Nursing Pellico Ch 28 Renal 788-802

Size of renal stones that may pass spontaneously

0.5 to 1 cm.

When patient must be evaluated for urethral tear before urinary catheterization

Pelvic fracture, blunt trauma, trauma related to MVA, penetrating injury, recent urethral or bladder neck surgery. Blood at meatus.

Causes of cystine stones

Occur only in patients with rare inherited defect in renal absorption of cystine.

Foods high in purine

Shellfish, anchovies, asparagus, mushrooms, organ meats.

Oxalate-containing foods

Spinach, strawberries, rhubarb, tea, peanuts, wheat bran.

Season when stones are more common

Spring and summer since dehydration is more likely.

Significance of dusky stoma

Stoma should be pink or red. Dusky stoma indicates impaired perfusion. Notify surgeon. Ischemic stoma may turn purple, brown, or black. Necrotic stoma needs surgery. Superficial ischemia may be monitored until dusky mucosa sloughs.

Cutaneous ureterostomy

Surgeon brings detached ureter through abdominal wall to opening in skin. If unilateral, patient will still void normally from other kidney, so there will be two sources of urine output, ureterostomy and per urethra. Both sources must be documented in I&O. If MD asks for UA, must send one for both sources of urine.

Types of genitourinary trauma

Urethral, ureteral, bladder. May be from pelvic fracture, pulling out Foley with balloon, traumatic Foley insertion, MVA, sports injury with blunt force to abdomen an pelvis, penetrating injury, "Lorena Bobbitt" injury, etc.

Diagnosing calculi

KUB or ultrasonograpy, IV urography, or retrograde pyelography. Blood chemistry and 24-hour urine to measure calcium, uric acid, creatinine, sodium, pH, and total volume are part of workup. Urine is strained and stones collected for analysis to determine etiology.

Risk factors for urinary tract cancer

Cigarettes. Environmental exposure: Dyes, rubber, leather, ink, paint. Recurrent or chronic bacterial UTI. Bladder stones. High urinary pH. High cholesterol intake. Pelvic radiation therapy. Cancers of prostate, colon, and rectum in males.

Patients with urolithiasis need to be encouraged to: A. increase their fluid intake B. participate in strenuous exercise C. supplement their diet with calcium D. limit their voiding to every 6-8 hours

A.

Types of renal stones and how common (percent)

Calcium (75% of all renal stones). Uric acid (5-10%). Struvite (15%). Cystine (1-2%).

Nephrolithiasis

Calculi in kidneys.

Tumors that metastasize to bladder

Prostate, colon, rectum in males. Lower gynecologic tract in females.

Urolithiasis

Calculi in urinary tract.

How often check stoma for perfusion

q.4 hours.

Renal colic

Acute pain from calculi accompanied by CVA tenderness, nausea, and vomiting.

Cancer grade

Degree of cell differentiation

A major goal when caring for a catheterized patient is to prevent infection. Select all the nursing actions that apply: A. Empty the collection bag at least every 8 hours to reduce bacterial growth. B. Disconnect the tubing to collect urine samples. C. Suspend the drainage bag off the floor. D. Wash the perineal area with soap and water at least twice daily. E. Irrigate the catheter every 24 hours.

A, C, D. Never disconnect the tubing to collect samples, irrigate, or ambulate the patient since this will allow bacteria to enter the closed system. Drainage systems should have an aspiration or puncture port from which a specimen can be obtained. The drainage system should not be disconnected.

An elderly man is seeing his urologist for an annual check up. The provider is concerned with s/s he detects for bladder cancer. Which of the following s/s is diagnostic for bladder cancer? A. painless gross hematuria B. deep flank and abdominal pain C. muscle spasm and abdominal rigidity over the flank D. decreasing kidney function associated with fever and hematuria

A.

The nurse is participating in a bladder retraining program for a patient who had an indwelling catheter for 2 weeks. The nurse knows that, during this process, straight catheterization, after catheter-free intervals, can be discontinued when the residual urine is: A. 500 mL. B. 400 mL. C. 200 mL. D. < 100 mL.

D. Residual urine greater than 100 mL is considered diagnostic of urinary retention.

Nursing diagnoses for patients with renal stones

Acute pain related to inflammation, obstruction, and abrasion or urinary tract. Deficient knowledge regarding prevention of recurrence of renal stones. Deficient knowledge regarding role of diet in treatment of renal stones. Impaired urinary elimination due to presence of renal stones.

