bacterium Escherichia coli , commonly found in feces. Other less common pathogens include Staphylococcus saprophyticus, Klebsiella spp., and Enterobacter . Lower UTIs include urethritis, pros- tatitis, and cystitis. Upper UTIs include pyelonephritis and ureteritis. UTIs are the most common health-acquired infection (HAI). People who have had a UTI often develop repeat infections. It is important that education on how to prevent repeat UTIs is provided.
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Risk Factors for Urinary Tract Infections • Aging increases the incidence of UTIs due to diminished immune function, diabetes, estrogen decline in women, enlarged prostate that obstructs urine flow in men, or a neurogenic bladder that fails to completely empty. UTI is the most common cause of acute bacterial sepsis in patients older than 65. • Contamination in the perineal and urethral areas , which can ascend the urinary tract, may occur from genital piercing; fecal soiling; sexual intercourse that massages bacteria into the urinary meatus; or infections such as vaginitis, epididymitis, or prostatitis. • Faulty valves causing reflux of urine do not maintain one-way urine flow along the urinary tract. Reflux can be congenital or acquired because of previous infections. • Female anatomic and genetic differences make women more susceptible to UTIs because of the short length of the female urethra and its proximity to the vagina and anus. Some women with recurrent UTIs have a shorter distance from the urethra to anus. Genetic factors may play a role in women who have a certain phenotype for developing UTIs. • Instrumentation infection occurs from instruments or tubes inserted into the urinary meatus. The most common cause of instrumentation infection is insertion of a urinary catheter. Bacteria ascend around or within the catheter. Bacterial colonization begins within 48 hours of indwelling catheter insertion. • Previous UTIs might provide a reservoir of bacteria that can cause reinfection. • Stasis of urine in the bladder results from voiding infrequently or obstruction. Urine stasis promotes bacterial growth, which can ascend to higher structures. NURSING CARE TIP When caring for a patient at risk for an internal catheter- associated urinary tract infection (CAUTI), limit the use of a urinary catheter, always use infection control procedures, and discontinue use as soon as possible. CAUTI is a Never Event—that is, hospitals will not be paid by Medicare for the costs of care provided if this condition occurs during hospitalization. An external female catheter, the Purewick (www.pure wickathome.com), keeps females who are incontinent dry without being invasive. This reduces the risk of CAUTI. The Purewick is an external sponge/suction catheter that is placed between the labia and the gluteus muscles. It is attached to a suction device at the lowest setting to absorb and wick away the urine. Signs and Symptoms UTIs are characterized by shared signs and symptoms along with location-specific symptoms (Table 37.1). Decline in mental status and fever in a patient with an indwelling
Table 37.1 Urinary Tract Infection (Urethritis, Cystitis, Pyelonephritis) Summary
Signs and Symptoms
All: Voiding urgency, frequency, and burning; cloudy, foul-smelling urine; hematuria Older adult: Fatigue, confusion, and delirium Cystitis: Pelvic pain or pressure Pyelonephritis: Costovertebral tenderness, high fever, chills, nausea/vomiting Urinalysis: White blood cells, red blood cells, casts, bacteria, positive for nitrites Urine culture: Positive Antimicrobial for causative organism Encourage fluids Phenazopyridine (Pyridium)
Diagnostic Tests
Therapeutic Measures
Complications
Pyelonephritis Urosepsis
Priority Nursing Diagnoses
Acute Pain Impaired Urinary Elimination Ineffective Health Maintenance Behaviors
catheter meets diagnostic criteria for a UTI. In older adults, the typical presenting symptom is generalized fatigue. New- onset confusion or delirium may be present in the older adult, but a fever may not be. Types of Urinary Tract Infections Urethritis Urethritis is inflammation of the urethra caused by a chem- ical irritant, bacterial infection, trauma, or exposure to a sexually transmitted infection (STI). Posttraumatic urethritis can occur with intermittent catheterization or instrumenta- tion of the urethra. Bubble bath, bath salts, and spermicidal agents are urethral irritants and should be avoided by anyone with a history of UTI. Gonorrhea and chlamydia are STIs that can cause urethritis in men. Signs and symptoms of urethritis are listed in Table 37.1. The male patient may have discharge from the penis. Urinalysis and urine culture are used to diagnose urethritis. It is treated on the basis of the cause. In cases of sexual transmission, the sexual partner(s) must also be treated. Phenazopyridine (Pyridium),
• WORD • BUILDING • urethritis: urethr—urethra (canal that discharges urine from bladder) + itis—inflammation
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a urinary analgesic, treats dysuria. Explain to the patient that urine turns orange while taking phenazopyridine.
