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The Genito-Urinary System

Medical Surgical Nursing Review

Outline of review
Recall the anatomy and physiology of the
Renal System Renal Assessment Renal Laboratory Procedure Common Conditions:
UTI Kidney Stones ARF and CRF

Outline of review
BPH Prostatic cancer

Urological Assessment
Nursing History
Reason for seeking care Current illness Previous illness Family History Social History Sexual history

Urological Assessment
Key Signs and Symptoms of Urological Problems EDEMA associated with fluid retention Renal dysfunctions usually produce ANASARCA

Urological Assessment
Key Signs and Symptoms of Urological Problems PAIN Suprapubic pain= bladder Colicky pain on the flank= kidney

Urological Assessment
Key Signs and Symptoms of Urological Problems HEMATURIA Painless hematuria may indicate
URINARY CANCER! Early-stream hematuria= urethral lesion Late-stream hematuria= bladder lesion

Urological Assessment
Key Signs and Symptoms of Urological Problems DYSURIA Pain with urination= lower UTI

Urological Assessment
Key Signs and Symptoms of Urological Problems POLYURIA More than 2 Liters urine per day OLIGURIA Less than 400 mL per day ANURIA Less than 50 mL per day

Urological Assessment
Key Signs and Symptoms of Urological Problems Urinary Urgency Urinary retention

Urinary frequency

Urological Assessment
PHYSICAL EXAMINATION Inspection Auscultation Percussion Palpation

Urological Assessment
Laboratory examination 1. Urinalysis 2. BUN and Creatinine levels of the serum 3. Serum electrolytes

Urological Assessment
Laboratory examination Radiographic IVP KUB x-ray KUB ultrasound CT and MRI Cystography

Implementation Steps for selected problems


Provide PAIN relief Assess the level of pain Administer medications usually narcotic ANALGESICS

Implementation Steps for selected problems


Maintain Fluid and Electrolyte Balance Encourage to consume at least 2 liters of fluid per day In cases of ARF, limit fluid as directed Weigh client daily to detect fluid retention

Implementation Steps for selected problems


Ensure Adequate urinary elimination Encourage to void at least every 2-3 hours Promote measures to relieve urinary retention:
Alternating warm and cold compress Bedpan Open faucet Provide privacy Catheterization if indicated

Urinary Tract Infection (UTI)

Bacterial invasion of the


kidneys or bladder (CYSTITIS) usually caused by Escherichia coli

Urinary Tract Infection (UTI)


Predisposing factors include 1. Poor hygiene 2. Irritation from bubble baths 3. Urinary reflux 4. Instrumentation 5. Residual urine, urinary stasis 6. Dehydration

Urinary Tract Infection (UTI)


PATHOPHYSIOLOGY The invading organism ascends the urinary tract, irritating the mucosa and causing characteristic symptoms
Ureter= ureteritis Bladder= cystitis Urethra=Urethritis Pelvis= Pyelonephritis

Urinary Tract Infection (UTI)


Assessment findings Low-grade fever Abdominal pain Enuresis Pain/burning on urination Urinary frequency Hematuria

Urinary Tract Infection (UTI)


Assessment findings: Upper UTI Fever and CHIILS Flank pain Costovertebral angle tenderness

Urinary Tract Infection (UTI)


Laboratory Examination 1. Urinalysis 2. Urine Culture

Urinary Tract Infection (UTI)


Nursing interventions Administer antibiotics as ordered Provide warm baths and allow client to void in water to alleviate painful voiding. Force fluids. Nurses may give 3 liters of fluid per day Encourage measures to acidify urine (cranberry juice, acid-ash diet).

Urinary Tract Infection (UTI)


Provide client teaching and discharge
planning concerning a. Avoidance of tub baths b. Avoidance of bubble baths that might irritate urethra c. Importance for girls to wipe perineum from front to back d. Increase in foods/fluids that acidify urine.