A pt is prescribed a diet moderately reduced in calcium to prevent renal stones. The nurse instructs the pt to avoid: A. citrus fruits B. milk C. pasta D. whole grain breads

B.

The nurse advises a pt with renal stones to avoid eating shellfish, and organ meats. She states that these foods should be avoided because she knows that his renal stones are composed of which of the following substances? A. Calcium B. Uric acid C. Struvite D. cystine

B.

A nurse caring for a patient with a neurogenic bladder knows to assess for the major complication of: A. Permanent distention. B. Infection. C. Consistent pain. D. Daily and painful spasms.

B. Infection is caused by an increased urinary bacterial count that results from incomplete and delayed emptying of the bladder.

A patient is admitted to a hospital with a diagnosis of spastic, neurogenic bladder. The nurse is aware that the pathophysiology of this condition is primarily due to which of the following occurrences? A. Bladder distended until overflow incontinence occurs. B. Patient's inability to exert motor control. C. Presence of a lower motor neuron lesion. D. Inability of the bladder muscle to contract forcefully.

B. Neurogenic bladder dysfunction results from a lesion of the nervous system that results in urinary incontinence. Spastic bladder is caused by any spinal cord lesion above the voiding reflex. There is a loss of conscious sensation and control. A spastic bladder empties on reflex.

Classic triad of urethral trauma symptoms

Blood at meatus. Inability to void. Distended bladder.

A women comes to her provider's office with s/s of kidney stones. Which of the following should be the primary medical management goal? A. determine the stone type B. relieve any obstruction C. relieve the pain D. prevent nephron destruction

C.

When being instructed on methods for managing the mucous in their urinary diversion, pts should be reminded to do which of the following? A. increase fiber intake B. consume high levels of citrus fruits and juices C. increase consumption of cranberry juice D. avoid caffeine consumption

C. Acidifies urine and manages mucus production.

A patient is diagnosed with a complicated UTI. Which of the following drugs will the patient most likely begin initial pharmacologic therapy? A. Phenazopyridine. B. Fluoroquinolone. C. Cephalosporin. D. Nitrofurantoin.

C. The general treatment of choice for a complicated UTI is cephalosporin or an ampicillin/aminoglycoside complication. The other drugs are used to treat uncomplicated UTIs.

Medical management of stones

Control pain until cause can be eliminated. Opioids and NSAIDs. NSAIDs may also reduce swelling and facilitate passage of stone. Hot baths or moist heat to flanks. Encourage fluids to help pass stone, 8-10 glasses of water daily with goal of passing 2 L of urine daily. IV fluids, if needed. If stone does not pass or there are complications, endoscopic or surgical procedures may be needed. Open surgical procedures are rare now.

Types of cutaneous urinary diversions

Conventional ileal conduit. Cutaneous ureterostomy. Vesicostomy. Nephrostomy.

2 types of urinary diversion

Cutaneous: Urine drains through opening created in abdominal wall and skin. Continent: Portion of intestine creates reservoir for urine.

Diagnosing bladder cancer

Cystoscopy (most important). Excretory urography, CT, ultrasound, Bimanual exam with patient anesthetized. Tumor biopsy for definitive diagnosis. Cytology of urine and saline bladder washings used in staging.

Cancer stage

Degree of local invasion and presence or absence of metastases.

Urinary diversion

Diverts urine to new exit site, usually through skin stoma. Usually performed for cancer, but also for intractable interstitial cystitis, damage to bladder, trauma, urethral stricture, other.

Nursing evaluation of patient with renal stones

Expected outcomes generally include: Reports relief of pain. States increased knowledge of health-seeking behaviors to prevent recurrence. Experiences no complications.

Treatment of calcium stones

For some types of calcium stones, patients must restrict calcium intake. Liberal fluid intake. Restrict protein and sodium. May use medication like ammonium chloride. Thiazide diuretics may reduce calcium loss and urine and lower PTH levels.

Patient education to prevent recurrent urinary infection

Hygiene: Shower rather than tub bath. Clean front to back after BM. Fluid intake: Drink liberal amounts daily. Avoid alcohol, caffeine, and other urinary tract irritants. Voiding habits: Void every 2 to 3 hours during day and completely empty bladder. Avoids overdistention and compromised blood supply. For women, void immediately after sex. Therapy: Take meds as prescribed. May need antibiotics long term. May need special timing of meds. Consider acidification of urine with 1000 mg of vitamin C daily or cranberry juice. Test urine for bacteria if MD prescribes. Notify MD if fever or signs and symptoms persist. Regular followup with provider.

