Care of Patients With Disorders of the Urinary System

Chapter 34: Care of Patients With Disorders of the Urinary System

Learning Objectives

Theory
  • Examine the signs and symptoms of selected urologic inflammatory disorders (e.g., cystitis, urethritis, and pyelonephritis) and relevant nursing interventions.
  • Explain nursing management for patients with acute or chronic glomerulonephritis.
  • Analyze patient conditions that create a risk for acute renal failure.
  • Compare the needs of patients on long-term hemodialysis with those using peritoneal dialysis.
  • Present the benefits and special problems associated with kidney transplantation.
Clinical Practice
  • Provide postoperative nursing care for patients after kidney surgery.
  • Select specific nursing responsibilities for patients with kidney stones.
  • Provide postoperative nursing care for patients after surgery for urinary diversion.
  • Perform interventions to increase patient compliance in the treatment of chronic kidney failure.
  • Devise a nursing care plan for a home care patient with renal failure.

Cystitis

Etiology and Pathophysiology
  • Female urethra and Escherichia coli: The primary cause of cystitis in females.
  • "Honeymoon" cystitis: Refers to cystitis occurring after sexual activity.
  • Estrogen depletion with aging: Leads to structural atrophy and urinary dysfunction, promoting urinary stasis.
Signs and Symptoms
  • Painful urination.
  • Frequent and urgent urination.
  • Low back pain.
  • Recurrent tendency: May present with less acute symptoms between flare-ups, such as fatigue, anorexia, and a constant feeling of bladder pressure.
  • Older adults: May present with confusion, cloudy urine, hematuria, and other signs of infection.
Treatment and Nursing Management
  • Antibiotics: Primary treatment.
  • Topical estrogen: For postmenopausal women.
  • Encourage fluids: 88 to 1212 large glasses unless contraindicated.
  • Cranberry products: May alter urine pH.
  • Sitz bath and hot water bottles: For comfort.
  • Patient Education: Teach how to prevent urinary tract infections (UTIs).
  • Vitamin C: May be recommended.

Urethritis

Etiology and Pathophysiology
  • Gonococcus and herpes virus: Common causative organisms.
  • Nonspecific urethritis: Caused by various non-gonococcal organisms.
  • Childbirth: Can be a risk factor.
  • Chemical irritation: Another potential cause.
Signs and Symptoms
  • Burning.
  • Itching.
  • Frequency in voiding.
  • Painful urination.
  • Discharge: Purulent if gonorrhea is present.
Diagnosis
  • Based on symptoms and patient history, including possible exposure to sexually transmitted infections (STIs).
  • Culture and sensitivity of urine: Obtained to identify causative organisms.
  • Culture specimens: Used to rule out STIs.
Treatment and Nursing Management
  • Similar to cystitis.
  • Nurse awareness: Especially for possible gonorrheal infection (until diagnosis is established) to prevent spread to the eyes.

Pyelonephritis

Etiology and Pathophysiology
  • Acute pyelonephritis: Often due to stasis of urine.
  • Chronic infection: Can lead to scar tissue formation.
Signs and Symptoms
  • Acute state: Fever, chills, headache, malaise, nausea and vomiting, and flank pain radiating to the thigh and genitalia.
  • Chronic state: Subtle and gradual scarring, leading to weight loss, low-grade fever, and weakness.
Diagnosis
  • Manifestations and physical assessment.
  • Urine culture and sensitivity.
  • Kidneys, ureter, and bladder (KUB) radiography and intravenous pyelogram (IVP): Used to identify obstruction.
Treatment
  • Prompt treatment and prevention of recurrence.
  • Correct obstruction: Stone removal and formation prevention.
  • Bed rest, analgesics, and antipyretics.
  • Antibiotics.

