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DISORDER Urinary retention also known as ischuria a lack of ability to urinate a common complication of benign prostatic hyperplasia (BPH)

PH) can also be caused by nerve dysfunction, constipation, infection, or medications (including anticholin ergics, antidepressa nts,COX-2 inhibitors, amphetam ines and opiates).

CLINICAL MANIFESTATION poor urinary stream with intermittent flow straining sense of incomplete voiding and hesitancy (a delay between trying to urinate and the flow actually beginning). incontinence nocturia (need to urinate at night) and high frequency may cause: complete anuria ( a medical emergency), Pain hydronephrosis, Pyonephrosis kidney failure and sepsis

Urinary incontinence involuntary leakage of urine a common and distressing problem results from an underlying treatable medical condition but is under-reported

vary from person to person. Typical symptoms include a sudden, strong urge to urinate (urgency) urinating frequently (frequency)

ASSESSMENT AND MEDICAL MANAGEMENT NURSING DIAGNOSTIC FINDINGS MANAGEMENT Ultrasound of the Initial management should Facilitate bladder bladder(common findings) be urethral catheterization emptying followed by at least one Provide privacy, run slow rate of flow voiding trial. water, have the client intermittent flow Avoid drugs like tricyclic assume a normal voiding large amount of urine antidepressants and position and provide pain retained in the bladder after instructed the patient to relief. urination (50 ml of post-void drink small volumes of Promote relaxation of the residual urine) water or tea or to sit in a sphincter by providing massive increase in bladder warm bath or take a warm sitz baths, warm capacity (normal capacity shower. showers, and hot tea to being 400-600 ml). drink Ordered diagnostic tests for The patient can be asked to void every three to four Obtain and record strict urinary retention: hours, regardless of his or urinary output Urinalysis may give a clue to her urgency. If the client cannot void, underlying UTI perform intermittent BUN and serum creatinine catheterization may reflect acute renal failure Prepare the client for Urinalysis and electrolytes surgical intervention if are essential as renal failure indicated. often follows chronic Provide health education retention. If urinary calculus, on measure to prevent check urate, calcium and UTI phosphate. Renal ultrasound, IVP, rethrography Stress test the patient The treatment options Must provide support relaxes, then coughs range from conservative and encouragement vigorously as the doctor treatment, behavior Patient teaching is watches for loss of urine. management, medications important and should be and surgery. Urinalysis urine is tested provided verbally and in for evidence of infection, In all cases, the least writing. The patient urinary stones, or other invasive treatment is should be taught to contributing causes. started first. The success develop and use a log of treatment depends on or diary to record timing Blood tests blood is taken,

to medical practitioners is also a related condition for defecation known as fecal incontinence.

or awakening two or more times throughout the night to urinate. Bedwetting can also occur.

sent to a laboratory, and examined for substances related to causes of incontinence. Ultrasound sound waves are used to visualize the kidneys, ureters, bladder, and urethra. Cystoscopy a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder. Urodynamics various techniques measure pressure in the bladder and the flow of urine. Urine dipstick may react positively for blood, WBCs, and nitrates indicating infection Urine microscopy shows RBCs and many WBCs per field without epithelial cells Urine culture is used to detect presence of bacteria and for antimicrobial sensitivity testing Patients with indwelling catheters may have asymptomatic bacterial colonization of the urine without UTI. In these patients, UTI is diagnosed and treated only when

UTI Caused by the presence of pathogenic microorganisms in the urinary tract with or without signs and symptoms May predominate at the bladder or at the urethra Bacteriauriapresence of the bacteria in the urine Recurrent UTIs may indicate relapse and reinfection

Dysuria Frequency, urgency, nocturia Suprapubic pain and discomfort Microscopic or gross hematuria

the correct diagnoses in the first place Absorbent pads and urinary catheters may help those individuals who continue to have incontinence Absorbent products include shields, undergar ments, protective underwear, briefs, diapers , adult diapers and underpads. Hospitals often use some type of incontinence pad, a small but highly absorbent sheet placed beneath the patient Amoxicillin Doxycycline (should not be used under age 8) Cephalosporins Nitrofurantoin Sulfa drugs (sulfonamides) Trimethoprimsulfamethoxazole Quinolones (should not be used in children) Phenazopyridine hydro chloride (Pyridium) may be used to reduce the burning and urgency associated with cystitis ascorbic acid may be

of pelvic floor muscle exercises, frequency of voiding, any changes in the bladder function and any episodes of incontinence. Explain the medications to the patient and the family. If surgical correction is undertaken, the procedure and its desired outcomes are described to the patient and family.

Culture

urine to identify the bacte ria present and a sensitivity t est to determine the most effective antibiotic. Nursing personnel m u s t ensure th at proper technique is use d during collection of the s pecimen in order to prevent conta mination of the specime. Fluids should be encoura ged in order to "flush" the system of the bacteria. Frequent voiding should be encouraged to preven

symptoms are present

recommended to decrease the concentration of bacteria in the urine. Treatment options for a renal abscess are intravenous antibiotics and drainage of the abscess by an open operation or by inserting a catheter through a needle in the skin overlying the kidney with X-ray guidance. This more recent technique, called percutaneous drainage , has become the more frequent method of drainage.

t urinary stasis.
I.V. fluids and antibiotics

should be administered a s ordered Monitor the patient for sepsis, fluid intake and output and general response to treatment. Change the outer dressings frequently.

