Assessment

1. Urologic Health History

Location, character, and duration of pain, if

present and its relationship to voiding History of urinary tract infections, including fast treatment and hospitalization Previous renal or urinary diagnostic test or use of indwekking urinary catheters History of hematuria, nocturia, and renal calculi

 Female Patients:

Number of types of deliveries Vaginal infection, discharge, or irritation Contraceptive practice Presence or history of genital lessions or sexually transmitted diseases Habits:
Use of tobacco Alcohol Recreational activities Any prescription or over the counter medications

 Signs

and Symptoms of Urinary Tract Disease

Pain Changes in voiding
Frequency, urgency, dysuria, hesitancy, incontenence, enuresis, polyuria, and hematuria

Physical Assessment
Tenderness over the costovertebral angle Digital rectal examination to detect prostatic

hyperplasia which is common cause of urinary difficulty in men In males: anatomic location of urethral opening, discharges, and edema around the meatal edges. Inguinal area: enlarged nodes, inguinal hernia, and varicocoele. In women: examine vulva, urethra and vagina Edema and changes in body weight

2. Diagnostic Tests
o Urinalysis to diagnose disease and

screen undetected disorders; to monitore effectiveness of treatment o Radiography

Kidney-Ureter-Bladder (KUB) X-ray pathologic illustration of kidney, ureter, and bladder without the use of conrtast medium; to detect presence of urinary calculi and masses Intravenous Pyelography (IVP) series of x-ray filmstaken after injection of a contrast medium to visualize renal system

o Magnetic Resonance Imaging (MRI) use of o o o

o o

electromagnetic radiation to obtain detailed images of the bodys soft tissue Renal Angiography injection of radiopaque dye into the renal blood stream to reveal status of renal blood vessels Ultrasonography use of sound waves passed into the body through a transducer to detect abnormalities of internal tissues and organs Radionuclide Studies to examine renal perfussion and function Endoscopy performed transurethrally to allow visualization of the whole urinary tract to detect presence of urinary calculi, infection, strictures, bladder tumors and prostatic obstruction Biopsy to confirm malignancies in the urinary tract and kidneys Urodynamic Studies to determine abnormalities in voiding related to pathology of the lower urinary tract

3. Gerontological Considerations
Renal and urinary tract functions change

with age Glomerular filtration rate decreases with age, beginning between ages 35-40 years Tubular function, icluding reabsorption an concentrating ability, is also reduce in increasing age Limitations in mobility would make patients limit their own fluid intake to minimize the frequency of voiding or the risk of incontinence

B. Care for Clients with Urinary and Renal Dysfunction

1. Dysfunctional Voiding Patterns

a. Nursing Process for Clients with Urinary Reflux Assessment

Cystoscopy to evaluate obstruction Ultrasound to detect pressence of

hydronephrosis IVP evaluate the entire urinary tract

Nursing interventions
Assess high risk patient for urinary reflux Assist client for surgery Medical management: surgical procedure

to correct abnormalities that caused the reflux Nursing interventions after sugery Assess the color of urine Assess and clean the insicion site daily Prevent infection

b. Nursing Process for Clients with Urinary Retention Assessment

Distended bladder Inability to empty the bladder completely Residual urine of more than 100 ml

Nursing interventions

Monitor urine output Initiate measures to stimulate voiding Catheterize the client Prevent infection Prevent tissue injury

C. Nursing Process for Clients with Urinary Incontinence Assessment

Involuntary loss of urine Urodynamic studies to help evaluate obstruction or

dysfunction in urine mechanism UTZ and catheterization to determine residual urine

Nursing Interventions

Teach client about Kegel exercise Institute bladder training Monitor I and O Develop a voiding schedule If the client is obese, advise to reduce weight. Medical management: electrical stimulation and anticholinergic medications.

2. Cystitis

Assessment

Inflammation of urinary bladder Most common form of UTI

Nursing Interventions

Burning pain during urination Hematuria Cloudy urine Lower back pain Abdominal distention Diarrhea Nausea

Instruct the client to avoid alcohol and caffeinated drinks Increase fluid intake Teach the client about meticulous perineal care to

prevent infection Teach cleint about acid-ash diet Medical management: analgesics and antibiotics

3. Urethritis
Inflammation of the urethra Usually and ascending infection

Assessment

Burning sensation and pain during urination

Purulent urethral discharge

Presence of pus in the urine

Nursing

Interventions

Warm sitz bath is encourage

Increase fluid intake
Prompt antibiotic therapy and analgesics may

be prescribed

4. Ureteritis
Inflammation of the ureter secondary to

pyelonephritis Ussually subsides once kidney infection is resolved

Urosepsis
A bacteremia that originates from the urinary

tact resulting from prolonged catheterization, immunosupression therapy, and chemotherapy

Assessment Lower abdominal pain

Urinary urgency and frequency Nocturia dyspaerunia

 Nursing

Interventions

WOF infection
Assist in the collection of specimen for C/S

testing Medical management: IV aminoglycosides, beta-lactam, antibiotics, and cephalosporins