Nursing Diagnoses, Planning, and Implementation
Acute Pain related to inflammation and infection of urinary structures EXPECTED OUTCOME: The patient will report relief from pain and discomfort. • Administer phenazopyridine (Pyridium) as ordered to relieve pain . • Apply heat to suprapubic area to relieve discomfort . Ineffective Health Maintenance Behaviors related to lack of knowledge on preventing and resolving UTIs EXPECTED OUTCOME: The patient will state understanding of prevention of UTIs and be free from UTIs. • Suggest eating foods that may prevent UTIs, including polyphenols (cranberry or blueberry products, coffee, black tea, and dark chocolate) for potential preventive action against UTIs . • Reinforce teaching to drink fluids, including water to produce clear light-yellow urine, to prevent dehydration and flush bacteria from urinary tract . • Reinforce teaching to void as soon as the urge occurs or every 3 hours while awake to empty the bladder and lower bacterial counts, reduce stasis, and prevent infection . • Reinforce teaching females to wipe from front to back to prevent spreading bacteria from anal area to urinary meatus . • Reinforce teaching females to wear cotton crotch underwear and avoid constricting clothing such as tight jeans to allow air circulation to reduce moisture . • Reinforce teaching to avoid perfumed feminine hygiene products, bubble bath and bath salts, scented toilet paper, and tub baths, which can irritate the urethra or introduce bacteria into the urinary meatus . • Reinforce teaching to void after sexual intercourse to flush bacteria from the urinary tract that entered the urinary meatus . • Reinforce teaching signs and symptoms of UTI to report to detect UTI . • Reinforce teaching to finish all prescribed antibiotic medications as directed to prevent recurrent infection or resistance to antibiotics . Evaluation The outcomes have been met if the patient verbalizes relief of pain and burning, and describes ways to prevent UTI.
Cystitis Cystitis is inflammation of the bladder wall, usually caused by a bacterial infection. E. coli causes most UTIs. Cystitis can also result from catheter use, chemical irritants, medications, or radiation therapy. Chronic interstitial cystitis, or painful bladder syndrome, has no known cause. Signs and symp- toms are listed in Table 37.1. Urinalysis or sometimes cys- toscopy is used for diagnosis. Urinalysis findings for cystitis include cloudy urine, WBCs, bacteria, sometimes red blood cells (RBCs), positive nitrites, and positive leukocyte ester- ase (pyuria). Urine culture and sensitivity are done if indi- cated. Bacterial cystitis is often treated with nitrofurantoin (Macrobid, Macrodantin), sulfamethoxazole and trimetho- prim (Bactrim, Septra), or fosfomycin (Monurol). Instruct patient to finish all prescribed medications to prevent bac- terial resistance and have a follow-up urinalysis or culture. Encourage fluids to flush the bladder. Pyelonephritis Pyelonephritis is infection of one or both kidneys, which can be serious. Bacteria can travel from the ureters to the bladder and then up to the kidneys. Young women and older adults experience this infection most. Risk factors for uncom- plicated pyelonephritis include a history of UTIs within the past year, sexual intercourse, or spermicide use. Complicated pyelonephritis risk factors are diabetes, weak immune sys- tem, or structural or obstruction problems. In addition to shared UTI signs and symptoms, high fever, chills, nausea/ vomiting, flank pain, and costovertebral tenderness (tender- ness at the angle where rib and vertebrae join with palpation) indicate pyelonephritis. Urinalysis shows cloudy urine, bacte- ria, WBCs, pyuria, positive nitrites, and casts. The urine cul- ture will have 100,000 or more colony-forming units (CFU) per milliliter. In acutely ill patients, blood cultures may be obtained. Antibiotics are given orally or, if the patient is hos- pitalized, intravenously (Table 37.2). After treatment, there is usually no lasting kidney damage. However, frequent kidney infections can result in scarring and loss of kidney function. Urosepsis Urosepsis is sepsis caused by a UTI. Septic shock and death can result so prompt treatment is essential. Older adults are at greater risk for urosepsis. Nursing Process for the Patient With a Urinary Tract Infection Data Collection Ask what the patient’s usual pattern of voiding is and if changes have occurred. Document the presence of a cathe- ter, recent urinary instrumentation, or surgery. Note the pres- ence of signs or symptoms (see Table 37.1). Inspect the urine for volume, color, concentration, cloudiness, blood, or foul odor. Review urinalysis and culture results.
