NU 236 Care of the Adult II: Genitourinary

Micturation

urination

Dysuria

painful or difficult urination

Frequency

need to void often

Hesitancy

difficulty starting urine flow

Urgency

sudden intense feeling to void

Nocturia

awakened from sleep to void

Anuria

output < 100 cc/day

Oliguria

decreased urine output (100-400cc/day)

Polyuria

excessive urination (>2000 ml/day)

Azotemia

increased BUN, creatinine in the blood; indicative of renal impairment

Uremia

presence of urinary waste in the blood; sign of renal failure

Adrenal Glands

a pair of endocrine glands that sit just above the kidneys

Urinary Changes with Aging

Decreased blood flow to kidneys

Decreased filtration

Decreased bladder capacity

Weakened sphincter muscles

Shortened urethra (women)

If a patient is making

Kidneys not making urine

Bladder is not letting urine out

Nursing Interventions: Elderly

Encourage urination 2-4 hours

Observe for atypical UTI signs (confusion)

Nocturia

Provide privacy, help, and voiding stimulants

___________ is a safety issue in the elderly.

nocturia

New onset confusion in an elder, think?

UTI

Diagnostics: Labs

Creatinine

BUN

Glomerular filtration rate

Serum Creatinine

blood test measuring the end product of protein/muscle metabolism; increase indicates renal disease, as it only increases when 50% of renal function is impaired

Blood Urea Nitrogen (BUN)

blood test measuring the kidney's ability to excrete nitrogen, a byproduct of liver protein metabolism;

abnormal is not specific to kidney disease

Urinalysis

the examination of urine to determine the presence of abnormal elements

Obtaining a Urinalysis

Instruct pt. to wipe 3x, front to back

Start void, discard first few seconds, then obtain mid-void sample

Also can be obtained by catheterization

Urine Culture/Sensitivity

used to identify causative organisms and antibiotics in suspected infections; can take 24-48 hr

Obtaining a Urine C&S

Must be mid-stream, clean catch, or catheter and should be done BEFORE antibiotics are given

Clean Catch

a method of obtaining a urine specimen using a special cleansing technique; also called midstream urine

How are catheter specimens collected?

sterile aspiration from the catheter PORT, not collection bag

24 Hour Urine

all urine within the designated time frame is collected to measure a variety of things (creatinine clearance, nitrogen, sodium, etc.) to rule in or out various disease

Collecting 24 Hour Urine

At the start time, have patient void and discard then collect ALL urine and keep on ice

Put up signs in BR to remind staff

At 24 hr point, patient can void or empty catheter to add that urine to specimen and send it labeled to the lab

Ultrasonography

ultrasound uses sound waves to identify kidney structures; no contrast and is not painful

Bladder Scan

non-invasive bedside test the RN can perform with/without order at bedside; helpful for checking post-void residual

Kidney, Ureter, and Bladder X-Ray (KUB)

measures size of organs and can identify obvious stones, stictures, obstructions; check pregnancy status

Intravenous Pyelography (IVP)

series of x-rays that give information about the kidney size, shape, and rate of excretion with radiopaque dye injected IV

Nursing Interventions: IVP

Bowel prep and NPO midnight

Assess kidney function (Nephrotoxic) and allergy to contrast

Education

Contraindications: IVP

Pregnancy

Contrast allergy

Recent renal surgery or severe renal impairment

What must be considered with any procedure/test using contrast media?

History of renal insufficiency

Metformin in the last 48 hrs; must be d/c due to risk of lactic acidosis

Hydration status

NPO

Renal Arteriography

invasive procedure that assesses renal blood flow by injecting contrast into the renal arteries

Interventions: Renal Arteriography

SAME for all contrast procedures/bowel prep.

Assess for bleeding and check site often

Strict bedrest for 6 hrs to prevent bleeding

Renal Biopsy

invasive procedure that requires a permit and can be closed or open to check for kidney cancer

Interventions: Renal Biopsy

Patient is at major risk for bleeding!

