Nursing Management of Urological Disorders 2/12/26

Nursing Management of a Client with Urological Disorders

References:

  • Hinkle, Cheever, Overbaugh (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15th Ed).

  • Chapters used: Chapter 49: Urinary Disorders; p. 1605-1610, 1610-1611, 1611-1616, 1620-1625, 1626-1629.

Student Learning Outcomes

  • Correlate the pathophysiology, medical treatment, complications, and nursing interventions for urologic disorders.

  • Prioritize nursing care for urologic disorders to reduce risk potential.

  • Design nursing care plans for clients with urologic disorders that incorporate pharmacological, dietary, lifestyle, and lifespan considerations.

  • Differentiate signs and symptoms of urologic disorders.

  • Correlate abnormal urologic assessment and diagnostic findings to priority nursing actions.

  • Explain available community resources and settings for clients with urologic disorders.

Urinary Incontinence

  • Prevalence: More than 25 ext{ million} adults in the US have urinary incontinence, which is often underreported and undiagnosed.

    • Women are affected 2 times more often than men.

    • It is more common in older adults.

  • Risk Factors (Referenced from Chart 49-4, p. 1611):

    • Cognitive impairments (leading to functional incontinence).

    • Inability to get to the toilet on time (leading to urge incontinence).

    • Age-related factors (e.g., Benign Prostatic Hyperplasia - BPH), which can cause overflow incontinence.

    • High-impact exercise (contributing to stress incontinence).

    • Pelvic muscle weakness (contributing to urge incontinence).

    • Pregnancy (leading to stress incontinence).

  • Assessment & Diagnostic Findings:

    • Detailed description of the problem.

    • History of medication use (e.g., diuretics, muscle relaxants).

    • Voiding history (frequency, nocturia).

    • Diary of intake & output.

    • Bladder scans to check for residual urine.

  • Treatment - Behavioral Therapy (Nonpharmacological):

    • Voiding diary.

    • Prompted voiding.

    • Kegel exercises.

  • Causes and Nursing Interventions (Referenced from Chart 49-5, p. 1613 - for student review and discussion):

    • The nurse would recommend interventions based on the identified cause (e.g., behavioral therapies for urge incontinence, pelvic floor exercises for stress incontinence, managing underlying conditions for overflow incontinence). Other interventions could include fluid management, timed voiding, and avoiding bladder irritants.

  • Medications:

    • Anticholinergics: Inhibit bladder contraction.

      • Examples: oxybutynin, tolterodine, fesoterodine.

    • Tricyclic Antidepressants: Decrease bladder contractions and increase bladder neck resistance.

      • Examples: amitriptyline, duloxetine.

    • Alpha-Adrenergic Blockers: Used primarily when incontinence is related to BPH.

      • Examples: tamsulosin, doxazosin, terazosin.

  • Surgical Intervention:

    • A common technique involves placing a tape (sling) to support the urethra and bladder, particularly for stress incontinence.

Urinary Retention

  • Definition: The inability to empty the bladder completely during attempts to void.

  • Potential Consequences: Can lead to overflow incontinence, chronic infections, pyelonephritis, hydronephrosis, and sepsis.

  • Reasons/Causes:

    • Diabetes.

    • Prostate enlargement.

    • Urethral pathology (e.g., infection, tumor, stone).

    • Pelvic injury/trauma.

    • Pregnancy.

    • Neurological disorders (e.g., stroke, spinal cord injury (SCI), Multiple Sclerosis (MS), Parkinson's disease, neurogenic bladder).

    • Medications (e.g., anticholinergics, narcotics).

  • Assessment & Diagnostic Findings:

    • Time of last urination.

    • Volume of urine voided.

    • Appearance of urine.

    • Presence of residual urine (checked via bladder scan or catheterization).

    • Presence and nature of pain.

    • Frequency of urination.

  • Complications:

    • Kidney stones (urolithiasis or nephrolithiasis).

    • Pyelonephritis.

    • Sepsis.

    • Hydronephrosis.

  • Nursing Management:

    • Goals: Prevent bladder overdistention, treat infection, and correct obstruction.

    • Strategies:

      • Encourage normal voiding patterns (e.g., provide privacy, ensure effective positioning).

      • Promote use of bathroom, commode, or standing at the edge of the bed (avoid bedpan, PureWick if possible).

      • Apply warmth to relax sphincters (e.g., sitz baths, warm compresses to the perineum, showers).