Acute Glomerulonephritis

Etiology and Pathophysiology
  • Beta-hemolytic streptococcal infection: A common trigger.
  • Immune response: Antigen-antibody reaction.
Signs, Symptoms, and Diagnosis
  • Sudden onset: Fever, chills, flank pain, edema, puffiness about the eyes, visual disturbances, and marked hypertension.
  • Diagnostic tests: Urinalysis (UA), creatinine and blood urea nitrogen (BUN), and complete blood count (CBC).
  • Urine characteristics: Smoky appearance, positive for red blood cells, positive for protein, and increased specific gravity.
Treatment
  • Initial therapy: Intravenous methylprednisolone and cyclophosphamide.
  • Dietary modifications: Sodium-restricted diet and fluid therapy; low-protein, high-carbohydrate diet.
  • Plasmapheresis: Used for autoimmune disorders.
Nursing Management
  • Clinical history: Obtain detailed patient history.
  • Edema monitoring: Watch for signs of cardiac failure and pulmonary edema.
  • Bed rest: Until hematuria, proteinuria, and hypertension subside.
  • Sodium restriction: Enforce dietary restrictions.
  • Medication administration: Antihypertensives and diuretics.
  • Specialized treatments: Plasmapheresis and corticosteroids.
  • Shunt assessment and care: If a shunt is present.
  • Monitor for complications: Continuously assess for adverse developments.

Chronic Glomerulonephritis

Etiology and Pathophysiology
  • Can develop rapidly or progress slowly over time.
  • Kidney atrophy: Leads to decreased functional nephrons and eventual renal failure.
Signs and Symptoms
  • Generalized edema.
  • Headache associated with hypertension.
  • Fatigue, dyspnea, weight loss, loss of strength.
  • Increasing irritability.
  • Nocturia.
  • Urine findings: Proteinuria and hematuria.
  • Progression to kidney failure.
  • Acute exacerbations may occur.
Diagnosis
  • Routine examination: May reveal retinal hemorrhage.
  • Laboratory tests: Urinalysis (UA), creatinine, BUN, CBC, and electrolytes.
  • Expected findings: Proteinuria, urinary casts, elevated BUN and creatinine, anemia, hyperkalemia, hypermagnesemia, increased phosphorus, decreased serum calcium, and decreased albumin.
Treatment
  • Latent stage: Symptomatic treatment.
  • Dialysis.
  • Kidney transplant.

Nephrotic Syndrome

Signs and Symptoms
  • Proteinuria, hyperlipidemia, hypoalbuminemia, and severe edema.
  • Facial and periorbital edema: Often present in the morning.
  • Lower extremity edema: More evident at the end of the day.
  • Irritable, tired, or lethargic.
Diagnostic Tests
  • Urinalysis and serum tests for protein and lipids.
  • Renal biopsy.
Treatment
  • Dietary management: Adequate protein; low-fat, low-sodium diet; supplemental multiple vitamins and minerals.
  • Medications: Diuretics, antibiotics, cortisone, and cyclophosphamide.
Nursing Management
  • Monitor intake and output.
  • Record daily weight.
  • Encourage rest.
  • Provide skin care.
  • Encourage compliance with dietary and medication regimen.

Hydronephrosis

Etiology and Pathophysiology
  • Dilation of the renal pelvis and ureters: Caused by obstruction.
  • Compensatory hypertrophy: The unaffected kidney may enlarge to compensate.
Signs, Symptoms, and Diagnosis
  • Severe pain.
  • Signs of kidney failure.
  • Diagnosis: Urologic examination and detailed radiographs.
Treatment
  • Nephrostomy tube or ureteral stent placement to relieve obstruction.
Nursing Management
  • Postoperative care:
    • Monitor for hemorrhage and assess dressing.
    • Ensure proper positioning.
    • Encourage coughing and deep breathing exercises.

Renal Stenosis

  • Description: Blocked or narrowed renal artery.
  • Consequences: Hypertension and chronic renal failure.
  • Diagnosis: Magnetic resonance imaging (MRI), computed tomography (CT) scan, or ultrasonography, which may show decreased kidney size.
  • Treatment: Antihypertensives, balloon angioplasty, or stent placement.

