Nursing Care of Clients with Urinary Tract Disorders

1
Nursing Care of Clients with Urinary Tract
Disorders

• Chapter 29

2
The Renal System
3
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
• nocuria, pyuria, hematuria
• supra pubic pain

4
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.

5
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

6
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.

7
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.

8
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
• CBC-systemic response

9
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

10
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

11
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

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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

13
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.

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Glomerulonephritis

• Fall in GFR activates the renin-angiotensin-aldost
  erone 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.

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Glomerulonephritis
16
Glomerulonephritis
17
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.

18
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

19
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.

20
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.

21
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.

22
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.

23
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

24
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

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Renal Calculi
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The Client with Urinary CalculiObstructive
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-

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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.)

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Types of Calculi
29
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.

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The Client with Urinary Calculi

• Treatment
• Surgery
• lithotrispy
• crushing of calculi
• cystoscopy
• Nursing Care
• Pain management
• Altered Urinary Elimination - strain urine,
  patent catheter tubing

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Kidney Stones
32
Lithotripsy
33
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.

34
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.

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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.

36
Bladder tumor (Congenital disorders)
37
Bladder Cancer
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The Client with Urinary Tumor

• Bladder most common site. 10th cause of cancer
• Death.
• Risk Factors
• gt50 years old
• male
• cigarette smoking
• Chronic inflammation of the bladder.
• Symptoms - painless hematuria, urgency and
  dysuria.

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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.

40
The Client with Urinary Tumor

• Diagnosis
• UA for cytology
• IVP, Renal Ultrasound, CT Scan, Cystoscopy with
  biopsy
• Treatment
• Pharmacology - chemotherapy
• Radiation therapy
• Surgery

41
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

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Stoma for ileal conduit
43
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!

44
Nursing Care - Review

• Urinary Tract infections?
• Signs/symptoms, diagnostic studies, treatment
• Renal Calculi?
• Bladder Cancer?

45
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

46
Benign Prostatic Hypertrophy
47
The Client with Neurogenic Bladder

• Spinal Cord injury
• frequent spastic contraction of the bladder
• involuntary bladder emptying
• Treatment
• self catheterization
• surgery - urinary diversion

48
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,
  over-distended and loss small amounts of urine
• Reflex - involuntary loss of large amount
• Functional - physical or environmental

49
The Client with Urinary Incontinence

• Treatment
• Correct underlying problem - cysocele,
  urethrocele, enlarged prostate gland
• Toileting schedule
• to bathroom
• diaper change

50
Polycystic Kidney Disease
51
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!

52
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 acid-base
  imbalances are the defining characteristics.

53
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.

54
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).

55
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.

56
Chronic Kidney DiseaseChronic 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.

57
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 develop- transplant or
  dialysis are necessary.

58
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.

59
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.

60
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.

61
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

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• 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

63

• 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

64

• What findings are considered abnormal?
• What about a C S?
• Treatment?

65
ESRD

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

66
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

67
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

68
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

69
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

70
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