Urology

A WET BED

-Acid-Base Balance
-Water Removal
-Erythropoiesis
-Toxin Removal
-Blood Pressure Control
-Electrolyte Balance
-Vitamin D Activation

Bacteriuria

Bacterial count >100,000 colonies/ml - infection is present

Urinary frequency

Voiding more than every 3 hours

Urinary retention

Inability to completely empty the bladder

Oliguria

Urine OP < 400 ml in 24 hrs or 0.5ml/kg/hr over 6 hours

Anuria

Urine OP < 50 ml/day

Where does a nurse need to focus when preforming a head to toe for a urinary issue?

Focusing on abdomen, suprapubic region, genitalia, low back and lower extremities

T/F: palpation of the kidneys is a normal finding

False, this may indicate enlargement

What are some physical symptoms to look out for in an assessment for urology disorders?

- Pain (OLDCARTS)
- Changes in voiding problems
- GI symptoms (N/V, diarrhea, abdominal pain or discomfort)
- Unexplained anemia

What is important in a health hx for renal disorders?

Risk factors and PMHx of stones or UTIs

Examples of genetically passed down renal disorders

- Polycystic kidney disease (PKD)
- Renal cystic disease
- Diabetes
- CAD
- Pulmonary HTN

What is important in a family history assessment for renal disorders?

- Genetically passed disorders
- Male infertility or cystic fibrosis
- Renal tumors or cancers

How does HTN relate to renal disorders?

Renal insufficiency

How does BPH relate to renal disorders?

Oliguria/anuria

How does exposure to chemicals, UTIs, Caluli, DM, and old age relate to renal disorders?

AKI

How does advanced age (incomplete emptying), spinal cord injury, procedures (cystoscopy and catheterization) , MS, and vaginal childbirth (incontinence only) relate to renal disorders?

UTI and incontinence

How does DM, MS, stroke, BPH, mass/tumor, calculi, trauma, and spinal cord injury relate to renal disorders?

Neurogenic bladder/retention

How does gout, Crohn's, hyperparathyroidism, ileostomy, immobilization, cancer, renal tubular acidosis, granulomatous diseases, and PKD relate to renal disorders?

Renal calculi

How does pelvic surgery and radiation therapy to the pelvis relate to renal disorders?

Structural trauma

What are some urine tests?

- Urinalysis (UA)
- Urine culture and sensitivity
- 24hr urine collection
- Osmolality
- Specific gravity

Urinalysis (UA)

Checks color, clarity, pH, specific gravity, and presence of cells/protein/ glucose/ketones

What is normal urine output (UO)?

1mL/kg/hr (1-2L/day)

24hr urine collection

- Picture of the kidney's ability to clear solutes from plasma
- Usually measuring creatinine in urine

Osmolality

- Measures presence of solutes in urine

- Normal range: 200-800

- Less is best!

Specific gravity

- Measures density compared to water

- Normal range is 1.005-1.025

What can an abnormally low specific gravity show?

Can be from DI, glomerulonephritis, and hyperhydration

What can abnormally high specific gravity show?

Can be from diabetes mellitus, nephritis, and dehydration

BUN

End product of protein metabolism

(8-20 mg/dL)

What does a high BUN indicate?

Indicate the kidneys are not filtering well​​

Creatinine

Waste product that is not filtered appropriately in presence of renal damage

(male 0.6-1.2 mg/dL; female 0.4-1 mg/dL)

eGFR

Used to identify the stage of kidney disease

Stage 1 GFR rate

90+

Possible kidney damage (protein in urine) with normal kidney function

Stage 2 GFR rate

60-89

Kidney damage with mild loss of function

Stage 3a GFR rate

45-59

Mild to moderate loss of function

Stage 3b GFR rate

30-44

Moderate to severe loss of function

Stage 4 GFR rate

15-29

Severe loss of kidney function

Stage 5 GFR rate

Less than 15

Kidney failure or ESRD

Gerontologic considerations: Renal

- GFR decreases 1pt/yr starting age 35-40

- Increases risk for AKI due to structural changes

- Increased risk of dehydration and hypernatremia associated with decreased thirst

Gerontologic considerations: Urology

Decrease muscle tone and decreased vasopressin and ADH levels leads to:
- increased residual urine
- Increased risk of UTI
- Increased likelihood of urinary incontinence
- May self limit fluid intake (watch for dehydration)
- Symptoms may appear as other GI issues

What is AKI?

Renal damage resulting in a rapid loss of function (impaired filtration/regulatory functions)

What is the criteria to diagnose AKI?

