The Genito-Urinary SystemMedical Surgical Nursing Review

Outline of reviewRecall the anatomy and physiology of the Renal SystemRenal Assessment Renal Laboratory ProcedureCommon Conditions:UTIKidney StonesARF and CRF

Outline of reviewBPHProstatic cancer

Urological Assessment Nursing HistoryReason for seeking careCurrent illnessPrevious illnessFamily HistorySocial HistorySexual history

Urological Assessment Key Signs and Symptoms of Urological ProblemsEDEMAassociated with fluid retentionRenal dysfunctions usually produce ANASARCA

Urological Assessment Key Signs and Symptoms of Urological ProblemsPAINSuprapubic pain= bladderColicky pain on the flank= kidney

Urological Assessment Key Signs and Symptoms of Urological ProblemsHEMATURIAPainless hematuria may indicate URINARY CANCER!Early-stream hematuria= urethral lesionLate-stream hematuria= bladder lesion

Urological Assessment Key Signs and Symptoms of Urological ProblemsDYSURIAPain with urination= lower UTI

Urological Assessment Key Signs and Symptoms of Urological ProblemsPOLYURIAMore than 2 Liters urine per dayOLIGURIALess than 400 mL per dayANURIALess than 50 mL per day

Urological Assessment Key Signs and Symptoms of Urological ProblemsUrinary Urgency

Urinary retention

Urinary frequency

Urological Assessment PHYSICAL EXAMINATIONInspectionAuscultationPercussionPalpation

Urological Assessment Laboratory examinationUrinalysisBUN and Creatinine levels of the serumSerum electrolytes

Urological Assessment Laboratory examinationRadiographicIVP KUB x-rayKUB ultrasoundCT and MRICystography

Implementation Steps for selected problemsProvide PAIN reliefAssess the level of painAdminister medications usually narcotic ANALGESICS

Implementation Steps for selected problemsMaintain Fluid and Electrolyte BalanceEncourage to consume at least 2 liters of fluid per dayIn cases of ARF, limit fluid as directedWeigh client daily to detect fluid retention

Implementation Steps for selected problemsEnsure Adequate urinary eliminationEncourage to void at least every 2-3 hoursPromote measures to relieve urinary retention:Alternating warm and cold compressBedpan Open faucet Provide privacyCatheterization 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 includePoor hygieneIrritation from bubble bathsUrinary refluxInstrumentationResidual urine, urinary stasisDehydration

Urinary Tract Infection (UTI)

PATHOPHYSIOLOGYThe invading organism ascends the urinary tract, irritating the mucosa and causing characteristic symptomsUreter= ureteritisBladder= cystitisUrethra=UrethritisPelvis= Pyelonephritis

Urinary Tract Infection (UTI)

Assessment findingsLow-grade feverAbdominal painEnuresisPain/burning on urinationUrinary frequencyHematuria

Urinary Tract Infection (UTI)

Assessment findings: Upper UTIFever and CHIILSFlank painCostovertebral angle tenderness

Urinary Tract Infection (UTI)

Laboratory ExaminationUrinalysisUrine Culture

Urinary Tract Infection (UTI)

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

Urinary Tract Infection (UTI)

Provide client teaching and discharge planning concerninga. Avoidance of tub baths b. Avoidance of bubble baths that might irritate urethrac. Importance for girls to wipe perineum from front to backd. Increase in foods/fluids that acidify urine.

