Urinary disorder PDF

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Urinary Disorder...

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CARE OF THE PATIENT WITH A URINARY DISORDER I.

Anatomy and Physiology 1. Nitrogenous waste (urea, ammonia, and creatinine) - Produced when proteins break down. 2. Kidneys help with: a. Regulating water, electrolytes, secretion of erythropoietin (that stimulates the RBC's). 3. Urinary system include: a. 2 kidneys b. 2 ureters c. The bladder - Collects and stores urine d. The urethra - Transports urine from the bladder to outside the body 4. Urinary system responsible for: - Maintenance of homeostasis in the body 5. Primary function of the kidneys: a. Excretion of waste products b. Regulates the body's water, electrolytes, secretion of erythropoietin, and acid-base balance. c. Removes the waste, excess water, and electrolytes from blood and concentrates them into urine. A. Kidneys -

Lie behind the parietal peritoneum (retroperitoneal), just below the diaphragm, on each side of the vertebral column. Dark-red, bean shaped 4 to 5 inches (10 to 12 cm)long 2 to 3 inches (5 to 7.5 cm) wide. 1 inch thick. a) Hilus

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The indentation of the kidney where the renal artery enters and the renal vein and the ureter exit the kidney

b) Adrenal glands - Part of the endocrine system; sitting near the top of each kidney. Secretes hormones that help control bp and heart rate. c) Adrenal cortex - Primarily secretes mineralocorticoid hormone called aldosterone. d) Primary regulator of aldosterone: - The level of potassium concentration in the plasma e) Changes evoked through the adrenal glands produce changes in kidney function. 1. Gross Anatomic Structure (in order) a) Renal capsule - Outer covering of the kidney is a strong layer of connective tissue. b) Renal cortex - Directly beneath the renal capsule c) Medulla - Beneath the cortex - Darker color d) Pyramids - Medulla contains this triangular pyramid Continuing inward, the narrow points of the pyramid (papillae) e) Papillae - Empty urine into the calyces.

f) Calyx (“calyces” plural) - Cuplike extensions of the renal pelvis that guide urine into the main part of the renal pelvis. g) Renal pelvis - Expansion of the upper end of the ureter h) Ureter - Drains the finished product, urine, Into the i) Bladder 2. Microscopic structure a) Nephron - Each kidney contains more than 1 million nephrons - The nephron is the functional unit of the kidney - It is responsible for filtering the blood and processing the urine (1) Three major functions: - Controlling body fluid levels by selectively removing or retaining water - Assisting with the regulation of the pH of the blood - Removing toxic waste from the blood (2) Two main structures of the nephron: (a) Renal corpuscle (b) Renal tubule (3) Efferent vs. afferent (a) afferent- delivering blood to glomerulus (b) efferent- blood leaves the glomerulus through an efferent arteriole. (4) Glomerulus - Filtrates water and blood products. (5) Distal convoluted tubule

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part of the nephron does secretion happen.

(6) BP drops when the body has suffered Increased fluid loss by hemorrhage, diaphoresis, vomiting, diarrhea. (7) The juxtaglomerular apparatus - which also regulates systemic blood pressure and filtrate formation. - regulates the function of each nephron (8) Juxtaglomerular cells - contain the enzyme renin and sense blood pressure (9) 3 phases of urine formation (a) Filtration of water and blood products. (b) Reabsorption of water, glucose, and necessary ions back into the blood. (c) Secretion of certain ions, nitrogenous waste products, and drugs occurs. (10) ADH causes the cells of the distal convoluted tubules to increase their rate of water reabsorption. This returns the water to the bloodstream, increasing BP to be more normal and causes the urine to become more concentrated B. Urine composition and characteristics 1. Urine comes from one component which is uric acid. 2. 1000 to 2000 ml of urine each day body forms. 3. 95% water, the remainder 5% is nitrogenous waste and salts. 4. Transparent yellow with a characteristic odor. Yellow is due to urochrome, a pigment resulting from the body's destruction of hemoglobin is the normal characteristics of urine. 5. Slightly acidic/pH: 4.6 to 8 & specific gravity: 1.003 to 1.030 6. Urine sterile - It is slightly sterile, but at room temp. it rapidly decomposes and develops the odor of ammonia. C. Urine abnormalities 1. Albumin

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2.

Indicates possible renal disease, increased blood pressure, or toxicity of the kidney cells from heavy metals.

Glucose in the urine (glycosuria) - Most indicates a high glucose level.