Urinary Tract Infection (UTI)


Pharmacology 1. Sulfa drugs
Highly concentrated in the urine Effective against E. coli! Can cause CRYSTALLURIA

2. Quinolones
Not given to less than 18 because they can cause cartilage degradation

3. Pyridium= urinary antiseptic


Can cause urine discoloration

Nephrolithiasis/Urolithiasis

Presence of stones
anywhere in the urinary tract
Calcium oxalate and uric acid

Nephrolithiasis/Urolithiasis
Pathophysiology Predisposing factors a. Diet: large amounts of calcium and oxalate b. Increased uric acid levels c. Sedentary life-style, immobility d. Family history of gout or calculi e. Hyperparathyroidism

Nephrolithiasis/Urolithiasis
Pathophysiology Supersaturation of crystals due to stasis Stone formation May pass through the urinary tract OBSTRUCTION, INFECTION and HYDRONEPHROSIS

Nephrolithiasis/Urolithiasis
Assessment findings 1. Abdominal or flank pain 2. Renal colic radiating to the groin 3. Hematuria 4. Cool, moist skin 5. Nausea and vomiting

Nephrolithiasis/Urolithiasis
Diagnostic tests 1. KUB Ultrasound and X-ray: pinpoints location, number, and size of stones 2. IVP: identifies site of obstruction and presence of non-radiopaque stones 3. Urinalysis: indicates presence of bacteria, increased protein, increased WBC and RBC (hematuria)

Nephrolithiasis/Urolithiasis
Medical management 1. Surgery a. Percutaneous nephrostomy: tube is inserted through skin and underlying tissues into renal pelvis to remove calculi. b. Percutaneous nephrostolithotomy: delivers ultrasound waves through a probe placed on the calculus.

Nephrolithiasis/Urolithiasis
Medical management 2. Extracorporeal shock-wave lithotripsy: delivers shock waves from outside the body to the stone, causing pulverization 3. Pain management : Morphine or Meperidine 4. Diet modification

Nephrolithiasis/Urolithiasis
Nursing interventions 1. Strain all urine through gauze to detect stones and crush all clots. 2. Force fluids (30004000 cc/day). 3. Encourage ambulation to prevent stasis.

Nephrolithiasis/Urolithiasis
Nursing interventions 4. Relieve pain by administration of analgesics as ordered and application of moist heat to flank area. 5. Monitor intake and output

Nephrolithiasis/Urolithiasis
Nursing interventions 6. Provide modified diet, depending upon stone consistency: Calcium, Oxalate and Uric acid stones

Nephrolithiasis/Urolithiasis
Nursing interventions Calcium stones limit milk/dairy products provide acid-ash diet to acidify urine (cranberry or prune juice, meat, eggs, poultry, fish, grapes, and whole grains)

Nephrolithiasis/Urolithiasis
Nursing interventions Oxalate stones avoid excess intake of foods/ fluids high in oxalate (tea, chocolate, rhubarb, spinach) maintain alkaline-ash diet to alkalinize urine (milk; vegetables; fruits except prunes, cranberries, and plums)

Nephrolithiasis/Urolithiasis
Nursing interventions Uric acid stones reduce foods high in purine (liver, beans, kidneys, venison, shellfish, meat soups, gravies, legumes) maintain alkaline urine

Nephrolithiasis/Urolithiasis
Nursing interventions 7. Administer allopurinol (Zyloprim) as ordered, to decrease uric acid production
Allopurinol Rashes Nasal congestion

Nephrolithiasis/Urolithiasis
8. Provide

client teaching and discharge planning concerning Prevention of Urinary stasis by maintaining increased fluid intake especially in hot weather and during illness; mobility; voiding whenever the urge is felt and at least twice during the night

Nephrolithiasis/Urolithiasis
8. Provide

client teaching and discharge planning concerning: Adherence to prescribed diet Need for routine urinalysis (at least every 34 months) Need to recognize and report signs/ symptoms of recurrence (hematuria, flank pain).