Renal abscess A pus-filled cavity that develops in the kidney as a result of inflammation. The inflammation may result from other purulent infections in the body. It is most common in young adults.

Fever Chills CVA tenderness on palpation abdominal pain with guarding dull ache or palpable mass in the flank hematuria, leukocytosis looks seriously ill

The patient with a renal abscess may report a recent history of a cutaneous boil or carbuncle and may complain of malaise, fever, chills, anorexia, weight loss dull pain over the kidney. The patient often has an increased white blood cell count and bacteria often are present in the blood and urine. X-ray findings depend on the extent and the duration of the infection. Small renal abscesses can be difficult to recognize. Ultrasounds and CT scans are most helpful in recognizing a renal abscess. CT scans appear to be the diagnostic procedure of choice with an accuracy of about 96 percent.
Tuberculin skin test Mantoux test, which

Renal Tuberculosis Caused by bacteria (Mycobacterium tub erculosis) and is a disease that

Feeling of Fullness Back and Stomach

should be considered for

Provide instructions

Pain
Frequent Urination or

Trouble Urinating

involves intradermal administration of 0.1 mL of 5 tuberculin units (TU) as a

treatment of latent tuberculosis if appropriate. Aminoglycosides (STM, capreomycin and amikacin)

about taking prescribed medications properly. Men are instructed to use condoms during

normally affects the lungs but it can affect many other body organs such as the kidney. The tuberculosis bac terium is initially inhaled into the lungs where it can then spread to other organs.

Distention Most people with renal

cysts do not experience any symptoms. They are usually diagnosed while performing an Xray for another illness

partial protein derivative (PPD), usually at the flexor surface (dorsal or volar) of the forearm BCG Imaging studies

should be avoided in patients with mild to severe kidney problems because of the increased risk of damage to the kidneys. If the use of aminoglycosides cannot be avoided (ex: in treating drug-resistant TB) then serum levels must be closely monitored and the patient warned to report any side-effects (deafness in particular). If patient have end-stage renal failure and have no useful remaining kidney function, then aminoglycosides can be used In mild renal impairment, no change needs to be made in dosing any of the other drugs routinely used in the treatment of TB. In severe renal insufficiency (GFR<30), the EMB dose should be halved (or avoided altogether). The PZA dose is 20 mg/kg/day (UK recommendation) or three-quarters the normal dose (US recommendation), but not much published evidence is available to support this.

sexual intercourse to prevent spread of the organisms. Encourage the patient to maintain a healthy lifestyle with a wellbalanced diet, adequate intake of fluids and exercise.

Renal cyst Renal cysts are the cysts present in the kidney. It is common to have more than one renal cyst, which in maximum cases, are benign (not dangerous). The severity of the symptoms may vary according to the underlying causes of the condition.

Urethral Strictures

Kidney pain Renal cysts are identified after conducting imaging Difficulty in urination tests such as ultrasound, CT Frequent urination (computed tomography) and presence of blood tinge magnetic resonance imaging in urine (MRI) scan. Hypertension Pain on the belly, side and back. In case of renal cysts caused by tapeworm infestation, the symptoms usually accompany the presence of tapeworm segments and/or eggs in urine and stool At times, renal cysts may lead to complications like kidney infections and cancer. Obstructive voiding A physical examination may symptoms namely: show the following: Decreased force of Decreased urinary stream urinary stream

When using 2HRZ/4HR in patients on dialysis, the drugs should be given daily during the initial highintensity phase. In the continuation phase, the drugs should be given at the end of each hemodialysis session and no dose should be taken on non-dialysis days. There are no specific treatments for small and benign renal cysts. If there are any noticeable signs and symptoms of renal cysts, then the physician may conduct imaging tests in order to detect any changes in the cyst size In case of a growing or cancerous renal cyst, surgical removal is necessary for the cure. Another effective treatment option for complicated renal cysts is the percutaneous sclerotherapy, conducted by injecting sterile alcohol, particularly ethanol. Instrumental treatment
Urethral Dilitation with

Advise the patient to avoid sports and occupations that present a risk for trauma to the kidney.

Patients should be

urethral sounds or filiform

monitored (and treated) for urinary tract infection, including

Incomplete emptying of the bladder Urinary terminal dribbling Urinary intermittency Deflected urinary stream Increased frequency of micturation Acute or chronic retention of urine Hydronephrotic signs due to back pressure Blood in the semen Bloody or dark urine Decreased urine output Difficulty urinating Discharge from the urethra Frequent or urgent urination Inability to urinate (urinary retention) Incontinence Painful urination (dysuria) Pain in the lower abdomen Pelvic pain Slow urine stream (may develop suddenly or

