UROLOGIC SYSTEM Mary Susan Goodrich, RN, BSN, MSN, MBA, CMSRN, COS-C Saint Luke s Health System SPRING 2016 Objectives Describe a complete nursing assessment of the urologic system Document a nursing plan of care for patients with urologic disease/dysfunction Relate the treatments used for urologic diseases to the pathophysiologic cause Analyze the effectiveness of nursing care with patients with urologic dysfunction Nursing Assessment/Monitoring NURSING HISTORY Pertinent past and present history of urologic problems (changes in amount of urine, difficulty with urination, hesitancy, pain, changes in colour,.) Medications taken including OTC, herbals Medical problems/conditions (diabetes, cardiovascular disease, hypertension,.) Family history (DM, HTN, CV, cancer ) Lifestyle/Social history (ETOH abuse, drug abuse, hobbies, religious beliefs, occupation,...) Nursing Assessment/Monitoring Physical Assessment Inspection: skin, eyes, mouth, chest, periphery, abdomen Diagnostic Studies Blood and urine studies Palpation: skin, periphery, abdomen Radiologic and imaging studies Percussion: abdomen Auscultation: chest, periphery, abdomen 1
Urinalysis Urinalysis A screening tool not useful in diagnosis of disease process but very useful in providing clues to hemostasis and fluid volume. Teach patient how to obtain a clean catch mid-stream sample, first morning void is best. Since urine starts to degrade in 1 hour, get sample to lab as quickly as possible. Normal results should be: Colour yellow (light to amber) Clarity clear Odor slightly aromatic Specific gravity 1.010-1.025 ph 4.5-8 Negative for: protein, glucose, ketones, bilirubin, nitrites, leukocyte esterase, and casts Serum Creatinine Serum Creatinine Results from an end-product of protein breakdown in muscle cells. An excellent indicator or renal failure if no muscle breakdown present Slightly higher in men than women because of higher muscle mass. Some medication may elevate serum creatinine such as ascorbic acid, barbiturates, and diuretics Normal results should be: 0.5-1.1mg/dl (some institutions will result out men and women s results as different normal ranges) Values greater than 1.5mg/dl indicate loss of renal function Values greater than 2mg/dl indicate renal insufficiency Blood urea nitrogen (BUN) End product of protein metabolism. Influenced by fluid volume, dietary protein intake, and catabolism. Alone, is not a good indicator or renal disease as this will also increase in GI bleeds, fluid volume depletion Changes in BUN must be correlated with creatinine to determine renal failure. Normal results: 7-20mg/dl Review of BUN : Cr ratio Divide BUN by Creatinine Ex: BUN 24, Cr 0.6 thus 24/0.6=40 Levels < 12: liver disease, acute tubular necrosis, low protein reserves, starvation state Levels 12-20: normal Levels > 20: With normal creatinine: dehydration, high protein diet, catabolic state, GI bleed With elevated creatinine: renal failure 2
KUB It is the most frequently used radiologic study for the urinary system. It shows kidney size, position, structure, calculi, and other lesions. Safe and painless procedure. Uses high frequency sound waves to see internal structures, and evaluate the speed, direction, and patterns of flow Used to assess kidney size, shape, position, hydronephrosis, tumors, cystic disease It is useful in patients with renal failure and in detecting complications after kidney transplantation. ULTRASOUND Can by noninvasive, I.V. contrast is often given to enhance the views obtained Especially helpful in evaluating renal or bladder mass lesions/cysts/stones, obstructions, and renal artery stenosis. Before tests with contrast: check for prior history of contrast sensitivity After tests that had I.V. contrast, check for hypersensitivity reaction and hematoma at injection site CT SCAN/MRI MRI IV PYELOGRAM ACUTE PYELONEPHRITIS Also known as excretory urography, is an X-ray examination that provides a detailed picture of the kidneys and lower urinary tract. Patients are instructed not to eat or drink for at least 6 hours before the test. Also known as acute infective tubulointerstitial nephritis. Is a sudden inflammation caused by bacteria. Results from bacterial infection of the kidneys. Infecting bacteria usually are normal intestinal and fecal flora that grow readily in urine. May result from an inability to empty the bladder (neurogenic bladder), urinary stasis, or urinary obstruction due to tumors, strictures, or BPH 3
ACUTE PYELONEPHRITIS Complications Recurrence of pyelonephritis if not treated appropriately.. Signs and symptoms Urgency, frequency, burning during urination,. ***Elder tip: may exhibit altered mental status or GI or pulmonary symptoms rather than the usual febrile responses Pyuria (pus in urine), bacteriuria (>100,000 organisms). ACUTE PYELONEPHRITIS Antibiotics to the specific infecting organisms Though urine is sterile after 48-72 hours of antibiotics, the course of therapy is 10-14 days. Nursing Considerations Antipyretics for fever Encourage fluids to achieve urine output of >2,000 ml/day Teach proper technique for collecting a cleancatch urine specimen Stress the importance of completing prescribed antibiotic therapy CHRONIC PYELONEPHRITIS Is a persistent kidney inflammation that can scar the kidneys. This may lead to chronic renal failure. The etiology may be bacterial, metastatic, or urogenous. May have had a childhood history of unexplained fevers or bedwetting. Clinical effects may include flank pain, anemia, low urine specific gravity. Effective treatment of chronic pyelonephritis requires control of hypertension, elimination of the existing obstruction (when possible), and long-term antimicrobial therapy. UTI (Cystitis-bladder infection & urethritis-urethral infection) Urinary tract infections are common, especially among women The majority of urinary tract infections affect the lower urinary tract (bladder and urethra) Certain factors such as sexual intercourse, pregnancy, urinary obstruction and the virulent nature of some bacteria all contribute to the likelihood of an infection Causes: most of the UTIs are from a single, gram-negative, enteric bacterium, such a Ecoli, Klebsiella, Proteus, Enterobacter, Pseudomonas. Cystitis (Bladder infection) Inflammation of the bladder wall Signs and Symptoms Frequency and urgency with urination.. clean-catch midstream urine specimen. 