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Nursing Care of Clients with

Urinary Tract Disorders

Chapter 29

The Renal System

The Client with Urinary Tract


Infection (Infectious/inflammatory
Cystitis- Women more likely; aging any area

of the urinary tract bladder most common.


inflammation of the bladder
Clinical Manifestations

dysuria
frequency
urgency
nocturia, pyuria, hematuria
supra pubic pain

Pathophysiology UTI
Urinary tract sterile above the urethra due to
Adequate urine volume
Unimpeded urine flow
Complete bladder emptying
Risk factors for UTI-discussion
Cystitis- bladder mucosa becomes inflamed and congested with
blood ( from the bacteria). Purulent discharge forms and the
mucosa bleeds. This creates the CM of cystitis.
Catheter-Associated UTI- The longer the catheter remains in
place, the greater the risk for infection. Bacteria enter the
bladder by migrating through urine within the catheter or by
moving up the urethra outside the catheter. Bacteria enter the
catheter system at the connection between the catheter and
drainage system or through the emptying tube of the bag.

The Client with Urinary Tract


Infection
Pyelonephritis
inflammation of renal pelvis,

Acute or chronic.
Clinical Manifestations

Are Systemic

Urinary - same as cystitis, with CVA tenderness


G.I. - vomiting, diarrhea
Cardio - tachycardia
Hematological - leukocytosis

Pyelonephritis
Bacteria usually Ecoli enter the kidney from the lower urinary

tract.
Risk: Pregnancy, obstruction and congenital malformation,
Vesicouretral reflex risk factor in children- urine moves from the
bladder back toward the kidney, adults too.
Infection can spread from the renal pelvis to the cortex, the
inflamed kidney becomes edematous.
Abscesses may form and kidney tissue can be destroyed by the
inflammatory process.
CM- Older adults change in behavior, confusion, incontinence or
deterioration in condition.
Chronic pyelonephritis leads to fibrosis and scarring of the renal
pelvis. Chronic kidney disease and end-stage renal disease are
possible consequences.

Treatment Pylonephritis
10-21 days of antibiotic therapy, intravenous antibiotics may be

necessary/ usual.
Encouraging health promotion behaviors:
Generous fluid intake 1 liter per day
Void when urge is felt-3 hours at most 2 better.
Women cleanse the perineal area from front to back after void and
defecating
Void before and after sexual intercourse- women
Avoid bubble baths feminine hygiene sprays and vaginal douches
Cotton briefs avoid underwear make of synthetic materials
Acidic urine= cranberry juice, vitamin c.

The Client with Urinary Tract


Infection
Systemic Symptoms

Musculosketetal - muscle tenderness


Metabolic - fever, chills, malaise

Interdisciplinary Care
Labs and Diagnostics
UA- identify blood cells and bacteria in urine
Gram Stain and culture- What organism?
Eliminate the cause
Prevent relapse
Identify contributing factors

The Client with Urinary Tract


Infection
Intravenous pylogram (IVP)

dye used to visual renal pelvis


check allergies - iodine

Voiding cystogram

x-ray while voiding dye solution

Cystoscopy

direct visualization of bladder

The Client with Urinary Tract


Infection
Pharmacology

7 to 10 days of oral anti-microbial therapy

bactrim, septra- Sulfa drugs

Cipro, Pyridium

Nursing Care

Pain

Assess
Relieving measures
Increase fluids

The Client with Urinary Tract


Infection
Nursing Care

Altered Patters of Urinary Elimination

I&O
color, clarity, character

Quick access
Avoid caffeine

Knowledge Deficit

Disease process

The Client with Urinary Tract


Infection
Nursing Care- health promotion

Follow treatment regimen


teach prevention- Void at least every
2 hours. Well hydrated.
Limit caf. Beverages.
Women- void after intercourse
Hygiene practices
Clothing practices

Glomerulonephritis
These diseases involving the glomerulus are the leading cause of

chronic kidney disease in the UA.


