Chapter 37
Nursing Care of Patients With Disorders of the Urinary System
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The patient must wear an ostomy bag to collect urine as urine continually flows from the stoma. This is why it is referred to as an incontinent urinary diversion. CONTINENT URINARY DIVERSION. Continent urinary diver- sion surgeries do not require use of an ostomy bag. Instead, they require lifelong self-catheterization on a set schedule to empty the urine. They are not done as frequently today as in the past due to the development of the orthotopic neobladder. One type of a continent diversion is the Indiana pouch, which has a reservoir created using a portion of the ascending colon and terminal ileum with the ileocecal valve keeping the urine inside the reservoir (see Fig. 37.5). ORTHOTOPIC NEOBLADDER. This continent urinary diver- sion surgery involves formation of an orthotopic bladder using a section of the intestine to make a neobladder ( neo = “new”) and implanting both the ureters and the urethra into the neo- bladder (see Fig. 37.5). It may be the preferred type of diver- sion because it does not require an ostomy bag or lifelong catheterization. After this surgery, the patient can void through the urethra, although incontinence may be an issue, especially at night, and intermittent catheterization may be needed. Nursing Care Nursing care of the postoperative urological patient is similar to care following a major surgical procedure (see Chapter 12). Urine output is monitored. Obstruction of urine output must be reported to prevent complications. A consultation with a nurse who specializes in wound, ostomy, and continence (WOC) care or an ostomy support group may be helpful before and after surgery. The patient is taught to monitor the stoma and care for the urinary diversion and surrounding skin after surgery. This may involve wearing an ostomy appliance or frequently draining the continent pouch with a catheter. Be sensitive to the patient’s anxiety about caring for the urinary diversion. Body image disturbance may occur because of the change in body function. Assist the patient with coping interventions and learning signs and symptoms of infection to report. Cancer of the Kidney Cancer of the kidney is among the 10 most common cancers in both men and women. The American Cancer Society (2021b) estimate for 2021 is for more than 76,080 new cases of kidney cancer in the United States. Kidney cancer is diagnosed most often in those age 65 to 74. Men have twice the incidence of women. Risk factors include smoking, obesity, hypertension, long-term kidney dialysis, genetics (although rarely), and exposure to radiation, asbestos, and industrial pollution. Signs and Symptoms The three classic symptoms of kidney cancer are hematu- ria, dull pain in the flank area, and a mass in the area. Less specific symptoms include fever, weight loss, night sweats, hypertension, anemia, polycythemia, swelling in the legs, fatigue, anorexia, and constipation. Often the cancer has metastasized before it is diagnosed because the kidney has a
large volume of circulating blood, which increases the risk of cancer spread. In addition, the disease has few early symp- toms. Symptoms of metastasis may be the first evidence of kidney cancer and include weight loss, cough, bone frac- tures, liver abnormalities, and increasing weakness. Diagnostic Tests Diagnostic tests include a cystoscopy and pyelogram, ultra- sound examination of the kidneys, CT scan of the abdo- men, and MRI. A definitive diagnosis is made with a renal biopsy. Therapeutic Measures Surgery is the commonly used treatment for cancer of the kid- ney. A radical nephrectomy removes the entire kidney along with the adrenal gland and other surrounding structures, including fascia, fat, and lymph nodes. In nephron-sparing surgery, only the tumor is removed, and the healthy part of the kidney is saved. Radiation therapy, immunotherapy, or chemotherapy may be used after the surgery. Nursing Care After nephrectomy, postoperative nursing care mirrors that of any major surgery (see Chapter 12). Monitor urine output. Report changes in urine amount or color, bleeding, or signs of infection. The patient should be monitored for shortness of breath or diminished breath sounds on the affected side. Surgically induced or spontaneous pneumothorax may occur after a nephrectomy. Reinforce discharge teaching for wound care, pain management, medications, and follow-up care.
RENAL SYSTEM TRAUMA
Causes of trauma to the kidney, ureters, and bladder include motor vehicle accidents, sports injuries, falls, and gunshot and stab wounds. Bladder trauma or rupture may occur with pelvic fractures or trauma from a blow to the lower abdomen when the bladder is full. Data collection includes a history of the injury and inspection of the abdomen and flank for asymmetry, bruising, or swelling. Flank or abdominal pain, hematuria, and inability to void may be present. Diagnostic tests include urinalysis, ultrasound, CT, and MRI. Treatment depends on the injury and may include a urinary catheter or surgical intervention. Nursing care includes monitoring vital signs, pain management, measuring I&O, and moni- toring IV fluids.
POLYCYSTIC KIDNEY DISEASE
Polycystic kidney disease is a hereditary disorder that can result in CKD. It is characterized by formation of multiple cysts in the kidney that can eventually replace normal kidney
• WORD • BUILDING • nephrectomy: nephr—kidney + ectomy—excision
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