Practical nursing theory 4 Exam PDF

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Practical nursing theory 4 ExamINFECTIOUS AND INFLAMMATORY DISORDERS OF THEURINARY SYSTEMURINARY TRACT INFECTION Urinary tract infections (UTIs) are the most common bacterial infections in women.  UTIs include cystitis (an inflammatory condition of the urinary bladder, characterized by pain, urgen...

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Practical nursing theory 4 Exam INFECTIOUS AND INFLAMMATORY DISORDERS OF THE URINARY SYSTEM URINARY TRACT INFECTION  Urinary tract infections (UTIs) are the most common bacterial infections in women.  UTIs include cystitis (an inflammatory condition of the urinary bladder, characterized by pain, urgency and frequency of urination, and hematuria), pyelonephritis (inflammation—usually caused by infection—of the renal parenchyma and the collecting system), and urethritis (inflammation of the urethra).  Predisposing factors to UTIs include factors that increase urinary stasis (e.g., tumours, stones, urinary retention); foreign bodies (e.g., indwelling catheter); anatomical factors (e.g., congenital defects); factors compromising immune response (e.g., diabetes mellitus, HIV); and functional disorders (e.g., constipation, voiding dysfunction).  Sexual intercourse promotes “milking” of bacteria from the vagina and the perineum and may cause minor urethral trauma that predisposes women to UTIs.  Escherichia coli (E. coli) is the most common pathogen leading to a UTI.  UTI symptoms include dysuria, frequent urination (more than every 2 hours), urgency, and suprapubic discomfort or pressure. Flank pain, chills, and the presence of a fever indicate an infection involving the upper urinary tract (pyelonephritis).  UTIs are diagnosed by dipstick urinalysis to identify the presence of nitrites (indicating bacteriuria), WBCs, and leukocyte esterase (an enzyme present in WBCs indicating pyuria). A voided midstream technique yielding a clean-catch urine sample is preferred.  Trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin is often used to empirically treat uncomplicated or initial UTIs. Additional drugs may be used to relieve discomfort.  Health promotion activities include teaching preventive measures such as (1) emptying the bladder regularly and completely, (2) evacuating the bowel regularly, (3) wiping the perineal area from front to back after urination and defecation, and (4) drinking an adequate amount of liquid each day. ACUTE PYELONEPHRITIS  Pyelonephritis is an inflammation of the renal parenchyma and collecting system (including the renal pelvis). The most common cause is bacterial infection that begins in the lower urinary tract. Recurring infection can result in chronic pyelonephritis.

Clinical manifestations vary from mild fatigue to the sudden onset of chills, fever, vomiting, malaise, flank pain, and the bothersome lower urinary tract symptoms (LUTS) characteristic of cystitis.  Patients with severe infections or complicating factors, such as nausea and vomiting with dehydration, require hospital admission.  Patients with mild symptoms may be treated on an outpatient basis with antibiotics for 14 to 21 days.  Interventions include teaching about the disease process with emphasis on (1) the need to continue drugs as prescribed, (2) the need for a follow-up urine culture to ensure proper management, and (3) identification of risk for recurrence or relapse. CHRONIC PYELONEPHRITIS  Chronic pyelonephritis is a term used to describe a kidney that has become shrunken and has lost function owing to scarring or fibrosis.  It usually occurs as the outcome of recurring infections involving the upper urinary tract. However, it also may occur in the absence of an existing infection and a recent or remote history of UTIs.  Chronic pyelonephritis is diagnosed by radiological imaging and histological testing. Imaging studies reveal a small, contracted kidney with a thinned parenchyma. Pathological analysis reveals loss of functioning nephrons, infiltration of the parenchyma with inflammatory cells, and fibrosis.  Chronic pyelonephritis often progresses to end-stage renal disease when both kidneys are involved, even if the underlying infection is successfully eradicated. 

URETHRITIS • Urethritis is an inflammation of the urethra, most commonly from a sexually transmitted bacterial or viral infection.  Manifestations include a discharge, particularly in men, with dysuria, urgency, and frequency.  Treatment is based on the underlying cause and providing symptomatic relief. URETHRAL DIVERTICULA  Urethral diverticula are outpouchings in the urethra that result from obstruction and rupture of the periurethral glands. They are associated with childbearing, urethral instrumentation, dilation, and infections.  Symptoms include dysuria, postvoid dribbling, frequency, urgency, suprapubic discomfort or pressure, and dyspareunia.  Surgery is the best treatment option, although stress urinary incontinence is a frequent complication. INTERSTITIAL CYSTITIS

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Interstitial cystitis (IC) is a chronic, painful inflammatory disease of the bladder characterized by symptoms of urgency/frequency and pain in the bladder and/or pelvis. No single treatment has been identified to treat IC. Various therapies, including dietary and lifestyle alterations and medications, are used to alleviate symptoms.

