Disturbance in Urinary & Renal Function

By: Ronald Joseph J. Rebollido, R.N. M.N.

OBJECTIVES

Learning Objectives: On completion of this lecture concept, the students will be able to

1. Describe the anatomy & physiology of the urinary/renal system.

2. Identify the assessment parameters used for determining the status of renal function.

3. Describe diagnostic studies used to determine renal function.

4. Discuss the role of the kidneys in regulating fluid & electrolyte balance, acid-base balance & blood pressure.
5. Explain the different disorders of the urinary tract system.

6. Described the nursing management of the hospitalized client with renal diseases.

7. Use the nursing process as a framework of care of clients with renal problems.

COURSE OUTLINE

I. Anatomic & Physiology Overview:

a. Anatomy of the kidneys and urinary system
b. Functions of the kidneys, ureters, bladder and urethra

II. Assessment of the renal & urinary system:

a. Health history & clinical manifestations
- Physical assessment
- Genitourinary pain (characteristics)
- Problems associated with changes in voiding

b. Diagnostic Examinations
- Urinalysis (urine color & possible causes)
- Urine Specific Gravity
- Creatinine clearance test (24-hour urine test)
- Serum creatinine & BUN test
- Uric acid test
- KUB (kidneys, ureters, bladder studies)
- Bladder ultrasonography
- Computed tomography (CT scan) & Magnetic Imaging Resonance
- Nuclear scans
- Intravenous pyelography
- Cystography
- Voiding cystourethrography
- Renal angiography
- Urologic endoscopic procedure
- Biopsy
- Urodynamic test

III. Management of patients with renal & urinary dysfunctions:

a. Fluid & electrolyte imbalance in renal disorders
b. Dysfunctional voiding pattern
- Urinary retention
- Urinary incontinence
Stress incontinence
Urge incontinence
Reflex incontinence
Overflow incontinence
- Neurogenic bladder
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 Spastic/reflex bladder
Flaccid bladder
c. Dialysis
- Hemodialysis
- Continuous Renal Replacement Therapies
- Peritoneal dialysis
- Care of the hospitalized dialysis patient
d. Kidney surgery

IV. Renal and urinary disorders:

a. Infections of the urinary tract
- Lower urinary tract infections
- Upper urinary tract infections
Acute pyelonephritis
Chronic pyelonephritis
b. Primary glomerular diseases
- Acute glomerulonephritis
- Chronic glomerulonephritis
- Nephrotic syndrome
c. Renal Failure
- Acute renal failure (ARF)
- Chronic renal failure (CRF)
Kidney Transplantation
d. Urolithiasis
e. Genitourinary Trauma
- Renal trauma
- Ureteral trauma
- Bladder trauma
- Urethral trauma
f. Renal tumors
g. Cancer of the bladder
h. Urinary diversion
i. Other renal & urinary tract disorders
- Nephrosclerosis - Urethral strictures
- Hydronephrosis - Renal cysts
- Urethritis - Congenital anomalies
- Renal abscess - Interstitial cystitis

Anatomy and Physiology of the Renal System

Kidneys:

- Each person has two kidneys, each is attached to the abdominal wall at the level of the last thoracic & first three lumbar
vertebrae.

- Kidneys are enclosed in the renal capsule.

- Cortex is the outer layer of the renal capsule.

- Medulla is surrounded by the cortex.

- Nephron makes up the functional unit of the kidneys.

Functions of the Kidneys:

1. Maintain homeostasis of the blood & acid-base balance.

2. Excrete end products of body metabolism.
3. Control fluid & electrolyte balance.
4. Excrete bacterial toxins, water-soluble drugs & drug metabolites.
5. Secrete renin & erythropoietin which play a role in the function of PTH & vitamin D.
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Nephron:

- Nephron is the functional renal unit.

- Composed of glomerulus & tubules.

Glomerulus:

- Glomerulus is encased in Bowman’s capsule.

- It filters the fluid out of blood.

Tubules:

- Includes proximal, distal and Loop of Henle.

- Fluid is converted to urine in the tubules & then the urine moves to the pelvis of the kidney.
- Urine flows from the pelvis then through the ureter & empties into the bladder

Bladder:

- Storage of urine.
- Ureterovesical sphincter prevents reflux of urine from the bladder to the ureter.
- Total capacity of the bladder is 1 liter or 1,000 ml.

Prostate Gland:

- Prostate gland surrounds the male urethra.

- Contains a duct that opens into the prostatic portion of the urethra & secretes the alkaline portion of seminal fluid.

PHYSIOLOGY of the UPPER and LOWER URINARY TRACTS

1. Urine formation
2. Excretion of waste products
3. Regulation of electrolyte excretion (Na+, K+)
4. Regulation of acid secretion
5. Regulation of water excretion
6. Autoregulation of blood pressure
7. Renal clearance
8. Regulation of red blood cell production
9. Vitamin D synthesis
10. Secretions of prostaglandins
11. Urine Storage
12. Bladder emptying

DIAGNOSTIC EVALUATION

I. URINALYSIS

Urinalysis – a urine test for evaluation of the renal system and for determining renal disease.

Nursing responsibilities:

1. Wash perineal area and use a clean container.

2. Obtain 10to15 ml. of the first morning sample.
3. Note that refrigirated samples may alter the specific gravity.
4. If the client is menstruating, indicate it on the form.

URINE COLOR

Changes in urine color & possible causes:

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1. Colorless to pale yellow – diluted urine due to diuretics, alcohol, diabetes insipidus, glycosuria, excess fluid intake,
renal disease

2. Yellow to milky white – Pyuria, infection & vaginal cream

3. Bright yellow – multiple vitamin preparations

4. Pink to red – RBC, menses, surgery (bladder & prostate gland), Hgb. breakdown, medications (phenytoin, rifampicin,
phenothiazine), beets, blackberries

5. Blue to blue green – Dyes, methylene blue, pseudomonas, medication (phenylsalicylate, amitriptyline)

6. Orange to amber – Concentrated urine due to DHN, fever, bile, excess bilirubin or carotene, medications (thiamine,
phenazopyridium HCL, nitrofurantoin)

7. Brown to black – Old RBC’s, urobilinogen, melanin, bilirubin, severe DHN, medications (iron prep., metronidazole,
quinine, methyldopa & cascara)

II. SPECIFIC GRAVITY

Urine specific gravity – a test that measures the ability of the kidneys to concentrate urine.

Nursing responsibilities:

1. The test can be measured by multiple-test dipstick (most common), refractometer (lab settings) and urinometer (least
accurate)

2. Presence of contrast agents, glucose & proteins can interfere correct reading.

3. Cold specimen produces a false high reading.

III. URINE Culture & Sensitivity

Urine C&S – is a test that identifies the presence of microorganisms & determine the specific antibiotics that will treat the
existing microorganism.

Nursing responsibilities:

1. Clean the perineal area & urinary meatus with bacteriostatic solution.
2. Collect midstream urine in a sterile container.
3. Send specimen to lab ASAP.
4. Do not force fluids to client.
5. Identify any sources of potential contaminants (hands, skin, hair, clothing, vaginal & rectal secretions)

IV. CREATININE CLEARANCE TEST

24-hour urine test – a timed urine specimen test that evaluates kidney function & progression of renal disease.