Monitor bleeding, VS, urine output, H&H, shock symptoms

Strict bedrest for 6 hours after

Monitor urine character; hematuria is okay but NO clots

No strenous activity for 1-2 weeks

Cystoscopy

invasive or operative procedure that requirres consent; scope is inserted through the urethra and is used to diagnose urethral/bladder trauma, tumors, stones, or enlarged prostate OR treat these and can be done OR/office

Nursing Interventions: Cystoscopy

Monitor airway, VS, urine output, bleeding, and signs of infecton

May have catheter after, monitor urine characteristics (should be pink)

Encourage fluids to clear urine

Urinary Tract Infection

infection of one or more organs of the urinary tract

Upper urinary tract infection

pyelonephritis

Lower urinary tract infections

Cystitis

Urethritis

Prostatitis

Bladder Bundle

Make catheter policies and protocols and assess and document the NEED for catheters

When should Foleys be used?

Operative ONLY as necessary

Urine output monitoring in the critically ill

Acute retention/obstruction

Assistance in pressure ulcer healing for incontinence

At patient request, to improve comfort at EOL

Interventions: Foley Catheters

Remove ASAP (preferably 24 hrs)

Foley care

Keep bag below bed

Empty bag and monitor/document output

Assess need for catheter daily

Suprapubic Catheter

indwelling catheter inserted directly in the bladder through an abdominal incision above the pubic bone; used in patients requiring long-term catheterization and should be washed with soap and water daily and changed 1x/month

Cystitis

inflammation of the bladder that can be infectious or non-infectious (chemicals/radiation)

Causes: Cystitis

E-coli

Foleys!

Assessment: Cystitis

Frequency

Urgency

Dysuria

Backache

Incontinence

Fullness

Urosepsis

spread of infection from the urinary tract to the bloodstream that results in a systemic infection; elderly are at HIGH risk with 15% fatality and can present with fever, tachycardia, and confusion

Labs: Cystitis

Urinalysis for bacteria/WBC/RBC

Urine culture/sensitivity for bacterial type

Nursing Interventions: Bladder Hygiene

Encourage 8-10 glasses of fluid a day

Wipe front to back

Good glucose control

Vitamin C/cranberry juice to acidify

Voiding after intercourse

Cotton underwear

Avoid douches, bubble baths, powder, or sprays

Nursing Interventions: Cystitis

Manage pain and treat infection

Regular bladder hygiene

> 3 infections/year = further workup for an immune or structural cause

Medications: Cystitis

Abx after culture

Anesthetic (pyridum) makes urine red

Anticholinergics (antispasmotics)

Pyelonephritis

bacterial infection of the upper urinary tract that often requires hospitalization

Assessment: Pyelonephritis

High risk patients

Fever

Chills

Tachycardia

Flank pain

CVA tenderness

N/V

Malaise

Urinalysis for WBC/bacteria

KUB or cystogram

Interventions: Pyelonephritis

Manage infection, pain, and fever

Analgesics and antibiotics

Encourage fluid

Surgery for structural causes

Monitor for renal failure

Hydronephrosis

the dilation (swelling) of one or both kidneys

Urolithiasis

kidney stones; cause not entirely understood

Assessment: Urolithiasis

Assess for renal colic

May have nausea/vomiting, sweating

Hematuria

Dysuria

Fever

KUB, IVP, or CT

Risks: Urolithiasis

Infection

Urinary stasis/retention

Dehydration

Increased uric acid

Family history

Renal Colic

excruciating spasmodic pain caused by kidney stones

Nursing Interventions: Urolithiasis

Manage pain and risk for infection

Strain all urine

Narcotics IVP for quick relief

IV fluids

If unable to pass a kidney stone, what can be done?