Causes of calcium stones

Hypercalcemia and hypercalciuria. Hyperparathyroidism. Renal tubular acidosis. Cancers. Granulomatous disease (TB, sarcoidosis) because granulomas may produce excess vitamin D. Excess vitamin D intake. Excess milk and alkali intake. Myeloproliferative diseases (leukemia, polycythemia vera, multiple myeloma). Insufficient fluid intake.

UTI risk factors

Inability to empty bladder completely. Urinary obstruction: Congenital, urethral stricture, bladder neck contracture, bladder tumor, stones, ureteral compression, neuro abnormalities. Immunosuppression. Instrumentation or catheterization of urinary tract. Inflammation or abrasion of urethral mucosa. Contributing conditions: Diabetes, pregnancy, neuro disorders, gout, urinary stasis.

Treatment of struvite stones

Increase fluid intake

Post-op care for surgical treatment of renal stones

Increase fluids to assist in passage of stones. Monitor for signs and symptoms of complications: fever, decreased urine output, pain. Except for electrohydraulic lithotripsy, expect hematuria that should disappear in 4-5 days.

Treatment of cystine stones

Low-protein diet. Alkalinize urine. Increase fluid intake.

Clinical manifestations of calculi

May be asymptomatic if there is no obstruction as may happen with some kidney stones. Stones in renal pelvis may cause deep ache in costovertebral region. Hematuria and pyuria may be present. Pain may radiate anteriorly toward bladder in female and testis in male. Nausea, vomiting, diarrhea, and abdominal discomfort may occur. Patient may have urgency, but void very little. Stones in bladder usually produce irritation and hematuria and may be associated with UTI. There may be obstruction if they lodge in bladder neck.

Ureteral trauma

May be gunshot wound or injury during gynecologic surgery. Often asymptomatic. Fistulas can form as urine leaks. Can be detected with IV urography. Surgical repair with stent placement is usually necessary.

Bladder trauma

May be pelvic fracture or blow to abdomen with bladder full. Ecchymosis may be present. Bladder may rupture intra- or extraperitoneally or both. Complications include hemorrhage, shock, sepsis.

General measures to avoid all types of stones

Stop medications that cause stones. 3-4 g sodium per day (sodium competes with calcium for reabsorption in kidney). Avoid oxalate-containing foods. Drink 2 glasses of water at bedtime and 1 glass with each awakening to prevent concentrated urine at night. Avoid sudden increases in environmental temperature that lead to sweating and dehydration. Contact provider at first sign of UTI.

Nephrostomy

Surgeon inserts catheter into renal pelvis via incision in flank or by percutaneous catheter placement into kidney. Wears nephrostomy bag, which is similar to Foley bag and must be kept lower than level of kidney so that urine will not reflux. Empty q.4 hours. Patient has 2 sources of urine output, nephrostomy and per urethra from other kidney.

Indiana pouch

Surgeon introduces ureters into a segment of ileum and cecum. Urine is drained periodically by inserting a catheter into the stoma. This is only source of urine in these patients.

Ureterosigmoidostomy

Surgeon introduces ureters into sigmoid colon, allowing urine to flow into colon and out rectum as frequent watery diarrhea. This is patient's only source of urine output. UA not possible because it would be mixed sample with feces.

Vesicostomy

Surgeon sutures bladder to abdominal wall and creates stoma through abdominal and bladder wall. Only one source of urine output.

Kock pouch (continent ileal urinary diversion)

Surgeon transplants ureters to an isolated segment of small bowel, ascending colon, or ileocolonic segment and develops effective continence mechanism or valve. Urine is drained by inserting catheter into stoma. This is only source of urine in these patients.

Most common form of bladder cancer

Transitional cell carcinoma.

Nursing management of genitourinary trauma

Assess frequently for flank and abdominal pain, muscle spasm, and swelling over flank. Instruct patient on incision care and adequate fluid intake. Patient with bladder rupture may have gross bleeding for several days after repair. Monitor patient for hypotension. Tell patient to restrict activity for 1 month after trauma to minimize chance of bleeding.