Nursing responsibilities:

1. Encouraged fluids before & during the test.

2. Avoid tea, coffee & medications during testing.
3. Refer if client is taking corticosteroids or thyroid hormones.
4. Refrigerate the specimen & add preservatives.

V. CREATININE & BUN TEST

Creatinine – measures the effectiveness of renal function.

normal value: 0.7-1.5 mg./dl. or 60-130 mmol./L.

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Blood Urea Nitrogen – serves as index of renal function.

normal value: 10-20 mg./dl. or 3.5-7 mmol/L.

Nursing responsibility:

1. Aseptic technique in drawing blood sample.

VI. URIC ACID TEST

Uric acid – a 24-hour urine collection to diagnose gout & kidney disease.

Nursing responsibilities:

1. Encourage fluids & regular diet.

2. Refrigerate specimen and add preservatives.

VII. KUB (kidneys, ureters & bladder) Radiograph

KUB – an x-ray film of the urinary system & adjacent structures that is used to detect urinary calculuses.

Nursing responsibility:
1. No specific preparation is necessary.

VIII. BLADDER ULTRASONOGRAPHY

Bladder ultrasound – is a non-invasive method of measuring the volume of urine in the bladder.

- it is performed for evaluating urinary frequency or inability to urinate.

IX. COMPUTED TOMOGRAPHY

CT scan – it is an imaging method that provides cross-sectional views of the kidney & urinary tract.

Nursing responsibilities:

1. Obtain informed consent if a dye is used.

2. Assess for allergies to iodine, contrast dyes or shellfish.
3. Instruct client to lie still & flat on bed during test.
4. Assess for claustrophobia & medicate as ordered.
5. Encourage increased oral fluid intake.
6. Monitor for allergic reaction.
7. Inform client of metallic taste, hot, flushed sensation when the dye is injected.

X. MAGNETIC RESONANCE IMAGING

MRI – a non-invasive technique that provide excellent cross-sectional views of the kidney and urinary tract.

Nursing responsibilities:

1. Remove all metal objects from the client.

2. Determine if client has pacemaker, metal implants, implanted defibrillator because client can’t undergo the test.
3. Assess for claustrophobia & medicate as ordered.
4. Instruct to remain still & flat on bed.
5. If dye will be used; sign consent, assess for allergies & encourage fluids.
6. Client may resume normal activities.

XI. INTRAVENOUS PYELOGRAM

IVP – a test where a radiopaque dye is injected that outlines the renal system & to identify abnormalities in the system.

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Nursing responsibilities:

1. Obtain consent.
2. Assess for allergies (radiopaque dyes, iodine & seafoods)
3. Withhold foods & fluids after midnight.
4. Administer laxatives as prescribed.
5. Inform client of metallic taste, hot, flushed sensation once dye is injected.
6. Monitor for allergic reactions.
7. Monitor V/S & I/O.
8. Encourage oral fluid intake.
9. Assess for venipuncture bleeding.

XII. RENAL ANGIOGRAPHY

Renal Angiography – the injection of radiopaque dye through a catheter for examination of the renal arterial supply.

Nursing responsibilities:

1. Obtain consent.
2. Assess for allergies (radiopaque dyes, iodine & seafoods)
3. Withhold foods & fluids after midnight.
4. Inform client of metallic taste, hot, flushed sensation once dye is injected.
5. Instruct client to void before procedure
6. Asses & mark the peripheral pulses
7. Assess color & temperature of involved extremity.

XIII. RENAL SCAN

Renal scan – an intravenous (IV) injection of a radioisotope for visual imaging of renal blood flow.

Nursing responsibilities:

1. Obtain consent.
2. Assess for allergies
3. Instruct to remain still & flat on bed.
4. Monitor for allergic reactions.
5. Encourage oral fluid intake.
6. Note that radioactivity is eliminated in 24-hours.

XIV. CYSTOMETROGRAM

Cystometrogram – measures how much pressure the bladder can hold, how much pressure builds up inside the bladder
as it stores urine, and how full it is when there is urge to urinate.

Nursing responsibilities:

1. Inform client of voiding requirements during the procedure.

2. Monitor client’s voiding after the procedure.

XV. CYSTOSCOPY

Cystoscopy – the bladder mucosa is examined for inflammation, calculuses or tumors by means of a cystoscope.

Nursing responsibilities:

1. Obtain an informed consent.

2. Withhold food & fluids post midnight.
3. Monitor V/S & I/O.
4. Encourage deep breathing exercises.
5. Monitor for leg cramps.
6. Note that pink-tinged or tea colored urine is common.
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7. Monitor fro bright red urine or clots & refer.

XVI. RENAL BIOPSY

Renal biopsy – insertion of a needle into the kidney to obtain a sample of tissue for examination.

Nursing responsibilities:

1. Obtain informed consent.

2. Assess V/S & clotting studies.
3. Withhold food & fluids after midnight.
4. Supine position & bed rest for 8 hours.
5. Provide pressure on biopsy site for 30 minutes.
6. Avoid heavy lifting & strenuous activities.
7. Encourage fluid intake 1.5-2 liters.

ASSESSMENT OF URINARY & RENAL FUNCTION

Assessment of the Urinary & Renal Function

1. Health History- Assessment of risk factors associated with renal disorders

a. Associated medical conditions – Diabetes Mellitus, gout, SLE, “strep throat” infection,
Impetigo, BPH, Crohn’s disease, Hyperparathyroidism
b. Exposure to chemicals – Plastics, Rubber, Tar & Pitch
c. Family history of renal diseases
d. Frequent urinary tract infections
e. High-sodium diet
f. History of hypertension
g. Medication use
i. Trauma and injury

2. Unexplained Anemia – most common “fatigue”, shortness of breath & exercise intolerance. Hemoglobin count: good
indicator in presence of anemia.

3. Gastrointestinal Symptoms – Gastrointestinal symptoms may occur with urologic conditions because of shared
autonomic & sensory innervation and reno-intestinal reflexes.

Common symptoms: N&V, diarrhea, abdominal pain & distention

4. Genitourinary pain – caused by distention of some portion of the urinary tract due to obstructed urine flow,
inflammation & swelling of tissues.

Characteristics of Genitourinary Pain:

a. Kidney – dull constant ache, if sudden distention of capsule pain is sharp, stabbing & colicky
in nature.

Location: costovertebral angle & may extend to umbilicus

Causes: acute obstruction, kidney stone, blood clot, trauma & acute pyelonephritis

b. Bladder – dull, continuous pain, intense w/ voiding, severe if bladder full.

Location: suprapubic area

Causes: overdistended bladder, infection, interstitial cystitis, tumor

c. Ureteral – severe, sharp, stabbing pain, colicky in nature.

Location: costovertebral angle, flank, lower abdominal area, testis or labium

Causes: ureteral stone, edema or stricture, blood clot

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 d. Prostatic – vague discomfort, feeling of fullness in perineum, vague back pain.

