Chapter 37
Nursing Care of Patients With Disorders of the Urinary System
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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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