3-5 day course of oral antibiotics.. URETHRITIS (Urethral infection) Signs and symptoms Frequent urination, burning pain during urination, pus in the urine, and in men, penile discharge.. It is difficult to differentiate a urethral infection from a bladder infection because the S/S are similar.. How serious is a urethral infection? Most cases go away after treatment. Depends on the causes of the infection. 4
Maintain hydration by drinking plenty of fluids. Cranberry juice may have infectionfighting properties Urinate promptly when the urge arises. PREVENTING UTIs Maintain hygiene by wiping from front to back after urinating and after a bowel movement. Also, after sexual intercourse, the bladder should be emptied as soon as possible. Avoid irritation by avoiding use of deodorant sprays, douches and powders as they can irritate the urethra. CAN DRINKING CRANBERRY JUICE PREVENT UTIs????? It is not an old wives tale anymore!!! For years, many believed that either eating cranberries or drinking the juice, made the urine more acidic and provided a home remedy to prevent infection. E coli is a common cause or UTI. Can be a nuisance and at it s worse can lead to kidney damage. With concerns about the overuse of antibiotics, attention turned to prevention and this little red fruit. Researchers at Harvard University first showed that cranberry juice did decrease growth of the E coli infection, but were not sure why. It was found later by researchers at Tulane University, that cranberry juice changed the shape of E coli by inhibiting the growth of hair-like filaments that otherwise allow the bacteria to attach to the lining of the bladder. This caused the bacteria to be flushed naturally away through urination. Then later by researchers at Rutgers University, identified the substances, called concentrated tannins, that prevent E coli from attaching to the lining of the urinary tract So, have YOU had your 10 ounce glass of cranberry juice today?????? INTERSTITIAL CYSTITIS Inflammation of the bladder wall, may be noninfectious or abacterial Signs and Symptoms Similar to those of a bladder infection. Generally arrive at by ruling out all other possible causes for the symptoms, such as infection, cancer or bladder overactivity INTERSTITIAL CYSTITIS Nursing interventions Reinforce chronicity of disease and need for longterm therapy Educate about eliminating caffeine, acidic foods, ASA (which is an acidic medication) Need to increase fluid intake Possible bladder retraining There is no simple treatment to eliminate the signs and symptoms and not one treatment works for everyone Oral medications, nerve stimulation, bladder distention, medications instilled into bladder, surgery May form anywhere in the urinary tract, but usually develop in the renal pelvis or calyces Causes Signs & Symptoms Nursing interventions NEPHROLITHIASIS (RENAL CALCULI) NEPHROLITHIASIS Dietary alterations to reduce concentration of stone-forming substances Low Calcium Diet for calcium stones Avoid milk, dairy, flour, dried fruits Low Purine Diet for uric acid stones Avoid organ meats, shellfish, wines Low Oxalate diet for calcium oxalate Avoid spinach, chocolate, tea, cola 5
NEUROGENIC BLADDER A bladder dysfunction caused by an interruption of normal bladder innervation. At one time, thought to result primarily from spinal cord injury, but now.. Complications include incontinence, residual urine retention Signs and symptoms are a wide range, depending on the underlying cause and its effect on the structural integrity of the bladder NEUROGENIC BLADDER the patient s history may include a condition or disorder that can cause neurogenic bladder, incontinence and disruptions of micturition. : the goals of treatment are to maintain the integrity of the upper urinary tract, control infection and prevent urinary incontinence. Nursing Interventions Care for those varies according to the underlying cause and method of treatment. BENIGN PROSTATIC HYPERPLASIA Prostate enlargement to the point where urethra is compressed Pathophysiology Causes Nursing assessment Diagnostic tests TRANSURETHRAL RESECTION OF PROSTATE (TURP) Nursing considerations post TURP Discharge instructions REFERENCES The Kidneys and How They Work, National Kidney and Urological Diseases Information (2012). Clearinghouse. Retrieved from http://kidney.niddk.nih.gov/kudiseases/pubs/yourkidneys/ National Kidney Foundation. http://www.kidney.org/index.cfm Shergill, I., et al. (2010) Medical Therapy in Urology. New York: Springer Wolters & Kluwer. (2013) Medical Surgical Nursing Made Incredibly Easy. Pennsylvania: Lippincott, Williams and Wilkins Wolters & Kluwer. (2013) Professional Guide to Diseases. New York: Lippincott, Williams and Wilkins http://www.renal.org/home.aspx 6