Location: perineum and rectum

Causes: prostate cancer, acute or chronic prostatitis

e. Urethral – pain variable, severe during & immediately after voiding.

Location: Male – along penis to meatus, Female – urethra to meatus

causes: infection, trauma, foreign body & irritation of bladder neck

5. Changes in voiding – Problems associated with changes in voiding.

a. Frequency – frequent voiding more than every 3 hours

b. Urgency – strong desire to void
c. Dysuria – painful or difficult voiding
d. Hesitancy – delay, difficult in initiating voiding
e. Nocturia – excessive urination at night
f. Incontinence – involuntary loss of urine
g. Enuresis – involuntary voiding during sleep
h. Polyuria – increased volume of urine voided
i. Oliguria – urine output less than 400 ml./day
j. Anuria – urine output less than 50 ml./day
k. Hematuria – red blood cells in the urine
l. Proteinuria – abnormal amounts of protein in the urine

Common Fluid & Electrolyte Disturbances in Renal Disease:

1. Fluid volume deficit

2. Fluid volume excess
3. Sodium deficit (Hyponatremia)
4. Sodium excess (Hypernatremia)
5. Potassium deficit (Hypokalemia)
6. Potassium excess (Hyperkalemia)
7. Calcium deficit (Hypocalcemia)
8. Calcium excess (Hypercalcemia)
9. Bicarbonate deficit (Metabolic acidosis)
10. Bicarbonate excess (Metabolic alkalosis)
11. Protein deficit
12. Magnesium deficit (Hypomagnesemia)
13. Magnesium excess (Hypermagnesemia)
14. Phosphorus deficit (Hypophosphatemia)
15. Phosphorus excess (Hyperphosphatemia)

Dysfunctional voiding patterns:

A. Urinary incontinence - involuntary loss of urine that is sufficient to be considered a problem.

I. Types:

a. Stress incontinence – is the involuntary loss of urine through an intact as a result of a sudden increase in intra-
abdominal pressure (sneezing, coughing, changing position)

b. Urge incontinence – is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed.

c. Reflex incontinence – is the involuntary loss of urine due to hyperreflexia in the absence of normal sensation
associated with voiding.

d. Overflow incontinence – is the involuntary loss of urine associated with overdistention of the bladder.

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e. Functional incontinence – caused by severe cognitive impairment (dementia), difficulty to identify the need to void &
physical impairments.

f. Iatrogenic incontinence – caused by medications (alpha-adrenergic agents)

II. Risk factors:

1. Pregnancy: vaginal delivery, episiotomy

2. Menopause
3. Genitourinary surgery
4. Pelvic muscle weakness
5. Immobility
6. Diabetes mellitus
7. Incompetent urethra due to trauma & sphincter relaxation
8. High-impact exercise
9. Morbid obesity
10. Stroke
11. Cognitive disturbance: dementia, Parkinson’s disease
12. Medications: diuretics, sedatives, hypnotics, opioids
13. Caregiver or toilet unavailable

III. Diagnostic studies: Urinalysis & Urine culture

IV. Medical Management:

1. Behavioral therapy
a. Fluid management
b. Standardized voiding frequency
- Timed voiding
- Prompted voiding
- Habit retraining
- Bladder retraining
c. Pelvic Muscle Exercise (PME) – Kegel exercise
d. Vaginal Cone Retention Exercises
e. Transvaginal or Transrectal electrical stimulation
f. Neuromodulation

2. Pharmacologic Therapy

a. Anticholinergics: Oxybutynin (Ditropan), Dicyclomine (Antispas) – urge incontinence

b. Tricyclic antidepressant – Imipramine, Doxepin, Desipramine & Nortriptyline
c. Pseudoephedrine (Sudafed) – stress incontinence
d. Estrogen – for all types of incontinence

3. Surgical Management

a. Periurethral bulking – is a semi-permanent procedure in which small amounts of artificial collagen are
placed within the walls of the urethra to enhance closing pressure of the urethra.

b. Modified artificial sphincter – used of a silicone-rubber balloon as a self-regulating pressure mechanism

can be used to close the urethra.

B. Urinary retention – is the inability to empty the bladder completely during attempts to void.

I. Causative factors:
a. Postoperative clients
b. General anesthetics
c. Diabetes mellitus
d. Prostatic enlargement
e. Trauma (Pelvic injuries)
f. Urethral pathologies (infection, tumor & calculus)
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 g. Stroke
h. Spinal cord injury
i. Medications (Anticholinergic, Antispasmodic, Tricyclic & antidepressant)

II. Clinical manifestations:

a. Lower abdominal pain
b. Bladder fullness
c. Sensation of incomplete bladder emptying

III. Complications: Chronic infections, calculi, kidney deterioration, perineal skin breakdown

IV. Diagnostic studies: Urinalysis & Ultrasound bladder scanner

V. Medical Management:
a. Catheterization
b. Suprapubic catheterization

VI. Nursing Management:

a. Provide privacy & a conducive environment

b. Sitz baths & warm compress
c. Offering encouragement & reassurance
d. Give analgesic as ordered
e. Catheterization

NEUROGENIC BLADDER

Neurogenic bladder – is a dysfunction that results from a lesion the nervous system.

I. Types:
a. Spastic (reflex) bladder – common type, spinal lesion above the voiding reflex, bladder empties on
reflex with minimal or no controlling influence to regulate its activity.

b. Flaccid bladder – caused by lesion on lower motor neuron by trauma, bladder continues to fill &
becomes greatly distended and overflow incontinence occurs.

II. Causative factors:

a. Spinal cord injury

b. Spinal tumor
c. Herniated vertebral disk
d. Multiple sclerosis
e. Congenital defects (spina bifida, myelomeningocele)
f. Infection
g. Diabetes mellitus

III. Complications:

a. Infections (urinary stasis & catheterization)

b. Urolithiasis
c. Bone demineralization (immobility)
d. Renal failure (vesicoureteral reflux)
e. Hydronephrosis

IV. Medical Management:

a. Objectives (long-term)

1. Preventing overdistention of the bladder

2. Emptying the bladder regularly & completely
3. Maintaining urine sterility with no stone formation
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 4. Maintaining adequate bladder capacity with no reflux

b. Pharmacologic therapy
1. Parasympathomimetic medication - Bethanechol (Urecholine)

c. Catheterization
1. Indwelling catheter
2. Suprapubic catheterization

V. Nursing Management:

a. Assess the drainage system.

b. Check the color of urine.
c. Monitor intake & output.
d. Monitor signs of infections (UTI): cloudy/malodorous urine, fever, chills, anorexia, hematuria & malaise

DIALYSIS

Dialysis – is used to remove fluid and uremic waste products from the body when the kidneys cannot do so.

I. Types according to urgency or need:

a. Acute dialysis – is indicated when there is a high & rising level of serum potassium, fluid overload,
pulmonary edema, acidosis, poisoning or medication overdose from the blood.

b. Chronic (maintenance) dialysis – is indicated in CRF, known as end-stage renal disease (ESRD).

