Urinary Tract

Disorders
Renal Failure
 Renal Failure
• Results when the kidneys cannot remove
wastes or perform regulatory functions
• A systemic disorder that results from many
different causes
• Acute renal failure is a reversible syndrome
that results in decreased glomerular filtration
rate (GFR) and oliguria
• Chronic renal failure (ESRD) is progressive;
irreversible deterioration of renal function
results in azotemia
Common Characteristics in
ARF and CRF
↓ waste product excretion
chaotic acid and base regulation
elevation of electrolytes
water retention
↓ production of erythropoietin
↓active vitamin D secretions
↑ renin activation
Acute Renal Failure
 Acute Renal Failure
Sudden interruption of kidney
function to regulate fluid and
electrolyte balance and remove toxic
products from the body

Most common and important

manifestation: OLIGURIA
 Kidney Function
The Nephron produces Impaired urine production
urine to eliminate waste and azotemia
Secretes Erythropoietin
ANEMIA
to increase RBC
Calcium and Phosphate
Metabolism of Vitamin D
imbalances
Produces bicarbonate
Metabolic ACIDOSIS
and secretes acids
Excretes excess
HYPERKALEMIA
POTASSIUM
 Acute Renal Failure
PATHOPHYSIOLOGY

3. Pre-renal failure

5. Intra-renal failure

7. Post-renal failure
 Acute Renal Failure
PATHOPHYSIOLOGY
Prerenal CAUSE:
Factors interfering with perfusion and
resulting in diminished blood flow and
glomerular filtrate, ischemia, and oliguria

Include CHF, cardiogenic shock, acute

vasoconstriction, diabetes mellitus,
hemorrhage, burns, traumatic accidents,
septicemia, hypotension, anaphylaxis
 Acute Renal Failure
PATHOPHYSIOLOGY
Intrarenal CAUSE:
Conditions that cause direct damage to
the nephrons
Include acute tubular necrosis (ATN),
endocarditis, malignant hypertension,
acute glomerulonephritis, tumors, blood
transfusion reactions, hypercalcemia,
nephrotoxins (certain antibiotics, x-ray
dyes, pesticides, anesthetics)
 Acute Renal Failure
PATHOPHYSIOLOGY
Postrenal CAUSE:
Mechanical obstruction anywhere from
the tubules to the urethra

Includes calculi, BPH, tumors, strictures,

blood clots, trauma, and anatomic
malformation
 Pre-Renal
Decreased renal tissue perfusion
from:
– DM (most common)
– Hypovolemia
– Shock
– Hemorrhage
– Burns
– Impaired cardiac output
– Diuretic therapy
 Intra-Renal
• AGN acute glomerulonephritis
Infection of kidney due to immune response
Previous infection from group A beta hemolytic
streptococcus
S/Sx – proteinuria, hematuria, oliguria, edema
and HPN
• CGN chronic glomerulonephritis
Non infectious slowly developing disease
S/Sx – same with AGN
• Nephrotic Syndrome
Severely damaged glomerular activity that leads
to increased capillary permeability
S/Sx – proteinuria, hypoalbuminemia, edema
and hyperlipidemia
Caused by CGN, DM and SLE
 Post-Renal
Due to obstruction or disruption to
urine flow anywhere along the urinary
tract:
– Cystitis
– Urethritis
– Pyelonephritis
– Urolithiasis
– Injuries to the bladder and urethra
– Cancer of the bladder
– Prostatitis
– BPH
 Acute Renal Failure
Four phases of acute renal failure
(Brunner and Suddarth)