• WORD • BUILDING • cystitis: cyst—closed sac containing fluid + itis—inflammation pyelonephritis: pyelo—pelvis + nephr—kidney + itis—inflammation urosepsis: uro—urine + sepsis—infection in the blood
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Table 37.2 Medications Used to Treat Urinary Tract Infections
Medication Class/Action Antibiotics Effective against E. coli and Enterococcus faecalis Example fosfomycin (Monurol)
Nursing Implications Dissolve packet in ½ cup of cool water to drink immediately. Teach: Only 1 dose is needed for UTI. Diarrhea is a common side effect that subsides when medication is stopped.
Effective against E. coli, enterococci, Staphylococcus aureus, Klebsiella spp., and Enterobacter Example nitrofurantoin (Macrobid, Macrodantin) Nursing Implications Teach: Avoid taking with antacids. Take with food or milk and full glass of water. Beta-Lactam Antibiotics Effective against Escherichia coli, Klebsiella spp., and Serratia Example
Nursing Implications Check allergies and renal function.
ceftriaxone (Rocephin) cefepime (Maxipime) aztreonam (Azactam)
Fluoroquinolones Effective against E. coli, Klebsiella spp., Pseudomonas, and other organisms. Example ciprofloxacin (Cipro) levofloxacin (Levaquin)
Nursing Implications Do not give if pregnant. Absorption may be decreased if given within 2 hr of aluminum antacids. Give with large amounts of water. Teach:
Avoid sunlight or wear sunscreen of 30 HPF or more. Report tendon aches promptly as tendon may rupture.
Sulfonamides Effective against E. coli; used for uncomplicated UTIs. Example trimethoprim-sulfamethoxazole (Bactrim, Septra)
Nursing Implications Do not give if allergic to sulfa. Do not give if pregnant. Dose may need adjustment with renal disease. Teach: Avoid sunlight or wear sunscreen of 30 SPF or more. Take with large amounts of water.
Urinary Analgesic Topical analgesic that relieves pain urgency and frequency associated with UTI. Example phenazopyridine (Pyridium) Nursing Implications Urine color changes to red-orange.
Avoid in renal insufficiency. Changes urine glucose testing.
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Stone in calyx
CRITICAL THINKING & CLINICAL JUDGMENT
Stone free in pelvis
Mrs. Milan is a 25-year-old woman who, after a weekend getaway with her husband, notices symptoms of dysuria, frequency, and urgency. She visits her health-care provider (HCP) and is diagnosed with a UTI. She is placed on an oral antibiotic. Critical Thinking (The Why) 1. What predisposed Mrs. Milan to developing a UTI? 2. What urinalysis findings would you expect for Mrs. Milan? Clinical Judgment (The Do) 3. What education do you provide to Mrs. Milan to prevent UTIs? 4. What do you include in Mrs. Milan’s teaching plan for her therapeutic regimen? Suggested answers are at the end of the chapter.
Staghorn stone
Hydroureter
Ureteral stone
Bladder stones
UROLOGICAL OBSTRUCTIONS
Urethral stone
Urinary tract obstruction interferes with the flow of urine along the urinary tract. It can develop rapidly or slowly. Obstruction can be partial or complete or unilateral or bilat- eral. It is always a significant problem as urine will back up from the point of the blockage, eventually distending the kidney ( hydronephrosis ) and increasing pressure on the structures of the kidney. If not relieved, this pressure can damage the kidney, impair its function, and ultimately lead to CKD. Urethral Strictures A urethral stricture is a narrowing of the lumen of the ure- thra from scar tissue. It creates a diminished urinary stream, dysuria, frequency, and frequent UTIs. Strictures occur from injury, STIs, tissue trauma from use of catheters or surgical instruments, cancer, or an enlarged prostate (see Chapter 43). Treatment of a urethral stricture includes catheterization to drain the obstructed urine; mechanical dilation by the urolo- gist, who inserts dilators over a wire to stretch open the ure- thra; endoscopic urethrotomy, which removes the stricture; surgical repair ( urethroplasty ); or implantation of a stent (hollow tube). Renal Calculi (Urolithiasis) Renal calculi (urolithiasis) are stones ( calculi; one stone is a calculus ) in the urinary tract. They usually form in the kid- ney (nephrolithiasis; Fig. 37.1) but may form in the ureter (ureterolithiasis). Pathophysiology Crystals start to form when (1) urine is too concentrated, resulting in high levels of calcium, oxalate (from plants), phosphorus or uric acid; and (2) substances such as citrate that inhibit stone formation are low. Crystals bind together
FIGURE 37.1 Location of calculi in the urinary tract.