II Types according to methods of therapy:

a. Hemodialysis
b. Continuous Renal Replacement Therapy (CCRT)
c. Peritoneal dialysis

TYPES OF DIALYSIS

I. Hemodialysis – is the most commonly used method dialysis, objective is to extract toxic nitrogenous substances from
the blood & to remove excess water. Blood laden with toxins & nitrogenous waste is diverted from the client to a machine,
a dialyzer in which the blood is cleansed & then returned to the client.

Important components of hemodialysis:

a. Dialyzer – known as “artificial kidney”, serves as a synthetic semipermeable membrane replacing the
glomeruli & tubules as the filter for the impaired kidneys.

b. Dialysate – is a solution made up of all the important electrolytes in their ideal extracellular concentrations.

- a dialysate need not to be sterile because bacteria are too large to pass through but needs water treatment
& must meet specific standards to ensure a safe water supply.

Process involved in dialysis: Diffusion, osmosis and ultrafiltration

Vascular access:

1. Subclavian, Internal Jugular & Femoral catheters - immediate and a temporary access to the client’s blood
circulation by a catheter, it can be used for several weeks.

- complications are Hematoma, infection, thrombosis & inadequate flow.

2. Fistula – a permanent access created surgically by joining (anastomosing) an artery to a vein, either side to side or end
to side.
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 - the fistula takes 4-6 weeks to mature before it is ready for use.

- encourage patient to exercise the arm (squeezing a rubber ball) to increase the size of these
vessels.

3. Arteriovenous graft – is a subcutaneous interposing of a biologic, semibiologic or synthetic graft material between an
artery and vein.

- commonly used synthetic graft is polytetraflouroethylene (PTFE).

- common sites are the forearm & upper arm or upper thigh.

- complications are Infection & thrombosis.

Complications of Hemodialysis:

1. Atherosclerotic cardiovascular disease

2. Dialysis Disequilibrium (headache, N&V, restlessness, decreased level of consciousness & seizures)

3. Hypertriglyceridemia

4. Heart failure, Angina Pain & Stroke

5. Hypotension (dizziness, N&V, tachycardia, diaphoresis)

6. Dysrhythmias

7. Anemia & fatigue

8. Air embolism

9. Gastric ulcers

10 Painful muscle cramping

11. Dialysis Encephalopathy

Nursing Management in Hemodialysis:

1. Monitor vital signs.

2. Monitor laboratory results before, during & after dialysis.
3. Assess the client for fluid overload before the procedure.
4. Weigh the client before & after.
5. Hold antihypertensive & other medications.
6. Monitor for shock & hypovolemia during the procedure.
7. Provide adequate nutrition.

CONTINUOUS RENAL REPLACEMENT THERAPIES

II. Continuous Renal Replacement Therapy (CRRT) – indicated for clients with acute or chronic renal failure & who are
clinically unstable to hemodialysis.

- does not produce rapid fluid shifts, does not require dialysis machine & dialysis personnel and can initiated
quickly in hospitals without dialysis facilities.

Types of Continuous Renal Replacement Therapy (CRRT):

1. Continuous Arteriovenous Hemofiltration

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2. Continuous Arteriovenous Hemodialysis

3. Continuous Venovenous Hemofiltration

4. Continuous Venovenous Hemodialysis

III. Peritoneal Dialysis – the peritoneum is the dialyzing membrane (semi-permeable membrane) & substitutes for kidney
function during kidney failure.

- works on the principles of diffusion & osmosis, and the dialysis occurs via the transfer of fluid & solute
from the bloodstream through the peritoneum.

Contraindication of peritoneal cavity:

1. Peritonitis
2. Recent abdominal surgery
3. Abdominal adhesions
4. Impending renal transplant

Peritoneal Dialysis Access – a surgical insertion of a siliconized rubber catheter into the abdominal cavity is required to
allow infusion of dialysis fluid.

- insertion site is 3-5 cms. below umbilicus because this area is relatively avascular & has less facial
resistance.

- 1-2 weeks after insertion a fibroblasts & blood vessels occurs into the cuffs of the catheter, which fix the
catheter in place & provide an extra barrier against dialysate leakage & bacterial invasion.

Types of Peritoneal Dialysis:

1. Continuous Ambulatory Peritoneal Dialysis – closely resembles renal function because it is a continuous process,
does require a machine & promotes client independence.

- client performs self-dialysis 24 hrs. a day, 7 days a week & 4 dialysis cycles are administered per day,
including an 8 hour dwelling time overnight, 1.5-2 liter of dialysate are instilled into the abdomen & allowed to dwell
as prescribed.

2. Automated Peritoneal Dialysis – it is a continuous dialysis process and requires a peritoneal cycling machine

Methods of Automated Peritoneal Dialysis:

a. Continuous Cycling Peritoneal Dialysis

b. Intermittent Peritoneal Dialysis

c. Nightly Peritoneal Dialysis

PERITONEAL DIALYSIS INFUSION PROCESS

One exchange = 1 infusion (inflow), dwell & outflow

a. Inflow – the infusion of 1-2 liter of dialysate as ordered is infused by the gravity into the peritoneal space,
take 10-20 minutes.

b. Dwelling Time – the amount of time that the dialysate solution remains in the peritoneal cavity is prescribed
by the physician & can last 20-30 minutes to 8 or more hours depending on the type of dialysis used

c. Outflow – fluid drains out of body by gravity into the drainage bag.

Note: Dialysis uses an open system that presents a risk of infection.

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Complications of Peritoneal Dialysis:

1. Peritonitis
2. Abdominal Pain
3. Insufficient outflow
4. Leakage around the catheter site
5. Characteristics of outflow
-during the first or initial exchanges, the outflow may be bloody, outflow should be clear & colorless
thereafter.
- brown color indicates bowel perforation.
- outflow same color with urine indicates bladder perforation
- cloudy outflow indicates peritonitis

Nursing Management: Before the Peritoneal Dialysis

1. Monitor vital signs.

2. Obtain weight.
3. Have the client void.
4. Assess electrolyte & glucose levels.

During treatment: Peritoneal Dialysis

1. Monitor vital signs and I&O. (note for: Hypertension & Hypotension)
2. Monitor for signs of infection.
3. Monitor for signs of respiratory distress, pain or discomfort.
4. Monitor malaise, nausea & vomiting.
5. Assess the catheter site dressing for wetness or bleeding.
6. Monitor dwell time as prescribed by the physician & initiate outflow.
7. Do not allow dwell time to extend beyond the physician’s order.
8. Monitor outflow for color and clarity.
9. If outflow is less than inflow, the difference should be counted as intake.

KIDNEY SURGERY

I. Considerations: a client may undergo surgery to remove obstructions that affects the kidney, to inset a tube for draining
the kidney or to remove the kidney involved in unilateral kidney disease, renal carcinoma or kidney transplantation.

A. Preoperative considerations – surgery is performed only after a thorough evaluation of renal function.
- client preparation is important to ensure that optimal renal function is maintained.