Acute renal failure

Sudden interruption of
kidney function to regulate fluid and electrolyte balance and remove toxic products from the body

Acute renal failure

Most important
manifestation: OLIGURIA

Kidney function
The Nephron produces urine to eliminate waste Secretes Erythropoietin to increase RBC Metabolism of Vitamin D Produces bicarbonate and secretes acids Excretes excess POTASSIUM
Impaired urine production and azotemia

ANEMIA Calcium and Phosphate imbalances Metabolic ACIDOSIS HYPERKALEMIA

Acute renal failure


PATHOPHYSIOLOGY 1. Pre-renal failure

2. Intra-renal failure 3. Post-renal failure

Acute renal failure


PATHOPHYSIOLOGY Prerenal CAUSE: Factors interfering with perfusion and resulting in diminished blood flow and glomerular filtrate, ischemia, and oliguria; include CHF, cardiogenic shock, acute vasoconstriction, hemorrhage, burns, septicemia, hypotension, anaphylaxis

Acute renal failure


PATHOPHYSIOLOGY Intrarenal CAUSE: Conditions that cause damage to the nephrons; include acute tubular necrosis (ATN), endocarditis, diabetes mellitus, malignant hypertension, acute glomerulonephritis, tumors, blood transfusion reactions, hypercalcemia, nephrotoxins (certain antibiotics, x-ray dyes, pesticides, anesthetics)

Acute renal failure


PATHOPHYSIOLOGY Postrenal CAUSE:

Mechanical obstruction anywhere


from the tubules to the urethra; includes calculi, BPH, tumors, strictures, blood clots, trauma, and anatomic malformation

Acute renal failure


Three phases of acute renal failure

1. Oliguric phase

2. Diuretic phase
3. Convalescence or recovery phase

Acute renal failure


Four phases of acute renal failure (Brunner and Suddarth) 1. Initiation phase 2. Oliguric phase 3. Diuretic phase 4. Convalescence or recovery phase

Acute renal failure


Assessment findings: The Three Phases of Acute Renal Failure

1. Oliguric phase Urine output less than 400 cc/24 hours duration 12 weeks Manifested by dilutional hyponatremia, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia, and metabolic acidosis Diagnostic tests: BUN and creatinine elevated

Acute renal failure


Assessment findings: The Three Phases of Acute Renal Failure 2. Diuretic phase Diuresis may occur (output 35 liters/day) due to partially regenerated tubules inability to concentrate urine Duration: 23 weeks; manifested by hyponatremia, hypokalemia, and hypovolemia Diagnostic tests: BUN and creatinine slightly elevated

Acute renal failure


Assessment findings: The Three Phases of Acute Renal Failure 3. Recovery or convalescent phase: Renal function stabilizes with gradual improvement over next 312 months

Acute renal failure


Laboratory findings: 1. Urinalysis: Urine osmo and sodium 2. BUN and creatinine levels increased 3. Hyperkalemia 4. Anemia 5. ABG: metabolic acidosis

Acute renal failure


Nursing interventions Monitor fluid and Electrolyte Balance Reduce metabolic rate Promote pulmonary function Prevent infection Provide skin care Provide emotional support

Acute renal failure


Nursing interventions 1. Monitor and maintain fluid and electrolyte balance. Measure l & O every hour. note excessive losses in diuretic phase Administer IV fluids and electrolyte supplements as ordered. Weigh daily and report gains. Monitor lab values; assess/treat fluid and electrolyte and acid-base imbalances as needed

Acute renal failure


Nursing interventions 2. Monitor alteration in fluid volume. Monitor vital signs, PAP, PCWP, CVP as needed. Weigh client daily. Maintain strict I & O records.

Acute renal failure


Nursing interventions 2. Assess every hour for hypervolemia Maintain adequate ventilation. Restrict FLUID intake Administer diuretics and antihypertensives

Acute renal failure


Nursing interventions 3. Promote optimal nutritional status. Administer TPN as ordered. With enteral feedings, check for residual and notify physician if residual volume increases. Restrict protein intake to 1 g/kg/day Restrict POTASSIUM intake HIGH CARBOHYDRATE DIET, calcium supplements

Acute renal failure


Nursing interventions 4. Prevent complications from impaired mobility (pulmonary embolism, skin breakdown, and atelectasis) 5. Prevent fever/infection.
Assess for signs of infection. Use strict aseptic technique for wound and catheter care.