Discharge from the urethra Enlarged (distended) bladder Enlarged or tender lymph nodes in the groin (inguinal) area Enlarged or tender prostate Hardness (induration) on the under surface of the penis Redness or swelling of the penis Sometimes the exam reveals no abnormalities. Tests include the following: Cystoscopy Post-void residual (PVR) volume Retrograde urethrogram Tests for chlamydia and gonorrhe a Urinalysis Urinary flow rate Urine culture

catheter Bougies of increasing size (gum, elastic, continuous dilatation) (this is a seldom used method/treatment modality due to the increased possibility of infection, discomfort, and time involved) PRN Urethral Dilitation, usually every three to six months Emergency treatment
Dilatation with filiform and

followers, and drainage of the urinary bladder through the follower catheter/lumen Cystoscope guided insertion of filiform and followers, and drainage of the urinary bladder through the follower catheter/lumen Visual Internal Urethrotomy with placement of Foley catheter and urinary drainage system for 7 days post-procedure Insertion of a suprapubic catheter with catheter drainage system

patient instruction/education on detection of the symptoms of UTI and undergo a non-invasive Uroflowmetric Study at annual intervals for at least five years (post surgery). Additionally, after age 40, it is recommended that the prostate be monitored (in males) at intervals as determined by the physician/practitioner overseeing the situation. Patient education and counseling is an important aspect of the successful resolution, and continued care for the stricture patient.

gradually) Spraying of urine stream Swelling of the penis

Surgery
Visual

Internal urethrotomy
Single-

Stage urethroplasty
Multiple-Stage

Nephrosclerosis a clinical syndrome characterized by long-term essential hypertension, hypertensive retinopa thy, left ventricular hypertrophy, minimalproteinuria, and progressive renal insufficiency. Most cases are diagnosed based solely on clinical findings. based on the assumption that progressive renal failure in a patient with long-standing hypertension, moderate proteinuria, and no evidence suggesting an alternative diagnosis characterizes hypertensive

Headache Giddiness (sometimes

related to posture)
Neck discomfort Easily tired Nauseous and/or

Blood pressure may be extremely high. An eye examination will reveal changes that indicate high blood pressure, including swelling of the optic nerve, retinal bleeding, or other problems with the retina. Tests to determine damage to the kidneys may include:

vomiting
Protein in urine

urethroplasty Urethral stent insertion Medications to control blood pressure (antihypertensive) Lowering of dietary salt (2g/day) Exercise regularly (if blood pressure is not dangerously high)

Explain to the patient and family the importance of the prescribed medications

BUN Creatinine Arterial blood gas analysis Urinalysis A chest x-ray may show lung congestion. The congestion results from fluid forced into the lungs by heart failure as a consequence of the high blood pressure. This disease may also alter the results of the following tests:
Aldosterone Renin

Prevention or strategies to help maintain good blood pressure:


Maintenance of ideal body

weight Limiting salt intake Cease smoking Avoid excessive alcohol intake Regular exercise

nephrosclerosis. Hydronephrosis the enlargement (distention) of the urine collecting structures and pelvis of both kidneys. Bilateral means both sides.

Urinary casts

Signs of hydronephrosis are generally seen during pregnancy ultrasound studies. There are no symptoms in the fetus. In the newborn, any urinary tract infection is reason to suspect some type of obstructive problem in the kidney. An older child who gets repeat urinary tract infections should be evaluated for possible obstruction. Urinary tract obstruction usually has no other symptoms beyond an increased number of urinary tract infections.

Bilateral hydronephrosis may be seen on: CT scan of the abdomen or kidneys IVP Pregnancy (fetal) ultrasound Renal scan Ultrasound of the abdomen or kidneys

Placing a Foley catheter may relieve the obstruction. Other treatment options include draining the bladder or relieving pressure with nephrostomy tubes placed through the skin (percutaneous) or stents placed in the ureters to allow urine to flow from the kidney to the bladder. Once the blockage is treated, the underlying cause (such as an enlarged prostate) must be identified and treated.

Implement teaching that

meets the patients needs (practicing careful personal hygiene, increase fluid intake, urinating regularly and adhering to the therapeutic regimen).

Acute Glomerulonephritis Refers to a group of kidney diseases in which there is an inflammatory reaction in the glomeruli Not an infection of the kidney, but rather the result of the immune

Tea colored urine,

active urinary sediment, this

Includes

Monitor VS, I&O, and

oliguria
Puffiness of face,

edema of extremities
Fatigue and anorexia,

possible headache
Hypertension (mild-

severe), headache
Anemia, from loss of

RBCs into the urine

means that signs of active kidney inflammation can be detected when the urine is examined under the microscope. Such signs include red blood cells, white blood cells, proteinuria (blood proteins in the urine), and

antihypertensives, diuretics, drugs for management of hyperkalemia, H2 blockers, and phosphatebinding agents Antibiotic therapy to eliminate infection Fluid intake is restricted

maintain dietary restrictions during acute phase Encourage rest during the acute phase Administer medications as ordered Carefully monitor fluid balance

mechanisms of the body

"casts" of cells that have leaked through the glomeruli and have reached the tubule, where they develop into cylindrical forms. A kidney biopsy is essential to establish a diagnosis of AGN, determine the cause, and create an effective treatment plan

