6.

3 URINARY DISORDERS
Prof. Sandra M. Covarrubias || October 2, 2021 MEDSURG
Transcribers: Abdelnasser, Fatima Sharnadine M.
Editors:Abdelnasser, Fatima Sharnadine M.

URINARY DISORDERS INTERVENTION

• Education. Explain the nature and purpose
CYSTITIS of the antibiotic therapy and emphasize the
 Urinary Tract infection importance of completing the prescribed
 Infection in the different parts of the urinary course of therapy or, with long-term
tract prophylaxis adhering strictly to the ordered
❖ Invasion of a bacteria ; E. COLI dosage.
 More common in women; shorter urethra • Increased fluid intake. Fluid intake of 2-3
2 TYPES OF URINARY TRACT INFECTION L/day.
➢ Lower Urinary Tract Infection • Prescribed juices. Fruit juices, and oral
✓ Urethra doses of Vitamin C.
✓ Bladders 1. GI disturbance. Watch for GI disturbances
➢ Upper Urinary Tract Infection from antimicrobial therapy. Relieve pain.
✓ Ureters Suggest a
✓ Kidneys 2. Warm sitz bath
• ENTRY. For infection to occur, bacteria must 3. A collection of specimen. Teach the woman
gain access to the bladder. to clean the perineum properly and keep the
• ATTACHMENT. The bacteria then must labia separated during voiding because a non
attach to the colonize the epithelium of the contaminated midstream specimen is
urinary tract to avoid being washed out with essential for accurate diagnosis.
voiding.
• EVASION. The bacteria evade host defense EDUCATION
mechanism. • Maintain hydration
• INFLAMMATION. After the bacteria has • Urinate promptly
evaded the defense mechanism of the body, • Maintain hygiene
inflammation now starts to set in. CYSTITIS • Sexual hygiene
ETIOLOGY • Avoid irritation
❖ Primarily E. Coli. • Compliance to meds and U/A after a week.
❖ Bladder incompetence. The ability to empty
the bladder completely could lead to infection.
❖ Bladder Tumors. Urine flow is obstructed by NEPHROLITHIASIS/UROLITHIASIS
the tumor, causing urinary stasis. ➢ Nephro: kidneys; Lithiasis: stones
❖ Decreased natural host defenses. ➢ Nephrolithiasis/Urolithiasis refers to stones
Immunosupression and a weak immune (calculi) in the urinary tract.
system could predispose the patient to ➢ Stones are formed in the urinary tract when
infection. the urinary concentration of substances such
❖ Ascending infection. Lower UTIs result from as calcium oxalate, calcium phosphate, and
ascending infection by a single gram negative, uric acid increases.
enteric bacterium such as Escherichia Coli, ➢ Stones vary in size
Klebsiella, Proteus, Enterobacter, ➢ Factors that favor formation of stones include
Pseudomonas, and Serratia. infection, urinary stasis, and periods of
❖ Shortness of the female urethra. The high immobility, all of which slow renal drainage
incidence of lower UTI among women may and alter calcium metabolism.
result from the shortness of the female ➢ The problem occurs predominantly men ages
urethra, which predisposes women to infection 20-55.
caused by bacteria from the vagina. PREDISPOSING FACTORS
MANIFESTATIONS • Diet
✓ Burning • Sedentary lifestyle/immobility
✓ Frequency • History of gout, hyperthyroidism, calculi
✓ Nocturia • Increase uric acid levels
✓ Dysuria
TREATMENT CAUSES
➢ Antibiotic Therapy • Stasis
✓ Few side effects • Dehydration
✓ The length of treatment: 3-5 days • Heredity
✓ Drug of choice. Single dose antibiotic • Excessive intake of Vitamins C and D
therapy with amoxicillin or • Grapefruit juice
trimethroprim-sulfamethoxazole & • Purine (gout)
Nitrofurantonin • Congenital renal abnormalities
✓ Urine culture. A urine culture taken 1 • Some medications such as acetazolamide
to 2 weeks later (Diamox) or indinavir (Crixivan)
➢ Analgesic: Pyridium
MANIFESTATION
✓ Pain:
o Intense, deep ache and tenderness in
costovertebral region
o Excruciating, colicky, wavelike pain
(ureters)
o Acute pain that radiates anteriorly and
downward toward bladder in female
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[MEDSURG] 6.3 URINARY DISORDERS – Prof. Sandra Covarrubias

and toward testes in male (renal

pelvis)
✓ Hematuria and pyuria
✓ Nausea, vomiting, abdominal discomfort,
diarrhea
✓ Urinary retention