Increase in baseline serum Cr by 50% or greater

What does AKI look like clinically?

- Changes to BUN, Cr, and GFR
- Fluid and electrolyte imbalances
- Acidosis
- UO may be effected
- Critically ill patient: lethargy, drowsiness, HA, muscle twitching, seizures

AKI: initiation phase

Begins at the initial insult to kidney function and ends when the oliguria phase starts

AKI: oliguria phase

Increase of serum concentration of substances usually excreted by kidneys (ex – creatinine, K+, phos, mag); UO drops to 400ml/day or less

- Watch for uremic symptoms, life threating electrolyte imbalances such as hyperkalemia may also develop

AKI: diuresis pahse

Gradual increase in GFR and UO, stabilization of labs with possible decrease

- Continue to monitor for uremic symptoms and for possible dehydration

AKI: recovery phase

Labs return close to patient baseline; permanently decreased GFR will be present (1-3%)

What can cause AKI?

- Changes to perfusion
- Injury to renal tissue (Ischemia)
- Physical comorbidities (DM present in ~40% of AKI cases)

T/F: Volume depletion, impaired cardiac function, vasodilation, and increased diuresis (physiological or medication) can cause an AKI

True

Examples of renal tissue injury

- Infections or obstructions in the renal/urologic tract
- Transfusion reactions or hemolytic anemia
- Trauma/crushing injuries
- Rhabdomyolysis
- Nephrotic agents (NSAIDS, ACE inhibitors, chemicals, contrasts, etc...)

Goal of AKI treatment

Restore normal chemical balance and prevent further complications

Interdisciplinary interventions for AKI

- Treat underlying cause
- Mange fluid balance, avoid excess
- Provide renal replacement therapy (RRT)
- Strict asepsis for infection prevention

Nursing interventions for AKI

- Assess/monitor daily weights, BP, CVP, I/O balance, total UO per 24 hrs, blood and urine labs (electrolytes: especially K+), physical assessment
- Aeptic techniques
- Plan and provide appropriate patient education and psychosocial support

How are UTIs identified?

By location, upper or lower

Upper UTIs include...

Pyelonephritis, interstitial nephritis, and abscess (renal or perirenal)

Lower UTIs include...

Cystitis (bladder), prostatitis (prostate), and urethritis (urethra)

What are the complications of an untreated UTI?

AKI, CKD, or urosepsis

Risk factors for UTI

- Bacteria in the urinary tract

- Female gender - anatomy (shorter), pregnancy, and intercourse

- Immunosuppression

- Urinary stasis and/or backwards flow

- Instrumentation of the urinary tract (catheters/procedures)

Geriatric risk factors for UTI

- Cognitive impairment
- Frequent use of antimicrobials
- Multiple chronic medical conditions
- Immunocompromise
- Immobility
- Incomplete emptying of bladder
- Low fluid intake, dehydration
- Poor hygiene/stool incontinence

HARD TO VOID

Hormone changes (pregnancy, menopause)
Antibiotics (changes normal flora)
Renal stones (obstructs flow)
Diabetes (high BG and poor immunity)
Toiletries powders, perfumes, bubble baths)
Obstruction (BPH, masses/tumors)
Vesicoureteral reflux (Urine returns to ureters)
Overextended bladder (immobility, spinal cord injury)
Invasive (intercourse, indwelling catheter, procedure)
Disease states

T/F: a UTI in a patient with a catheter can be asymptomatic

True

Nursing interventions for UTI

- Pain relief
- Antibiotics, analgesics, and antispasmodics
- Heat therapy for pain and spasm relief
- Increase fluid intake, but avoiding irritants (coffee, tea, citrus, etc...)
- Education

What are causes of lower UTIs?

Bacteria and reflux of urine into the bladder

Lower UTI assessment findings for the elderly

Incontinence, delirium, decreased sensation leading to no report of symptoms

Lower UTI assessment for post menopausal women

Malaise, nocturia, incontinence, foul-smelling urine

Treatment for lower UTI

- Anti-infectives/antibiotics and urinary analgesics; 3-5 days
- Be sure to administer them timely and check for nursing implications

How is an upper UTI caused?

Typically caused by bacteria traveling upward from the bladder or from a blood stream infection that reaches the kidneys

Pyelonephritis

Bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys

T/F: upper UTIs are not a common cause of urosepsis

False

Acute upper UTI/pyelonephritis assessment findings

Chills, fever, low back/flank pain, N/V, headache, malaise

Chronic upper UTI/pyelonephritis assessment findings

Asymptomatic unless the patient is experiencing an acute exacerbation and may also show poor appetite, excessive thirst, and weight loss

How is an upper UTI/pyelonephritis treated?