Dietary protein is

Monitor pulmonary

restricted moderately if there is oliguria and the BUN is elevated. It is restricted more drastically if acute renal failure develops Carbohydrates are increased liberally to provide energy and reduce catabolism of protein K and Na intake is restricted in presence of hyperkalemia, edema, or signs of heart failure

Chronic Glomerulonephritis May be due to repeated episodes of acute nephritic syndrome, hypertensive nephrosclerosis, hyperlipidemia, chronic tubulointerstitial injury or hemodynamically

Hypertension or UA- fixed specific gravity of elevated BUN and 1.010, variable proteinuria serum creatinine levels and urinary casts Loss of weight and Blood studies related to renal strength, increasing failure progression: irritability, nocturia, hyperkalemia, metabolic headaches, dizziness acidosis, anemia, and digestive hypoalbuminemia, disturbances decreased serum calcium and increased serum Patient appears poorly phosphorus and nourished, with a yellowhypermagnesemia gray pigmentation of the skin, periorbital and Impaired nerve conduction,

If hypertension is presentlower BP with Na and water restriction Weight is monitored daily and diuretic medications are prescribed to treat fluid overload Proteins of high biologic value are provided to support good nutritional status UTIs are treated promptly Dialysis is considered early

artery pressure and CVP, if indicated Monitor for signs and symptoms of heart failure Observe for hypertensive encephalopathy, any evidence of seizure activity Explain that the patient must have follow-up evaluations of BP, urinary protein, and BUN concentrations Encourage patient to treat infections promptly Tell patient to report any signs of decreasing renal function and to obtain treatment immediately Observe for common fluid and electrolyte disturbances in renal disease; report changes in cardiac and neurologic status Give emotional support Educate patient and family about prescribed treatment plan and the risk of noncompliance Teach family and patient about the dialysis, how to

mediated glomerular sclerosis Kidneys are reduced to as little as one fifth of the normal size and consists of largely fibrous tissue Cortex layer shrinks to 1-2 mm in thickness or less, scarring occurs, branches of the renal artery are thickened. Can progress to stage 5 chronic kidney disease and require renal replacement therapies

Acute Renal Failure Results when kidneys are unable to remove metabolic waste and perform their regulatory functions Rapid loss of renal function due to damage to the kidneys

peripheral edema and pale mucous membrane BP is normal or severely elevated Retinal findingshemmorhage, exudates, narrowed tortuous arterioles and papilledema Anemia causes pale membranes Cardiomegaly, gallop rhythm, distended neck veins and other signs of heart failure Crackles in lungs Peripheral neuropathy with diminished deep tendon reflexes Neurosensory changes occur late in the illness, resulting in confusin and limited attention span Pericarditis with pericardial friction rub and pulsus paradoxus Critical illness and lethargy with persistent nausea, vomiting and diarrhea. Skin and muous membranes are dry. CNS manifestations: drowsiness, headache, muscle twitching, seizures

mental status changes Chest x-ray: cardiac enlargement and pulmonary edema ECG: normal or may reflect left ventricular hypertrophy CT and MRI- decreased in size of the renal cortex

in the course of the disease to keep patient in optimal physical condition, prevent fluid and electrolyte imbalances, and minimize the risk of complications of renal failure

care for the access site, dietary restrictions and other necessary life modifications Remind patient and family of the importance of health screenings Instruct patient to inform all health care provides about the diagnosis of glomerulonephritis

Urine output measurements Renal ultrasonography, CT and MRI scans BUN, creatinine, electrolyte analyses

Fluid balance is managed on the basis of daily weight, serial measurements of central venous pressure, serum and urine concentrations, fluid losses, BP, and clinical status. Fluid excesses are treated with mannitol, furosemide, or

Monitor for complications Assist in emergency treatment fluid and electrolyte imbalances Assess progress and response to treatment Provide physical and emotional support Keep family informed

Three major categories: a. prerenalhypoperfusion b. intrarenalparenchymal damage to the glomeruli or kidney tubules c. postrenal- urinary tract obstruction

Urine output scanty to normal; urine may be bloody with low specific gravity Steady rise in blood urea nitrogen (BUN) may occur depending on degree of catabolism; serum creatinine values increase with disease progression Hyperkalemia may lead to dysrhytmias and cardiac arrest Progressive acidosis, increase in serum phosphate concentrations and low serum calcium levels may be noted Anemia from blood loss due to uremic GI lesions, reduced RBC life-span, and reduced erythropoietin production

ethacrynic acid to initiate duresis and prevent or minimize subsequent renal failure Blood flow is restored to the kidneys with the use of IV fluids, albumin, or blood product transfusions Dialysis is started to prevent complications Cation exchange resins (orally or by retention enema) IV dextrose 50%, insulin, and calcium replacement for the patient who is hemodynamically unstable Shock and infection are treated if present ABG are monitored when severe acidosis is present Sodium bicarbonate to elevate plasma pH Ventilator measures if respiratory problems develop Phosphate-binding agents to control elevated serum phosphate concentrations Replacement of dietary proteins to provide max benefit and minimize uremic symptoms Caloric requirements are met with high-