LABORATORY AND TESTINGS

• Urinalysis
• Urine (24 hr): Cr, uric acid, calcium,
phosphorus, oxalate, or cystine may be
elevated.
• Urine culture:
• Electrolytes: Elevated levels of magnesium,
calcium, uric acid, phosphates, protein • Urinary obstruction is the most common reason
• BUN/Cr: Abnormal (high in serum/low in urine) • Urinary diversion
secondary to high obstructive stone in kidney o Following a ureteral injury
causing ischemia/necrosis. o Ureteral fissure/fistula
• KUB x-ray: Shows presence of calculi and/or o Hemorrhagic cystitis
anatomical changes in the area of the kidneys o Stenosis of urostomy
or along the course of the ureter. o Herniation of urostomy
• IVP: Provides rapid confirmation of urolithiasis • Access for therapeutic interventions, such as:
as a cause of abdominal or flank pain. Shows o Stone removal
abnormalities in anatomical structures o Antegrade stent insertion and removal
(distended ureter) and outline of calculi. NURSING MANAGEMENT
• Cystoureteroscopy: Direct visualization of 1. Fluid management
bladder and ureter may reveal stone and/or 2. Infection risk and wound care/stoma care
obstructive effects. a. Loin pain
• Ultrasound of kidney: To determine b. Elevated temperature
obstructive changes, location of stone; without c. Fever/chills
the risk of failure induced by contrast medium. d. Purulent urine output or deterioration in
vital signs
TREATMENT 3. Management of the tub and appliance
• Opioid analgesic agents (to prevent shock and
syncope) and nonsteroidal anti-inflammatory
drugs (NSAIDS)
• Increased fluid intake
• Dietary recommendation

STONE REMOVAL PROCEDURES

• Ureteroscopy: Stones fragmented with use of
laser, electrohydraulic lithotripsy, or
ultrasound and then removed.
• Percutaneous nephrostomy; endourologic
methods
• Electrohydraulic lithotripsy/Extracorporeal
shock wave lithotripsy (ESWL).
• Chemolysis (stone dissolution): alternative for
those who are poor risks or have easily
dissolved stones (struvite)
NURSING INTERVENTION
• Strain all urine
• Increase fluid intake
• Relieve pain: analgesic

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[MEDSURG] 6.3 URINARY DISORDERS – Prof. Sandra Covarrubias

A. ACUTE RENAL FAILURE INTRARENAL FAILURE

• A sudden altered regulation of fluid and
electrolyte o Poorly treated prerenal failure
o Nephrotoxins
• Toxic products
o Obstetric Complications
• REVERSIBLE o Crush Injuries
B. PATHOPHYSIOLOGY o Myopathy
Underlying Problems o Transfusion Reaction
There are underlying problems that cause the o Acute Glomerulonephritis
development of ARF such as hypovolemia, o Acute Interstitial Nephritis
o Acute Pyelonephritis
hypotension, reduced cardiac output and failure, and
o Bilateral Renal Vein Thrombosis
obstruction of the kidney. o Malignant Nephrosclerosis
Blood Flow o Papillary Necrosis
As theses underlying problems affect the body, the o Polyarteritis Nodosa
blood flow to the kidneys reduces. o Renal Myoma
Decreased Kidney Function o Sickle Cell Disease
o Systemic Lupus Erythematous
With the inadequate blood flow to the kidney, there is o Vasculitis
impaired kidney function.
Failure POSTRENAL FAILURE
If the underlying conditions are not treated and
corrected, they can lead to permanent damage of the o Bladder Obstruction
kidneys. o Ureteral Obstruction
o Urethral Obstruction
CAUSES OF RENAL FAILURE

