UNIT NINE
720
Understanding the Urinary System
Nursing Care Plan for the Patient With Chronic Kidney Disease
Nursing Diagnosis: Excess Fluid Volume related to kidney’s inability to excrete fluid Expected Outcomes: Fluid volume will be stable as evidenced by stable weight, absence of edema, clear lung sounds, and blood pressure within the patient’s normal parameters. Evaluation of Outcomes: Is weight stable? Is edema absent? Are lungs clear? Is blood pressure within the patient’s normal parameters? Intervention Rationale Evaluation
Monitor weight daily at same time; report gain of more than 2 pounds.
Is weight stable? Should HCP be notified of change?
Those retaining fluid will have weight gain.
Monitor intake and output and for presence of edema.
Is intake more than output? Is edema present? Are these changes?
This reveals degree of fluid retention.
Are symptoms of heart failure present?
Monitor and report crackles in lungs, shortness of breath, frothy sputum, jugular vein distention, tachycardia, arrythmias.
These are symptoms of heart failure that may accompany fluid overload.
Reinforce teaching to maintain sodium and fluid restrictions as ordered.
Does patient understand and maintain sodium and fluid restriction?
For those on dialysis, fluid intake is restricted so that weight gains are no more than 1 to 3 kg between dialysis sessions.
• Consult dietitian for calorie count need and renal diet restrictions to develop a dietary plan . • Provide frequent oral care to reduce urine taste in mouth and enhance appetite . • Offer antiemetics before meals and frequent small meals to prevent nausea . Key Points • UTIs are most often an ascending infection, starting at the external urinary meatus and moving up toward the bladder and kidneys, that are frequently caused by the bacterium Escherichia coli , which is commonly found in feces. • Lower UTIs include urethritis, prostatitis, and cystitis. Upper UTIs include pyelonephritis and ureteritis. UTIs are the most common hospital-acquired infection. • Older adults have an increased incidence of UTIs due to diminished immune function, diabetes, and a neurogenic bladder that fails to completely empty. • Renal calculi (urolithiasis) are stones in the urinary tract that usually begin in the kidney (nephrolithiasis) but can be found in the ureter (ureterolithiasis). IV fluids, NSAIDs, and lithotripsy (sound shock waves or laser energy to break the stone into small fragments) treat renal calculi. • Hydronephrosis (distention of the renal pelvis and calices) results from obstruction of urine flow in the urinary tract. This increases pressure on the structures of the kidney, which can damage the kidney, impair its function, and ultimately lead to acute or chronic kidney disease. Obstruction causes are stricture in a ureter or the urethra, renal calculi, tumors, or an enlarged prostate.
Evaluation Outcomes have been achieved if the patient maintains intact skin, does not develop infection, is free from bleeding, and maintains ideal weight. See also “Nursing Care Plan for the Patient With Chronic Kidney Disease.”
• Cancer of the bladder often starts as a benign growth on the bladder wall that undergoes cancerous changes. Some cancers occur as small, wartlike growths on the inside of the bladder. Others form large tumors that grow into the muscle wall of the bladder and require surgical removal. • Those who smoke develop bladder cancer twice as often as people who do not smoke. • Urinary diversion is used after a cystectomy: urostomy or ileal conduit (section of the ileum or colon becomes conduit for urine); continent urinary diversion (ileum made into a reservoir for urine with ureters implanted into the side), which requires self-catheterization at 4-hour intervals; orthotopic neobladder (section of intestine made into a neobladder with ureters and urethra implanted into the neobladder), which allows the patient to void through the urethra. • Risk factors for kidney cancer include smoking, obesity, hypertension, long-term kidney dialysis, genetics (rare), and exposure to radiation, asbestos, and industrial pollution. • Causes of trauma to the kidney, ureters, and bladder include motor vehicle accidents, sports injuries, falls, and gunshot and stab wounds.
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