Flitration which is the first step in urine formation occurs in the
glomerulus.
Inflammatory condition that affects the glomerulus. Acute or chronic.
May be a primary disorder or may occur secondary to a systemic
disease such as lupus.
-Damages the capillary membrane and allows blood cells and proteins
to escape from the vascular compartment into the filtrate
CM- Hematuria, proteinuria, loss of plasma proteins in the blood which
leads to hypoalbuminemia. Edema follows caused by reduced osmotic
draw within blood vessels.
Glomerular filtration is disrupted, GFR falls and azotemia occurs.
Azotemia- increased blood levels of nitrogenous wastes, urea,
creatinine.

Glomerulonephritis
Fall in GFR activates the renin-angiotensin-aldosterone system

leads to water retention and hypertension.


Acute glomerulonephritis follows an infection with group A beta
Strep such as strep throat.
Protein complexes from the infection become trapped in the
glomerular membrane causing an inflammatory response and
drawing WBC to the area.
Inflammation damages the glomerular capillary walls and makes
them more porous. Plasma proteins and blood cells escape into
the urine.

Glomerulonephritis
Initiating event
Infection
Chronic dx
Glomerular capillary
Membrane
inflammation
Increased
Glomerular
permeability

Decreased
GFR

Glomerulonephritis
Decreased GFR
Increased
Glomerular
Permeability

Hematuria

Proteinuria
Hypoalbuminemia
Edema

Azotemia

Activation of the
Renin angiotensinAldosterone
System
Na and water ret
Hypertension
Edema

Glomerulonephritis
CM- acute develop abruptly, 10-14 days after

the initial infection


Nausea, malaise, arthralgias, proteinuria.
Hypertension and edema (periorbital)more
often in children and young adults, not elderly
Symptoms may subside spontaneously, most
people recover completely, some may
develop chronic glomerulonephritis never
regaining full kidney function.

Nephrotic Syndrome
Group of symptoms results when glomerular tissues

are damaged and there is significant protein lost in


the urine.
No one cause may result in adults from primary
kidney disorder or systemic disease such as diabetes
or lupus.
CM- proteinuria, low serum albumin levels, high
blood lipids and edema, thromboemboli very
common.
May resolve without effects, adults less likely to
recover than children. May have persistent
proteinuria and progressive renal impairment that
leads to renal failure

Chronic Glomerulonephritis
Result of kidney damage by a systemic disease such as

diabetes.
May occur with no previous kidney disease or apparent cause.
Slow progressive destruction of glomeruli and nephrons.
Kidneys decrease in size and surfaces become granular as
nephrons are destroyed. Proteinuria.
CM- Develop slowly, renal failure may develop years to decades
after the disease is diagnosed.
Diabetic nephropathy-impairs filtration and elimination. Damage
in 15-20 yrs of diagnosis
Lupus nephritis- hematuria and proteinuria, inflammatory lesions
in the glomerulus. Chronic or acute may progress rapidly.

Diagnostic test
Antistrepolysin (ASO)titer- Identifies antibodies to

group A beta-hemolytic strep.


ESR- erythrocyte sedimantation rate will be elevated
in glomerulonephritis. Indicator of inflammation.
BUN and serum creatinine levels are increased in
kidney disease.
Serum electrolytes- will be elevated in kidney disease
UA- blood and protein in the urine, 24 hour urine and
creatinine
KUB to evaluate kidney size, kidney scan or biopsey.

Medications
No specific drug tx for glomerulonephritis.
Glucocorticoids such as prednisone.
Penicillin or other antimicrobials for infection.
Antihypertensives and diuretics to lower BP

and to reduce edema


NSAID for patients with nephrotic syndrome
to reduce inflammation.

Dietary Management
Glomerulonephritis
Sodium intake is restricted.
Dietary proteins may be increased when

protein is being lost in the urine/if azotemia is


present dietary protein is restricted.
When protein is restricted complete proteins
such as meat, fish, eggs, soy or poultry
should be given; these supply all the
essential amino acids required for growth and
tissue maintenance.

Nursing- Health Promotion


Advise to the effective treatment of streptococcal

infections in all age groups.