ASSESSMENT
o Lethargy
o Dryness
o CNS Symptoms
o Increase creatinine

C. ASSESSMENT AND DIAGNOSTICS

1. URINE
VOLUME
• Usually less than 100 mL/24 hr (anuric
phase) or 400 mL/24 hr (oliguric phase),
which occurs within 24-48 hr after renal
1. PRERENAL insult. Non-oliguric (more than 400 mL/24
Sudden and severe drop in blood pressure (shock) or hr) renal failure also occurs when renal
interruption of blood flow to the kidneys from severe damage is associated with nephrotoxic
injury or illness. agents.
COLOR
2. INTRARENAL
• Dirty, brown sediment indicates the
Direct damage to the kidneys by inflammation, toxins, presence of RBC’s, hemoglobin,
drugs, infection, or reduced blood supply. myoglobin, porphyrins.
3. POSTRENAL SPECIFIC GRAVITY
Sudden obstruction of urine flow due to enlarged • Less than 1.020 reflects kidney disease,
prostate, kidney stones, bladder tumor, or injury. with loss of ability to concentrate; fixed at
1.010 reflects severe renal damage.
pH
PRERENAL FAILURE • Greater than 7 found in urinary tract
infections (UTI’s), renal tubular necrosis,
o Arrythmias and CRF.
o Cardiac Tamponade OSMOLALITY
o Cardiogenic Shock • Less than 350 mOsm/kg is indicative of
o Heart Failure tubular damage, and urine/serum ratio is
o Myocardial Infarction often 1:1.
o Burns CREATININE (Cr) CLEARANCE
o Dehydration • Renal function may be significantly
o Diuretic Overuse decreased before blood urea nitrogen
o Hemorrhage (BUN) and serum Cr show significant
o Hypovolemic Shock elevation.
o Trauma SODIUM
o Antihypertensive Drugs • Usually increased if ATN is cause for ARF,
o Sepsis more than 40 mEq/L if a kidney is not able
o Arterial Embolism to reabsorb sodium, although it may be
o Arterial or Venous Thrombosis decreased in other causes of prerenal
o Tumor failure.
o Disseminated Intravascular BICARBONATE
Coagulation • Elevated if metabolic acidosis is present.
o Eclampsia RED BLOOD CELLS -------------
o Malignant Hypertension
o Vasculitis Page 3 of 5
[MEDSURG] 6.3 URINARY DISORDERS – Prof. Sandra Covarrubias
PROTEIN
• High-grade proteinuria (3-4+) strongly
indicates glomerular damage when RBC’s
and casts are also present. Low-grade
proteinuria (1-2+) and white blood cells
(WBC’s) may be indicative of infection or
interstitial nephritis.
CASTS
• Usually signal renal disease or infection.
Cellular casts with brownish pigments and
numerous renal tubular epithelial cells are
diagnostic of ATN. Red casts suggest
acute glomerular nephritis.
2. BLOOD
BUN/Cr
• Elevated and usually rise in proportion
with ratio of 10:1 or higher.
CBC
• Hemoglobin (Hb) decreased in presence
of anemia. RBC’s often decreased
because of increased fragility/decreased
survival.
ARTERIAL BLOOD GASES
• Metabolic acidosis (pH less than 7.2) may
develop because of decreased renal ability
to excrete hydrogen and end products of
metabolism. Bicarbonate decreased.
SODIUM
• Usually increased but may vary.
POTASSIUM
• Elevated related to retention and cellular
shifts (acidosis) or tissue release (red cell
hemolysis).
CHLORIDE, PHOSPHORUS, AND MAGNESIUM
• Usually elevated
CALCIUM
• Decreased.
SERUM OSMOLALITY
• More than 285 mOsm/kg; often equal to
urine.
PROTEIN
• Decreased serum level may reflect protein
loss via urine, fluid shifts, decreased
intake, or decreased synthesis because of
lack of essential amino acids.
KIDNEY, URETER, BLADDER (KUB)
• X-ray: demonstrates size of
kidneys/ureters/bladder, presence of
cysts, tumors, and kidney displacement or
obstruction.
RETROGRADE PYELOGRAM
• Outlines abnormalities of renal pelvis and
ureters.
RENAL ARTERIOGRAM
• Assesses renal circulation and identifies
extravascularities, masses.
ENDOUROLOGY
• Direct visualization may be done of
urethra, bladder, ureters, and kidney to
diagnose problems, biopsy, and remove
small lesions and/or calculi.
ELECTROCARDIOGRAM (ECG)
• May be abnormal, reflecting electrolyte