Ureteral colic

Acute, excruciating, colicky, wavelike pain radiating down the thigh and into the genitalia.

Causes of struvite stones

Akaline, ammonia rich urine caused by urease splitting bacteria: Proteus, Pseudomonas, Klebsiella, Staphylococcus, Mycoplasma. Neurogenic bladder, foreign bodies, and UTI are predisposing factors.

Medications that may cause stones

Antacids, acetazolamide, vitamin D, laxatives, high doses of aspirin.

Treatment of uric acid stones

Avoid foods high in purine. May use allopurinol to reduce serum uric acid and urinary excretion of it.

Possible complications of ileal conduit

Infection, dehiscence, urine leakage, ureteral obstruction, ileus, gangrene of stoma. Delayed complications include ureteral obstruction, stoma stenosis, renal deterioration from reflux, pyelonephritis, calculi. May have hyperchloremic acidosis. Stoma ischemia and necrosis. Stoma retraction and mucocutaneous separation. Separation usually does not require surgery, but if stoma retracts into peritoneum, surgery is required.

A female patient visits her primary health care provider with a complaint of frequency of urination and incontinence when she sneezes. The health care provider suspects the patient is experiencing cystitis. The nurse knows that this is most likely due to which of the following? A. Interruption in the protective effects of glycosaminoglycan. B. Disturbance in the normal bacterial flora of the vagina. C. Reflux of urine from the urethra into the bladder. D. Dysfunction of the bladder neck or urethra.

C. With coughing, sneezing, or straining, the bladder pressure increases, which may force urine from the bladder into the urethra. When the pressure returns to normal, the urine flows back into the bladder, bringing into the bladder bacteria from the interior portions of the urethra.

Types of urinary tract cancers

Cancers of bladder, kidney, renal pelvis, ureter, prostate and other structures. Transitional cell (90%), squamous cell, adenocarcinoma, sarcoma, other.

Management of bladder cancer

Chemotherapy, radiation, surgery. Transurethral resection or fulguration for benign papillomas. Intravesical BCG is form of immunotherapy, especially good for superficial bladder cancer. Superficial bladder cancers tend to recur after resection or fulguration and need intense followup. Radical cystectomy for invasive cancer. Radical cystectomy in men is bladder, prostate, seminal vesicles, and perivesical tissue. In women, bladder, lower ureters, uterus, fallopian tubes, ovaries, anterior vagina, urethra. Then need urinary diversion.

Planning for patients with renal stones

Goals may include relief of pain, prevention of recurrence, absence of complications.

Causes of uric acid stones

Gout. Myeloproliferative disorders.

Types of continent urinary diversions

Indiana pouch. Kock pouch (continent ileal urinary diversion). Kock pouch with end attached to urethra (males only). Ureterosigmoidostomy.

General causes of all types of renal stone

Infection, urinary stasis, and immobility, which slow renal drainage and alter calcium metabolism. Anatomic derangements: polycystic kidneys, horseshoe kidney, chronic stricture, medullary sponge disease. Inflammatory bowel disease, ileostomy, and bowel resection because patients absorb more oxalate.

Kock pouch with modification for males only

Kock pouch is modified by attaching one end of the pouch to the urethra allowing more normal voiding. (Female urethra is too short for this.) These patients could have 2 sources of urine output because they could void per urethra or catheterize pouch.

Risk factors for stones

Men more than women. Usually in third to fifth decade. Recurrence is common. UTI and stasis are associated with stones, so anatomy plays a role. Metabolic defects and genetic conditions play a role. Spring and summer season as dehydration is a factor.

Medical management of genitourinary trauma

Monitor H&H. Monitor urine output. Monitor for signs of shock and acute peritonitis. For urethral trauma, may need suprapubic catheter with surgical repair and Foley for 1 month.

Pathophysiology of calculi

No cause found in many patients. Certain substances precipitate as gravel or stone anywhere in urinary tract depending on amount of substance, ionic strength and pH of urine. Stones occur more in dehydrated patient. In many patients, no cause is found. Stones block flow of urine. Obstruction develops, causing increase and hydrostatic pressure and distention of proximal ureter and renal pelvis with destruction of renal architecture.

