UNIT NINE
702
Understanding the Urinary System
Patients with stones may experience extreme pain. Flank pain may radiate to the genitals. All urine must be strained to detect stones. If a stone is found, it is sent to the labora- tory for analysis. Precise measurement of intake and output (I&O) is important. Obstruction may occur at the bladder neck or urethra. With obstruction, anuria (less than 50 mL of urine output daily) or oliguria (less than 400 mL of urine output daily) might occur. Obstruction is an emergency and must be reported and treated immediately to preserve kidney function. Urine is observed for hematuria. Temperature is monitored for elevation, which could indicate an infection. CUE RECOGNITION 37.2 A patient with a ureterolithiasis asks you to empty the urinal. What action do you take? Suggested answers are at the end of the chapter.
• Reinforce teaching on need for fluid intake of 2 to 3 quarts per day. Dilute urine helps prevent stone formation . • Reinforce teaching to patient about prescribed medication to prevent recurrence of renal stones . EVALUATION. Outcomes have been achieved if the patient is comfortable, free from infection, and verbalizes how to prevent renal calculi. Hydronephrosis Hydronephrosis is distention of the renal pelvis and calices from obstruction of urine flow. It is usually treatable once the condition is detected. Obstruction of urine flow can result from a stricture in a ureter or the urethra, renal calculi, tumors, or an enlarged prostate. One or both kidneys can be affected, depending on the location of the obstruction. As urine backs up it distends the ureter and then the kidney, which enlarges, and pressure increases within it (Fig. 37.3). Unrelieved pressure within the kidneys causes the kidneys to become sacs filled with urine instead of functioning kidneys. In a matter of hours, the blood vessels and renal tubules can be damaged extensively if the pressure is not relieved. If the onset of obstruction is gradual, the patient initially may be asymptomatic. If the obstruction progresses, flank and back pain may occur. A UTI may develop with symp- toms of frequency, urgency, and dysuria. Immediate treatment of hydronephrosis is to relieve the urinary retention, often by inserting a urinary catheter. The cause of the obstruction must be treated medically or surgi- cally. A stent may be placed inside a ureter during cystoscopy to ensure passage of urine as the ureter heals (Fig. 37.4). To relive pressure within the kidney and prevent kidney damage, a nephrostomy tube can be inserted directly into the kidney pelvis to drain urine into a collecting bag (see Fig. 37.4). This tube exits through an incision in the flank area. Monitor the nephrostomy tube to ensure it drains adequately. It should not be kinked or clamped, which would result in continuation of the hydronephrosis and possible kidney damage. I&O is carefully measured. If both a nephrostomy tube and urinary catheter are present, output from each should be measured and documented separately. Urine retention must be recognized and reported promptly.
NURSING DIAGNOSIS, PLANNING, AND IMPLEMENTATION.
Acute Pain related to the presence of, obstruction by, or movement of a stone within the urinary tract
EXPECTED OUTCOME: The patient will verbalize relief of pain at tolerable level within 30 minutes of report of pain.
• Monitor location and severity of pain using a pain rating scale such as 0 to 10. Renal colic pain typically occurs in the flank or costovertebral angle and may radiate to the abdominal, pelvic, and genital areas . • Administer medication for pain as ordered to promote comfort . • Apply heat to painful area to reduce pain and promote comfort . • Encourage ambulation to facilitate the passage of the stone through the urinary system . Risk for Infection related to the introduction of bacteria from obstructed urinary flow and instrumentation EXPECTED OUTCOME: The patient will remain infection free. • Monitor temperature and urine amount, color, clarity, and odor and report abnormal findings as abnormalities may indicate infection . • Encourage fluid intake to flush bacteria and stones . Deficient Knowledge related to lack of knowledge of prevention of stone recurrence and diet EXPECTED OUTCOME: The patient will verbalize an under- standing of how to prevent renal calculi. • Ask about patient’s understanding of how to prevent renal calculi to establish baseline knowledge . • Consult dietitian after stone analysis and reinforce diet teaching to prevent formation of specific types of stones .
TUMORS OF THE RENAL SYSTEM
Cancer of the Bladder Cancer of the bladder is the most common cancer of the uri- nary tract. The American Cancer Society (2021a) estimates that, in 2021, new cases of bladder cancer were more than 83,730 in the United States. Bladder cancer occurs most commonly in men and in adults over 55, with the average age being 73.
• WORD • BUILDING • anuria: an—without + uria—urine oliguria: olig—small + uria—urine
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