IMMUNOLOGICAL DISORDERS OF THE KIDNEY GLOMERULO-NEPHRITIS  Immunological processes involving the urinary tract predominantly affect the renal glomerulus. The disease process results in glomerulonephritis , an immune-related inflammation of the glomeruli characterized by proteinuria, hematuria, decreased urine production, and edema.  Clinical manifestations of glomerulo-nephritis include varying degrees of hematuria (ranging from microscopic to gross) and urinary excretion of various formed elements, including RBCs, WBCs, and casts.  Acute post-streptococcal glomerulo-nephritis (APSGN) develops 5 to 21 days after an infection of the pharynx or skin (e.g., streptococcal sore throat, impetigo) by nephrotoxic strains of group A -hemolytic streptococci. Manifestations include generalized body edema, hypertension, oliguria, hematuria with a smoky or rusty appearance, and proteinuria.  APSGN management focuses on symptomatic relief. This includes rest, edema and hypertension management, and dietary protein restriction when an increase in nitrogenous wastes (e.g., elevated BUN value) is present.  One of the most important ways to prevent the development of APSGN is to encourage early diagnosis and treatment of sore throats and skin lesions. GOODPASTURE’S SYNDROME • Goodpasture’s syndrome is a rare autoimmune disease characterized by the presence of circulating antibodies against glomerular and alveolar basement membranes. RAPIDLY PROGRESSIVE GLOMERULO-NEPHRITIS  Rapidly progressive glomerulo-nephritis (RPGN) is glomerular disease associated with rapid, progressive loss of renal function over days to weeks.  RPGN can occur in a variety of situations: (1) as a complication of inflammatory or infectious disease (e.g., APSGN), (2) as a complication of a multisystemic disease (e.g., systemic lupus erythematosus, Goodpasture’s syndrome), (3) as an idiopathic disease, or (4) in association with the use of certain drugs (e.g., penicillamine).

CHRONIC GLOMERULO-NEPHRITIS • Chronic glomerulo-nephritis is a syndrome that reflects the end stage of glomerular inflammatory disease. It is characterized by proteinuria, hematuria, and slow development of uremic syndrome. Treatment is supportive and symptomatic. NEPHROTIC SYNDROME  Nephrotic syndrome describes a clinical course that can be associated with a number of disease conditions, including multisystem diseases such as diabetes or systemic lupus erythematosus, infections, and neoplasms, and also certain drugs.  It results when the glomerulus is excessively permeable to plasma protein, causing proteinuria that leads to low plasma albumin and tissue edema. o Treatment is focused on symptom management. o A major nursing intervention is related to edema. Edema is assessed by weighing the patient daily, accurately recording intake and output, and measuring abdominal girth or extremity size.

OBSTRUCTIVE UROPATHIES • Urinary obstruction refers to any anatomical or functional condition that blocks or impedes the flow of urine. It may be congenital or acquired. URINARY TRACT CALCULI  Factors involved in the development of urinary stones include metabolic, dietary, genetic, climatic, lifestyle, and occupational influences. Other factors are obstruction with urinary stasis and urinary tract infection with urea-splitting bacteria.  The five major categories of stones (lithiasis) are (1) calcium phosphate, (2) calcium oxalate, (3) uric acid, (4) cystine, and (5) struvite (magnesium–ammonium phosphate).  Urinary stones cause clinical manifestations when they obstruct urinary flow. Common sites of complete obstruction are at the UPJ (the point where the ureter crosses the iliac vessels) and at the uretero-vesical junction (UVJ).  Management of a patient with renal lithiasis consists of managing the acute attack (treating the symptoms of pain, infection, or obstruction), and evaluating the cause of stone formation to prevent further development of stones.  Lithotripsy (use of sound waves to break renal stones into small particles) is used to eliminate calculi from the urinary tract. Outcome for lithotripsy is based on stone size, stone location, and stone composition.

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The goals are that the patient with urinary tract calculi will have (1) relief of pain, (2) no urinary tract obstruction, and (3) an understanding of measures to prevent further recurrence of stones. To prevent stone recurrence, the patient should consume an adequate fluid intake to produce a urine output of approximately 2 L/day. Additional preventive measures focus on reducing metabolic or secondary risk factors (e.g., restricting dietary purines).