Renal Stones

Overview
  • May present as renal staghorn calculus.
  • Variations: Composition and environment (acidic or alkaline) influence stone type.
  • Management principles: Identify type and cause, implement preventive measures, select appropriate treatment method.
Causative Factors
  • Gastrointestinal conditions: Bariatric surgery, short bowel syndrome, or other conditions that decrease oxalate absorption in the gut.
  • Inadequate fluid intake: Leads to concentrated urine and insufficient flushing of the urinary tract.
  • Sluggish urine flow: Occurs with bed rest or immobility.
  • Associated diseases: Diabetes, obesity, gout, and hypertension.
Types of Renal Stones
  • Calcium oxalate: Most common type.
  • Calcium phosphate.
  • Uric acid.
  • Struvite: More common in women.
  • Cystine.
Etiology and Pathophysiology
  • Calcium stones: Can be associated with parathyroid tumor.
  • Risk factors:
    • Male gender.
    • Family history of stones.
    • Immobility.
    • History of recurrent UTI.
Prevention
  • Adequate flow of dilute urine through the kidney.
  • Prevent UTI.
  • Urinary pH modification: Ascorbic acid or dietary modifications.
Signs and Symptoms
  • Severe pain: Especially for stones small enough to move along.
  • Flank pain: Radiates downward to genitalia and inner thigh, caused by obstruction and swelling of the ureter.
  • Nausea and vomiting.
Diagnosis
  • Urinalysis (UA) and KUB radiography.
  • IVP.
  • Serum levels of calcium, uric acid, and cystine.
Treatment
  • Flushing the stone: Oral intake or intravenous infusion of fluids.
  • Pain management: Opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and antispasmodics.
  • Antibiotics.
  • Irrigation: Via ureteral catheter or percutaneous nephrostomy.
  • Stent placement.
  • Extracorporeal shockwave lithotripsy (ESWL).
  • Cystoscopy and surgery.
Nursing Management
  • Pain management.
  • Fluid intake: 30003000 to 40004000 mL per day.
  • Early ambulation.
  • Adjunctive therapy for ESWL: Corticosteroids, calcium channel blockers, alpha agonists.
  • Percussion, diuresis, and inversion (PDI) therapy: To aid stone passage.
  • Straining of urine to collect stones for analysis.
Cystoscopy or Surgery
  • Surgical procedures: Nephrolithotomy, pyelolithotomy, and ureterolithotomy.
  • Monitoring post-op: Infection, hemorrhage, and leakage of fluid.
  • Initial assessment: Changes in urinary output, characteristics of the urine, risk factors and history, and other assessment data.

Trauma to Kidneys and Ureters

Etiology and Pathophysiology
  • Blunt trauma: Motor vehicle accidents, sports injuries, or occupational incidents.
  • Penetrating injuries: May also involve ureteral trauma.
  • Severity: Can range from minor contusion to severe hemorrhage and hypovolemic shock.
Signs, Symptoms, and Diagnosis
  • Manifestations: Massive hemorrhage, hematuria, abdominal or flank pain, and possibly an enlarged flank mass.
  • Diagnostic tests:
    • Urinalysis, hemoglobin and hematocrit, and electrolytes.
    • BUN and creatinine.
    • Radiologic studies: KUB, IVP, or CT scan.
    • Rhabdomyolysis leading to acute renal failure (ARF).
Treatment
  • Bleeding is often self-limiting.
  • Lacerations and contusions without renal function interruption: Bed rest.
  • Severe kidney damage: Nephrectomy may be required.
Preoperative Care
  • Monitor for hypovolemic shock, cardiovascular changes, urinary output, and size of flank mass.
  • Grey Turner sign: Bruising over the flank or lower back, indicative of retroperitoneal bleeding.
  • Monitor urinary output and indwelling urinary catheter.
Postoperative Care
  • (Not detailed in the slides, but implied by the heading.)