Extracorporeal Shock Wave Lithotripsy

Ureteroscopy/stent

Percutaneous nephrostoureterolithotomy

Open surgery if large

Ureteral Stent

insertion of a tube into the ureter to prevent/treat obstruction of urine flow; used for 3-7 days and fever should be reported, patient can remove if MD says string is showing

Nephrostomy Tube

a tube inserted through the abdominal wall into the renal pelvis to drain urine; change sterile dressing every 2-3 days or when wet, patient can shower if they wrap but NO baths

Renal Cell Carcinoma

cancer of the kidneys

Causes: Renal Cell Carcinoma

tobacco/chemical exposure

Assessment: Renal Cell Carcinoma

Usually asymptomatic

Dull, aching flank pain

Hematuria

Fever

Anemia

Hypercalcemia

Diagnosed with CT scan

Treatment: Renal Cell Carcinoma

nephrectomy

Nephrectomy

surgical removal of a kidney that can be radical or laparascopic

Risks: Nephrectomy

BLEEDING

Adrenal insufficiency

Respiratory complications

Nursing Interventions: Nephrectomy

Check for bleeding UNDER patient

Check for BP drop indicating bleeding

Check for abdominal distention

Watch for adrenal insufficiency and treat with IV fluid/blood if needed

Vitals often

Vigilant turn, cough, deep, breathe due to high risk for pneumonia

Adrenal Insufficiency

condition in which the adrenal glands underproduce necessary hormones; indicated by large urinary output followed by oliguria/hypotension

Testicular Cancer

rare cancer common among age 15-35 with often unknown cause, but can be undescended testes, family hx, or caucasian

Assessment: Testicular Cancer

Assess for unilateral lump or swelling

Patient should do TSE monthly

Treatment: Testicular Cancer

very treatable with orchiectomy; discuss sperm storage and or prosthesis

Orchiectomy

removal of one or both of the testes

Bladder Cancer

cancer of the bladder that is caused by smoking

Assessment: Bladder Cancer

Painless, intermittent hematuria with clots

Diagnosed with cystoscopy or CT for spread

Treatment: Bladder Cancer

Instill toxic substances into bladder (non-surgical)

TURBT (Partial cystectomy)

Complete cystectomy

TURBT

transurethral resection of bladder tumor

Complete cystectomy

removal of the entire bladder or surrounding muscle/tissue

Ileal conduit (Urostomy)

use of a small piece of small bowel to convey urine to the ureters and to a stoma in the abdomen; requires a ostomy bag for life to drain urine/mucus and is used for incontinent patients

Continent Internal Ileal Reservoir

small dimple in skin opens to. a bladder made of bowel; patient needs to self-cath intermittently for the rest of their life

Interventions: Ileal Conduit

Inspect stoma

Change flange/pouch every 3-5 days

Attach to large drainage bag at night

Benign Prostatic Hypertrophy

enlargement of the prostate gland that is very common in older men

Assessment: BPH

Weak stream

Distention

Frequency

Urgency

Nocturia

Retention

Treatment: BPH

Drug therapy

Frequent ejaculation

Avoid alcohol, diuretics, caffeine, fluid before bed

Avoid anticholinergics, antihistamines, and decongestants

Transurethral resection of the prostate

Trans-Urethral Resection of the Prostate (TURP)

an instrument is inserted up the urethra to remove the section of the prostate that is blocking urine flow

Interventions: TURP

May have CBI to keep catheter from clotting with a 3-way foley and 3000mL NS bags

Assess color of drainage to determine drip rate

Dark red or clots = speed up

Pink tinged/clear = slow down

No output = shut off and hand irrigate to clear clots

Encourage 2000mL/day

Must void independently to go home

Continous Bladder Irrigation

flushing the bladder with normal saline to prevent clot formation; foley output - irrigation = true urine output

Bladder Spasms

contractions, possibly painful, of the musculature of the urinary bladder

Prostate Cancer

common, slow growing cancer of the prostate gland that can spread; risks are age, family hx, and African American

Screening: Prostate Cancer

After age 50, DRE/PSA

Begin screening at 40 for African Americans

Digital Rectal Exam (DRE)

insertion of a finger into the male rectum to palpate the rectum and prostate

Prostate Specific Antigen (PSA)

blood test to screen for prostate cancer; > 4 = BPH/cancer

Prostate Cancer vs. BPH

BPH is benign and occurs in > 50% males

Prostate cancer is hard/irregular on a DRE, while BPH is boggy/uniform on DRE

Prostate cancer occurs in the periphery of the gland while BPH is in the center