STRICTURES • A stricture is an abnormal temporary or permanent narrowing of the lumen of a hollow organ; in this context, of the ureter or the urethra. Ureteral Strictures • Ureteral strictures can affect the entire length of the ureter, from the UPJ to the UVJ. Urethral Strictures • A urethral stricture is the result of fibrosis or inflammation of the urethral lumen o Causes of urethral strictures include trauma, urethritis, iatrogenic (following surgical intervention), or a congenital defect. o Clinical manifestations associated with a urethral stricture include a diminished force of the urinary stream, sprayed stream, or a split urine stream. The patient may report feelings of incomplete bladder emptying with urinary frequency and nocturia.

RENAL VASCULAR PROBLEMS  

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Vascular problems involving the kidney include (1) nephrosclerosis, (2) renal artery stenosis, and (3) renal vein thrombosis. Nephrosclerosis is a vascular disease of the kidney characterized by sclerosis of the small arteries and arterioles of the kidney, resulting in renal tissue destruction. It may be benign or malignant. o Treatment for benign nephrosclerosis is the same as that for essential hypertension. o Malignant nephrosclerosis is treated with aggressive antihypertensive therapy. Renal artery stenosis is a partial occlusion of one or both renal arteries and their major branches due to atherosclerotic narrowing or fibromuscular hyperplasia. The goals of therapy are control of BP and restoration of perfusion to the kidney. Renal vein thrombosis, an embolus occurring in the renal vein, may occur unilaterally or bilaterally. Trauma, extrinsic compression (e.g., tumour, aortic aneurysm), renal cell carcinoma, pregnancy, contraceptive use, and nephrotic syndrome are associated with renal vein thrombosis.

o Anticoagulation is important in treatment because there is a high incidence of pulmonary emboli. Corticosteroids may be used for the patient with nephrosis.

HEREDITARY RENAL DISEASES POLYCYSTIC KIDNEY DISEASE  Polycystic kidney disease (PKD) is characterized by thin-walled cysts ranging in size from several millimetres to several centimetres in diameter that fill the cortex and medulla and destroy surrounding tissue by compression.  Diagnosis is based on clinical manifestations, family history, IVP, ultrasound (best screening measure), or CT scan.  There is no specific treatment for PKD. A major aim is to prevent or treat infections of the urinary tract. Nephrectomy may be necessary if pain, bleeding, or infection becomes chronic.

RENAL INVOLVEMENT IN METABOLIC AND CONNECTIVE TISSUE DISEASES • Diabetic nephropathy is the primary cause of end-stage renal failure in Canada. Diabetes mellitus affects the kidneys by causing microangiopathic changes.  Amyloidosis is a group of disorders evidenced by impaired organ function from the infiltration of tissues with a hyaline substance (amyloid); kidney involvement is common.  Gout, a syndrome of acute attacks of arthritis caused by hyperuricemia, can also result in significant renal disease.  Systemic lupus erythematosus is a connective tissue disorder characterized by the involvement of several tissues and organs, particularly the joints, skin, and kidneys. It results in clinical manifestations similar to glomerulo-nephritis.  Systemic sclerosis (scleroderma) is a disease of unknown etiology characterized by widespread alterations of connective tissue and by vascular lesions in many organs.

URINARY TRACT TUMOURS KIDNEY CANCER  There are no characteristic early symptoms of kidney cancer. Many patients with kidney cancer go undetected.  Diagnostic tests include IVP with nephrotomography, ultrasound, angiography, percutaneous needle aspiration, CT, and MRI. Radionuclide isotope scanning is used to detect metastases. BLADDER CANCER

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Risk factors for bladder cancer include cigarette smoking, exposure to dyes used in the rubber and cable industries, chronic use of phenacetin-containing analgesics, and chronic, recurrent renal calculi. Gross, painless hematuria (chronic or intermittent) is the most common clinical finding with bladder cancer. Surgical therapies for bladder cancer include transurethral resection with fulguration (electrocautery), laser photocoagulation, and open loop resection with fulguration. Postoperative management following bladder cancer surgery includes instructions to drink a large volume of fluid each day for the first week following the procedure and to avoid intake of alcoholic beverages. Intravesical therapy is chemotherapy that is locally instilled. Chemotherapeutic or immune-stimulating agents can be delivered directly into the bladder by a urethral catheter. BCG is the treatment of choice for carcinoma in situ.