3. Initiation phase
4. Oliguric phase
5. Diuretic phase
6. Convalescence or recovery phase
 Acute Renal Failure
Assessment findings: The Phases
of Acute Renal Failure
1. Oliguric phase
• Urine output less than 400 cc/24 hours
• Duration 1—2 weeks
• Manifested by dilutional hyponatremia,
hypocalcemia, hyperkalemia,
hyperphosphatemia,, hypermagnesemia,
and metabolic acidosis
• Diagnostic tests: BUN and creatinine
elevated
 Acute Renal Failure
Assessment findings: The Three
Phases of Acute Renal Failure
2. Diuretic phase
• Diuresis may occur (output 3—5
liters/day) due to partially regenerated
tubule’s inability to concentrate urine
• Duration: 2—3 weeks; manifested by
hyponatremia, hypokalemia, and
hypovolemia
• Diagnostic tests: BUN and creatinine
slightly elevated
 Acute Renal Failure
Assessment findings: The Three
Phases of Acute Renal Failure
3. Recovery or convalescent phase:
Renal function stabilizes with gradual
improvement over next 3—12 months
 Clinical Course:
• Oliguric-anuric phase
may last 7-14 days
• Non-oliguric or high output RF
nitrogenous waste products are still high
in the blood.
• Diuresis Phase
return to normal urine output in 1 to 3
months
• Convalescent Recovery Period
may take 6 months to 1 year from the initial
onset
Collaborative Problems/Potential
Complications
Hypocalcemia
Hyperkalemia
Pericarditis
Pericardial effusion
Pericardial tamponade
Hypertension
Anemia
Bone diseases
 Acute Renal Failure
Laboratory Findings:
2. Urinalysis: Increase urine
osmolality
3. BUN and creatinine levels
increased
4. Hypokalemia or Hyperkalemia
5. Hyponatremia to Hypernatremia
6. Anemia
7. ABG: metabolic acidosis
 Acute Renal Failure
Management
I&O
Weighing
Infection monitoring
Examine gross and occult blood in urine
Diet (CHON moderate, increase CHO)
Electrolyte management
Neurologic assessment
Nursing Process—Assessment of the
Patient With Renal Failure
Fluid status

Nutritional status

Patient knowledge

Activity tolerance

Self-esteem

Potential complications
Nursing Process—Diagnosis of the
Patient With Renal Failure
FVE related to decreased GFR and sodium
retention
Risk for infection related to reduced host
defenses
Altered Nutrition related to catabolic state,
anorexia
Risk for internal bleeding related to stress
ulcer
Altered thought processes related to effects
of uremic toxins to CNS
Nursing Process—Planning the Care of
the Patient With Renal Failure