Acute renal failure


Nursing interventions 6. Support client/significant others and reduce/ relieve anxiety.
Explain pathophysiology and relationship to symptoms. Explain all procedures and answer all questions in easy-to-understand terms Refer to counseling services as needed

7. Provide care for the client receiving dialysis

Acute renal failure


Nursing interventions 8. Provide client teaching and discharge planning concerning Adherence to prescribed dietary regimen Signs and symptoms of recurrent renal disease Importance of planned rest periods Use of prescribed drugs only Signs and symptoms of UTI or respiratory infection need to report to physician immediately

Chronic Renal Failure

Gradual, Progressive
irreversible destruction of the kidneys causing severe renal dysfunction. The result is azotemia to UREMIA

Chronic Renal Failure


Predisposing factors: DM= worldwide leading cause Recurrent infections Exacerbations of nephritis urinary tract obstruction hypertension

Chronic Renal Failure


PATHOPHYSIOLOGY As renal functions decline Retention of end-products of metabolism

Chronic Renal Failure


PATHOPHYSIOLOGY STAGE 1= reduced renal reserve, 4075% loss of nephron function STAGE 2= renal insufficiency, 7590% loss of nephron function STAGE 3= end-stage renal disease, more than 90% loss. DIALYSIS IS THE TREATMENT!

Chronic Renal Failure


Assessment findings 1. Nausea, vomiting; diarrhea or constipation; decreased urinary output 2. Dyspnea 3. Stomatitis 4. Hypertension (later), lethargy, convulsions, memory impairment, pericardial friction rub

Chronic Renal Failure


Dermatologic CNS
dry skin, pruritus, uremic frost seizures, altered LOC, anorexia, fatigue Acute MI, edema, hypertension, pericarditis

CVS
Pulmo Hema Musculoskeletal

Uremic lungs Anemia


loss of strength, foot drop, osteodystrophy

Chronic Renal Failure


Diagnostic tests: a. 24 hour creatinine clearance urinalysis b. Protein, sodium, BUN, Crea and WBC elevated c. Specific gravity, platelets, and calcium decreased D. CBC= anemia

Chronic Renal Failure


Medical management 1. Diet restrictions 2. Multivitamins 3. Hematinics and erythropoietin 4. Aluminum hydroxide gels 5. Anti-hypertensive 6. Anti-seizures

DIALYSIS

Chronic Renal Failure


Nursing interventions 1. Prevent neurological complications. Assess every hour for signs of uremia (fatigue, loss of appetite, decreased urine output, apathy, confusion, elevated blood pressure, edema of face and feet, itchy skin, restlessness, seizures).

Chronic Renal Failure


Nursing interventions 1. Prevent neurological complications. Assess for changes in mental functioning. Orient confused client to time, place, date, and persons Institute safety measures to protect client from falling out of bed.

Chronic Renal Failure


Nursing interventions 2. Promote optimal GI function. Assess/provide care for stomatitis Monitor nausea, vomiting, anorexia Administer antiemetics as ordered. Assess for signs of Gl bleeding

Chronic Renal Failure


Nursing interventions 3. Monitor/prevent alteration in fluid and electrolyte balance 4. Assess for hyperphosphatemia (paresthesias, muscle cramps, seizures, abnormal reflexes), and administer aluminum hydroxide gels (Amphojel) as ordered

Chronic Renal Failure


Nursing interventions 5. Promote maintenance of skin integrity. Assess/provide care for pruritus. Assess for uremic frost (urea crystallization on the skin) and bathe in plain water

Chronic Renal Failure


Nursing interventions 6. Monitor for bleeding complications, prevent injury to client. Monitor Hgb, hct, platelets, RBC. Hematest all secretions. Administer hematinics as ordered. Avoid lM injections

Chronic Renal Failure


Nursing interventions 7. Promote/maintain maximal cardiovascular function. Monitor blood pressure and report significant changes. Auscultate for pericardial friction rub. Perform circulation checks routinely.

Chronic Renal Failure


Nursing interventions 7. Promote/maintain maximal cardiovascular function. Administer diuretics as ordered and monitor output. Modify drug doses 8. Provide care for client receiving dialysis.