URINARY INCONTINENCE AND RETENTION 

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Urinary incontinence (UI) is an uncontrolled loss of urine that is of sufficient magnitude to be a problem. The prevalence of incontinence is higher among older women and older men, but it is not a natural consequence of aging. Transient causes of UI include confusion or depression, infection, urinary retention, restricted mobility, fecal impaction, or drugs. Urinary retention is the inability to empty the bladder despite micturition or the accumulation of urine in the bladder because of an inability to urinate. Urinary retention is caused by two different dysfunctions of the urinary system: bladder outlet obstruction and deficient detrusor (bladder muscle) contraction strength. Acute urinary retention is the total inability to pass urine via micturition, and is a medical emergency that requires prompt recognition and bladder drainage. Chronic urinary retention is defined as incomplete bladder emptying despite urination. Evaluation for UI and urinary retention includes a focused history, physical assessment, and a bladder log or voiding record whenever possible. Management strategies for UI include lifestyle interventions such as an adequate volume of fluids and reduction or elimination of bladder irritants from the diet. Behavioural treatments include scheduled voiding regimens (timed voiding, habit retraining, prompted voiding, bladder retraining and urge-suppression strategies), and pelvic floor muscle training. Short-term urinary catheterization may be performed to obtain a urine specimen for laboratory analysis. Complications from long-term use

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(>30 days) of in-dwelling catheters include bladder spasms, pain, and urosepsis. While the patient has a catheter in place, nursing actions should include maintaining patency of the catheter, managing fluid intake, providing for the comfort and safety of the patient, and preventing infection. The ureteral catheter is placed through the ureters into the renal pelvis. The catheter is inserted either (1) by being threaded up the urethra and bladder to the ureters under cystoscopic observation, or (2) by surgical insertion through the abdominal wall into the ureters. The suprapubic catheter is used in temporary situations such as bladder, prostate, and urethral surgery. The suprapubic catheter is also used long-term in selected patients.

SURGERY OF THE URINARY TRACT RENAL AND URETERAL SURGERY  Common indications for nephrectomy include a renal tumour, polycystic kidneys that are bleeding or severely infected, massive traumatic injury to the kidney, and the elective removal of a kidney from a donor. A kidney can be removed by laparoscopic nephrectomy.  In the immediate postoperative period following renal surgery, urine output should be determined at least every 1 to 2 hours. URINARY DIVERSION  Numerous urinary diversion techniques and bladder substitutes are possible, including an incontinent urinary diversion, a continent urinary diversion catheterized by the patient, or an orthotopic bladder substitution so that the patient voids urethrally.  Common peristomal skin problems associated with an ileal conduit (procedure in which a 15- to 20-cm segment of the ileum is converted into a conduit for urinary drainage) include dermatitis, yeast infections, product allergies, and shearing-effect excoriations.  Discharge planning after an ileal conduit includes teaching the patient symptoms of obstruction or infection and care of the ostomy.

URINARY SYSTEM STRUCTURES AND FUNCTIONS OF THE URINARY SYSTEM  The urinary system consists of two kidneys, two ureters, a urinary bladder, and a urethra.  The bladder provides storage, and the ureters and urethra are the drainage channels for the urine after it is formed by the kidneys. Kidneys

The primary functions of the kidneys are (1) to filter waste products from the bloodstream, (2) to maintain fluid and electrolyte and acid– base balance in the body, and (3) to excrete metabolic waste products.  The kidneys also function to regulate blood pressure, bone density, and erthyropoesis, produce erythropoietin, activate vitamin D, and produce and secrete renin.  The outer layer of the kidney is termed the cortex, and the inner layer is called the medulla.  The nephron is the functional unit of the kidney. Each kidney contains about 1 million nephrons.  A nephron is composed of a glomerulus, Bowman capsule, and the tubular system. The tubular system consists of the proximal convoluted tubule, the loop of Henle, and the distal convoluted tubule.  The kidneys receive 20% to 25% of cardiac output of blood supply.  The primary function of the kidneys is to filter the blood and maintain the body’s internal homeostasis.  Urine formation is the result of a multistep process of filtration, reabsorption, secretion, and excretion of water, electrolytes, and metabolic waste products. Glomerular function • Blood is filtered in the glomerulus, a capillary network within the kidneys that comprises up to 50 capillaries and is a semipermeable membrane that allows for filtration.  The hydrostatic pressure of the blood within the glomerular capillaries causes a portion of blood to be filtered across the semipermeable membrane into Bowman capsule.  The ultrafiltrate is similar in composition to blood except that it lacks blood cells, platelets, and large plasma proteins.  The amount of blood filtered by the glomeruli in a given time is termed the glomerular filtration rate (GFR). The normal GFR is about 125 mL/min. 

Tubular function...