Urinary Tract Infection (UTI)

Pharmacology1. Sulfa drugsHighly concentrated in the urineEffective against E. coli!Can cause CRYSTALLURIA

2. QuinolonesNot given to less than 18 because they can cause cartilage degradation

3. Pyridium= urinary antisepticCan cause urine discoloration

Nephrolithiasis/UrolithiasisPresence of stones anywhere in the urinary tract Calciumoxalateand uric acid

Nephrolithiasis/Urolithiasis PathophysiologyPredisposing factorsa. Diet: large amounts of calcium and oxalateb. Increased uric acid levelsc. Sedentary life-style, immobilityd. Family history of gout or calculie. Hyperparathyroidism

Nephrolithiasis/Urolithiasis PathophysiologySupersaturation of crystals due to stasis

Stone formation

May pass through the urinary tract

OBSTRUCTION, INFECTION and HYDRONEPHROSIS

Nephrolithiasis/Urolithiasis Assessment findingsAbdominal or flank painRenal colic radiating to the groin3. Hematuria4. Cool, moist skin5. 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/UrolithiasisMedical management1. Surgerya. 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/UrolithiasisMedical management2.Extracorporeal shock-wave lithotripsy: delivers shock waves from outside the body to the stone, causing pulverizationPain management : Morphine or MeperidineDiet modification

Nephrolithiasis/UrolithiasisNursing interventions1. 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/UrolithiasisNursing interventions4. Relieve pain by administration of analgesics as ordered and application of moist heat to flank area.5. Monitor intake and output

Nephrolithiasis/UrolithiasisNursing interventions6. Provide modified diet, depending upon stone consistency: Calcium, Oxalate and Uric acid stones

Nephrolithiasis/UrolithiasisNursing interventionsCalcium stoneslimit milk/dairy productsprovide acid-ash diet to acidify urine (cranberry or prune juice, meat, eggs, poultry, fish, grapes, and whole grains)

Nephrolithiasis/UrolithiasisNursing interventionsOxalate 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/UrolithiasisNursing interventionsUric acid stonesreduce foods high in purine (liver, beans, kidneys, venison, shellfish, meat soups, gravies, legumes)maintain alkaline urine

Nephrolithiasis/UrolithiasisNursing interventions7. Administer allopurinol (Zyloprim) as ordered, to decrease uric acid productionAllopurinol RashesNasal congestion

Nephrolithiasis/Urolithiasis

8. Provide client teaching and discharge planning concerningPrevention 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 dietNeed 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 wasteImpaired urine production and azotemiaSecretes Erythropoietin to increase RBCANEMIAMetabolism of Vitamin DCalcium and Phosphate imbalancesProduces bicarbonate and secretes acidsMetabolic ACIDOSISExcretes excess POTASSIUMHYPERKALEMIA

Acute renal failurePATHOPHYSIOLOGYPre-renal failure

Intra-renal failure

Post-renal failure

Acute renal failurePATHOPHYSIOLOGYPrerenal 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 failurePATHOPHYSIOLOGYIntrarenal 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 failurePATHOPHYSIOLOGYPostrenal CAUSE: Mechanical obstruction anywhere from the tubules to the urethra; includes calculi, BPH, tumors, strictures, blood clots, trauma, and anatomic malformation

Acute renal failureThree phases of acute renal failure

Oliguric phase

Diuretic phase

Convalescence or recovery phase

Acute renal failureFour phases of acute renal failure (Brunner and Suddarth)Initiation phaseOliguric phaseDiuretic phaseConvalescence or recovery phase

Acute renal failureAssessment findings: The Three Phases of Acute Renal Failure1. Oliguric phaseUrine output less than 400 cc/24 hoursduration 12 weeksManifested by dilutional hyponatremia, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia, and metabolic acidosisDiagnostic tests: BUN and creatinine elevated

Acute renal failureAssessment findings: The Three Phases of Acute Renal Failure2. Diuretic phaseDiuresis may occur (output 35 liters/day) due to partially regenerated tubules inability to concentrate urineDuration: 23 weeks; manifested by hyponatremia, hypokalemia, and hypovolemiaDiagnostic tests: BUN and creatinine slightly elevated

Acute renal failureAssessment findings: The Three Phases of Acute Renal Failure3. Recovery or convalescent phase: Renal function stabilizes with gradual improvement over next 312 months

Acute renal failureLaboratory findings:Urinalysis: Urine osmo and sodiumBUN and creatinine levels increasedHyperkalemiaAnemiaABG: metabolic acidosis

Acute renal failureNursing interventionsMonitor fluid and Electrolyte BalanceReduce metabolic ratePromote pulmonary functionPrevent infectionProvide skin careProvide emotional support

Acute renal failureNursing interventions1. Monitor and maintain fluid and electrolyte balance.Measure l & O every hour. note excessive losses in diuretic phaseAdminister 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 failureNursing interventions2. Monitor alteration in fluid volume.Monitor vital signs, PAP, PCWP, CVP as needed.Weigh client daily.Maintain strict I & O records.