Anti-infectives/antibiotics and urinary analgesics for 2 weeks

__________ imaging or _________ may be ordered for pyelonephritis

CT, pyelogram

What are complications of chronic pyelonephritis?

ESKD, HTN, and renal calculi

Stress incontinence

Happens with sneezes, laughing, exertion, etc... (no structural damage)
M-after prostatectomy; F-after pregnancy

Overflow incontinence

Overdistended bladder due to bladder muscle dysfunction or obstructed outflow

Urge incontinence

Aware of need to void but can't get to a toilet quickly enough

Functional incontinence

Physical or cognitive impairment

Iatrogenic incontinence

External medical factors (ex - medications)

Neurogenic bladder

A nervous system disorder that impacts voiding, by causing either incontinence or retention

How does neurogenic bladder relate to incontinence?

It can lead to functional incontinence, spastic muscle tone, empties with no controlling influence/regulation

How does neurogenic bladder relate to retention?

- Flaccid muscle tone - no bladder contraction so the bladder becomes overdistended; must be straight-cath'd to empty
- May eventually lead to overflow incontinence when it is too full

What are complications of neurogenic bladder?

Infection, impaired skin integrity, renal calculi

Nursing considerations for incontinence

- Assessment should include discussion of symptoms
- Skin care!!
- Patient education: bladder training, fluid management, pelvic floor exercise
- Surgery
- Financial impact/support/resources

Nursing consideration for retention

- Older adults may retain 50-100ml due to changes in bladder tonicity
- Ask the patient lots of questions to understand their voiding patterns
- Palpate for bladder distention and lower abdominal pain

Nursing interventions for retention

- Promote good body position for elimination
- Apply warmth to perineum
- Reduce caffeine
- Request MD order for bladder ultrasound to check for retention/distention or post-void residual
- Straight cath if indicated, try to avoid indwelling catheters

Type of catheters

Intermittent/straight, indwelling, suprapubic

When are catheters used?

ONLY WHEN NECESSARY
- Retention/neurogenic bladder
- Post-op following urological procedures
- Stage 3-4 skin injuries of the perineum
- Urinary tract obstruction
- End-of-life care/critical illness care

Nursing considerations for catheters

- CAUTI prevention
Catheter care bundle:
- Below the bladder, not on the floor, perineal care 2x/day and prn, secured to leg, no kinks in tubing
- Is it truly needed?
- Skin care
- Asepsis of catheter bag /ports

Causes of renal calculi

- Increased serum calcium levels create the most common stones, about 80%

- Struvite (mixture of magnesium, ammonia, and phosphate in an alkalotic urine)

- Excess uric acid (acidic urine, pH < 5.5)

T/F: renal calculi are more common in men than women

True

Diagnostics for renal calculi

CT and blood and urine tests

Calcium oxalate foods

Peanuts, dark leafy greens, beets, chocolate, sweet potatoes

_________ stones are a mixture of Mg, ammonia, and phosphate and are common in women and start from bacteria exposure

Struvite

__________ stones are common in men and for people with large amounts of dietary protein (and gout)

Uric Acid

Assessment findings for renal calculi

- Pain - lower abdomen/dysuria
- Signs of obstruction - hematuria, frequency/oliguria
- Fever & chills
- Nausea & vomiting
- Diaphoresis & pallor
Elevated HR, RR, and BP

Nursing interventions for renal calculi

- Pain meds, heat therapy

- Increase fluid intake, unless contraindicated; avoid activities that may cause sweating

- Monitor for s/s of UTI and for blood/stones in urine

- Save stones for lab analysis

- Monitor I&O for oliguria/anuria

- Dietary restrictions: foods high in, protein, sodium (table salt), or oxalate

Medical interventions for renal calculi

Ureteroscopy, lithotripsy or nephrolithotomy

What are diagnostics for urinary tract cancers?

CT, MRI, ultrasound, manual exam, and biopsy

Bladder cancer

- The 6th most common cancer
- 25% of the patients are 65 or older
- more common in men than women
- Smoking increases one's risk by 50%
- Accounts for 15,000+ deaths/year

What is the treatment for bladder cancer?

- Surgical treatment is radical cystectomy with urinary diversion
- Transurethral resection or cauterization may be done for benign tumors