Chapter 28: Nursing Management: Patients With Urinary Disorders
Bladder retraining following removal of an indwelling catheter begins with:
Instructing the client to follow a 2- to 3-hour timed voiding schedule. Explanation: Immediately after the removal of the indwelling catheter, the client is placed on a timed voiding schedule, usually 2 to 3 hours.
A client undergoes surgery to remove a malignant tumor followed by a urinary diversion procedure. Which postoperative procedure is the most important for the nurse to perform?
Maintain skin and stomal integrity. Explanation: The most important nursing management in postoperative procedure is to maintain skin and stomal integrity to avoid further complications, such as skin infections and urinary odor.
A client is being treated for renal calculi and suspected hydronephrosis. Which measure should the nurse take to help maintain a record of the kidneys' function?
Monitor the client's intake and output. Explanation: Monitoring and recording the client's intake and output provides information about the kidneys' function. It also helps identify any arising complications such as hydronephrosis.
The nurse is employed in a urologist's office. Which classification of medication is anticipated for clients having difficulty with urinary incontinence?
Anticholinergic Explanation: Pharmacologic agents that can improve bladder retention, emptying, and control include anticholinergic drugs. In this classification are medications such as Detrol, Ditropan, and Urecholine. Diuretics eliminate fluid from the body but do not affect the muscles of urinary elimination. Anticonvulsant and cholinergic medications also do not directly help with control.
The nurse is caring for a postoperative client who has a Kock pouch. Nursing assessment findings reveal abdominal pain, absence of bowel sounds, fever, tachycardia, and tachypnea. The nurse suspects which of the following?
Peritonitis Explanation: Clinical manifestations of peritonitis include abdominal pain and distention, absence of bowel sounds, nausea and vomiting, fever, changes in vital signs.
Which medication may be ordered to relieve discomfort associated with a UTI?
Phenazopyridine Explanation: Phenazopyridine is a urinary analgesic ordered to relieve discomfort associated with UTIs. Nitrofurantoin, ciprofloxacin, and levofloxacin are antibiotics.
A patient taking an alpha-adrenergic medication for the treatment of hypertension is having a problem with incontinence. What does the nurse tell the patient?
When the medication is discontinued or changed, the incontinence will resolve. Explanation: Iatrogenic incontinence refers to the involuntary loss of urine due to extrinsic medical factors, predominantly medications. One such example is the use of alpha-adrenergic agents to decrease blood pressure. In some people with an intact urinary system, these agents adversely affect the alpha receptors responsible for bladder neck closing pressure; the bladder neck relaxes to the point of incontinence with a minimal increase in intra-abdominal pressure, thus mimicking stress incontinence. As soon as the medication is discontinued, the apparent incontinence resolves.
A client is prescribed amitriptyline (an antidepressant) for incontinence. The nurse understands that this drug is an effective treatment because it:
increases bladder neck resistance. Explanation: Some tricyclic antidepressant medications (amitriptyline, nortriptyline, and amoxapine) are useful in treating incontinence because they decrease bladder contractions and increase bladder neck resistance. Anticholinergic drugs such as oxybutynin chloride (Ditropan), reduce bladder spasticity and involuntary bladder contractions. Bethanechol (Urecholine) helps to increase contraction of the detrusor muscle, which assists with emptying of the bladder.
Bladder retraining following removal of an indwelling catheter begins with
instructing the client to follow a 2- to 3-hour timed voiding schedule. Explanation: Immediately after the removal of the indwelling catheter, the client is placed on a timed voiding schedule, usually 2 to 3 hours, not 6 hours. At the given time interval, the client is instructed to void. Immediate voiding is not usually encouraged. If bladder ultrasound shows 100 mL or more of urine remaining in the bladder after voiding, straight catheterization may be performed to ensure complete bladder emptying.
Bladder retraining following removal of an indwelling catheter begins with:
instructing the client to follow a 2- to 3-hour timed voiding schedule. Explanation: Immediately after the removal of the indwelling catheter, the client is placed on a timed voiding schedule, usually 2 to 3 hours, not 6 hours. At the given time interval, the client is instructed to void. Immediate voiding is not usually encouraged. If bladder ultrasound shows 100 mL or more of urine remaining in the bladder after voiding, straight catheterization may be performed to ensure complete bladder emptying.
The nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which statement by the client provides evidence that client teaching was effective?
"My urine will be eliminated through a stoma." Explanation: An ileal conduit is a non-continent urinary diversion whereby the ureters drain into an isolated section of ileum. A stoma is created at one end of the ileum, exiting through the abdominal wall.