about condition Screen all medications, parenteral fluids and all oral intake for hidden sources of potassium Monitor cardiac function for signs of hyperkalemia Maintain daily weight and I&O records Report indicators of deteriorationg F&E status immediately. Reduce exertion and metabolic rate during most acute stage with bed rest Prevent or treat fever and infection promptly Assist patient to cough, turn, and take deep breaths frequently Encourage and assist patient to move and turn Practice asepsis Perform meticulous skin care Bath patient with cool water Explain rationale of treatment to patient and family Encourage family to touch and talk to patient during dialysis

carbohydrate feedings; parenteral nutrition K and P restriction Chronic renal failure is a progressive loss in renal function over a period of months or years progressive deterioration of renal function, which ends fatally in uremia approximately 20 million Americans have some type of chronic kidney disease most cases are asymptomatic until later stages most common causes of CKD are diabetes mellitus, hypertensio n, and glomerulonephri tis Blood pressure is increased due to fluid overload and production of vasoactive hormones created by the kidney via the RAS (reninangiotensin system), increasing one's risk of developing hypertensio n and/or suffering from congestive heart failure Urea accumulates, leading to azotemia and ultimately uremia (sym ptoms ranging from lethargy to pericarditis and ence phalopathy). Urea is excreted by sweating and crystallizes on skin ("uremic frost"). Potassium accumulate s in the blood (known as hyperkalemia with a range of symptoms including malaise and potentially fatal cardiac arrhythmias) Erythropoietin synthesi s is decreased CBC- anemia ( a characteristic sign) Elevated serum creatinine, BUN, phosphorus Decreased serum calcium, bicarbonate, and proteins, especially albumin ABG levels- low blood pH, low carbon dioxide, low bicarbonate 24-hour urine for creatinine, protein, creatinine clearance

Control of blood pressure and treatment of the original disease Generally, angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor antagonists (ARBs) are used, as they have been found to slow the progression of CKD to stage 5 Currently, several compounds are in development for CKD. These include, but are not limited to, bardoxolone methyl, olmesartan medoxomil, sulodexide, and avosentan. Replacement of erythropoietin and cal citriol, two hormones processed by the kidney, is often necessary in patients with advanced

Maintain the client on complete bed rest Implement intervention to prevent infection and the complications of immobility Observe the client for metabolic acidosis Observe the fluid and electrolyte balance hourly. Insert an indwelling urinary catheter and measure output and specific gravity hourly Provide only enough fluid intake to replace urine output to avoid an edema Monitor the client's diet to provide high carbohydrates, adequate fats, and low protein Reduce the client's potassium intake to help prevent elevated potassium levels. Observe for the arrhytmias and cardiac arrest Provide frequent oral hygiene to avoid tissue irritation and sometime

(potentially leading to anemia, which causes fatigue) Fluid volume overload symptoms may range from mild edema to lifethreatening pulmonary edema Hyperphosphatemia due to reduced phosphate excretion, associated with hypocalcemia (due to 1,25 hydroxyvitamin D3]] deficiency), which is due to stimulation of fibroblast growth factor23. o Later this progresses to secondary hyperparathyroidism, re nal osteodystrophy and vascular calcification that further impairs cardiac function. Metabolic acidosis, due to accumulation of sulfates, phosphates, uric acid etc. This may cause altered enzyme activity by excess acid acting on enzymes and also increased excitability of cardiac and neuronal membranes by the

CKD.Phosphate binders are also used to control the serum phosphate levels When one reaches stage 5 CKD, renal replacement therapy is required, in the form of either dialysis or a transplant. Aggressive treatment of hyperlipidemia is warranted.

ulcer formation caused by urea and other acid waste products Provide the client with hard candy and chewing gum to stimulate saliva flow and decrease thirst. Maintain skin care with cool water to relive pruritus and remove uremic frost Administer stool softeners to prevent colon irritation Provide emotional reassurance to the client and family Provide hemodialysis or peritoneal dialysis as ordered.

Urolithiasis Stones in the urinary tract Formed when urinar concentration of substance such as calcium oxalate, calcium phosphate, and uric acid increases Stones vary in size Factors that favour formation of stones: infection, urinary stasis, and periods of immobility (slow renal drainage and alter calcium metabolism) Affects men more than women

promotion of hyperkalemia due to excess acid (acidemia) Stones in Renal pelvis: X-rays of the kidneys, Intense, deep ache in ureters, and bladder (KUB) costovertebral region or bu ultrasonography, IV urography, or retrograde Hematuria nd pyuria pyelography Pain that radiates anteriorly and downward Blood chemistries and a 24hour urine test for toward bladder in female measurement of calcium, and toward testes in uric acid, creatinine, sodium, male pH, and total volume. Acute pain, nausea and vomiting, costovertebral Chemical analysis is performed to determine area tenderness (renal stone composition colic) Abdominal discomfort Diarrhea Ureteral Colic (Stones Loged in Ureter): Acute, excruciating, colicky, wavelike pain, radiating down the thigh to the genetalia Frequent desire to void, but little urine passed; usually contains blood (known as the ureteral colic) Stones Lodged in Bladder: Irritation associated with UTI and hematuria Urinary retention, if stones obstruct bladder neck