B. Intraoperative consideration: renal surgery requires various client positions to expose the surgical site adequately.

Three surgical approaches:

1. Flank
2. Lumbar
3. Thoracoabdominal

C. Postoperative consideration: kidney is a highly vascular organ, hemorrhage & shock are the chief complications of
renal surgery.

INFECTIONS OF THE URINARY TRACT

UPPER URINARY TRACT INFECTIONS

A. Ureteritis – is an inflammation of the ureter commonly associated with pyelonpehritis.

B. Pyelonephritis – is an inflammation of the renal pelvis & the parenchyma commonly caused by bacterial invasion.

I. Causative Agent: Escherichia Coli (E. Coli)

II. Types of Pyelonephritis:

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1. Acute Pyelonephritis – often occurs after bacterial contamination of the urethra or following invasive procedure of the
urinary tract, it can progress to bacteremia or chronic pyelonephritis.

Clinical Manifestations:

1. Fever & chills 4. Flank pain affected side

2. Frequency & urgency 5. Dysuria
3. Nausea & headache 6. Cloudy, bloody, foul-smelling urine

2. Chronic Pyelonephritis – occurs following chronic obstruction with reflux or chronic disorders.

- is a slow progressive disease usually associated with recurrent acute attacks & it can lead to chronic renal
failure.

Clinical Manifestations:

1. Poor urine concentration ability

2. Pyuria
3. Azotemia
4. Proteinuria
5. Anemia
6. Acidosis
7. Hypertension

III. Nursing Management:

1. Monitor the vital signs.

2. Monitor I&O.
3. Monitor weight.
4. Encourage increased fluid intake up to 3,000 ml. a day.
5. Encourage adequate rest.
6. Instruct a high-calorie, low-protein diet.
7. Provide warm, moist compresses to the flank area.
8. Monitor for signs of renal failure.
9. Administer analgesics, antipyretics, antibiotics, urinary antiseptics & antiemetics as prescribed.

LOWER URINARY TRACT INFECTION

A. Cystitis – is inflammation of the bladder from infection or obstruction of the urethra, more common in women than
men.

I. Causative Agent:

1. E. Coli
2. Enterobacter
3. Pseudomonas
4. Serratia

II. Causative Factors:

1. Bladder distention
2. Calculus (stones)
3. Allergens or irritants (soaps, sprays, bubble bath, napkins)
4. Indwelling urethral catheter
5. Invasive urinary tract procedures
6. Hormonal changes causing alterations in vaginal flora
7. Urinary stasis

III. Clinical Manifestations:

15
1. Frequency & urgency
2. Burning on urination
3. Incomplete emptying of the bladder
4. Hematuria
5. Cloudy, dark, foul-smelling
6. Bladder spasm
7. Malaise, fever & chills
8. Nausea & vomiting
9. Lower abdominal discomfort or back discomfort
10. Inability to void

IV. Nursing Management:

1. Obtain specimen for C&S before giving antibiotics.

2. Encourage increase fluid intake up to 3,000 ml./day. (sulfonamides can cause crystals)
3. Administer medication as prescribed.
4. Strict aseptic technique in catheterization.
5. Maintain closed urinary drainage systems if with indwelling catheter.
6. Provide meticulous perineal care if with catheter.
7. Instruct to take antibiotics on schedule & the entire course.
8. Follow-up urine culture after treatment.

B. Urethritis – is an inflammation of the urethra commonly associated with sexually transmitted diseases & may occur with
cystitis.

- in men it is caused by gonorrhea or chlamydial infection.

- in women it is caused by hygiene spray, perfumed sanitary napkin or toilet paper, spermicidal jellies &
changes in the vaginal mucosal lining.

I. Clinical Manifestations:

1. Burning on urination (MEN) 1. Frequency (WOMEN)

2. Frequency & urgency 2. Urgency & Nocturia
3. Nocturia 3. Painful urination
4. Painful urination 4. Difficulty voiding
5. Discharge from penis 5. Lower abdominal pain

II. Nursing Management:

1. Encourage increased fluid intake.

2. Prepare client for STD testing.
3. Administer antibiotics as prescribed.
4. Encourage hot sitz bath.
5. Avoid intercourse until symptoms subside or treatment of STD is complete.
6. Avoid the use of perfumed toilet paper or sanitary napkins & feminine hygiene spray.
7. If strictures occurs, prepare for dilation & instillation of antiseptic in the urethra.

Medical Management:

1. Identification of causative agent by urine C&S.

2. Urinary antibiotics: Sulfadiazine (sulfonamides), Ciprofloxacin (fluoroquinolones)
3. Urinary antispasmodics: (Ditropan) Oxybutynin chloride, (Pro-Banthine) Probantheline bromide
4. Urinary analgesics: (Pyridium) Phenazopyridine hydrochloride
5. Urinary cholinergics: (Urecholine) Bethanechol chloride
6. Urinary Antiseptics: (Furadantin, Macrodantin) Nitrofurantoin, (Cinobac) Cinoxacin
7. Additional fluids to dilute the urine.
8. Warm sitz baths.
9. Urinary dilation & instillation of antiseptic.

PRIMARY GLOMERULAR DISEASES

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GLOMERULONEPHRITIS

Glomerulonephritis – includes a variation of disorders, most of which are caused by an immunological reaction.

- destruction, inflammation & sclerosis of the glomerular structure, loss of kidney function develops.

- inflammation of the glomeruli results from an antigen-antibody reaction produced from an infection elsewhere
in the body.
I. Types:

1. Acute glomerulonephritis – occurs 2 to 3 weeks after streptococcal infection.

2. Chronic glomerulonephritis – can occur after the acute phase or slowly overtime.

II. Complications:

1. Heart failure
2. Hypertensive encephalopathy
3. Pulmonary edema
4. Renal Failure

III. Clinical Manifestations:

1. Increased antistreptolysin O titer (used to diagnose disorders caused by streptococcal infections)

2. Gross hematuria

3. Proteinuria

4. Dark, smoky, cola-colored or red-brown urine

5. Oliguria or Anuria

6. Headache, chills & fever

7. Anorexia, nausea & vomiting

8. Edema in face, periorbital area, feet or generalized edema

9. Hypertension, Low urinary pH & flank pain

10. Increased BUN & Creatinine

IV. Medical Management:

1. Antibiotics (Penicillin) to treat underlying infections.

2. Dietary restriction of sodium, fluids & protein.
3. Diuretics & antihypertensives to control blood pressure.
4. Complete bed Rest.

V. Nursing Management:

1. Monitor I&O, daily weight & urine specific gravity.

2. Instruct patient to obtain treatment for infections, specifically sore throats & URTI.
3. Report signs of bloody urine, headache or edema.
4. Monitor for fluid overload, ascites, pulmonary edema & CHF.
5. Monitor BUN & creatinine level.
6. Restrict fluid as ordered.
7. Provide a high-calorie & low protein diet.
8. Provide bed rest & limited activity.
17
9. Administer antibiotics, diuretics & antihypertensive.

NEPHROTIC SYNDROME
Nephrotic syndrome – a set of clinical manifestations arising from protein wasting caused by diffuse glomerular damage.