3. Erythrocytes in the urine (hematuria) - may indicate infection, tumors, or renal disease. occasionally could mean a kidney stone (renal calculus/calculi) and irritation causes hematuria. 4. Ketone bodies (ketoaciduria or ketonuria) - appears when too many fatty acids are oxidized. Seen with DM, starvation, or any other metabolic condition which fats are rapidly catabolized. 5. Leukocytes (white blood cells in the urine) - most likely associated with an infection in the urinary tract

D. Ureters 1. Extension of the renal pelvis and extended downward 10 to 12 inches to the lower part of the urinary bladder. 2. Once the urine has been formed in the nephrons, it passes to the paired ureters. 3. As the ureter enters the bladder, internal mucous membrane folds act as a valve to prevent backflow of urine. E. Urinary bladder 1. Temporary storage pouch of urine. 2. 750 to 1000 mL can bladder hold urine, when it reaches 250 mL's the person has a conscious desire to urinate. A moderately full bladder holds 450 mL. 3. Sphincters of the bladder a) internal sphincter- located at the bladder neck, involuntary muscle. b) external sphincter- composed of skeletal or voluntary muscle at the terminus of the urethra. F. Urethra 1. Terminal portion of the urinary system.

2. Male urethra serves as passageway for urine and semen. G. Effects of normal aging on the urinary system 1. Aging kidney lose 50% of function from age 40 to age 70 this occurs because of decreased blood supply and loss of nephrons. II.

Laboratory and diagnostic examination A. Urinalysis 1. Most common diagnostic study for urinary problems. 2. Urine culture and sensitivity - may be done to confirm suspected infections, to identify causative organisms, and to determine appropriate antimicrobial therapy. Also used for periodic screening when the threat of a UTI persists. 3. Common substances to monitor kidney function: a) total urine protein b) Creatinine c) Urea d) Uric acid levels e) Catecholamines 4. Low - Temporary elevated levels are common with illness, 5. Chronic elevated levels - seen with cardiac and renal damage. 6. Abnormal kidney results: a) Creatinine- nonspecific; may be kidney failure, urinary obstruction, and infections b) Uric acid- results from the breakdown of purines. Low levels may be tied to alcohol use and glomerulonephritis. c) Catecholamines- made by nervous tissue and the adrenal glands, levels may be elevated with ingestion of many medications including tricyclic antidepressants and amphetamines, metastatic cancers, bone marrow disorders, and gout. low levels are seen with MAO inhibitors and salicylates.

7. Urinalysis completed by a clean-catch specimen and catheterized specimen. 8. You want a 24-hour culture because the kidneys excrete substances in varying amounts and rates during a 24-hour period B. Specific gravity of urine - indicates a patient's hydration status and gives information about the kidneys ability to concentrate urine. decreased by high fluid intake; increased in dehydration or high blood sugars - Normal range: 1.003-1.030. C.

BUN (blood serum nitrogen) - used to determine the kidneys ability to rid the blood of nonprotein nitrogenous waste and urea, which results from protein breakdown (catabolism). May be performed to assess overall functioning of kidneys, monitor progression of kidney disease or evaluate the effectiveness of prescribed therapies. - Normal range: 10-20 mg/dL - NPO 8 hours before blood test - Elevated ranges may indicate dehydration, heart disease, and a high protein diet.

D. Blood (serum) creatinine - used in skeletal muscle contraction; as with BUN entirely excreted by your kidneys. Elevated levels may mean dehydration, preeclampsia, and muscular dystrophy, pyelonephritis or glomerulonephritis, reduced kidney function or renal failure. Low levels may be from myasthenia gravis or late stage muscular dystrophy. E.

Creatinine clearance - present in blood and urine; generated during muscle contraction and then excreted by glomerular filtration. Levels directly related to muscle mass; usually measured for 24 hours. Pt avoids strenuous activity, fasting blood sample done at the beginning and one at the end. Follow procedure for a 24 hour urine collection to test the urine for this. F. Prostate specific antigen (PSA) - used to test the prostate health of men being treated for cancer, or as a diagnostic screening. Elevated levels may result from prostate cancer,

inflammation, infection, UTI, etc. Does not officially diagnosed. If levels are high, additional studies are warranted. G. Urine Osmolality - Determines the number of particles per volume of water. Sometimes more informative than urine specific gravity but harder test to perform.. May be used along with urine sampling for when pituitary disorders are suspected. Results provide information on the concentrating ability of the kidney. H. Kidney-Ureter-Bladder Radiography - assesses the general state of the abdomen and the size, structure, and position of the urinary tract structures. No prep needed for pt. May involve changing positions on the radiography table. Findings may include tumors, calculi, glomerulernephritis, cysts, and other conditions. I. IV pyelography (IVP) or IV Urography (IVU) - evaluates structures of the urinary tract, filling of the renal pelvis with urine, and transport of urine via the ureters to the bladder. ASK if pt is allergic to iodine or iodine containing foods). Pt prep- eating a small dinner the night before, 8hrs NPO, non gas forming laxative. J.