Pharmacologic and Nutritional Therapy: Opioid analgesics agents (to prevent shock and syncope) and nonsteroidal anti-inflammatory drugs (NSAIDs) Increase fluid intake unless patient is vomiting For calcium stones: reduced dietary protein and sodium intake; liberal fluid intake; medications to acidify urine, such as ammonium chloride and thiazide diuretics if parathormone production is increased For uric stones: low-purine and limited protein diet; allopurinol (Zyloprim) For cystine stones: lowprotein diet; alakalinization of urine; increased fluids For oxalate stones: dilute urine; limited oxalate intake (spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran) Stone Removal Procedures: Ureteroscopy: stones fragmented with use of

Administer opioid analgesics (IV or IM) with IV NSAIDS as prescribed Encourage patient to assume a position of comfort Assist patient to ambulate to obtain some pain relief Encourage increased fluid intake and ambulation Begin IV fluids if patient cannot take adequate oral fluids Monitor total urine output and patterns of voiding Encourage ambulation as a means of moving the stone through the urinary tract Strain urine through gauze Crush any blood clots passed in urine, and inspect sides of urinal and bedpan for clinging stones Instruct patient to report decreased urine volume, bloody or cloudy urine, fever, and pain Monitor VS for early

Possible urosepsis if infection is present with stone

Benign Prostatic Hypertrophy Enlargement of the prostate gland, extending upward into the bladder Obstructing the outflow of urine Incomplete emptying of the bladder and urinary retention leading to urinary stasis may result in hydronephrosis, hydroureter and urinary tract infections

Prostate is large, rubbery and nontender. Prostatism )obstructive and irritative symptom complex) is noted. Hesitancy in starting urination, increased frequency of urination, nocturia, urgency, abdominal staining Decrease in volume and force of urinary stream, interruption of urinary system, dribbling Sensation of incomplete emptying of the bladder, acute urinary retention

laser, electrohydraulic lithotripsy, or UTZ and then removed Extracorporeal shock wave lithotripsy (ESWL) Percutaneous nephrostomy; endourologic methods. Electrohydraulic lithotripsy Chemolysis (stone dissolution): alternative for those who are poor risks for other therapies, refuse other methods, or have easily dissolved stones (struvite). Surgical removal is performed in only 1%-2% of patients Physical examination, Immediate catheterization including digital rectal if patient cannot void examination Suprapubic cystostomy is UA to screen for hematuria sometimes necessary Pharmacologic: and UTI PSA level is obtained if the Alpha-adrenergic blockers patient has at lease a 10(alfuzosin, terazosin)year life expectancy relax smooth muscle of the bladder neck and Urinary flow-rate recording prostate and the measurement of postvoid residual (PVR) urine 5-alpha-reductase inhibitors Urodynamic studies, urethrocystoscopy and UTZ Antiandrogen agents may be performed (finasteride [Proscar])ddecrease size of prostate Complete blood studies, and prevents conversion including clotting studies of testosterone to

indications of infection

Observe for symptoms of urethral stricture(dysuria), straining, weak urinary stream Monitor for hemmorrhage and shock Provide meticulous aseptc care to the area around suprapubic tube Monitor for changes in bowel function Avoid using rectal tubes or thermometers and enemas after perineal surgery Use drainage pads to

Common in men older than 40 years

(more than 60 mL) and recurrent UTIs Fatigue, anorexia, nausea and vomiting, and pelvic discomfort are also reported, and ultimately azotemia and renal failure result with chronic urinary retention and large residual volumes

flank pain (kidney pain) bloody urine The kidney is injured in up to 10% no urine production (anuria) of patients who decreased urine output sustain significant (oliguria). abdominal trauma. Renal Trauma

About 65% of genitourinary injuries involve the kidney.

dihydrotestosterone (DHT) absorb excess urinary drainage Phytotherapeutic agents and dietary supplements Provide foam rubber ring (Serenoe repens [saw for patient comfort in palmetto berry] and sitting Pygeum africanum Anticipate urinary [African plum]) are not leakage around the recommended but wound for several days commonly used after catheter is removed Surgical: Transurethral microwave heat treatment Transurethral needle ablation Prostatic stents(only for patients with urinary retention) Transurethral resection of the prostate Transurethral incision of the prostate Transurethral electrovaporization Laser therapy Open prostatectomy Urinalysis and Hct Must assess the patient Strict bed rest Contrast-enhanced CT frequently during the Surgical repair for when moderate or severe first few days after injury moderate or severe injury suspected to detect flank and injuries and some Diagnosis should be abdominal pain, muscle penetrating injuries suspected in any patient spasm and swelling with the following situations: Most blunt renal injuries, over the flank. including all grade 1 and Penetrating injury 2 and most grade 3 and 4 After surgery, instruct between mid chest and injuries, can be safely lower abdomen about care of the treated without surgery. Significant deceleration incision and the

