372 Exam 3 Urinary system

Urinary priorities of care

hydration

safety: fall prevention, skin integrity, urinary infections

effective elimination

quality of life

Normal urinary elimination

Bladder capacity: 500 mL

PVR: <50-100 (w/older adults), >200 mL is pathologic

Urine output: 1000-2000 mL/24 hr, 500-1000 mL <intake volume

Urolithiasis interventions

Assess & manage renal colic pain, N/V, UA (esp. hematuria), diaphoresis; VS (fever & chills)

prep for IV pyelogram, cystoscopy, & other imaging

encourage hydration and low oxalate, protein, and sodium diet

prep for lithotripsy or Sx

Urolithiasis management

NSAIDs, oxybutynin, propantheline, opioids

Hydration to flush out stones

Urolithiasis diet recommendations

spinach, black tea, rhubarb

low Na leads to decreased Ca in urine, low purines prevents uric acid stones

BPH interventions

Assess for hematuria, BUN, PSA, US, biopsy results, and PVR

Administer alpha reductase inhibitor (finasteride) and blockers (tamsulosin)

Periop care (e.g., for suprapubic cystostomy or TURP).

BPH management

Transurethral resection of prostate (suprapubic or retropubic)

Postop care - assess for shock or hemorrhage, I/Os, encourage physical activity, assess PVR

Adrenergic/ACH agents

 antipsychotics (clozapine, quetiapine), TCAs (nortriptyline, amitriptyline) opioids, benzos, ipratropium

Pyelonephritis

Assess s/sx infection, frequency, dysuria, flank pain, serial urine culture, labs, bedrest during acute phase, antibiotics, analgesics

Geriatric changes to urinary system

Renal atrophy

Decreased tone and elasticity of bladder, ureter, and urethra

Decreased bladder capacity

Glomerular sclerosis

Decreased renal perfusion

Decreased ability to concentrate urine

Nursing interventions for urinary system in older adults

Incontinence care: Schedule voiding for bladder training & fall prevention, pelvic exercises, skin care, condom catheters & incontinence pads

Monitor I/Os & for infection

Encourage cranberry w/o added sugar

Urinary incontinence patient education

Hydration (~3 L/d)

Physical & bladder training

Diet recomendations & smoking cessation

Drug therapy

Notify provider (med changes, flank pain, infection cues, weight changes, or swelling) 

Bladder training

Schedule voiding every 45min-2 hours and go at that time regardless of urge, slowly increase period between voids by 15-30 minutes

goal is to work up to voiding interval of 3-4hrs.

Teach distraction techniques for urge suppression to avoid premature voiding.

Provide privacy and perhaps start running water while voiding if pt experiences hesitancy; do not leave pt on toilet/bedpan longer than 5 min.

Regular PA & kegel exercises

Meds for urinary incontinence

oxybutynin - anticholinergic, decreases involuntary contractions and relaxes bladder smooth muscle

mirabegron and midodrine - increases sympathetic tone

Urinary diversion system types

Bladder drainage system (Foley) – Clamp intermittently prior to removal to train bladder

Straight intermittent – For neurogenic badder; BPH; postop

Nephrostomy – Temporary; anchored in renal pelvis through flank incision; never clamp; pt may still void if unilateral

Ureterostomy – never irrigate

Suprapubic – Placed in bladder via abdominal incision; voiding may still occur

Urinary diversion systems care

Maintain Flow: 

• Avoid kinks; keep bag below the level of the kidneys/bladder, coil excess tubing

• Monitor output: >30 mL/hr,

• Irrigate toward patient only if ordered

• Avoid removing >1L at a time (clamp, wait 15-30 minutes  resume draining)

• Promote adequate hydration, physical activity, & voiding habits

Prevent & Monitor for Infection:

• Keep the catheter connected to drainage system except during irrigations

• Use sterile technique to obtain samples from the drainage port