A client with urinary tract infection is prescribed phenazopyridine (Pyridium). Which of the following instructions would the nurse give the client?
"This medication will relieve your pain." Explanation: Phenazopyridine (Pyridium) is a urinary analgesic agent used for the treatment of burning and pain associated with UTIs.
A client presents at the clinic with reports of urinary retention. What question should the nurse ask to obtain additional information about the client's report?
"When did you last urinate?" Explanation: The nurse needs to determine the last time the client voided.
Which client is at highest risk for developing a hospital-acquired infection?
A client with an i1619 Explanation: The invasive nature of an indwelling urinary catheter increases the client's risk of a hospital-acquired infection. The nurse must perform careful, frequent catheter care to minimize the client's risk. Although the client with a laceration, the client who's taking prednisone, and the client with Crohn's disease have a risk of infection, the one with an indwelling catheter is at the greatest risk.
A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program?
Assessing present voiding patterns Explanation: The guidelines for initiating bladder retraining include assessing the client's present intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client's fluid intake won't reduce or prevent incontinence. The client should be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.
Behavioral interventions for urinary incontinence can be coordinated by a nurse. A comprehensive program that incorporates timed voiding and urinary urge inhibition is referred to as what?
Bladder retraining Explanation: Bladder retraining includes a timed voiding schedule and urinary urge inhibition exercises. These exercises involve delaying voiding to help the patient stay dry for a set period of time. When one time interval is reached, another is set. The time is usually increased by 10 to 15 minutes, until an acceptable voiding interval is achieved.
A 69-year-old man is postoperative day 2 following a transurethral prostatic resection (TUPR). The patient had his urinary catheter removed at 06:00 this morning but has not voided in the 5 hours since the removal, despite the fact that he has been drinking large amounts of fluids. What nursing assessment will most accurately determine whether the patient is retaining urine?
Bladder ultrasound Explanation: Bladder ultrasound provides an accurate reading of a patient's current bladder volume. Palpation and inspection are also relevant assessments, but these are less accurate. Analysis of intake and output can be informative, but this does not include the important variable of urine production.
A 49-year-old male patient has just had an ileostomy created as part of the treatment plan for bladder cancer. The nurse has begun the patient's discharge planning process and is creating an appropriate plan of care. When planning this patient's care, what psychosocial nursing diagnosis should the nurse most likely prioritize?
Body image disturbance related to the presence of an ileostomy Explanation: Although none of the given diagnoses is implausible, the likelihood of a disturbance in body image is high in an adult who has undergone the creation of an ileostomy.
What is the most common presenting objective symptom of a urinary tract infection in older adults, especially in those with dementia?
Change in cognitive functioning Explanation: The most common objective finding is a change in cognitive functioning, especially in those with dementia; these clients usually exhibit even more profound cognitive changes with the onset of a UTI.
The nurse working with a client after an ileal conduit notices that the pouching system is leaking small amounts of urine. What is the appropriate nursing intervention?
Change the wafer and pouch. Explanation: Whenever a leaking pouching system is noted, the nurse should change the wafer and pouch. Attempting to secure or patch the leak with tape and/or barrier paste can trap urine under the barrier or faceplate, which will compromise peristomal skin integrity. Emptying the pouch will not rectify the leaking.
A patient has been diagnosed with a UTI and is prescribed an antibiotic. What first-line fluoroquinolone antibacterial agent for UTIs has been found to be significantly effective?
Cipro Explanation: Ciprofloxacin (Cipro) is a fluoroquinolone used to treat UTIs. Co-trimoxazole (Bactrim, Septra) is a trimethoprim-sulfamethoxazole combination medication. Nitrofurantoin (Macrodantin, Furadantin) is an anti-infective urinary tract medication.
The nurse has been asked to provide health information to a female patient diagnosed with a urinary tract infection. What appropriate instructions will the nurse provide? Select all that apply.
Cleanse around the perineum and urethral meatus after each bowel movement to reduce pathogens. Drink liberal amounts of fluid to flush out bacteria. Void every 2-3 hours to prevent overdistention of the bladder.
A female client who is diagnosed with a malignant tumor in her bladder is advised to undergo cystectomy followed by a urinary diversion procedure. Which of the following would be most important for the nurse to assess preoperatively?
Client's manual dexterity and vision Explanation:It is essential to assess manual dexterity, vision, and level of understanding of a client who undergoes a urinary diversion procedure, because this information will determine the client's ability to manage stoma care and self-catheterization following the urinary diversion procedure.