Acute renal failureNursing interventions2. Assess every hour for hypervolemiaMaintain adequate ventilation.Restrict FLUID intakeAdminister diuretics and antihypertensives

Acute renal failureNursing interventions3. 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/dayRestrict POTASSIUM intakeHIGH CARBOHYDRATE DIET, calcium supplements

Acute renal failureNursing interventions4. 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 failureNursing interventions6. 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 termsRefer to counseling services as needed7. Provide care for the client receiving dialysis

Acute renal failureNursing interventions8. Provide client teaching and discharge planning concerningAdherence to prescribed dietary regimenSigns and symptoms of recurrent renal diseaseImportance of planned rest periodsUse of prescribed drugs onlySigns and symptoms of UTI or respiratory infection need to report to physician immediately

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

Chronic Renal FailurePredisposing factors: DM= worldwide leading causeRecurrent infectionsExacerbations of nephritisurinary tract obstructionhypertension

Chronic Renal FailurePATHOPHYSIOLOGYAs renal functions decline

Retention of end-products of metabolism

Chronic Renal FailurePATHOPHYSIOLOGYSTAGE 1= reduced renal reserve, 40-75% loss of nephron functionSTAGE 2= renal insufficiency, 75-90% loss of nephron functionSTAGE 3= end-stage renal disease, more than 90% loss. DIALYSIS IS THE TREATMENT!

Chronic Renal FailureAssessment findings1. Nausea, vomiting; diarrhea or constipation; decreased urinary output2. Dyspnea3. Stomatitis4. Hypertension (later), lethargy, convulsions, memory impairment, pericardial friction rub

Chronic Renal Failure

Dermatologicdry skin, pruritus, uremic frostCNSseizures, altered LOC, anorexia, fatigueCVSAcute MI, edema, hypertension, pericarditisPulmoUremic lungsHemaAnemiaMusculoskeletalloss of strength, foot drop, osteodystrophy

Chronic Renal FailureDiagnostic tests: a. 24 hour creatinine clearance urinalysisb. Protein, sodium, BUN, Crea and WBC elevatedc. Specific gravity, platelets, and calcium decreasedD. CBC= anemia

Chronic Renal FailureMedical management1. Diet restrictions2. Multivitamins3. Hematinics and erythropoietin4. Aluminum hydroxide gels5. Anti-hypertensive6. Anti-seizuresDIALYSIS

Chronic Renal FailureNursing interventions1. 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 FailureNursing interventions1. Prevent neurological complications.Assess for changes in mental functioning.Orient confused client to time, place, date, and personsInstitute safety measures to protect client from falling out of bed.

Chronic Renal FailureNursing interventions2. Promote optimal GI function.Assess/provide care for stomatitisMonitor nausea, vomiting, anorexiaAdminister antiemetics as ordered.Assess for signs of Gl bleeding

Chronic Renal FailureNursing interventions3. Monitor/prevent alteration in fluid and electrolyte balance4. Assess for hyperphosphatemia (paresthesias, muscle cramps, seizures, abnormal reflexes), and administer aluminum hydroxide gels (Amphojel) as ordered

Chronic Renal FailureNursing interventions5. 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 FailureNursing interventions6. 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 FailureNursing interventions7. Promote/maintain maximal cardiovascular function.Monitor blood pressure and report significant changes.Auscultate for pericardial friction rub.Perform circulation checks routinely.