I. Classifications:

1. Minimal change nephrotic syndrome

2. Secondary nephrotic syndrome
3. Congenital nephrotic syndrome

II. Clinical Manifestations:

1. Hypoalbuminemia
2. Edema
3. Proteinuria
4. Hyperlipidemia
5. Anemia & Anorexia
6. Malaise & Irritability
7. Hematuria
8. Waxy pallor to the skin

III. Medical Management:

1. Supportive therapy
2. Sodium restricted diet
3. Cortocisteroid therapy:
- Prednisone (7-21 days response to drug)
- gradually discontinue the drug when good response noted (to prevent cardiovascular collapse)
4. Immunosuppressant therapy:
- Cyclophosphamide (Cytoxan)

IV. Nursing Management:

1. Monitor VS and I&O.

2. Monitor daily weights & potassium level (limit in the diet).
3. Bed rest if severe edema is present.
4. Instruct low-protein diet.
5. Administer diuretics as prescribed.
6. Provide a mild sodium restriction as ordered.
7. Administer Albumin, Plasma & Dextran (to rise osmotic pressure).
8. Administer corticosteroids & cytotoxic medications.
9. Administer anticoagulant (client who develops renal vein thrombosis).

RENAL FAILURE

Renal failure – is the loss of kidney function,.

- the signs & symptoms of renal failure caused by the retention wastes, the retention of fluids & the
inability of the kidneys to regulate electrolytes.

- types of renal failures includes acute & chronic renal failure.

I. Causes of Renal Failure:

A. PRERENAL – interference with renal perfusion.

Causes:
1. Hemorrhage
2. Hypovolemia
3. Decreased cardiac output
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 4. Decreased renal perfusion

B. INTRARENAL – damage to the parenchyma.

Causes:
1. Prolonged prerenal state
2. Nephrotoxins
3. Intratubular obstruction
4. Infections (glomerulonephritis)
5. Renal injury

C. POSTRENAL – obstruction in the urinary tract anywhere from the tubules to the urethral meatus.

Causes:
1. Calculi
2. Prostatic hypertrophy
3. Tumors

ACUTE RENAL FAILURE

I. Acute Renal Failure (ARF) – is the sudden loss of kidney function & is caused by renal cell damage from ischemia or
toxic substances.

- it can reversible and the prognosis depends on the cause & the condition of the client.

- near-normal or normal kidney function may resume gradually.

II. Causes:

1. Infection
2. Renal Artery occlusion
3. Acute kidney diseases
4. Dehydration
5. Diuretic therapy
6. Ischemia from hypovolemia, heart failure, septic shock & blood loss
7. Toxic substances

III. Phases of Acute Renal Failure (ARF):

1. OLIGURIC – 8 to 15 days duration and the longer the duration the less chance of recovery.

Clinical manifestations:

1. Nausea and vomiting

2. Hypertension
3. Edema
4. Signs of CHF and pulmonary edema
5. Urine output less than 400 ml./day

Diagnostic Findings:

1. Increased BUN and Creatinine

2. Increased potassium (hyperkalemia)
3. Decreased sodium (hyponatremia)
4. Fluid overload (hypervolemia)
5. High urine specific gravity more than 1.025

2. DIURETIC – urine output rises slowly and then diuresis this indicates recovery of the damaged nephrons.

Clinical manifestations:

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1. Excessive urine output 4 to 5 liters/day
2. Hypotension
3. Tachycardia
4. LOC improves

Diagnostic findings:

1. Decreased fluid volume (hypovolemia)

2. Decreased sodium (hypokalemia)
3. Further decreased in sodium (hyponatremia)
4. Low urine specific gravity

3. RECOVERY (convalescent) – a slow process and complete recovery may take 1 to 2 years

Clinical manifestations:

1. Urine volume is normal

2. Increased in strength
3. LOC stable
4. Client can develop Chronic Renal Failure (CRF)

Diagnostic findings:

1. Laboratory exam returns to normal range (BUN and

Creatinine)

IV. Medical Management:

1. Correct the underlying cause of renal failure (eliminate drugs & toxins, treat transfusion reactions, shock).

2. Peritoneal dialysis, Hemofiltration dialysis or Hemodialysis.

3. Diet therapy.
a. High carbohydrate & low protein diet.
b. Controlled sodium.
c. Controlled water.
d. High calcium intake.
e. Total parenteral nutrition & parental intralipid therapy.

4. Packed RBC, IV glucose & electrolytes.

5. Exchange resin (Kayaxelate) for hyperkalemia.

6. Antibiotics for infections & complete bed rest.

V. Nursing Management:

1. Monitor I&O.
2. Monitor the VS.
3. Monitor weight daily (½ to 1 lb. increase indicates fluid retention).
4. Give only enough fluids in oliguric phase to replace losses (400-500 ml./day).
5. Assess level of consciousness.
6. Monitor BUN, Creatinine & Electrolytes.
7. Provide low CHON, high fat and high carbohydrate diet.
8. Monitor for Edema and lung sounds (wheezes, crackles & rhonchi).
9. Monitor for Arrhythmias due to hyperkalemia.

CHRONIC RENAL FAILURE

I. Chronic Renal Failure (CRF) - is the progressive loss, ongoing deterioration & irreversible damage to the nephrons &
glomeruli resulting in Uremia or End-Stage Renal Disease (ESRD).

20
 - affects all of the major body systems & requires dialysis or kidney transplant to maintain life.

II. Causes:

1. Acute Renal Failure

2. Diabetes mellitus
3. Autoimmune diseases
4. Hypertension
5. Recurrent infections
6. Chronic urinary obstruction

STAGES OF CHRONIC RENAL FAILURE

Stage I - Diminished Renal Reserve

a. Renal function is reduced 40% to 50%.

b. No accumulation of metabolic wastes.
c. Nocturia and polyuria occur due to decreased ability to concentrate urine.

Stage II – Renal Insufficiency

a. Metabolic wastes begin to accumulate.

b. Oliguria and Edema occur.
c. Renal function is 20% to 40%.

Stage III – End Stage

a. Excessive accumulation of metabolic wastes.

b. Kidneys unable to maintain homeostasis.
c. Renal therapy is required.
d. Renal function is less than 10% to 15%.

III. Clinical manifestations:

1. Anorexia and Nausea

2. Hypertension
3. Kussmaul’s respirations
4. Uremic frost
5. Azotemia
6. Decreased urine output
7. Proteinuria
8. Anemia
9. Fluid overload and signs of CHF
10. Confusion & lethargy followed by convulsions and coma

IV. Medical Management:

1. Peritoneal dialysis
2. Hemodialysis
3. Renal transplant

V. Nursing Management:

1. Monitor serum electrolyte levels.

2. Weigh client daily.
3. Strict I&O.
4. Monitor edema, pulmonary edema.
5. Provide low-CHON, low Na & low K diet.
6. Encourage CHON intake to be of high biologic value (eggs, milk & meat).
7. Encourage strict adherence to meds regime.

21
UREMIC SYNDROME

Uremic Syndrome – is the accumulation of nitrogenous waste products in the blood because of the inability of the
kidneys to filter out the waste products.