Retrograde Pyelography - examination of the lower urinary tract with a cystoscope under aseptic conditions; urologist injects dye directly into the ureters to visualize the upper urinary tract. Urine can be obtained directly from the renal pelvis.

K. Voiding Cystourethrography - used to detect abnormalities of the bladder and urethra. Prep- enema before the test, a catheter inserted, and then dye inserted into the bladder to view the lower urinary tract. Pt is asked to urinate while radiographs are taken and then catheter removed. Findings may include structural abnormalities, diverticula, and reflux into the ureter L. Endoscopic Procedures - Consent required. - involves inserting a long, flexible tube (endoscope) down your throat and into your esophagus. 1. Nephroscopy

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done through the skin, provides visualization of the upper urinary structures

2. Cystoscopy - visual examination done to inspect, treat, or diagnose disorders of the urinary bladder and proximal structures. local anesthetic after the patient has been sedated, scope inserted into the urethra, continuous fluid irrigation of the bladder necessary so they can visualize. After care includes hydration and monitoring first void (which may be blood tinged from trauma of procedure) M. Renal angiography - Aids in evaluation blood supply to the kidneys, evaluates masses, and detects possible complications after a kidney transplant. NPO midnight or after, dye in injected. After procedure, have patient lie flat for several hours to avoid bleeding. Assess puncture site, maintain pressure on dressing. Assess circulation of affected extremity every 15 minutes for 1 hour, and then every 2 hours for 24 hours. N. Renal venography - provides information about kidneys venous drainage. Catheter injected into femoral artery, monitor bleeding site after for complications O. Computed tomography (CT Scan) - scan differentiates masses in the kidneys, urea and creatinine levels are obtaining before using dye, CT machine will move at intervals taking 3-D pictures, important for pt to lie still. P. Magnetic resonance Imaging - uses nuclear imaging resonance as its source of energy to obtain a visual assessment of body tissues. Q. Renal Scan - a radionuclide tracer substance in injected intravenously and computer generated images are then made. Pregnant nurses should not perform this. Scan provides information about parenchyma (the essential parts of an organ that are concerned with its function) R. Ultrasonography

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diagnostic tool that uses sound waves to produce images of deep body structures. Jelly applied over skin because it improves the transition of sound waves that are inaudible to the human ear, but they are converted into electrical impulses that are photographed for study. This can visualize size, shape, and position of kidney structures and locate abnormalities.

S. Transrectal Ultrasound - provides clear images of prostatic tumors that might otherwise go undiagnosed; the biopsy might take a sample of prostatic tissue T. Renal Biopsy - Biopsy of the kidney can be done surgical like or percutaneous (less invasive method of needle biopsy). Pt might have to hold breath, and be on bedrest for 24 hours, then the next 24 hours BRP only, then gradually more allowed 48-72 hours after. Monitor for complications, high temp, unrelieved pain, and difficulty voiding. U. Urodynamic Studies - These are indicated when neurological diseases are thought to be the cause of incontinence. These studies evaluate the activity level of the bladder. A catheter is inserted into the bladder, then hooked to a cystometer which measures bladder capacity and pressure, and nurse might ask about sensations of heat, cold, or ask the patients to void at times. III.

Medication consideration - The ability of the kidney to filter certain medications from the blood could be affected by renal disease, changes in urine pH, and age. - Patients with renal disease are given smaller doses of medicine to prevent further damage or drug toxicity. A. Diuretics to enhance urinary output - Increasing filtration of NA, CL, and H20 at various sites in the kidney. - Use for heart failure and hypertension/ 1. Thiazide diuretics - can cause hypokalemia, hyponatremia, hypercalcemia - Main use for diuretics is to manage systemic edema and control mild to moderate hypertension; may take a month to achieve optimal results

2. Loop (or high-ceiling) diuretics - Furosemide (lasix) - Inhibit tubular reabsorption of sodium and chloride. - Effective for patients who have impaired kidney function, heart failure, nephrotic syndrome, and pulmonary edema. - Can cause hypokalemia, hypochloremia, hyponatremia, hypocalcemia, and or hypomagnesemia. - Can lead to hypochloremic alkalosis - Side effects: rapid fluid loss: vertigo, hypotension, and possible circulatory collapse. 3. Potassium-sparing diuretics - Inhibits sodium reabsorption and potassium secretion. - Decrease sodium-potassium exchange. - Contraindicated in patients with hyperkalemia because further retention of potassium could cause cardiac dysrhythmia.