with other substances and form a calculus that enlarges and is not flushed from the urinary tract. The four main types of stones are calcium (with oxalate or phosphate), uric acid, struvite (rare, large, fast-growing stone found in alkaline urine caused by bacteria in chronic UTIs), and cystine (rare stone; hereditary; cystine is an amino acid found in foods). Most stones are made of calcium oxalate. Renal calculi can form in the renal pelvis and calyces, or in the ureter or blad- der. They range from the size of a grain of salt to staghorn (fill renal pelvis and extend into at least 2 calyces and are caused by urease-producing bacteria in chronic UTIs). Etiology Stone formation has numerous causes, some related specifi- cally to the type of stone. Nonmodifiable risk factors include genetics, family history of stones, and medical conditions such as cystinuria, diabetes mellitus, gout (men), hypertension, cer- tain intestinal disorders or bypass surgery, obesity, chronically high urine pH, or chronic UTI. Modifiable risk factors include inadequate fluid intake or excessive sweating from envi- ronment or exercise (concentrates urine); medications such as aspirin, indinavir (Crixivan), topiramate (Trokendi XR, Topamax), triamterene (Dyrenium), vitamin C supplements and vitamin D; calcium supplements between meals; dietary pattern; diet low in calcium, phytate, and potassium; or diet • WORD • BUILDING • hydronephrosis: hydro—pertaining to water + nephrosis— degenerative change in kidney urethroplasty: urethro—urethra + plasty—surgical repair
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Table 37.3 Renal Calculi Summary
high in fructose, oxalate, animal protein, vitamin C, sodium, and sucrose. Specific causes and ways to prevent stones are determined through analysis of the passed stone. Stones are more common in men than in women. After having one stone, risk of recurrence increases Signs and Symptoms Table 37.3 summarizes renal calculi and its signs and symp- toms. Stones can pass asymptomatically, but pain usually occurs when the stone moves. The most common signs and symptoms are mild to severe pain that occurs in waves (renal colic, flank pain) and hematuria.
Signs and Symptoms
Nephrolithiasis: Costovertebral angle pain Hematuria Ureterolithiasis: Severe, colicky (wavelike) pain from obstructed urine flow Flank, side, or lower abdomen pain radiating to genitalia Intense urge to void Frequency, dysuria, reduced output Hematuria due to irritation from stone Nausea/vomiting with severe pain Bladder stones: Hematuria Oliguria with obstruction of bladder outlet Computed tomography (CT) Renal ultrasound Abdominal x-ray Blood tests: Calcium, uric acid, blood urea nitrogen (BUN), creatinine Urinalysis: Hematuria, crystals, urine pH Two 24-hour urine collections Small stones : Hydration, analgesics, alpha blocker (Tamsulosin) Large stones, symptomatic: IV fluids Pain control Thiazide diuretic Allopurinol (Zylorprim) Lithotripsy Surgery: Percutaneous nephrolitho- tomy, ureteroscopy, cystoscopy, cystolitholapaxy
CUE RECOGNITION 37.1 A patient with renal calculus moans and yells when experiencing renal colic. What action do you take? Suggested answers are at the end of the chapter.
Diagnostic Tests
Complications Obstructed urine flow leads to hydroureter and hydrone- phrosis over time. If the obstruction is not relieved, shock and sepsis can occur. Damage from the pressure can occur, causing CKD. Prevention Adequate hydration (2–3 quarts) daily is recommended to prevent concentrated urine. Sweetened beverages and grape- fruit juice should be avoided. The Dietary Approaches to Stop Hypertension (DASH) eating plan and Mediterranean diet are recommended. For dietary guidelines, see “Nutrition Notes.” Encourage the patient to walk, which promotes the excretion of stones and reduces bone calcium resorption (release). Urocit-K (potassium citrate), which restores chem- icals in the urine that prevent crystals from forming to prevent calcium oxalate and uric acid stones, might be prescribed. Nutrition Notes Calcium oxalate stones. To prevent oxalate stones, limit sodium and animal protein, and consume adequate calcium to bind with oxalate. If a low-oxalate diet is pre- scribed, many foods may be restricted, including beets, chocolate, spinach, rhubarb, nuts, peanuts, and sweet potatoes. Calcium phosphate stones. Reducing dietary sodium and animal protein, avoiding cola beverages, and getting adequate calcium help prevent these stones. Uric acid stones. Renal calculi can be a complication of gout, which is a disorder of purine metabolism. Limit high- purine foods such as organ meats, anchovies, herring, sardines, alcoholic beverages, and gravy. Increasing fruits and vegetables may reduce uric acid stone formation.
Therapeutic Measures
Complications
UTI Hydroureter Hydronephrosis
Shock Sepsis Chronic kidney disease Acute Pain Risk for Infection Deficient Knowledge
Priority Nursing Diagnoses
Diagnostic Tests Blood tests (i.e. BUN, creatinine) assess renal function and urinalysis assesses for hematuria and infection. Imaging tests for renal stones and hydronephrosis include noncontrast
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