6. Interstitial Cystitis
Inflammation of the bladder wall eventually

causes disintegration of the lining and loss of bladder elasticity

Assessment

Severe, irritable voiding symptoms

Urinary frequency, nocturia, urgency,

suprapubic pressure, pain with bladder filling Markedly diminished bladder capacity

Nursing Interventions
Pain control

Bladder training
Urination schedule Pelvic muscle exercises

Medical management: anti-inflammatory,

anti-spasmodic, antihistamine, analgesics, tranquilizer, and opioid medications

7. Urinary Calculi

Calcifications in urinary tractand kidneys due to

increased urine concentration and urinary stasis

Types of Calculi
Calcium

Assessment

Oxalate Struvite Uric acid Xanthine

Sudden onset of severe and colicky pain

Nausea and vomiting Pallor Grunting respiration Inc. BP and Pulse

Nursing Interventions
Assess past history of UTIs and dirtary habits

Teach client to prevent urinary stasis

Inc. Fluid intake Diet modification: avoid syobe-forming foods

Medical management: analgesics and anti-

spasmodic to control pain, medication to prevent further development of urinary stones and surgical removal of the stone.

8. Bladder Trauma

Penetrating or Blunt injury to the bladder that may

Assessment

lead to bladder rupture which causes the urine to spill into the peritoneal cavity resulting to peritonitis and pelvic cellulitis. Hematuria Pain in the abdomen Fever Difficulty in voiding

Nursing Interventions

Assess the bladder integrity and ability to empty Insert suprapubic catheter to allow drainage of the

urine Monitor the output and presence of hematuria Monitor I and O Surgical procedure is necessary to repair the injury

9. Urethral Trauma

Ussually caused by pelvic fracture and other traumatic

10. Ureteral Trauma

accidents that result to urethral damage May lead to urethral strictures and impotence in men Difficulty invoiding, presence of hematuria, and altered urine stream Medical management: suprapubic catheterization and surgical repair
Ussually caused by abdominal or pelvic surgeries, gunshot

Assessment

wound, and stab wounds

Medical Management: surgical repair of the damaged ureter

Hematuria Flank pain Presence of extravasated urine Intraperitoneal mass Presence of urine in the external wound

11. Acquired Disorders of urinary and Renal System a. Nephrolithiasis

Presence of stones in the kidneys Clinical manifestations wjen the stone is

dislodged to the lower urinary tract Nursing interventions are the same with renal calculi

b. Pyelonephritis
Inflammation of the renal pelvis an renal

parenchyma resulting from bacterial infection in the kidney Characterized by enlarge kidneys with interstitial infiltrations of inflammatory cells

Assessement Acute Pyelonephritis

Chronic Pyelonephritis

High fever and chills Nausea Flank pain Headache Muscle pain Tenderness on the flank area Dysuria Urinary frequency and urgency Cloudy or bloody urine HTN Pyuria Azotemia Acidosis Proteinuria Poor urine-concentrating abaility

Nursing Interventions
Teach the client the importance of

completing the course anibiotic therapy Monitor I and O Monitor BP frequently Teach client about sodium restriction Medical management: antibiotic, analgesic and anti hypertensive medications

c. Hydronephrosis

Dilation of renal pelvis and calyces of one or

Assessment

both kidneys due to an obstruction

Flank and back pain due to acute obstructions Dysuria, chills, fever, tenderness, and pyuria (if

Nursing Interventions

infection is present) hematuria

WOF presence, location, intensity, and

Medical interventions: antibilotic therapy and surgical removal of the obstruction

characteristics of pain Monitor I and O Palpate the bladder to determine distention Monitor characteristics of urine

d. Glomerulonephritis

Inflammtion of glumerular capillaries caused by an

Assessment

immunologic reaction Results in proliferative infection ussually from group A betahemolytic group streptococcus Hematuria Proteinuria, hypoalbumineria Inc. BUN and creatinine Dec. Urine output Anemia, edema HTN, headache, malaise, flank pain Dyspnea, engorgement neck veins, cardiomegaly, pulmonary edema Confusion, somnolence, seisures Hyperkalemia Metabolic acidosis Inc.serum phosphorus, dec. Serum calium, hypermagnesemia

Medical Management
Plasmapheresis Antibiotic theraphy Diuretics, anti-hypertensives and restriction of

dietary sodium and water Monitor fluid and electrolytes volume Monitore cardiac and neurologic changes

e. Tabuloinstertitial disease

A type of renal disorder wherein the spaces

Assessment

between the renal tubules contain inflammatory cells Classified as acute and chronic Acute Fever Rash Oliguric renal failure Hematuria Chronic Interstitial edema Atrophy anf flattening of renal tubules Presence of fibrosis

Medical management

Allopurinol Cephalosporins Furosemide Penicillin Rifampicin Sulfonomides Captopril Cimetidine Litium NSAIDs Phenytoin Thiazide