The nurse is encouraging the client with recurrent urinary tract infections to increase fluid intake to 8 large glasses of fluids daily. Which beverage would the nurse discourage for this client?
Coffee in the morning Explanation: The nurse would discourage drinking coffee. Coffee, tea, alcohol, and colas are urinary tract irritants. Fruit juice, milk, and ginger ale are appropriate for drinking and counted toward the daily fluid total.
A client undergoes surgery to remove a malignant tumor, followed by a urinary diversion procedure. Which postoperative procedure should the nurse perform?
Maintain skin and stoma integrity Explanation: The most important postoperative nursing management is to maintain skin and stoma integrity to avoid further complications, such as skin infections and urinary odor. Determining the client's ability to manage stoma care, showing photographs, and suggesting a visit to a local ostomy group would be a part of the preoperative procedure.
A client who has a history of neurogenic bladder uses a permanent, indwelling catheter to facilitate urine elimination. What can this client consume to decrease the likelihood of bladder infection?
Cranberry juice Explanation: Cranberry juice or vitamin C may be recommended to keep the bacteria from adhering to the wall of the bladder and thus promoting their excretion and enhancing the effectiveness of drug therapy.
Which of the following accounts for the majority of ureteral injuries?
Crashes, falls, and assaults Explanation: Gunshot wounds account for 95% of ureteral injuries, which may range from contusions to complete transection. Unintentional injury to the ureter may occur during gynecologic or urologic surgery. Knife wounds and sports injuries do not account for the majority of ureteral injuries.
After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the students have understood the material when they identify which of the following as a cause of stress incontinence?
Decreased pelvic muscle tone due to multiple pregnancies Explanation: Stress incontinence is due to decreased pelvic muscle tone, which is associated with multiple pregnancies, obstetric injuries, obesity, menopause, or pelvic disease. Transient incontinence is due to increased urine production related to metabolic conditions. Urge incontinence is due to bladder irritation related to urinary tract infections, bladder tumors, radiation therapy, enlarged prostate, or neurologic dysfunction. Overflow incontinence is due to obstruction from fecal impaction or enlarged prostate.
An older adult client is being evaluated for suspected pyelonephritis and is ordered kidney, ureter, and bladder (KUB) x-ray. The nurse understands the significance of this order is related to which rationale?
Detects calculi, cysts, or tumors Explanation: Urinary obstruction is the most common cause of pyelonephritis in the older adult. A KUB may reveal obstructions such as calculi, cysts, or tumors. KUB is not indicated for detection of impaired renal function or reveal increased risk for chronic form of the disorder. Urine cultures will reveal causative microorganisms present in the urine.
A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?
Encouraging intake of at least 2 L of fluid daily Explanation: Encouraging a daily fluid intake of at least 2 L helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence.
A nurse is providing care for a patient who has had an indwelling urinary catheter in place for the past several days. To reduce this patient's risk of developing a catheter-related infection, the nurse should:
Ensure that the collection bag is always below the height of the patient's bladder. Explanation: The spout (or drainage port) of any urinary drainage bag can become contaminated when opened to drain the bag. Bacteria enter the urinary drainage bag, multiply rapidly, and then migrate to the drainage tubing, catheter, and bladder. By keeping the drainage bag lower than the patient's bladder and not allowing urine to flow back into the bladder, this risk is minimized. Clamping, frequent emptying, and disinfecting do not necessarily reduce the patient's risk of developing an infection.
A 60-year-old woman has begun a course of oral antibiotics for the treatment of a urinary tract infection (UTI). The patient's nurse should recognize that the causative microorganisms most likely originated from:
Fecal contamination from the patient's perineum Explanation: Most of the microorganisms the result in UTIs are a result of fecal contamination. UTIs do not usually result from proliferation of normal microbiota or ingested microorganisms.
Patients with urolithiasis need to be encouraged to:
Increase their fluid intake so that they can excrete up to 4 liters every day. Explanation: Fluids need to be increased up to 4 L/day to increase hydrostatic pressure within the urinary tract and thereby promote passage of the stone. This volume of fluid intake also helps prevent additional stone formation.
A nurse caring for a patient with a neurogenic bladder knows to assess for the major complication of:
Infection Explanation: Infection is caused by an increased urinary bacterial count that results from incomplete and delayed emptying of the bladder.
A 20-year-old male patient has been brought to the emergency department (ED) by ambulance with a gunshot wound that has resulted in urethral trauma. In light of this patient's injuries, the ED nurse should anticipate what intervention?