Nursing interventions for patients with renal stones

Pain relief. Opioids and NSAIDs. Patient assumes position of comfort, which may be fetal position. Ambulate patient if that helps. Monitor and manage complications. Increase fluids to prevent dehydration and promote stone passage. Ambulate patient to promote stone passage. I&Os. Strain urine. Blood clots should be crushed to look for stones. Monitor for decreased urine output, cloudy urine (infection). Also monitor vitals for signs of infection. Infection should be treated before efforts to dissolve stone. Educate patient on recurrence prevention, sign and symptoms of obstruction and infection, any medications administered. It is important that patient has supplies to strain urine and knows where to obtain more supplies.

Most common symptom of bladder cancer

Painless gross hematuria.

Characteristics of normal stoma

Pink and moist like inside of mouth. Insensitive to pain because it has no nerve endings. Vascular and may bleed when cleaned. Mucus may be visible in urine if part of intestine was used to create stoma.

Care and application of urinary diversion collection appliance.

They may be reusable or single use. Gather supplies and prepare new appliance according to directions with disk 1/8 larger than stoma. Remove old appliance. Clean site with soap and water, rinse well, and dry. Inspect skin for irritation. Use rolled gauze or tampon to wick urine and keep skin dry during bag change. Depending on which system used, put skin barrier or disk (some 1-piece, some 2-piece) in place over stoma, then attach bag. May use pouch cover or cornstarch between pouch and skin to keep dry and prevent irritation. Tape disposable system in picture frame fashion. Dispose of single use or wash reusable appliance.

Clinical manifestations of bladder cancer

Painless gross hematuria. Symptomatic UTI. Any alteration in voiding or change in urine. Pelvic or back pain may occur with mets.

Nursing assessment of patient with renal stones

Assess pain and associated symptoms, including UTI and obstruction. Inspect urine for blood and strain for stones or gravel. Assess predisposing factors and patient's knowledge of condition.

Nursing assessment of a patient who is complaining about urinary retention must include a history of current medications. Which of the following medications can cause urine retention by increasing bladder outlet resistance? A. Imipramine. B. Belladonna. C. Doxepin. D. Propranolol.

D. Beta-adrenergic blockers (ie, propranolol) increase bladder outlet resistance, which leads to increased urinary retention.

Select the most common fluid and electrolyte problem in the elderly that can cause urinary incontinence by masking the urge sensation. A. Fluid retention. B. Hypokalemia. C. Hypernatremia. D. Dehydration.

D. Dehydration decreases urine volume and may mask the urge sensation, causing urinary incontinence. When hydration occurs, urinary incontinence may resolve or be eliminated if the cause is identified.

Conventional ileal conduit

Surgeon transplants ureters to isolated section of terminal ileum, bringing one end to abdominal wall. Urine is collected in ileostomy bag. To take UA, empty bag and replace. Allow urine to collect and take sample. All urine output is through ostomy.

The nurse advises the patient with chronic pyelonephritis that he should: A. Limit his fluid intake to 1.5 L/day to minimize bladder fullness, which could cause backward pressure on the kidneys. B. Decrease his sodium intake to prevent fluid retention. C. Increase fluids to 3 to 4 L/24 hours to dilute the urine. D. Decrease his intake of calcium rich foods to prevent kidney stones.

C. Unless contraindicated, fluids should be increased to dilute the urine, decrease burning on urination, and prevent dehydration. A balanced diet would be recommended but there is no need to restrict sodium or calcium.

Surgical treatments for stones

Cystoscopy and ureteroscopy with stone basketing or lithotripsy to fragment and remove stone. Ureter may be stented for 48 hours to keep it patent. Extracorporeal shock wave lithotripsy. High-energy shock waves pass through skin and fragment stones in calyces of kidney. Stone fragments are passed. Patient is observed for obstruction and infection. Skin bruising is complication. EKG monitored during procedure for arrhythmia. Endourologic methods (percutaneous nephrostomy or nephrolithotomy). Nephroscope is passed percutaneously into renal parenchyma and stone retrieved by forceps or basketing. Electrohydraulic lithotripsy. Electric charge creates shock wave to fragment stone. Probe is passed through cystoscope and lithotriptor is placed near stone. After stone is extracted, percutaneous nephrostomy tube stays in for a while to make sure ureter is not obstructed by edema or clots. Nephrolithotomy: incision in kidney and stone removal. Nephrectomy if kidney is nonfunctional. Pyelolithotomy if stones in kidney pelvis. Ureterolithotomy if stones in ureter. Cystotomy if stones in bladder. Cystolithopaxy: Inserting instrument through urethra to crush stone.