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Two types: aldosterone antagonist and non aldosterone antagonist. Antagonist- prevents a particular cell response agonist - prolongs the response. 1. Aldosterone antagonist spironolactone (Aldactone): - blocks aldosterone in the distal tubule to promote potassium uptake in exchange for sodium excretion. Treatment for hypertension and edema. - Spironolactone is used most frequently for its potassium-sparing quality. 2. Non Aldosterone antagonist triamterene (Dyrenium) - Directly reduces ion transportation in the distal tubule, although it has little diuretic effect. - Triamterene is used instead to help limit the potassium-wasting effect of other diuretics.

4. Osmotic diuretics -

Act at the proximal convoluted tubule to increase plasma osmotic pressure, causing redistribution of fluid toward the circulatory vessels.

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Used to measure edema, promote systemic diuresis in cerebral edema, decrease intraocular pressure, and improve kidney function in acute renal failure (ARF). N/I for someone taking mannitol: Careful assess of cardiovascular system before admin because of the high risk of inducing heart failure. Avoid extravasation (escape of med from the blood vessels into the tissues), which may lead to tissue irritation or necrosis.

5. Carbonic anhydrase inhibitor diuretics - interferes with the bonding of water and carbon dioxide by the enzyme carbonic anhydrase (present in red blood cells) at the proximal convoluted tubule. Although it has limited usefulness as a diuretic, acetazolamide is used to lower intraocular pressure. - Converts water and carbon dioxide to bicarbonate. - Acetazolamide (Diamox) inhibits carbonic anhydrase, which leads to Diuresis 6. Nursing intervention: adding daily potassium sources. Potassium sources are baked potatoes, raw bananas, apricots, or navel oranges. B. Medications for urinary tract infections - Urinary antiseptics are divided into three groups: 1. Quinolones 2. Nitrofurantoin 3. Methenamine 1. Quinolones - Used to treat UTIs caused by Gram-negative microbes. - Side effects: Drowsiness, vertigo, weakness, nausea, vomiting. - Contraindicated in renal impairment 2. Nitrofurantoin - Is effective against both gram-positive and gram-negative microbes. - Side effects; Loss of appetite, nausea, vomiting

3. Methenamine - Methenamine hippurate (Mandelamine) suppresses fungi and gram-negative and gram-positive organisms. - Acidification of the urine by means of an acid-ash diet or other acidifiers to a pH of less than 5.5 is necessary for effective action of methenamine mandelate - used for patients with chronic, recurrent UTIs - Side effects: Nausea, vomiting, skin rash, urticaria C. Nursing interventions 1. When indicated, teach the patient to consume an acid-ash diet to help maintain a urine pH of 5.5 2. Soothe skin irritations with cornstarch or a bath of bicarbonate of soda or dilute vinegar. 3. Observe the patient receiving nalidixic acid for visual disturbances. IV.

V.

Nutritional considerations. - Urolithiasis is a calculi or stones formed anywhere in the urinary system Maintaining adequate urinary drainage - 1 French (1F) equals a diameter of 0.3 mm -

Urethral catheters range from 14F to 24F

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Ureteral catheters are usually 4F to 6F

A. Types of catheters 1. Coude catheter - has a tapered tip and is selected for ease of insertion when enlargement of the prostate gland is suspected. - Less traumatic during insertion

2. Foley catheter - has a balloon near its tip that may be inflated after insertion 3. Malecot and de Pezzer, or mushroom

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used to drain urine from the renal pelvis of the kidney

4. Robinson catheter - Multiple openings in its tip to facilitate intermittent drainage. 5. Ureteral catheters - Long and slender to pass into the ureters. 6. Whistle-tip catheter - Has a slanted, larger orifice at its tip to be used if there is blood in the urine. 7. Cystostomy, vesicostomy, or suprapubic catheter - Introduced by the health care provider through the abdominal wall above the symphysis pubis. - Diverts urine flow from the urethra as needed to treat injury to the bony pelvis, the urinary tract, or surrounding organs; strictures; or obstructions. 8. External (Texas) or condom catheter - Not actually a catheter but rather a drainage system connected to the external male genitalia. It is used for the incontinent male to reduce skin irritation from urine and reduce risk of infection from indwelling urinary catheter B.

Nursing interventions and medical management, and patient teaching 1. Follow aseptic technique to avoid introducing microorganisms from the environment. - NEVER rest the collecting bag on the floor. 2. Record I & O. For pr...