      • Interventions for residual urine: bladder scan for assessment, straight catheterization, or indwelling catheter insertion (as a last resort).

Neurogenic Bladder

  • Definition: A dysfunction resulting from a disorder or dysfunction of the nervous system, leading to incontinence.

  • Causes:

    • Spinal cord injury (SCI).

    • Spinal tumor.

    • Herniated vertebral disk.

    • Multiple sclerosis (MS).

    • Congenital disorders (e.g., spina bifida).

    • Infections affecting nerves.

    • Complications of diabetes (neuropathy).

  • Complications and Strategies:

    • Complications can mirror those of urinary retention, such as urinary tract infections, kidney stones, hydronephrosis, and potential renal failure.

    • Strategies focus on managing bladder emptying and preventing complications. (Discussed in Medical Management below).

  • Medical Management:

    • Goals:

      • Prevent overdistention of the bladder.

      • Ensure regular and complete bladder emptying.

      • Maintain urinary sterility with no stone formation.

      • Maintain adequate bladder capacity with no reflux.

    • Interventions:

      • Continuous, intermittent, or self-catheterizations.

      • External condom catheter.

      • Diet low in calcium to prevent stone formation.

      • Encourage mobility and ambulation.

      • Liberal fluid intake to flush the system.

      • Bladder training programs.

      • Parasympathomimetic medications (e.g., bethanechol) to stimulate bladder contraction.

  • Client Education:

    • Thorough education on procedures like straight catheterization is crucial for self-management.

Cancer of the Bladder

  • Prevalence: Bladder cancer affects approximately 15,000 people annually, with 25 ext{%} of cases occurring in individuals over the age of 65.

  • Metastasis: Cancers of the prostate, colon, rectum, and lower gynecologic tract in females may metastasize to the bladder.

  • Risk Factors:

    • Tobacco use (leading cause).

    • Genetic mutations.

    • Pelvic radiation.

    • Occupational exposure to chemicals.

  • Manifestations:

    • Visible, painless hematuria is the most common symptom.

    • Urinary tract infection is a common complication.

    • Alterations in voiding patterns.

    • Pelvic or back pain may occur with metastasis.

  • Assessment & Diagnostics:

    • Cystography.

    • CT and MRI scans.

    • Ultrasound.

    • Biopsies of the tumor and adjacent mucosa are definitive diagnostic procedures for evaluating prognosis and staging.

  • Surgical Management:

    • Transurethral Resection of a Bladder Tumor (TURBT):

      • For simple papillomas: Eradicates tumors through a surgical incision. Immunotherapy injection is often instilled and used as a treatment plan for 1 year.

      • For invasive cancers: May necessitate a radical cystectomy (complete removal of the bladder), which will result in the creation of an ileal conduit.

    • Patients may also undergo chemotherapy and/or radiation therapy.

  • Continuous Bladder Irrigation (CBI):

    • Often used post-surgically, especially after prostate or bladder procedures.

    • Involves a triple-lumen catheter; one lumen for irrigation solution inflow, one for balloon inflation (typically 30 ext{mL} or more), and one for drainage of urine and irrigation fluid.

Urinary Diversions

  • Purpose: To divert urine from the bladder to a new exit site, usually through a surgically created opening (stoma) in the skin. This is similar in concept to a colostomy for stool.

  • Ileal Conduit:

    • A segment of the ileum (small intestine) is used to create a urostomy.

    • The ureters are implanted into this isolated loop of ileum.

    • The ileal segment is brought out through the abdominal wall to form a stoma, allowing urine to continuously drain into an external urinary drainage bag.

  • Potential Complications & Preventions (Referenced from p. 1628 - for student review and discussion):

    • Complications can include parastomal hernia, stomal stenosis, urinary tract infections, skin irritation, and stone formation. Interventions focus on meticulous stoma and skin care, adequate fluid intake, barrier protection, and proper fitting of the appliance. (See Stoma & Skin Care below).

  • Stoma & Skin Care:

    • Inspection: Frequently inspect the stoma for color and viability (should be healthy pink/red).

    • Skin Around Stoma: Inspect for irritation, redness, and bleeding.

      • Use a skin barrier to protect the peristomal skin.

    • Appliance Fit: Ensure the appliance is fitted properly to avoid swelling and/or leakage.

    • Cleansing: Do not use moisturizing soaps/body washes around the stoma site because they can interfere with the adherence of the urinary drainage bag to the skin.