Insertion of a suprapubic catheter Explanation: In urethral trauma, unstable patients who need monitoring of urine output may need a suprapubic catheter inserted. Lithotripsy is not relevant to the treatment of genitourinary trauma. Cystoscopy and insertion of a urinary catheter could exacerbate the patient's injuries.
After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an IV infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that's draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last 2 consecutive hours. How can the nurse best explain this drop in urine output?
It's an abnormal finding that requires further assessment. Explanation: The drop in urine output to less than 30 ml/hour is abnormal and requires further assessment. The reduction in urine output may be caused by an obstruction in the urinary catheter tubing or deficient fluid volume from blood loss. The client's nothing-by-mouth status isn't the cause of the low urine output because the client is receiving I.V. fluid to compensate for the lack of oral intake. Ambulation promotes urination; however, the client should produce at least 30 ml of urine/hour.
A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region that radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?
Kidney Explanation: The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.
Which type of incontinence refers to the involuntary loss of urine due to extrinsic medical factors, particularly medications?
Latrogenic Explanation: Iatrogenic incontinence is the involuntary loss of urine due to extrinsic medical factors, predominantly medications. Reflex incontinence is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding. Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder.
A nurse who is taking care of a patient with a spinal cord injury documents the frequency of reflex incontinence. The nurse understands that this is most likely due to:
Loss of motor control of the detrusor muscle. Explanation: Spinal cord injury patients commonly experience reflex incontinence because they lack neurologically mediated motor control of the detrusor and the sensory awareness of the urge to void. These patients also experience hyperreflexia in the absence of normal sensations associated with voiding.
A patient has had surgery to create an ileal conduit for urinary diversion. What is a priority intervention by the nurse in the postoperative phase of care?
Monitor urine output hourly and report output less than 30 mL/hr. Explanation: In the immediate postoperative period, urine volumes are monitored hourly. Throughout the patient's hospitalization, the nurse monitors closely for complications, reports signs and symptoms of them promptly, and intervenes quickly to prevent their progression. If urinary drainage stops or decreases to less than 30 mL/hour, or if the client complains of back pain, the nurse needs to notify the physician immediately.
A nurse has been asked to speak to a local women's group about preventing cystitis. Which of the following would the nurse include in the presentation?
Need to urinate after engaging in sexual intercourse Explanation: Measures to prevent cystitis include voiding after sexual intercourse, wearing cotton underwear, urinating every 2 to 3 hours while awake, and taking showers instead of tub baths.
A nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:
Notify the physician about cloudy or foul-smelling urine. Explanation: The nurse should instruct the client to report the presence of foul-smelling or cloudy urine to the physician. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal because of residual stone products. Hematuria is common after lithotripsy.
A client has just undergone a urinary diversion procedure. What management issues related specifically to urinary diversion would be included in this client's care plan? Select all that apply.
Observe for leakage of urine or stool from the anastomosis. Maintain renal function. Assess for signs and symptoms of peritonitis.
A 49-year-old man has been brought to the emergency department by his wife, who states that her husband is experiencing a repeat episode of kidneys stones. When planning interventions for this patient's immediate care, what problem is likely to be the priority?
Pain Explanation: Urinary stones are typically accompanied by severe pain, the treatment of which would be a nursing priority.
A 64-year-old man is seeing his urologist for an annual check-up, post prostatectomy. The health care provider is concerned with the symptom he finds because it is considered diagnostic for bladder cancer. Which of the following signs/symptoms is diagnostic for bladder cancer?
Painless, gross hematuria Explanation: Although flank pain may occur, the painless, gross hematuria is characteristic of bladder cancer.
The nurse is providing an education program for the nursing assistants in a long-term care facility in order to decrease the number of UTIs in the female population. What interventions should the nurse introduce in the program? Select all that apply.
Perform hand hygiene prior to patient care. Assist the patients with frequent toileting. Provide careful perineal care.
If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection?
Perform meticulous perineal care daily with soap and water Explanation: Cleanliness of the area will reduce potential for infection. Strict aseptic technique must be used when inserting a urinary bladder catheter. The nurse must maintain a closed system and use the catheter's port to obtain specimens. The catheter bag must never be placed on the client's abdomen unless it is clamped because it may cause urine to flow back from the tubing into the bladder.
A client has developed urinary incontinence after having a urinary catheter in place for a few weeks. What is the initial nursing intervention the nurse should use to start the client with bladder training?
Place client on a timed voiding schedule. Explanation: Placing the client on a timed voiding schedule after a catheter removal will promote bladder muscle retraining. The nurse should do a bladder scan immediately after voiding, but this is not the initial action. The nurse does not need to complete urinary catheterization at specific intervals for initial bladder training. The client needs to limit fluids at night.
