Uworld-adult-urinary renal-1 PDF

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sphincter and structural supports of the bladder, are an essential part of the teaching plan but are not the priority for this client. It will take approximately 6 weeks for pelvic floor muscle strength to improve. o Natural bladder irritants (eg, smoking, caffeine, alcohol) increase incontinence and should be eliminated but are not the priority in this client o Pessaries relieve minor pelvic organ prolapse and may be used in some clients when initial conservative measures fail. This client should receive initial instruction on the importance of emptying the bladder often

ADULT HEALTH – URINARY/RENAL BLADDER CANCER •

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The tell-tale symptom of bladder cancer, seen in >75% of cases, is painless hematuria; the client will report seeing blood in the urine with no associated pain. As with many other types of cancer, the primary cause of bladder cancer is cigarette smoking or other tobacco use Poorer outcomes are seen with increased length of time as a smoker and higher number of packs per day. Clients who have family members with bladder cancer have an increased risk of developing bladder cancer themselves; however, the primary risk factor is tobacco use. Occupational carcinogen exposure is the second most common risk factor. Occupational exposures include printing, iron and aluminum processing, industrial painting, metal work, machining, and mining. Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols and vapors). Consuming a high-fat diet and using artificial sweeteners are risk factors for developing bladder cancer, but they are not the primary cause.

URINALYSIS

STRESS INCONTINENCE •

The nursing care plan for a client experiencing stress incontinence includes pelvic floor exercises, bladder training, incontinence products, and lifestyle modifications. o The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and urinary tract infections through bladder training. Teaching the client to empty the bladder every 2 hours when awake and every 4 hours at night reduces these risks o Pelvic floor exercises (eg, Kegel exercises), which strengthen the

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This client's urinalysis reveals that the client is most likely dehydrated. Amber color indicates concentrated urine. The specific gravity evaluates the ability of the kidneys to concentrate solutes in the urine. The normal urine specific gravity value ranges from 1.003 to 1.030. Causes of increased specific gravity include fluid deficit.

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Glucose should be absent in the urine. Its presence is suspicious for diabetes mellitus. Dysuria (burning or difficulty urinating) may be indicative of infection or inflammation. The number of white blood cells (WBCs) should be very few (0-5 per high power field), as seen in this client. Increased numbers indicate infection or inflammation. Hematuria is indicative of possible renal trauma. The normal range for red blood cells is 0-4 per high power field. None are present on this client's urinalysis results.

ARTERIOVENOUS GRAFT FISTULA

URGE INCONTINENCE •

Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate that is followed by urine leakage.

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UI may occur without cause or may result from spinal cord injury and impairment of the bladder (eg, interstitial cystitis) or neurological system (eg, Parkinson disease, stroke).

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Interventions for clients with UI include: o

Loss of excess weight to reduce pressure on the pelvic floor

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Anticholinergic medications (eg, oxybutynin, tolterodine) to decrease bladder spasms. Dry mouth (xerostomia) is a frequent adverse effect

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Avoidance of bladder irritants (eg, artificial sweeteners, caffeine, citrus juices, alcohol, carbonated drinks, nicotine)

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Pelvic floor exercises (eg, Kegel) to strengthen the muscles and help prevent urinary leakage

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Bladder training (eg, voiding every 2 hours while awake) and gradually lengthening intervals between voiding

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The creation of an AVF for hemodialysis access involves an anastomosis between an artery and a vein (usually the cephalic or basilic vein). The fistula permits the arterial blood to flow through the vein, causing the vein to become larger in diameter and the walls to thicken, enabling blood to flow at high pressures. After the AVF is placed, it takes 2-4 months for it to mature to accommodate the repeated venipunctures necessary for hemodialysis access. The major complications of an AVF are infection (especially in end-stage kidney disease and diabetes), stenosis, thrombosis, and hemorrhage. Clients are taught the following preventive interventions: Report numbness or tingling of the extremity to the HCP to prevent neuromuscular damage o Do not allow anyone (other than dialysis personnel) to draw blood or take blood pressure measurements on the extremity to prevent thrombosis o Avoid wearing restrictive clothing or jewelry to prevent thrombosis o Do not use the arm with vascular access to carry heavy objects (more than 5 lb [2.26 kg]); however, o

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exercises to increase strength could include squeezing a soft ball or sponge several times a day Check the function of the vascular access several times a day by feeling for vibration to assess for patency, stenosis, and clotting Do not sleep on the arm with vascular access or use creams or lotions on the site Monitor for signs of infection and bleeding after dialysis and report immediately Keep the site clean to help prevent infection

An arteriovenous fistula is a surgical connection of an artery to a vein created to provide vascular access for hemodialysis therapy in clients with kidney disease. Arterial blood flowing through this vein causes it to engorge and thicken (mature) over a period of several weeks, after which it can sustain frequent access by 2 large-bore needles required for dialysis. Maturing of the fistula is aided by having the client perform hand exercises, such as squeezing a rubber ball, that increase blood flow through the vein. Following fistula placement, it is important to monitor for patency. A palpable thrill (vibration) over the fistula or an auscultated bruit (blowing or swooshing sound caused by turbulent blood flow) indicates a patent fistula. Absence of the thrill or bruit can indicate potential clot formation in the fistula. Client reports of numbness or tingling as well as decreased capillary refill can also signal potential clotting. Capillary refill of 2 weeks) could indicate venous hypertension that may require surgery to prevent AVF failure. A loud swooshing sound (ie, bruit) auscultated over the AVF is expected due to turbulent blood flow at the arteriovenous anastomosis. Hand-grip exercises (eg, ball squeezing, hand flexing) are encouraged after AVF creation to promote fistula maturation. Postoperative surgical site pain is expected; however, pain distal to the AVF may indicate tissue ischemia.