- may occur as a result of acute & chronic renal failure.

I. Clinical Manifestations:

1. Oliguria
2. Presence of protein, RBCs & casts in the urine.
3. Elevated levels if urea, uric acid, potassium & magnesium in the urine

II. Nursing Management:

1. Monitor Vital signs.

2. Monitor electrolyte values.
3. Monitor Intake & Output.
4. Low protein diet (protein food must be in high quality)
5. Limit sodium, nitrogen, potassium & phosphate intake as prescribed.

KIDNEY TRANSPLANT

I. Kidney transplant – a human kidney from a compatible donor is implanted into a recipient.

- kidney transplant is performed for irreversible kidney failure.

- the recipient must take immunosuppressive medications for life to prevent tissue rejection.

II. Living Donors:

1. The most desirable source of kidneys for transplant is living related donors who match the client closely.

2. Donors are screened for:

a. ABO blood group.
b. Tissue-specific antigen.
c. Human leukocyte antigen suitability.
d. Mixed lymphocyte culture index (histocompatibility).

3. Donor must be in excellent health with two properly functioning kidneys.

4. The emotional well-being of the donor is determined.

5. Complete understanding of the donation process & outcome is necessary.

III. Cadaver Donors:

1. Must meet criteria of brain death.

2. Must be under 60 years of age.

3. Must have normal renal function.

4. No malignant disease present outside CNS.

5. No infection, abdominal & renal trauma.

6. Normal BP must be present.

7. Continuous ventilation & heartbeat are maintained.

22
V. Warm Ischemic Time – is the time elapsed between the cessation of perfusion & cooling of the kidney and the time
required for anastomosis of the kidney.

- maximum allowable warm ischemic time is 30 to 60 minutes.

- kidney can be cooled & then the maximum time for transplantation is increased to 24-48 hours.

V. Nursing Management: (A. Preoperative)

1. Verify histocompatibilty test.

2. Administer immunosuppressive medications to the recipient as prescribed 2 days before operation.

3. Maintain protective isolation.

4. Verify hemodialysis by the client was completed 24 hours before the operation.

5. Ensure that the client is free of any infection.

6. Assess renal studies.

7. Encourage verbalization of feelings.

B. Postoperative Management:

1. Monitor urine output every hour.

2. Maintain client is semi-fowlers position.

3. Note urine is pink & bloody initially but gradually returns to normal within several days weeks

4. Monitor for gross hematuria & clots and refer immediately.

5. Monitor 3-way bladder irrigation.

6. Foley catheter should be removed ASAP to prevent infection.

7. Maintain protective isolation precautions & monitor infection.

8. Monitor I.V fluids closely & fluid overload.

9. Assess for organ rejection.

10. Encourage coughing & deep-breathing exercises.

COMPLICATION OF KIDNEY TRANSPLANTATION

Complication: Graft rejection – except for identical twin donor & recipient, this is the major postoperative complication.

I. Clinical manifestations:

1. Fever
2. Malaise
3. Elevated white blood cell count
4. Graft tenderness
5. Signs of deteriorating renal function
6. Acute hypertension
7. Anemia

II. Types of graft rejection:

23
1. Hyperacute rejection – occurs immediately after surgery to 48 hours postoperatively.

management: removal of rejected kidney.

2. Acute rejection – occurs within 6 weeks postoperative but can occur as late as 2 years, potentially reversible with
increased immunosuppression.

management: high doses of corticosteroid administration, if not monoclonal antibodies.

3. Chronic rejection – occurs slowly months to years after transplant, rejection can irreversible.

management: immunosuppressive medications.

III. Instructions to the recipient client following kidney transplant:

1. Avoid prolonged periods of sitting.

2. Recognize signs & symptoms of infection and rejection.

3. Avoid contact sports.

4. Avoid exposure to person with infection.

5. Use medications as prescribed & maintain immunosuppressive therapy for life.

6. Know the signs & symptoms that require the need to contact the physician.

7. Ensure follow-up care.

URINARY TRACT OBSTRUCTION

A. Urolithiasis – refers to the formation of urinary stones, urinary calculuses are formed in the ureters.

B. Nephrolithiasis – refers to the formation of kidney stones formed in the renal parenchyma.

I. Causes:

1. Immobility
2. Hypercalcemia
3. UTI
4. Urine stasis
5. Genetic predisposition (heredity)
6. Concentrated urine
7. High intake of purine-rich foods
8. Dehydration

II. Clinical manifestations:

1. Pain (severe & acute)

a. Flank pain – stones at kidney or at upper ureters

b. Pain radiates to abdomen or scrotum – stones at the bladder or ureters
c. Colic pain – excruciating & spastic

2. Fever & chills

3. Nausea & vomiting

4. Abdominal distention

5. Hematuria
24
6. Dysuria

7. Pallor& diaphoresis

8. Urinary frequency with alternating retention

III. Medical Management:

1. Antibiotics & antiemetics

2. Narcotic analgesics (Morphine Sulfate & Demerol)
3. Non-surgical procedure:
a. Extracorporeal Shock Wave Lithotripsy (ESWL)
b. Ureteroscopy
c. Percutaneous Nephrostomy Tube
4. Surgical procedure:
a. Nephrolithotomy
b. Ureterolithotomy

IV. Nursing Management:

1. Strain all urine (very important)

2. Apply moist heat (as ordered)
3. Encourage increase oral fluid intake 3-4 liters per day.
4. Administer antibiotic & analgesics as ordered.
5. Monitor I&O and Vital Signs.
6. Assess for fever, chills & infection
7. Monitor for nausea & vomiting, diarrhea.
8. Turn & reposition immobilized clients.
9. Prepare client for surgical procedure if possible.
10. Assist client in performing relaxation techniques.

GENITOURINARY TRAUMA

A. Renal trauma – occurs following a blunt or penetrating injury to the ribs & upper lumbar vertebrae.

B. Bladder trauma – occurs following a blunt or penetrating injury causing compression of the abdominal wall & the
bladder or pelvic fracture.

C. Ureteral trauma – occurs following unintentional injury during surgery (most common causes)

D. Urethral trauma – occurs following blunt trauma to the lower abdomen or pelvic region.

I. Clinical Manifestations:

1. Anuria
2. Oliguria
3. Hematuria & Hemorrhage
4. Signs of shock (hypotension, tachycardia, rapid & thready pulse, diaphoresis, hypotension)
5. Pain over costovertebral area
6. Nausea & vomiting

II. Medical Management:

1. Surgery
2. Antibiotics
3. Catheterization

III. Nursing Management:

1. Monitor vital signs.

25
2. Monitor for hematuria, hemorrhage & signs of shock.
3. Promote bed rest.
4. Monitor pain level.
5. Prepare patient for catheterization.
6. Prepare the client for surgical repair of the laceration if prescribed.

KIDNEY TUMORS

Kidney tumors – may be benign or malignant, bilateral or unilateral, common sites of metastasis include bones, lungs,
liver, spleen or other kidney.

Adenocarcinoma- the most common cancer affecting the kidneys, incidence is higher in males.