Goals include maintaining IBW

without excess fluid,
Maintenance of adequate nutritional
intake,
Increased knowledge, participation in
activities within tolerance, improved
self-esteem, and absence of
complications
 Acute Renal Failure
Nursing Interventions
Monitor fluid and Electrolyte Balance
Reduce metabolic rate
Promote pulmonary function
Prevent infection
Provide skin care
Provide emotional support
 Acute Renal Failure
Nursing Interventions
1. Monitor and maintain fluid and
electrolyte balance.
Measure l & O every hour. Note
excessive losses in diuretic phase
Administer IV fluids and electrolyte
supplements as ordered.
Weigh daily and report gains.
Monitor lab values; assess/treat fluid and
electrolyte and acid-base imbalances as
needed
 Acute Renal Failure
Nursing interventions
2. Monitor alteration in fluid volume.
Monitor vital signs, PAP, PCWP, CVP as
needed to monitor excess fluids that may
lead to CHF.
Weigh client daily.
Maintain strict I & O records.
Assess for signs and symptoms of fluid
volume excess; keep accurate I&O and
daily weight records
 Acute Renal Failure
Nursing interventions
2. Monitor alteration in fluid volume.
Limit fluid to prescribed amounts
Identify sources of fluid
Explain to patient and family the rationale
for the restriction
Assist patient in coping with the fluid
restriction
Provide or encourage frequent oral hygiene
 Acute Renal Failure
Nursing Interventions
3. Assess every hour for hypervolemia
– Maintain adequate ventilation.
– Restrict FLUID intake
– Administer diuretics and
antihypertensives
 Acute Renal Failure
Nursing Interventions
4. Promote optimal nutritional status.
• Administer TPN as ordered.
• With enteral feedings, check for residual
and notify physician if residual volume
increases.
• Restrict protein intake to 1 g/kg/day
• Restrict POTASSIUM intake
• High Carbohydrate Diet, calcium
supplements
 Imbalanced Nutrition
Assess nutritional status, weight changes, and
lab data
Assess patient nutritional patterns and history;
note food preferences
Provide food preferences within restrictions
Encourage high-quality nutritional foods while
maintaining nutritional restrictions
Assess and modify intake related to factors that
contribute to altered nutritional intake, ie,
stomatitis or anorexia
Adjust medication times related to meals
 Acute Renal Failure
Nursing Interventions
5. Prevent complications from
impaired mobility (pulmonary
embolism, skin breakdown, and
atelectasis)
6. Prevent fever/infection.
– Assess for signs of infection.
– Use strict aseptic technique for wound
and catheter care.
 Acute Renal Failure
Nursing Interventions
7. Support client/significant others and
reduce/ relieve anxiety.
– Explain pathophysiology and relationship
to symptoms.
– Explain all procedures and answer all
questions in easy-to-understand terms
– Refer to counseling services as needed
8. Provide care for the client receiving
dialysis
Risk for Situational Low Self-
Esteem
Assess patient and family responses to
illness and treatment
Assess relationships and coping patterns
Encourage open discussion about changes
and concerns
Explore alternate ways of sexual expression
Discuss role of giving and receiving love,
warmth, and affection
 Acute Renal Failure
Nursing Interventions
8. Provide client teaching and discharge
planning concerning
Adherence to prescribed dietary regimen
Signs and symptoms of recurrent renal
disease
Importance of planned rest periods
Use of prescribed drugs only
Signs and symptoms of UTI or respiratory
infection need to report to physician
immediately
Chronic Renal Failure
 Chronic Renal Failure
• Gradual, progressive irreversible
destruction of the kidneys causing
severe renal dysfunction.
• The result is AZOTEMIA to UREMIA
• Dialysis or kidney transplant is
necessary
 Chronic Renal Failure
Progressive inability, over months to
years, of the kidneys to respond to change
in body fluids and electrolyte composition
with an inability of the kidneys to produce
sufficient urine.
GFR is less than 20% of normal and
creatinine is greater than 5 mg/dL.
 Chronic Renal Failure
Risk Factors
Polycystic kidney disease
Chronic glomerulonephritis
Chronic urinary obstruction
Chronic pyelonephritis
Severe hypertension
Congenital or acquired renal artery
stenosis and vascular disorders
Systemic lupus erythematosus
Chronic Renal Failure
Risk Factors
• Diabetes mellitus
worldwide leading cause
• Hereditary lesions
• Medications or toxic agents
• Recurrent infection
• Exacerbations of nephritis
 Chronic Renal Failure
Pathophysiology
Destruction of glomeruli -> reduced
glomerular filtration rate -> retention
of metabolic waste products ->
decreased urine output -> severe fluid,
electrolyte, acid-base imbalances ->
azotemia -> uremia -> death
 Chronic Renal Failure
Clinical Course:
• Decreased renal reserve 40-70% GFR
• Renal insufficiency 20-40% GFR
• Renal failure 15-20% GFR
• End-Stage Renal Disease ↓ 15% GFR
(Both kidneys are severely affected and
renal function is absent)
 Chronic Renal Failure
PATHOPHYSIOLOGY
STAGE 1= reduced renal reserve, 40-
75% loss of nephron function
STAGE 2= renal insufficiency, 75-90%
loss of nephron function
STAGE 3= end-stage renal disease,
more than 90% loss. DIALYSIS IS THE
TREATMENT!
3 Stages of Chronic Renal Failure
• Early stage (renal impairment)
unaffected nephrons compensate for the
lost nephrons which is 50% (40-75%)
and above of functional renal tissue
• Second stage (renal insufficiency)
more than 75%-90% of the functional
renal tissue is destroyed. GFR 20-40%
• Third stage (end-stage renal disease-
ERSD) more than 90% of the functional
tissue is destroyed. GFR is less than
15%
 Chronic Renal Failure
dry skin, pruritus, uremic
Dermatologic frost
seizures, altered LOC,
CNS anorexia, fatigue
Acute MI, edema,
CVS hypertension, pericarditis