Complete the full course of antibiotic therapy to
eradicate the bacteria.
Effectively managing diabetes, treating hypertension
and avoid drugs and substances that are potentially
damaging to the kidneys.
Changes in urine output, rising serum creatinine and
BUN levels should be reported to charge nurse.
Monitor for increased wt, increase in blood pressure
or edema

Nursing Diagnosis
Excess fluid volume related to plasma protein

loss and sodium and water retention.


Risk for infection r/t medication regeime
Risk for imbalanced nutrition: less than body
requirements related to anorexia
Deficient knowledge: Glomerulonephritis
related to lack of information
Anxiety related to prescribed activity
restriction

Renal Calculi

The Client with Urinary Calculi


Obstructive Disorders
Urolithisasis
development of stone in urinary system
nephrolithiasis - stone in kidney
Most common in US- Kidney.
formed by crystals - calcium, magnesium, uric
acid
Clinical Manifestations

depends on where stone is


Renal colic- Pain from obstructed urine flow,
tissue damage, distention and rough edged
stone. Discussion, book.
CVA-

The Client with Urinary Calculi


Diagnosis
KUB, IVP, Renal Ultrasound, UA
Treatment
Pharmacology Vital! - narcotic analgesic - M.S.,
demerol, after analysis- thiazide diuretics for ca stones
reduce urinary calcium excretion, can prevent future
stones.
Dietary - increase fluid = 3 liters/day, reduce calcuim
and uric acid intake. Foods that lower the urinary pH.
Acidic! Discussion.
Risk Factors: personal or family history, dehydration,
excess calcium, oxalate or protein intake, gout,
hyperparathyroidism or urinary stasis,
immobility(calcium out of bone into the bloodstream.)

Types of Calculi

Pathophysiology- Calculi-(Stones)
Stones are masses of crystals formed from

materials normally excreted in the urine.


Most are made of calcium
Stones form when a poorly soluble salt
(calcium phosphate) crystallizes.
When fluid intake is adequate, no stone
growth occurs.
Stone development is also affected by the pH
of the urine and the naturally occurring
compounds that inhibit stone development.

The Client with Urinary Calculi


Treatment

Surgery

lithotrispy
crushing of calculi

cystoscopy

Nursing Care

Pain management
Altered Urinary Elimination - strain urine,
patent catheter tubing

Kidney Stones

Lithotripsy

Hydronephrosis
An abnormal dilation of the renal pelvis and calyces.
Results from urinary tract obstructions or

vesicoureteral reflux. (backflow of urine from bladder


to ureters)
When urine outflow is obstructed pressure in the
renal pelvis increases and it dilates. The nephrons
and collecting tubules may be damaged thus
affecting kidney function.
CM- Acute renal failure may develop. Discussion.
Diagnosed by ultrasound or CT scan. Cystoscopy to
identify the cause.

Hydronephrosis
Prompt treatment is vital to preserve kidney

function.
Reestablishing urine flow from the affected
kidney.
Nephrostomey tube, ureteral stent or
indwelling catheter may be required.
Stents- used to keep ureters open and
promote healing, surgery or cystoscopy.
Temporary or longer periods if necessary.

Nursing Care Hydronephrosis


Preventing hydronephrosis and ensuring

urinary drainage.
Monitor intake and output
Monitor bladder emptying to identify impaired
urine outflow. Pelvic or abdominal tumors,
urinary calculi, adhesions and scarring from
previous surgeries or neurologic deficits.

Bladder tumor (Congenital disorders)

Bladder Cancer

The Client with Urinary


Tumor
Bladder most common site.

10th cause of cancer


Death.
Risk Factors

>50 years old


male
cigarette smoking
Chronic inflammation of the
bladder.

Symptoms - painless

hematuria, urgency and


dysuria.

Pathophysiology
Most are polyp like structures attached by a

stalk to the bladder mucosa. Superficial or


invasive.
Prognosis for full recovery is good.
Metastasis to pelvic lymph nodes. Lungs,
bones and liver are common.
Kidney tumors anywhere in the kidney invade
the renal vein. Often metastasized to other
organs include brain.