and acid-base imbalances.
D. PHASES
OLIGURIC PHASE
Reduction in GFR. The oliguria period is
accompanied by a rise in the serum concentration
of substances usually excreted by the kidneys
(urea, creatinine, uric acid, organic
acids, and the intracellular cations [potassium and
magnesium]). The minimum amount of urine
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needed to rid the body of normal metabolic waste
products is 400 mL. In this phase uremic
symptoms first appear and life-threatening
conditions such as hyperkalemia develop.
DIURESIS PHASE
Slow-gradual increase in U.O. In the diuresis
period, the patient experiences gradually
increasing urine output, which signals that
glomerular filtration has started to recover.
Laboratory values stop rising and eventually
decrease. Although the volume of urinary output
may reach normal or elevated levels, renal
function may still be markedly abnormal. Because
uremic symptoms may still be present, the need
for expert medical and nursing management
continues. The patient must be observed closely
for dehydration during this phase; if dehydration
occurs, the uremic symptoms are likely to
increase.
CONVALESENCE
Renal function stabilizes. The recovery period
signals the improvement of renal function and may
take 3 to 12 months. Laboratory values return to
the patient’s normal level. Although a permanent
1% to 3% reduction in the GFR is common, it is
not clinically significant.
E. MANAGEMENT
PHARMACOLOGIC THERAPY
Cation-exchange resins or Kayexalate can reduce
elevated potassium levels; IV dextrose 50%,
insulin, and calcium replacement may be
administered to shift potassium back into cells;
diuretic agents are often administered to control
fluid volume.
NUTRITIONAL THERAPY
Replacement of dietary proteins is individualized to
provide the maximum benefit and minimize uremic
symptoms; likewise, caloric requirements are met
with high-carbohydrate meals, because
carbohydrates have a protein-sparing effect; foods
and fluids containing potassium or phosphorus are
restricted; and after diuretic phase, the patient is
placed on a high-protein, high-calorie diet.
NURSING ASSESSMENT
Assess urine output
• Urine output varies from scanty to a
normal volume.
Assess blood in the urine
• Hematuria may be present in patients with
ARF.
Assess laboratory results
• Laboratory results may increase,
decrease, or stabilize and theses may
[MEDSURG] 6.3 URINARY DISORDERS – Prof. Sandra Covarrubias

indicate each phase of ARF.

INTERVENTION
Monitor fluid and electrolyte balance
• The nurse monitors the patient’s fluid and
electrolyte levels and physical indicators of
potential complications during all phases
of the disorder.
Reducing metabolic rate
• Bed rest is encouraged, and fever and
infection are prevented or treated
promptly.
Promoting pulmonary function
• The patient is assisted to turn, cough, and
take deep breaths frequently to prevent
atelectasis and respiratory tract infection.
Preventing infection
• Asepsis is essential with invasive lines and
catheters to minimize the risk of infection
and increased metabolism.
Providing skin care
• Bathing the patient with cool water,
frequent turning, and keeping the skin
clean and well moisturized and keeping
the fingernails trimmed to avoid
excoriation are often comforting and
prevent skin breakdown.
Provide safety measures
• Patient with CNS involvement may be
dizzy or confused.

DISCHARGE EDUCATION
Nutrition
• A referral to the nutritionist is made
because of the dietary changes required.
Problems to report
• The patient and family must know what
problems to report to the healthcare
provider.
Follow-up examinations
• The importance of follow-up examinations
and treatment is stressed to the patient
and family because of changing physical
and renal functions.

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