Important Drugs
Aluminum hydroxide (Amphogel) Kayexalate Binds with PHOSPHATE to decrease phosphorus Binds with POTASSIUM to manage hyperkalemia To decrease edema To increase RBC To manage Hypertension

Diuretics Erythropoietin (Epogen) Anti-Hypertensives

DIALYSIS
a procedure that is used to remove
fluid and uremic wastes from the body when the kidneys cannot function

DIALYSIS
Two methods 1. Hemodialysis 2. Peritoneal dialysis

DIALYSIS
Diffusion Osmosis Ultrafiltration

DIALYSIS
Nursing management 1. Meet the patient's psychosocial needs 2. Remember to avoid any procedure on the arm with the fistula (HEMO)
Monitor WEIGHT, blood pressure and fistula site for bleeding

DIALYSIS
Nursing management 3. Monitor symptoms of uremia 4. Detect complications like infection, bleeding (Hepatitis B/C and HIV infection in Hemodialysis) Peritonitis in peritoneal dialysis 5. Warm the solution to increase diffusion of waste products (PERITONEAL) 6. Manage discomfort and pain

DIALYSIS
Nursing management 7. To determine effectiveness, check serum creatinine, BUN and electrolytes

Male reproductive disorders


BPH Prostatic cancer

Male reproductive disorders


DIGITAL RECTAL EXAMINATION- DRE Recommended for men annually with age over 40 years Screening test for cancer Ask patient to BEAR DOWN

Male reproductive disorders


TESTICULAR EXAMINATION Palpation of scrotum for nodules and masses or inflammation BEGINS DURING ADOLESCENCE

Male reproductive disorders


Prostate specific antigen (PSA) Elevated in prostate cancer Normal is 0.2 to 4 nanograms/mL Cancer= over 4

Male reproductive disorders


BENIGN PROSTATIC HYPERPLASIA Enlargement of the prostate that causes outflow obstruction

Common in men older than 50 years


old

Male reproductive disorders


BENIGN PROSTATIC HYPERPLASIA Assessment findings 1. DRE: enlarged prostate gland that is rubbery, large and NON-tender 2. Increased frequency, urgency and hesitancy 3. Nocturia, DECREASE IN THE VOLUME AND FORCE OF URINE STREAM

Male reproductive disorders


BENIGN PROSTATIC HYPERPLASIA Medical management 1. Immediate catheterization 2. Prostatectomy 3. TRANSURETHRAL RESECTION of the PROSTATE (TURP) 4. Pharmacology: alpha-blockers, alphareductase inhibitors. SAW palmetto

BPH
NURSING INTERVENTION 1. Encourage fluids up to 2 liters per day 2. Insert catheter for urinary drainage 3. Administer medications alpha adrenergic blockers and finasteride 4. Avoid anticholinergics 5. Prepare for surgery or TURP 6. Teach the patient perineal muscle exercises. Avoid valsalva until healing

BPH
NURSING INTERVENTION: TURP Maintain the three way bladder irrigation to prevent hemorrhage Only initially the drainage is pinktinged and never reddish Administer anti-spasmodic to prevent bladder spasms

Prostate Cancer
a slow growing malignancy of the
prostate gland Usually an adenocarcinoma This usualy spread via blood stream to the vertebrae

Prostate Cancer
Predisposing factor
Age

Prostate Cancer
Assessment Findings 1. DRE: hard, pea-sized nodules on the
anterior rectum 2. Hematuria 3. Urinary obstruction 4. Pain on the perineum radiating to the leg

Prostate Cancer
Diagnostic tests 1. Prostatic specific antigen (PSA) 2. Elevated SERUM ACID
PHOSPHATASE indicates SPREAD or Metastasis

Prostate Cancer
Medical and surgical management 1. Prostatectomy 2. TURP 3. Chemotherapy: hormonal therapy to slow the rate of tumor growth 4. Radiation therapy

Prostate Cancer
Nursing Interventions 1. Prepare patient for chemotherapy 2. Prepare for surgery

Prostate Cancer
Nursing Interventions: Postprostatectomy 1. Maintain continuous bladder irrigation. Note that drainage is pink tinged w/in 24 hours 2. Monitor urine for the presence of blood clots and hemorrhage 3. Ambulate the patient as soon as urine begins to clear in color

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