Chronic Renal FailureNursing interventions7. Promote/maintain maximal cardiovascular function.Administer diuretics as ordered and monitor output.Modify drug doses8. Provide care for client receiving dialysis.

Important Drugs

Aluminum hydroxide (Amphogel)Binds with PHOSPHATE to decrease phosphorusKayexalateBinds with POTASSIUM to manage hyperkalemiaDiureticsTo decrease edemaErythropoietin (Epogen)To increase RBCAnti-HypertensivesTo manage Hypertension

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

DIALYSISTwo methods

1. Hemodialysis

2. Peritoneal dialysis

DIALYSISDiffusionOsmosisUltrafiltration

DIALYSISNursing managementMeet the patient's psychosocial needsRemember to avoid any procedure on the arm with the fistula (HEMO)Monitor WEIGHT, blood pressure and fistula site for bleeding

DIALYSISNursing management3. Monitor symptoms of uremia4. Detect complications like infection, bleeding (Hepatitis B/C and HIV infection in Hemodialysis) Peritonitis in peritoneal dialysis5. Warm the solution to increase diffusion of waste products (PERITONEAL)6. Manage discomfort and pain

DIALYSISNursing management7. To determine effectiveness, check serum creatinine, BUN and electrolytes

Male reproductive disordersBPHProstatic cancer

Male reproductive disordersDIGITAL RECTAL EXAMINATION- DRERecommended for men annually with age over 40 yearsScreening test for cancerAsk patient to BEAR DOWN

Male reproductive disordersTESTICULAR EXAMINATIONPalpation of scrotum for nodules and masses or inflammationBEGINS DURING ADOLESCENCE

Male reproductive disordersProstate specific antigen (PSA)Elevated in prostate cancerNormal is 0.2 to 4 nanograms/mLCancer= over 4

Male reproductive disordersBENIGN PROSTATIC HYPERPLASIAEnlargement of the prostate that causes outflow obstruction

Common in men older than 50 years old

Male reproductive disordersBENIGN PROSTATIC HYPERPLASIAAssessment findingsDRE: enlarged prostate gland that is rubbery, large and NON-tenderIncreased frequency, urgency and hesitancy Nocturia, DECREASE IN THE VOLUME AND FORCE OF URINE STREAM

Male reproductive disordersBENIGN PROSTATIC HYPERPLASIAMedical managementImmediate catheterizationProstatectomyTRANSURETHRAL RESECTION of the PROSTATE (TURP)Pharmacology: alpha-blockers, alpha-reductase inhibitors. SAW palmetto

BPHNURSING INTERVENTIONEncourage fluids up to 2 liters per dayInsert catheter for urinary drainageAdminister medications alpha adrenergic blockers and finasterideAvoid anticholinergicsPrepare for surgery or TURPTeach the patient perineal muscle exercises. Avoid valsalva until healing

BPHNURSING INTERVENTION: TURPMaintain the three way bladder irrigation to prevent hemorrhageOnly initially the drainage is pink-tinged and never reddishAdminister anti-spasmodic to prevent bladder spasms

Prostate Cancera slow growing malignancy of the prostate glandUsually an adenocarcinomaThis usualy spread via blood stream to the vertebrae

Prostate CancerPredisposing factorAge

Prostate CancerAssessment FindingsDRE: hard, pea-sized nodules on the anterior rectumHematuriaUrinary obstructionPain on the perineum radiating to the leg

Prostate CancerDiagnostic testsProstatic specific antigen (PSA)Elevated SERUM ACID PHOSPHATASE indicates SPREAD or Metastasis

Prostate CancerMedical and surgical managementProstatectomyTURPChemotherapy: hormonal therapy to slow the rate of tumor growthRadiation therapy

Prostate CancerNursing InterventionsPrepare patient for chemotherapyPrepare for surgery

Prostate CancerNursing Interventions: Post-prostatectomyMaintain continuous bladder irrigation. Note that drainage is pink tinged w/in 24 hoursMonitor urine for the presence of blood clots and hemorrhageAmbulate the patient as soon as urine begins to clear in color