CONTINUOUS BLADDER IRRIGATION Case: A client underwent a transurethral resection of the prostate (TURP) today and has a 3-way Foley urinary catheter with continuous bladder irrigation (CBI). The client reports lower abdominal pain rated as an 8 on a scale of 0-10. What action should the nurse carry out first?

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Blood and mucus can obstruct the Foley catheter if the CBI is not infused at a sufficient rate. Bladder pain will result from distention if the flow is obstructed. The nurse should ensure that there is adequate urinary drainage and no blockage from blood clots before treating the pain. If the urinary flow is obstructed, manual irrigation with sterile normal saline should be performed until there are no clots or the urine is clear/pink. Belladonna-opium suppositories or antispasmodics (eg, oxybutynin) are used for bladder spasms, an expected complication of the TURP procedure. Clients should be instructed not to urinate around the catheter as this would increase bladder pressure and spasms. Narcotics can be used for postoperative pain. If the urinary flow is adequate, a description of the pain would help to determine whether to give the client a narcotic or an antispasmodic. Before treating the resulting pain, the possibility of a physiological etiology for procedure-related pain (eg, blockage of urinary flow from blood clots) should be ruled out first. Large intestine peristalsis does not usually return for at least 24 hours. Intestinal pain is usually related to the presence of flatus. It is too soon for this to be the primary cause. An etiology related to the procedure should be ruled out first.

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medications. Maintaining perfusion and adequate blood pressure is the priority concern. With sudden release of bladder obstruction, cardiovascular autonomic activity occurs and the blood pressure and heart rate are reduced due to the excitation of the parasympathetic system. Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions. While asking if a bedpan is needed is an important nursing intervention, it does not aid in the assessment of urinary retention. Gathering assessment data indicating the presence of urinary retention is necessary prior to other interventions. The nurse should assess for fluid intake after assessing bladder distension. The client's skin turgor is assessed after the nurse checks for urinary retention and fluid intake. There is no need to assess skin turgor until other indicators of adequate fluid intake are reviewed.

PERITONEAL DIALYSIS

ACUTE URINARY RETENTION •

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Acute urinary retention is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis. However, these are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction can be associated with infection and kidney injury Dysuria from catheterization can be treated with analgesics or antispasmodic

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In peritoneal dialysis (PD), the abdominal lining (peritoneum) is used as a semipermeable membrane to dialyze clients with decreased kidney function.

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A catheter is placed in the peritoneal cavity for infusing and draining dialysate (dialysis fluid). Dialysate is infused and dwells in the abdomen, which allows waste products and electrolytes to cross the peritoneum into the dialysate for removal. After the prescribed dwell time, the dialysate, electrolytes, and wastes are drained via gravity. When administering PD, it is essential to use sterile technique when spiking and attaching bags of dialysate to the client's PD catheter to prevent contamination and infection Bacterial peritonitis, an infection of the peritoneum, is a potential complication of PD that may lead to sepsis. Signs of peritonitis should be reported to the health care provider. (Proper positioning of the catheter drainage bag (ie, below the abdomen) and the client (eg, Fowler or semi-Fowler position) promotes effluent outflow but is not a priority over infection prevention. Cloudy effluent may indicate infection, whereas bloody or brown effluent may indicate bowel perforation. Documenting effluent characteristics is important but not a priority over maintaining asepsis. During peritoneal dialysis (PD), a catheter is placed into the peritoneal cavity to infuse dialysate (dialysis fluid); the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid (effluent) drains out via gravity. Cloudy outflow (effluent), tachycardia, and low-grade fever are signs of peritonitis, an infection of the peritoneal cavity and a major concern with PD. Bloody fluid can indicate intestinal perforation or that the client may be menstruating. Brown effluent can indicate fecal contamination from perforation. All these findings need to be reported to the health care provider. Oliguria (very low urine output) is associated with acute or chronic kidney failure and is the reason the client is receiving peritoneal dialysis. It does not indicate a complication of PD.