12. Urinary Tract Infection (UTI)

Causative organism: E.coli, Enterobacter,

Assessment

Pseudomonas and serrafia species Ussually affects the bladder, although the urethra anf ureters may also be involve Painfuland burning sensation when voiding Voiding frequency and urgency Nocturia Incontenence Hematuria Lower back pain Fever and chills Nausea and vomiting Pain and tenderness in constovertebral angles (+) urine culture

Medical Management
Antibilothic therapy

Acid ash diet to decrease the rate of

bacterial multiplication

Nursing Interventions
Manage pain and provide comfort
Monitor I and O Increase fluid intake

Administer prescribe drugs

13. Primary Glumerular Disease a. Nephrotic syndrome

Glomerular disease characterized by marked

Assessment

proteinuria, hypoalbuminemia, edema and hyperlipidemia Increases glumerular permeability

Edema, pitting and ussualy found in dependent

Medical management

areas, periorbital area and abdomen Malaise, headache, irritability, fatigue

Diuretics, ACE inhibitors, antineoplastics,

Nursing Interventions
glumerulonephritis

immunosupressants and chlorambucil, corticosteriod

Same management as that of

14. Renal Failure

Results when kidneys are unable to remove the bods

Types: Acute Renal Failure (ARF) refers to the abrupt loss of kidney function Phases: Ologuric-Anuric or Non-oliguric Phase

metabolic watse or to perform their regulatory functions

Diuretic phase

Lasts 1-8 weeks Either oliguric or non-oliguric

Urine output may be 1000 to 2000 ml/day Glomerular filtration returns and leveling of the blood urea

Recovery phase

nitrogen occurs

Lasts 3-12 months Returns to pre-renal level

Assessment

Medical Mangement
Dialysis Manitol, furosemide, ethacrynic acid, ion

change resins or enema Low dose of dofamine infussion topromote renal perfusion

Nursing Interventions
Reduce metabolic rate to reduce

catabolism, release of potassium and endogenous watse products Implement and educate about dietary restrictions (low protein and potassium, high calorie)

b. Chronic Renal Failure (End-Stage Renal Disease)

Irreversible reduction of functioning renal tissue, leading to

Stages: Stage 1 (Reduced Renal Severe)

uremia and azotemia

Stage 2 (Renal Insufficiency)

75-95% of nephron function is lost

Nephrotic function is lost by 40-75% Patient is assymptomatic

Stage 3 (End-stage Renal Disease)

Kidney cannot concentrate urine Anemia, polyuria and nocturia develop

Less than 10% nephron is functioning All functions of the kidney are severely impaired Elevated creatine and BUN Electrolyte imbalances very evident

Assessment
Cardiovascular: HTN, CHF, pulmonary edema, pitting

edema,pericardial friction rub, pericardial tamponade, pericarditis, pericardial effusion, hyperkalemia, hyperlipidemia Integumentary: Pruritis, dry flaky skin, ecchymosis, purpura, uremic frost (gray-bronze skin color), thin, brittle nail, coarse thinning hair Gastrointestinal: uremic fetor (ammonia odor breath), metalic taste, mouth ulcers and bleeding, anorexia, nausea and vomiting, hiccups. Constipation or diarrhea, bleeding from GI tract Neurologic: altered level of conciousness, decrease concentration, confussion, muscle cramps, seizures, tremors, restlessness of legs, burning soles of the feet Others: anemia, throbocytopenia, amenorrhea, testicular athrophy, infectility, decrased libido, renal osteodystrophy, bone pain and fractures, foot drop

Medical Mangement

Nursing Interventions

Dialysis or renal transplant Electrolyte replacement Diuretics in early phase Regulation of fluids and sodium Sodium bicarbonate Erythropoetin- primary tx to correct anemia Antihypertensive therapy Dietary mgt. Topical lotions antihistamines

Provide high calorie, low Na and Potassium diet Monitor and manage complication of

hyperkalemia, pericarditis, pericardial effusion and tamponade, HTN anemia

15. Kidney Transplant

a. Complications

Surgical implantation of human kidney as an intervention

for irreversible kidney failure

Graft rejection Infection Urinary tract complications Non-infectious hepatitis Fluid and electrolyte imbalance

b. Preoperative nursing Interventions

Ensure that all test are done

c. Post operative Nursing Interventions

Administer immunosuppressive agents to prevent organ

rejection Assess for the signs of rejections (oliguria, edema, fever, incerasing BP, wt. Gain, swelling or tenderness over the transplant site)

16. Dialysis Process of eliminating fluid and uremic waste products when the body when the kidney fail to do so Relieve symptoms of renal failure temporarily until the client regains kidney function; sustain life in the client with the kidney irreversible disease a. Hemodialysis
Principles of Hemodialysis Diffusions remove the toxins and waste The dialysate controls the electrolyte levels in the blood Osmosis removes excess water from the clood