Trauma to the Bladder

Etiology and Pathophysiology
  • Violent blow or crushing injury: Can cause bladder perforation or rupture.
  • Risk factor: Bladder trauma is more likely to occur if the bladder is full.
Signs and Symptoms
  • Painful hematuria.
  • Inability to void.
  • Marked tenderness and spasm in the suprapubic areas.
  • Large mass (indicating extravasation of urine).
Diagnosis and Treatment
  • Diagnosis: Based on gross hematuria, suprapubic pain, and difficulty voiding.
  • Imaging: Retrograde or CT cystography.
  • Treatment: Suprapubic cystostomy if the bladder has ruptured or is perforated.
Nursing Management
  • Meticulous attention to drains and dressings.
  • Cold applications for swelling/pain.
  • Monitor for postoperative shock and massive hemorrhage.

Cancer of the Bladder

Etiology and Pathophysiology
  • Risk factors: Smoking (strong association), urban living.
  • Occupational exposure: To nitrates, dyes, rubber, or leather processing.
  • Bladder papilloma tumors: Can be highly invasive and prone to metastasis.
Signs and Symptoms
  • Hematuria (most common and often earliest sign).
  • Frequency, urgency, or dysuria.
Diagnosis
  • IVP, cystoscopy, or biopsy of tumor.
  • Complementary and alternative therapy considerations: maintaining a healthy bladder.
Treatment
  • Surgery: Cystectomy (bladder removal) or transurethral resection of the bladder tumor (TURBT).
  • Chemotherapy: Intravesical chemotherapy (instilled directly into the bladder).
  • Immunotherapy: Bacille Calmette-Guerin (BCG) instillations.
  • Photodynamic therapy.

Surgery for Urinary Diversion

  • Can range from minor to major surgical procedures.
  • Performed when bladder removal is necessary (e.g., due to cancer).
  • Types of urinary diversions:
    • Ileal conduit or ileal loop.
    • Cutaneous ureterostomy.
    • Vesicostomy.
    • Ureterosigmoidoscopy or sigmoid conduit.
    • Ileal reservoir (Kock, Indiana, Mainz, or Florida patch) - continent diversions.
    • Orthotopic bladder substitutes (neobladder).
Nursing Management (for Urinary Diversion)
  • Clarify orders regarding irrigation of tubes, drains, and stomas.
  • Postoperative care:
    • Observe for pain, abdominal rigidity, fever, and bleeding.
    • Urine should never stop flowing, regardless of the surgical procedure.
    • Monitor urine color and characteristics.
    • Assess stoma for appearance and skin irritation around it.
    • Implement measures to reduce odor of urine.
    • Provide psychological care and support.

Cancer of the Kidney

Etiology and Pathophysiology
  • Risk factors: Smoking and exposure to lead or phosphate.
Signs, Symptoms, and Diagnosis
  • Classic triad: Hematuria, palpable abdominal or flank mass, and flank pain.
  • Systemic symptoms: Fever, fatigue, weight loss, decreased appetite, and hypertension.
  • Diagnosis: Renal angiogram, arteriogram, CT, MRI, and ultrasonography.
Treatment and Management
  • Surgical removal of the affected kidney (nephrectomy): Performed before metastasis occurs.
  • Late presentation: Patients often do not have severe symptoms until metastases have occurred.
  • Chemotherapy: With a variety of drug regimens, used for metastatic cancer.
  • Immunotherapy: Sometimes attempted for recurrent tumors.

Acute Renal Failure (ARF)