Most renal injuries


(85 to 90% of cases) occur from blunt trauma, typically due to motor vehicle collisions, falls, or assaults. Most injuries are low grade. The most common accompanying injuries are to the head, CNS, spleen, and liver. Penetrating injuries usually result from gunshot wounds. Such patients usually have multiple intraabdominal injuries, most commonly to the liver, intestine, and spleen

injury
Direct blow to the flank In such patients, hematuria

strongly suggests renal injury; other indicators include the following: Seat-belt marks Diffuse abdominal tenderness Flank contusions Lower rib fractures Patients who develop hematuria after relatively minor trauma may have a previously undiagnosed congenital renal anomaly. Laboratory testing should include Hct and urinalysis. When imaging is indicated, contrast-enhanced CT imaging is usually used Gross hematuria Microscopic hematuria with hypotension (systolic pressure < 90 mm Hg) For penetrating trauma, CT is indicated for all patients with microscopic or gross hematuria. Rarely, angiography is indicated to assess persistent or delayed bleeding and may be combined with selective arterial embolization. Pediatric renal injuries are

Patients require strict bed rest until gross hematuria has resolved. Surgical repair is required for those with the following: Persistent bleeding (ie, enough to necessitate treatment for hypovolemia) Expanding perinephric hematoma Renal pedicle avulsion

importance of an adequate fluid intake. Monitor blood pressure to detect hypertension and advise the patient to restrict activities for about 1 month after trauma to minimize the incidence of delayed or secondary bleeding

evaluated similarly, except that all children with blunt trauma in whom urinalysis shows > 50 RBCs/highpower field require imaging. Renal Tumor Hematuria, lump or mass that can be felt in the kidney area, dull ache or pain in the back or flank, hypertension, abnormal number of red blood cells Patient's personal and family medical history and is taken and a thorough physical examination is conducted. The doctor usually orders blood and urine tests and may do one or more of the exams described below (if transitional cell carcinoma is suspected, other tests may be used). An IVP (intravenous pyelogram) is a test that lets the doctor see the kidneys, ureters, and bladder on xrays. The x-rays are taken after an injection of dye that shows up on the x-ray film. A CT (or CAT) scan is another x-ray procedure that gives detailed pictures of cross-sections of the body. The pictures are created by a computer. Ultrasound is a test that sends high-frequency sound waves, which cannot be heard by humans, into the kidney. The pattern of echoes produced by these It is treated with surgery, Before surgery, assure embolization, radiation the patient that the therapy, hormone therapy, body will adequately biological therapy, or adapt to the loss of a chemotherapy. One kidney. treatment method or a combination can be used, Administer prescribed depending on the patient's analgesics as needs. In many cases, the necessary. Provide patient is referred to comfort measures, such doctors who specialize in as positioning and different kinds of cancer distractions, to help the treatment. Sometimes, patient cope with several specialists work discomfort. together as a team. After surgery, Most patients with renal encourage tumor have surgery, diaphragmatic breathing nephrectomy. In some and coughing. cases, the surgeon removes the whole kidney Assist the patient with or just the part of the leg exercises, and turn kidney that contains the him every 2 hours to tumor. More often, the reduce the risk of surgeon removes the phlebitis. whole kidney along with the adrenal gland and the Check dressings often fat around the kidney. for excessive bleeding. Also, nearby lymph nodes Watch for signs of may be removed because internal bleeding, such they are one of the first as restlessness,

waves creates a picture called a sonogram. Healthy tissues, cysts, and tumors produce different echoes. An arteriogram is a series of x-rays of blood vessels. Dye is injected into a large blood vessel through a narrow tube called a catheter. Xrays show the dye as it moves through the network of smaller blood vessels around and in the kidney. MRI (magnetic resonance imaging) uses a very strong magnet linked to a computer to create pictures of cross-sections of the kidney. A nephrotomogram is a series of x-rays of crosssections of the kidney. The x-rays are taken from several angles before and after injection of a dye that outlines the kidney. If these tests suggest that a tumor is present, the doctor may confirm the diagnosis with a biopsy. A thin needle is inserted into the tumor to withdraw a sample of tissue. The tissue is examined under a microscope by a pathologist to check for cancer cells.

places where renal tumor spreads. In embolization, a substance is injected to clog the renal blood vessels. The tumor shrinks because it does not get the blood supply it needs to grow. In some cases, embolization makes surgery easier. When surgery is not possible, this treatment may help reduce pain and bleeding. Radiation therapy (also called radiotherapy) uses high-powered rays to damage cancer cells and stop them from growing. Radiation therapy can be used to shrink a tumor before surgery or to kill cancer cells that may remain in the body after surgery. For patients who cannot have surgery, radiation therapy may be used instead. Biological therapy is a new way of treating renal tumor. This treatment attempts to improve the

sweating, and increased pulse rate. Position the patient on the operative side to allow the pressure of adjacent organs to fill the dead space at the operative site, improving dependent drainage. If possible, assist the patient with walking within 24 hours of surgery. Provide adequate fluid intake, and monitor intake and output. Monitor laboratory test results for anemia, polycythemia, and abnormal blood chemistry values that may point to bone or hepatic involvement or may result from radiation therapy or chemotherapy Provide symptomatic treatment for adverse effects of chemotherapeutic drugs. Encourage the patient

When a diagnosis of renal tumor is made, it is important to know the extent, or stage, of the disease.