The Client with Urinary Tumor


Diagnosis

UA for cytology
IVP, Renal Ultrasound, CT Scan, Cystoscopy
with biopsy

Treatment

Pharmacology - chemotherapy
Radiation therapy
Surgery

The Client with Urinary Tumor


Surgery

cystectomy - removal of bladder


ileal conduit - creation of urinary diversion

portion of ilium from small intestine is formed into


a pouch the end brought to skin surface to form a
stoma
wears a pouch, empty frequently
good skin care
urine has mucous flecks

Stoma for ileal conduit

Radical nephrectomy
Removal of the affected kidney and

surrounding tissue.
Open technique to allow inspection of
surrounding tissues.
HP- No smoking!!, UA and cytology
Assess painless hematuria!

Nursing Care - Review


Urinary Tract infections?

Signs/symptoms, diagnostic studies, treatment

Renal Calculi?
Bladder Cancer?

The Client with Urinary Retention


Occurs when bladder does not

fully empty
Benign prostatic hypertrophy
25-50cc considered overflow
leads to UTI

Treatment

catheterization - intermittent or
indwelling
Cholinergic meds - urecholine

Benign Prostatic Hypertrophy

The Client with Neurogenic Bladder


Spinal Cord injury

frequent spastic contraction of the bladder


involuntary bladder emptying

Treatment

self catheterization
surgery - urinary diversion

The Client with Urinary


Incontinence

Impaired bladder control

impacts skin breakdown, infections, rashes,


embarrassment, isolation, withdrawal,
depression

Stress - associated with intrabdominal pressure


Urge - cant inhibit flow long enough to reach toilet
Overflow - inability to fully empty bladder, overdistended and loss small amounts of urine
Reflex - involuntary loss of large amount
Functional - physical or environmental

The Client with Urinary


Incontinence
Treatment

Correct underlying problem - cysocele,


urethrocele, enlarged prostate gland
Toileting schedule

to bathroom
diaper change

Polycystic Kidney Disease

Polycystic Kidney Disease


Hereditary disease in which cysts form on the kidneys, the

kidneys enlarge and their function is gradually destroyed.


Common affects children and adults.
Cysts in the nephrons microscopic to several centimeters in
size, they destroy functional kidney tissue.
Adult is slow and progressive, CM in 30-40.
CM- flank pain, micorscopic or frank hematuria,proteinuria,
polyuria, nocturia. UTI and stones are common. Hypertension
and renal failure.
DX- Renal ultrasound. Tx- fluids, Ace inhibitors, preserve kidney
function avoid UTIs. Will have renal failure and need dialysis or
kidney transplant.
Offspring of clients with polycystic kidney disease have 50%
chance of of inheriting the disorder. Genetic counseling!

Renal Failure
Kidneys are unable to remove accumulated

waste products from the blood.


Acute
Chronic or end stage chronic
Azotemia and fluid and electrolyte and acidbase imbalances are the defining
characteristics.

ARF
Acute renal failure is a rapid decline in renal

function with an abrupt onset.


Often reversible with prompt treatment.
10,000 affected per year in the US
Risk factors: Critically ill, major trauma,
surgery, infection, hemorrhage, severe heart
failure, lower urinary tract obstruction.

Pathphysiology ARF
Common cause:
Ischemia of the kidney
Nephrotoxins- agents that damage kidney tissue.
Prerenal- Most common results from conditions that

affect the blood supply to the kidney. Hemorrhage.


Shock or heart failure.
Intrarenal- damage to the nephrons by inflammation
(acute glomerulonephritis, HTN)
Postrenal- obstruction of urine outflow. (calculi or
urethral obstruction).

ARF
Oliguria less than 400 mL per day.
Increased BUN and creatinine levels.
GFR falls, tubular cells become necrotic and slough

and the nephron is unable to eliminate wastes


effectively. = ATN
ATN:
Initiation phase-hrs to days, initiating event.
Maintenance phase- sharp drop in GFR. 1-2 weeks.
Azotemia, edema, anorexia, oliguria
Recovery phase- improving kidney function,UO
increases, may last one year.

Chronic Kidney Disease


Chronic Renal Failure
Slow gradual process of kidney destruction.
May go on for years as nephrons are

destroyed and functional kidney tissue is lost.