Etiology
  • Sudden onset: Often due to physical injury, infection, inflammation, or damage from toxic chemicals.
  • Renal ischemia: Caused by circulatory collapse, severe dehydration, and prolonged hypotension.
Pathophysiology
  • Prerenal ARF: Decreased blood flow to the kidneys (e.g., hypovolemic shock or decreased cardiac output).
  • Intrarenal ARF: Direct damage to the kidney tissue (e.g., glomerular damage, acute tubular necrosis (ATN) caused by ischemia, toxins, or vascular disease).
  • Postrenal ARF: Obstruction of urine outflow (e.g., in the ureters, bladder, or urethra).
Signs and Symptoms
  • Changes in urine output and urine test results.
  • Electrolyte imbalances.
  • Fluid imbalance.
  • Acid-base imbalance.
  • Gastrointestinal effects (e.g., nausea, vomiting).
  • Mental status changes.
  • Anemia and platelet dysfunction.
  • Impaired wound healing and susceptibility to infection.
Diagnosis
  • Urinalysis.
  • Creatinine, BUN, CBC, electrolytes, and arterial blood gases.
  • Radiologic studies: Ultrasonography, IVP, CT, or MRI.
  • Renal biopsy.
Treatment
  • Correct the underlying cause.
  • Prevent or control complications.
  • Symptomatic treatment:
    • Correct fluid and electrolyte imbalance.
    • Manage anemia and hypertension.
    • Hemodialysis or peritoneal dialysis.
    • Address malnutrition, anemia, and potential for infection.
    • Continuous renal replacement therapies (CRRTs).
Nursing Management
  • Monitor for signs of fluid imbalance.
  • Report urine output of less than 3030 mL/h.
  • Monitor electrolytes.
  • Perform nutritional assessment.
  • Encourage optimal activities of daily living.
  • Emphasize hand hygiene to prevent infection.

Phases of Acute Tubular Necrosis

  • Oliguric or nonoliguric phase: Characterized by changes in urine output.
    • Older adult considerations: Unique presentations or challenges in older patients.
  • Diuretic phase: Increased urine output as renal function begins to recover.
  • Recovery phase: Gradual return of normal kidney function.

Chronic Renal Failure (CRF)

Etiology
  • Progressive loss of kidney function over time.
  • All causes of ARF may also lead to CRF.
  • Key underlying conditions: Hypertension, diabetes mellitus, sickle cell disease, glomerulonephritis, nephrotic syndrome, lupus erythematosus, heart failure, and liver cirrhosis.
  • Healthy People 2030 Goal: Reduce kidney failure due to diabetes.
  • Most common causes: Glomerulonephritis and nephrosclerosis.
Stages
  • Azotemia: Accumulation of nitrogenous waste products such as urea nitrogen and creatinine.
  • Stage 1: Diminished renal reserve.
  • Stage 2: Renal insufficiency.
  • Stage 3: End-stage renal disease.
Signs and Symptoms
  • Earliest sign of renal impairment: Inability of the kidneys to concentrate urine, leading to polyuria and nocturia.
  • Renal insufficiency progression: Oliguria and eventual anuria.
  • Uremia or uremic syndrome: Systemic symptoms due to waste product accumulation.
  • Uremic frost: Crystalline deposits on the skin in severe uremia.
  • Electrolyte imbalances, nutritional deficiency, and associated systemic effects.
Diagnosis
  • Creatinine and creatinine clearance tests.
  • Urinalysis with culture and sensitivity.
  • Hematocrit and hemoglobin.
  • Renal ultrasound, renal scan, CT scan, and renal biopsy.
Treatment and Management
  • Correct fluid and electrolyte imbalance.
  • Medications for symptom management and complication prevention.
  • Renal dialysis: Hemodialysis or peritoneal dialysis.
  • Kidney transplant.
  • Nursing management focused on all aspects of care.

Audience Response Questions

Question 1: Predialysis Nursing Intervention
  • The nurse is sending the patient to the dialysis clinic. Predialysis nursing intervention includes: (Select all that apply.)
    • Withholding anticoagulants.
    • Assessing dialysis access site.
    • Checking vital signs.
    • Monitoring laboratory values.
    • (Note: Administering antihypertensive medication usually depends on specific orders and timing relative to dialysis, as blood pressure may drop during dialysis. This requires careful clinical judgment and specific institutional protocols.)
Question 2: Peritoneal Dialysis Nursing Care
  • Nursing care of the patient undergoing peritoneal dialysis includes: (Select all that apply.)
    • Maintaining aseptic technique when accessing peritoneal catheter.
    • Weighing the patient before and after dialysis.
    • Monitoring vital signs.
    • Checking color and volume of effluent.
    • (Note: Instilling warmed dialysates slowly is important, but warming methods must be appropriate and controlled to avoid burns or peritonitis.)