I. Etiology: Unknown.

II. Clinical Manifestations:

1. Dull flank pain

2. Palpable renal mass
3. Painless gross hematuria

III. Medical Management:

1. Nephrectomy.

2. Radiation therapy if tumor is sensitive.

3. Chemotherapy & Hormonal therapy with (Provera) Medroxyprogesterone.

4. Palliative care if condition is terminal.

IV. Nursing Management:

1. Monitor abdominal distention (caused by bleeding).

2. Check bed linens under client for bleeding.
3. Monitor for S/S of shock.
4. Monitor urinary output. (30-50 ml. per hour).
5. Maintain a semi-fowlers position.
6. Do not irrigate or manipulate nephrostomy tube in place unless prescribed.
7. Administer pain medications.
8. Encourage intake of foods rich vitamins A, C & E and mineral selenium.

BLADDER CANCER

Bladder cancer – occur most frequently in men over 50 years old and sites of metastasis include lymph nodes, bone,
liver, & lungs.

I. Risk factors:

1. Smoking
2. Radiation
3. Exposure to certain chemicals
4. Schistosomiasis

II. Clinical Manifestations:

1. Frequency & Urgency

2. Dysuria
3. Painless hematuria
4. Direct visualization by cystoscopic examination

26
III. Medical Management:

1. Surgical intervention.
a. Resection of tumor
b. Cystectomy (removal of the bladder) & this procedure requires urinary diversion.
1. Ileal conduit
2. Continent ileal urinary reservoir
3. Nephrostomy
4. Ureterostomy

2. Radiation therapy.

3. Chemotherapy.

IV. Nursing Management:

1. Allow time for client to verbalize fears.

2. Prepare bowel preoperatively with laxatives, antibiotics & enemas.
3. Assess color & amount of urine, maintain patency of drainage system.
4. Expect a variety of psychologic manifestations such as anger or depression.
5. Encourage intake of foods rich in vitamin A, C & E and mineral selenium.

URINARY DIVERSION

ILEAL CONDUIT
A. Ileal Conduit (Ileal Loop) – section of the ileum is resected & attached to the ureters, one end of this ileal segment is
sutured closed & the other is brought to the skin as an ileostomy to drain urine.
- the most widely used technique to divert urine.

CONTINENT ILEAL URINARY RESERVOIR

B. Indiana Pouch – similar to an ileal conduit but involves creation of a nipplelike valve that can be drained by insertion of
a catheter.

NEPHROSTOMY
C. Nephrostomy – catheter inserted in kidney through an incision.

URETEROSTOMY
D. Ureterostomy – ureters implanted in abdominal wall to drain urine.

URETEROSIGMOIDOSTOMY
E. Ureterosigmoidostomy – the ureters are introduced into the sigmoid colon thereby allowing urine to flow through the
colon & out of the rectum.

I. Nursing Management:

1. Maintain urinary drainage, which will be fixed around the stoma to collect urine.
2. Cleanse the skin around stoma & under the drainage bag with soap & water.
3. Inspect for excoriation.
4. After skin is dry, apply skin adhesive to the area around the stoma & apply collection device
5. Encourage self-care, teach client to change the appliance.

OTHER RENAL & URINARY TRACT DISORDERS

A. Nephrosclerosis – is hardening or sclerosis of the arteries due to prolonged hypertension.

I Types of Nephrosclerosis:

1. Malignant (accelerated) – is often associated with malignant hypertension. (diastolic over 130 mmHg), common in
young male adults.

2. Benign Nephrosclerosis – common in older adults & associated with hypertension and artherosclerosis.
27
II. Clinical manifestation:
1. Proteinuria

III. Medical Management:

1. Antihypertensive drugs (ACE-inhibitors)

B. Hydronephrosis – is the distention of the renal pelvis & calices caused by an obstruction of normal urine flow.

I. Causative Factors:

1. Calculus
2. Tumors
3. Scar tissue
4. Ureter obstructions
5. Hypertrophy of the prostate

II. Clinical manifestations:

1. Hypertension
2. Headache
3. Flank pain
4. Electrolyte imbalance

III. Nursing Management:

1. Monitor VS frequently.
2. Monitor for electrolyte imbalance & dehydration.
3. Monitor for diuresis which can lead to fluid depletion.
4. Monitor weights daily.
5. Monitor urine for specific gravity, albumin & glucose.
6. Administer fluid replacement as prescribed.

C. Renal Abscess – caused by infection of the kidney which is localized in the renal cortex or extend into fatty tissues
around the kidney.

I. Causative agents:

1. Staphylococcus
2. E. Coli
3. Proteus

II. Clinical manifestations:

1. Fever & chills

2. Leukocytosis
3. Abdominal pain
4. Dull ache & palpable mass in the flank

III. Medical Management:

1. C&S and Antibiotics

2. Incision and drainage
3. Drains

D. Urethral strictures – is a narrowing of the lumen of the urethra as a result of scar tissue & contraction.

I. Causative factors:

1. Urethral injuries (surgery, catheters, cystoscopy)

28
2. Untreated gonorrhea
3. Prostatitis
4. Pyelonephritis
II. Clinical manifestations:
1. Nausea & vomiting
2. Frequency & urgency
3. Fever & chills
4. Anorexia

III. Medical Management:

1. Dilation of narowed area (Bougies or metal sounds)

2. Internal urethrotomy

E. Polycystic Kidney Disease – is a cystic formation & hypertrophy of the kidneys causing cystic rupture, infection,
formation of scar tissue & damaged nephrons.

- no way known to stop the progress of the disease & ultimate result of the disease is renal failure.

I Types of Polycystic Kidney Disease:

1. Infantile polcystic disease – an inherited autosomal recessive trait that result in the death of the infant within few
months after death.

2. Adult polycystic disease – an autosomal dominant trait that results in end-stage renal disease.

I. Clinical Manifestations:

1. Flank, lumbar & abdominal pain 2. Fever & chills

3. Hematuria, proteinuria & pyuria 4. UTIs
5. Calculuses 6.Hypertension
7. Palpable & enlarged kidneys

III. Nursing Management:

1. Monitor for gross hematuria (indicate cyst rupture).

2. Increased sodium & water.
3. Provide bed rest.
4. Prepare for percutaneous cyst puncture for relief of obstruction or draining an abscess.
5. Administer antihypertensives as prescribed.
6. Prepare for dialysis or renal transplantation.
7. Encourage the client to seek genetic counseling.

E. Interstitial cystitis – a chronic inflammatory condition of the bladder wall, frequently remain undiagnosed.

I. Etiology: Unknown

II. Clinical manifestation:

1. Nocturia & urgency

2. Suprapubic & Perineal pain
3. Fatigue & sleep disturbance

III. Medical Management:

1. Transcutaneous electrical nerve stimulation (TENS)

2. Bladder protectant: Pentosan Polysulfate Sodium (Elmiron), Dimethly Sulfoxide
Antispasmodic (Oxybutynin)
Urinary Mucosal Anesthetic agent: Phenazopyridine (Pyridium)

29
END OF CONCEPT

30