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Pruritus (itching) is a common finding in clients with kidney failure, and may occur due to dry skin, neuropathy, or skin deposits of waste products (eg, urea, calcium-phosphate) that are normally removed via the kidney. PD can help relieve this symptom of kidney failure by filtering waste products. Peritoneal dialysis uses the abdominal lining (ie, peritoneum) as a semipermeable membrane to dialyze a client with insufficient renal function. A catheter is placed into the peritoneal cavity, and dialysate (ie, dialysis fluid) is infused. The tubing is clamped to allow the fluid to remain in the cavity, usually for 20-30 minutes (dwell phase). The catheter is then unclamped to allow dialysate to drain via gravity. Insufficient outflow results most often from constipation when distended intestines block the catheter's holes. If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed medications (eg, stool softeners). The nurse should also check the tubing for kinks and reposition the client to a sidelying position or assist with ambulation. The drainage bag should be maintained below the abdomen to promote gravity flow. The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics (eg, alteplase) as prescribed. If these measures are ineffective, an x-ray may be needed to check the catheter location. The nurse should identify the problem before instilling additional fluids and perform routine assistive measures before contacting the health care provider.

HEMODIALYSIS •

Dialysis disequilibrium syndrome (DDS) is a rare but potentially lifethreatening complication that can occur in clients during the initial stages of hemodialysis (HD); it can be prevented by slowing the rate of dialysis.

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During HD, solutes (ie, urea) are removed more quickly from the blood than from the brain cells and cerebrospinal fluid, creating a concentration gradient that can lead to excess fluid in the brain cells and increased intracranial pressure. Characteristic neurologic manifestations include nausea and vomiting, headache, restlessness, change in mentation, and seizure activity. If DDS is suspected, the health care provider should be contacted immediately If severe, DDS can progress to coma and death. If DDS is identified during treatment, the rate of dialysis should be slowed or stopped. Treatment focuses on interventions to decrease cerebral edema and manage symptoms. Antihypertensives are withheld prior to HD to minimize the risk for hypotension. If the client is not hypotensive after HD, prescribed antihypertensives should be administered but are not the priority intervention for a client with DDS. Antiemetics should be administered to treat nausea associated with DDS, but they are not the priority intervention. Trendelenburg position may increase cerebral edema and would be inappropriate for a client with DDS. Prior to dialysis treatment, the nurse should assess the client's fluid status (weight, blood pressure, peripheral edema, lung and heart sounds), vascular access (arteriovenous fistula, arteriovenous grafts), and vital signs. The amount of fluid removed (ultrafiltration) is determined by calculating the difference between the last post-dialysis weight and the client's current pre-dialysis weight After the client is connected to the dialysis machine, IV heparin is added to the blood from the client to prevent clotting that can occur when blood contacts a foreign substance. Giving subcutaneous heparin prior to initiation is not necessary During dialysis, excess fluid is removed, making the client prone to hypotension. In addition, medications are removed from the blood during hemodialysis, making them ineffective. Many medications that are

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taken once daily can be held until after the dialysis treatment to prevent their removal. If blood pressure medications are given prior to dialysis, the client can develop hypotension during the dialysis and then uncontrolled hypertension (decreased drug concentrations). Arteriovenous fistulas are created by anastomosing an artery to a vein; a thrill can be felt when palpating the fistula, and a bruit can be heard during auscultation when the fistula is functioning properly. Medication administration may require modification on days that clients are scheduled to receive dialysis. The nurse should consider whether the medication will be dialyzed out of the client's system or may create adverse effects during dialysis. Fluid is removed during dialysis, which may cause hypotension. Typically, antihypertensives are held before dialysis to prevent hypotension. In addition, some medications are dialyzed out of the client's system and should therefore be held until after dialysis. Commonly held medications are water-soluble vitamins (eg, vitamins B and C), antibiotics, and digoxin. Clients with chronic kidney disease have high phosphorus levels as the kidney is unable to filter the phosphate from the body; dialysis also does not filter it. Therefore, the client should still take phosphate binders prior to dialysis. Phosphate binders (eg, calcium containing [calcium carbonate and calcium acetate]) and non-calcium containing [sevelamer and lanthanum]) block absorption of ingested phosphate from the intestine and excrete it through feces. Lispro is a fast-acting insulin that should be given 15-30 minutes before meals. It is appropriate to give scheduled lispro with breakfast prior to dialysis. Vitamin E is a fat-soluble vitamin that is not affected by dialysis. It is given to some clients to prevent leg cramps that can be experienced by dialysis clients.

CYSTOSCOPY •

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A cystoscopy is a procedure that uses a flexible fiber-optic scope inserted through the urethra into the urinary bladder with the client in the lithotomy position. Complications associated with cystoscopy include urinary retention, hemorrhage, and infection. Therefore, clients are instructed to notify the health care provider (HCP) immediately if they have bright red blood when urinating, blood clots, inability to urinate, fever >100.4 F (38 C) and chills, or abdominal pain unrelieved by analgesia. These conditions necessitate evaluation by the HCP and may require antibiotic therapy or the insertion of a urinary catheter to irrigate the bladder, remove clots, or drain the bladder Pink-tinged urine, frequency, and dysuria are expected for up to 48 hours following a cystoscopy. Clients are instructed to increase fluids, drink 4-6 glasses of water daily to help dilute the urine, and avoi...