Eventually the kidney is unable to excrete
metabolic wastes and regulate fluid and
electrolyte balance, this is ESRD. Which is
the final stage of chronic renal failure.
Highest in African Americans.
Diabetes is the leading cause of ESRD,
hypertension, glomerulonephritis.

ESRD
Nephrons are destroyed by disease, those

that remain hypertrophy to compensate for


the lost tissue. The increased demand on
these nephrons increased their risk for
damage and destruction.
Stage1- free of symptoms, early stage
Stage2- GFR falls sightly
Stage3- GFR decreased moderately
Stage4- uremia symptoms developtransplant or dialysis are necessary.

ESRD
Uremia- nausea, apathy, weakness, fatigue.
Vomiting, lethargy and confusion
Cardiovascular disease is the leading cause

of death in client with chronic kidney disease,


HTN is common.
Most meds are excreted by the kidneys.
Antihypertensive drugs are used to decrease
BP Lasix and ACE inhibitors.
Fluids and sodium intake are restricted. CHO
are increased. TPN may be initiated.

Renal replacement Therapy


Dialysis- Diffusion of solutes across a membrane

from an area of higher concentration to one of lower


concentration.
Used to remove excess fluid and waste products in
renal failure.
Blood is separated from a dialysis solution by a
semipermeable membrane. Water and solutes such
as urea and electrolytes diffuse across this
membrane, but proteins do not.
Dialysis compensates for the kidneys inability to
eliminate excess water and solutes.
2 or 3 sessions per week. Outpatient center.

Dialysis
Hemodialysis- Electrolytes, waste products

and excess water are removed from the body


by diffusion and filtration. The clients blood
is pumped through a dialyzer.
Peritoneal Dialysis- The peritoneum serves
as the dialyzing surface. Warmed dialysate is
instilled into the peritoneal cavity through a
peritoneal catheter.

Case Study
A 82 year old male resident in a nursing

home who is usually talkative and out-going


stays in his room during lunch. The nurse
notices while administering his medications
that he appears listless and is slightly
confused about the date.
Assessment reveals that he has slight

tenderness in the right flank areas. He


states he is tired and does not feel like
eating. Vital signs are T 99 P 88 R 20 B/P
118/62

The nurse asked him to void in a cup. The

client has some difficultly urinating and stands


to void. He voids 90mls of dark yellow
concentrated urine, it is cloudy and has a
strong odor.
The nurse instructs him to:
The nurse then:

UA results are:

Color yellow
S.G. 1.030
pH 7
Glucose negative
Ketones moderate
RBC 10
WBC 10
Bacteria moderate/ could be contamination
Nitrates- moderate- Always indicates infection

What findings are considered abnormal?


What about a C & S?

Treatment?

ESRD
Nursing Care- discussion
Kidney transplant- discussion
Fistula or graft for hemodialysis.
Differences from hemodialysis and peritoneal

dialysis.

NCLEX
A client is diagnosed with chronic

pyelonephritis. The nurse realizes that this


client is prone to developing:
A. cystitis
B. chronic renal failure
C. acute renal failure
D. renal calculi

NCLEX
A male client comes into the emergency

department with symptoms of renal colic.


The nurse realizes that this client most likely
has a calculi that is obstructing the:
A. renal pelvis
B. bladder
C. ureter
D. urethra

NCLEX
A male client has a history of calcium calculi.

Which of the following medications can be


prescribed to help this client?
A. furosemide (Lasix)
B. chlorothiazide (Diuril)
C. allopurinol (Alloprim)
D. NSAIDs

NCLEX
While being catheterized for urinary retention,

the client becomes diaphoretic and pale.


Which of the following can be implemented to
help this client?
A. Nothing, this is a normal response
B. Provide the client with fluids
C. Clamp the catheter after draining 500cc of
urine
D. Pull the urinary catheter

NCLEX
Three weeks after being treated for strep

throat, a client comes into the clinic with signs


of acute glomerulonephritis. Which of the
following manifestations will the nurse most
likely find upon assessment of this client?
A. periorbital edema
B. hunger
C. polyuria
D. polyphagia