way the body's immune system fights disease. Interleukin-2 and interferon are two forms of biological therapy being studied to treat advanced kidney cancer.

to express his anxieties and fears, and remain with him during periods of severe stress and anxiety. Be sure the patient understands what medications are to be taken at home, their effects, and dosages. Explain follow-up information, such as when the physician would like to see the patient. Provide and arrange for a home visit from nurses if appropriate. Reinforce any postoperative restrictions. Explain when normal activity can be resumed. Make sure the patient understands the need to have ongoing monitoring of the disease. Emphasize and give understanding of the lifestyle choices that can

aid in recovery e.g. Quit smoking, limit alcohol, eat more fruits, vegetables, and whole grains and less animal fat; exercise once you are able. Explain the possible adverse effects of radiation and drug therapy. Cancer of the Bladder More common in people older than 55 years Affects men more often than women(4:1) More common in Caucasians than in African Americans Tumors usually arise from at the base of the bladder and involves the uretral orifices and bladder neck Tobacco use- leading risk factor Cancers arising from the prostate, colon and rectum in males and from the lower gynaecologic tract in Visible, painless hematuria- most common Infection of urinary tract is common- frequency and urgency Any alteration in voiding or change in the urine Pelvic or back pain may cause metastasis Biopsies of the tumor and adjacent mucosa are definitive but the following are also used: Cystoscopy (the mainstay of diagnosis) Excretory urograph CT scan Ultrasonography Bimanual examination under anesthesia Cytologic examination of fresh urine and saline bladder washings Surgical treatment Transutheral resection or fulguration for simple papillomas with intravesical bacilli Calmette-Guerin is the treatment of choice Monitor for benign papillomas with cytology and cystoscopy periodically for the rest of the patients life Simple cystectomy or radical cystectomy for invasive or multifocal bladder cancer Trimodal therapy (TUR, radiation and chemotherapy) to avoid cystectomy remains investigational in the United States Pharmacologic: Provide stoma and skin care Encourage adequate fluid intake. Help the patient to relieve anxiety. Patient education about self-care

females may metastatize to the bladder

Nephrotic Syndrome Primary glomerular disease characterized by proteinuria, hypoalbuminemia, diffuse edema, high serum cholesterol, and hyperlipidemia. Seen in any condition that seriously damages the glomerular capillary membrane,

Edema- soft, pitting and commonly occurs around the eyes(periorbital), in dependent areas (sacrum, ankles, and hands) and in the abdomen (ascites) Malaise, headache, irritability

Protein electrophoresis and immuneelectrophoresis to determine type of protienuria exceeding 3.5 g/day Urine may contain increased WBC and granular and epithelial casts Needle biopsy ok the kidney for histologic examination to confirm diagnosis

Methotrexate (Rheumatrex), 5fluouracil (5-FU), vinblastine (Velban), doxorubicin (Adriamycin), and cistaplin (Platinol) Intravesical BCG Radiation therapy: perioperatively- reduce microextension and viability In combination with surgery to control inoperable tumors Hydrostatic therapy: for advanced bladder Ca. Formalin, phenol, or silver nitrate instillations to achieve relief of hematuria and strangury (slow and painful discharge of urine) Focused on treating the underlying disease state causing proteinuria and lipid-lowering agents for hyperlipidemia

Similar to acute glomerulonephritis As the disease worsens, management is similar to that of end-stage renal disease Provide adequate information about importance of following all medication and dietary regimens Convey to the patient the importance of communicating any

causing increased glomerular permeability with loss of protein in the urine Occurs with any intrinsic renal disease and systemic disease that cause glomerular damage, Constellation of clinical findings that result from glomerular damage Nephritic Syndrome Clinical manifestation of glomerular inflammation. Glomerulonephritisinflammation of the glomerular capillaries that can occur in acute and chronic forms

health-related change to their health care providers as soon as possible so that appropriate medication and dietary changes can be made before further changes occur within the glomeruli

Hematuria, edema, azotemia, proteinuria Hypertension BUN and serum creatinine levels may increase, anemia may be present Headache, malaise and flank pain may occur Elderly patients may have circulatory overload: dyspnea, engorged neck veins, cardiomegaly and pulmonary edema

Primary presenting feature: microscopic or gross hematuria Patients with an IgA nephropathy have an elevated serum IgA and low to normal complement levels Electron microscopy and immunofluorescent analysis help identify the nature of the lesion Kidney biopsy- definitive diagnosis

Primarily, treating symptoms, attempting to preserve kidney function and treating complications promptly Corticosteroids, managing hypertension and controlling proteinuria If residul streptococcal infection is suspectedpenicillin Dietary protein is restricted when renal insufficiency and nitrogen retention (elevated BUN) develop. Sodium is restricted for patients with edema, hypertension and heart failure

Give patient carbohydrates liberally to provide energy and reduce catabolism of protein Carefully measure and record I&O Provide patient education about the disease process Educate patient about symptom management and monitoring for complications Review fluid and diet restrictions with the atient to avoid worsening of edema and hypertension Instruct patient to notify patient when symptoms

of renal failure occur (fatigue, nausea and vomiting, diminishing urine output) or at the first sign of any infection

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