Which term refers to inflammation of the renal pelvis?
Pyelonephritis Explanation: Pyelonephritis is an upper urinary tract inflammation, which may be acute or chronic. Cystitis is inflammation of the urinary bladder. Urethritis is inflammation of the urethra. Interstitial nephritis is inflammation of the kidney.
Which type of incontinence refers to involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure?
Stress Explanation: Stress incontinence may occur with sneezing, coughing, or changing position. Overflow incontinence refers to the involuntary loss of urine associated with overdistention of the bladder. Urge incontinence refers to involuntary loss of urine associated with urgency. Reflex incontinence refers to the involuntary loss of urine due to involuntary urethral relaxation in the absence of normal sensations. Reference:
The nurse provides care for a client who is prescribed bladder retraining following urinary catheterization. Complete the following sentence by choosing from the lists of options: The nurse should first ask the client to _______________ then perform the prescribed _______________.
The nurse should first ask the client to urinate then perform the prescribed bladder scan
The nurse is assisting in the transport of a client with an indwelling catheter to the diagnostic studies unit. Which action made by the nursing assistant would require instruction?
The nursing assistant places the drainage bag on the client's abdomen for transport. Explanation: The nurse would instruct the nursing assistant to maintain the drainage bag lower than the genital region to avoid a backflow of urine into the bladder. The nursing assistant is correct to move the catheter and drainage bag with the client to not put tension on the catheter, place the drainage bag on the lower area of the wheelchair, and hold the drainage bag while the client is in the process of moving.
A client asks the nurse why cystitis is more common in women than in men. Which of the following body parts will the nurse include in the answer?
The urethra Explanation: Because the urethra is short in women, ascending infections or microorganisms carried from the vagina or rectum are common. Males have a longer urethra, causing the organisms travel farther to the bladder.
A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate, I can't control it and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?
Urge Explanation: Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet. Stress incontinence occurs when the client has an involuntary loss of urine that results from a sudden increase in intra-abdominal pressure. Overflow incontinence occurs when the client experiences an involuntary loss of urine related to an over distended bladder; the client voids small amounts frequently and dribbles. Functional incontinence occurs when the client has function of the lower urinary tract but cannot identify the need to void or ambulate to the toilet.
The nurse advises a patient with renal stones to avoid eating shellfish, asparagus, and organ meats. She emphasizes these foods because she knows that his renal stones are composed of which of the following substances?
Uric acid Explanation: Uric acid stones are found in patients with gout and myeloproliferative disorders. Therefore, a diet low in purines is recommended.
A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect?
Urinary calculi Explanation: Symptoms of a kidney or ureteral stone vary with size, location, and cause. Small stones may pass unnoticed; however, sudden, sharp, severe flank pain that travels to the suprapubic region and external genitalia is the classic symptom of urinary calculi. The pain is accompanied by renal or ureteral colic, painful spasms that attempt to move the stone. The pain comes in waves that radiate to the inguinal ring, the inner aspect of the thigh, and to the testicle or tip of the penis in men, or the urinary meatus or labia in women. Clients with acute glomerulonephritis may be asymptomatic or may exhibit fever, nausea, malaise, headache, edema (generalized or periorbital), pain, and mild to moderate hypertension. Clients with ureteral stricture may complain of flank pain and tenderness at the costovertebral angle and back or abdominal discomfort. A client with renal cell carcinoma rarely exhibits symptoms early on but may present with painless hematuria and persistent back pain in later stages.
Which of the following is the most common site of a nosocomial infection?
Urinary tract Explanation: The urinary tract is the most common site of nosocomial infection, accounting for greater than 3% of the total number reported by hospitals each year.
A client who has a history of neurogenic bladder presents with fever, burning, and suprapubic pain. What would the nurse suspect is the problem?
Urinary tract infection Explanation: Signs of a bladder infection include fever, chills, and suprapubic pain.
The nurse who teaches a client about preventing recurrent urinary tract infections would include which statement?
Void immediately after sexual intercourse. Explanation: Voiding flushes the urethra, expelling contaminants. Showers are encouraged, rather than tub baths, because bacteria in the bath water may enter the urethra. Coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants should be avoided. The client should be encouraged to void every 2 to 3 hours during the day and completely empty the bladder.
The nurse recognizes that test results that most likely indicate a urinary tract infection include:
WBC 50 Explanation: Increased white blood cell occurs in all clients with a UTI and indicates an infectious process is occurring.
