(PrepU) Chapter 49: Assessment and Management of Patients with Urinary Disorders

An ileal conduit is created for a client after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care?

Application of an ostomy pouch An ileal conduit involves care of a urinary stoma, much like that of a fecal stoma, including the application of an ostomy pouch, skin protection, and stoma care. Intermittent catheterizations and irrigations are appropriate for a continent urinary diverse such as a Kock or Indiana pouch. Exercises to promote sphincter control are appropriate for an ureterosigmoidoscopy.

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. 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.

Which instruction would be included in a teaching plan for a client diagnosed with a urinary tract infection?

Drink liberal amount of fluids. Clients diagnosed with a UTI should drink liberal amounts of fluids. They should void every 2 to 3 hours. Coffee and tea are urinary irritants. The client should shower instead of bathe in a tub because bacteria in the bathwater may enter the urethra.

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 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.

Which factor contributes to UTI in older adults?

Immunocompromise Factors that contribute to urinary tract infection in older adults include immunocompromise, high incidence of chronic illness, immobility, frequent use of antimicrobial agents, incomplete emptying of the bladder, and obstructed urine flow.

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 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.

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 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.

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 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 urinary tract infection?

Phenazopyridine Phenazopyridine is a urinary analgesic ordered to relieve discomfort associated with a UTI. Nitrofurantoin, ciprofloxacin, and levofloxacin are antibiotics.

An 82-year-old client experiences urinary incontinence. Which factor should the nurse assess before beginning a bladder training program for this client?

Physical and environmental conditions It is essential to assess the client's physical and environmental conditions before beginning a bladder training program, because the client may not be able to reach the bathroom in time. During the bladder training program, a change in environment may be an effective suggestion for the client. It is not so essential to assess the client's history of allergy, occupation, and smoking habits before beginning a bladder training program.

Sympathomimetics have which of the following effects on the body?

Relaxation of bladder wall Sympathomimetics mimic the sympathetic nervous system, causing increased heart rate and contractility, dilation of bronchioles and pupils, and bladder wall relaxation.

Which of the following is the most common site of a nosocomial infection?

Urinary tract 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.

The nurse is assessing a client's new stoma and observes that the stoma color is now dark purple. The appropriate nursing intervention is to

contact the physician. The appropriate nursing intervention when a newly created stoma is dark purple is to notify the physician. The physician or wound, ostomy, and continence (WOC) nurse will assess the stoma to determine whether it has superficial ischemia or is necrotic.

A client with urinary retention needs to undergo a procedure to insert an indwelling catheter. What should the nurse discuss with the health care provider before catheterization?

type and size of the catheter to be used Before catheterization, the nurse should inquire about the type and size of the catheter to be used and if the catheter should be removed or retained in place after the bladder is empty.

The nurse is employed in a urologist's office. Which classification of medication is anticipated for clients having difficulty with urinary incontinence?

Anticholinergic 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.

Which type of medication may be used to inhibit bladder contraction in a client with incontinence?

Anticholinergic agent Anticholinergic agents are considered first-line medications for urge incontinence. Estrogen decreases obstruction to urine flow by restoring the mucosal, vascular, and muscular integrity of the urethra. Tricyclic antidepressants decrease bladder contractions and increase bladder neck resistance. Stress incontinence may be treated using pseudoephedrine and phenylpropanolamine, ingredients found in over-the-counter decongestants.

The patient has been diagnosed with urge incontinence. What classification of medication does the nurse expect the patient will be placed on to help alleviate the symptoms?

Anticholinergic agents Anticholinergic agents inhibit bladder contraction and are considered first line medications for urge incontinence.

Which of the following is a potential cause of transient incontinence? Select all that apply.

Delirium Restricted activity Infection of urinary tract Atrophic vaginitis Stool impaction Potential causes of transient incontinence include delirium, restricted activity, infection of the urinary tract, atrophic vaginitis, and stool impaction.

Which type of incontinence refers to the involuntary loss of urine due to extrinsic medical factors, particularly medications?

Iatrogenic 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 client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program?

Assessing present voiding patterns 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.

Examination of a client's bladder stones reveals that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?

Low purine A low-purine diet is used for uric acid stones, although the benefits are unknown. Clients with a history of calcium oxalate stone formation need a diet that is adequate in calcium and low in oxalate. Only clients who have type II absorptive hypercalciuria—approximately half of the clients—need to limit calcium intake. Usually, clients are told to increase their fluid intake significantly, consume a moderate protein intake, and limit sodium. Avoiding excessive protein intake is associated with lower urinary oxalate and lower uric acid levels. Reducing sodium intake can lower urinary calcium levels.

A client with urinary incontinence asks the nurse for suggestions about managing this condition. Which suggestion would be most appropriate?

"Make sure to eat enough fiber to prevent constipation." Suggestions to manage urinary incontinence include avoiding constipation such as eating adequate fiber and drinking adequate amounts of fluid. Scented powders, lotions, or sprays should be avoided because they can intensify the urine odor, irritate the skin, or cause a skin infection. Stimulants such as caffeine, alcohol, and aspartame should be avoided. The client should void regularly, approximately every 2 to 3 hours to ensure 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." 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.

Which of the following is classified as a upper urinary tract infection (UTI)? Select all that apply.

Acute pyelonephritis Renal abscess Upper UTIs include acute pyelonephritis, renal abscess, perineal abscess, chronic pyelonephritis, and interstitial nephritis. Lower UTIs include cystitis, urethritis, and prostatitis.

Patients with urolithiasis need to be encouraged to:

Increase their fluid intake so that they can excrete up to 4 liters every day. 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 patient who has been treated for uric acid stones is being discharged from the hospital. What type of diet does the nurse discuss with the patient?

Low-purine diet For uric acid stones, the patient is placed on a low-purine diet to reduce the excretion of uric acid in the urine. Foods high in purine (shellfish, anchovies, asparagus, mushrooms, and organ meats) are avoided, and other proteins may be limited.

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 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 overdistended 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.

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. 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. 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.

A client has a suspected bladder cancer. What is the most common first symptom of a malignant tumor of the bladder?

painless hematuria The most common first symptom of a malignant tumor of the bladder is painless hematuria. Additional early symptoms include UTI with symptoms such as fever, dysuria, urgency, and frequency.