Pulmo Uremic lungs

Hema Anemia
loss of strength, foot drop,
Musculoskeletal osteodystrophy
 Chronic Renal Failure
Clinical Assessment
• Ammonia in skin (UREMIC FROST) and
alimentary tract by bacterial interaction
with urea- inflammation of mucous
membranes - Stress Ulcer
• Retention of Phosphate – decreased
serum calcium- muscle spasms- tetany
and increased parahormone release-
demineralization of bone.
• Failure of tubular mechanisms to regulate
blood bicarbonate- metabolic acidosis-
hyperventilation
 Chronic Renal Failure
Clinical Assessment
• Urea osmotic diuresis - flushing effect on
tubules - decreased reabsorption of
sodium - sodium depletion
• Waste product retention - depressed
bone marrow function - decreased
circulating RBC’s – renal tissue hypoxia -
decreased erythropoietin production -
further depression of bone marrow -
Anemia
Chronic Renal Failure
Laboratory Diagnostic Test
Electrolytes
– K+, Na, Phosporus
BUN & Creatinine
ABGs, CBC
Urinalysis
Renal ultrasound
IVP
Renal Biopsy
 Chronic Renal Failure:
Laboratory Diagnostics
• Serum Crea – elevated (normal 0.5-1.5 mg/dl)
• Serum BUN – elevated (normal 10-30 mg/dl)
• Serum electrolytes – all electrolytes are elevated
except for HCO3 and Calcium
• CBC – anemia (due to reduced erythropoietin
production)
• Renal Ultrasonography – to estimate renal size
and obstruction
• Serum uric acid – elevated (normal 2.7-7.7mg/dl)
• Phenolsulfonphthalein (PSP) excretion-
decreased/low (normal 60 to 75%)
 Chronic Renal Failure
Medical Management
Medications:
1. NaHCO3 administration
2. Blood Volume Expanders
3. Diuretics
4. Antacids & H2 Receptor Antagonist
5. Potassium & Phosphate binding
6. Give vit D and calcium supplement
7. Manage electrolyte imbalance
 Important Drugs
Aluminum hydroxide Binds with PHOSPHATE
(Amphogel) to decrease phosphorus

Binds with POTASSIUM

Kayexalate
to manage hyperkalemia

Diuretics To decrease edema

Erythropoietin (Epogen) To increase RBC

To manage
Anti-Hypertensives
Hypertension
 Chronic Renal Failure
Nursing Diagnosis
Fluids and electrolytes imbalance
Impaired skin integrity related to uremic frost
Constipation related to fluid restriction and
phosphate binding agent administration
High risk for injury (fracture) related to
osteoclast activity
Non compliance to therapeutic regimen related
to restrictions imposed by CRF and its
treatment
 Chronic Renal Failure
Nursing Diagnosis
Other Nursing Diagnosis
Fatigue
Ineffective individual coping
Body image disturbance
 Chronic Renal Failure
Nursing Interventions
1. Prevent neurological
complications.
Assess every hour for signs of uremia
(fatigue, apathy, confusion,
restlessness, seizure, loss of appetite,
decreased urine output, elevated
blood pressure, edema of face and
feet, itchy skin)
 Chronic Renal Failure
Nursing Interventions
1. Prevent neurological
complications.
Assess for changes in mental
functioning.
Orient confused client to time, place,
date, and persons
Institute safety measures to protect
client from falling out of bed.
 Chronic Renal Failure
Nursing Interventions
2. Promote optimal GI function.
Assess/provide care for stomatitis
Monitor nausea, vomiting, anorexia
Administer antiemetics as ordered.
Assess for signs of Gl bleeding
 Chronic Renal Failure
Nursing Interventions
3. Monitor/prevent alteration in fluid
and electrolyte balance
4. Assess for hyperphosphatemia
(paresthesias, muscle cramps,
seizures, abnormal reflexes), and
administer aluminum hydroxide gels
(Amphojel) as ordered
 Chronic Renal Failure
Nursing Interventions
5. Promote maintenance of skin
integrity.
Assess/provide care for pruritus.
Assess for uremic frost (urea
crystallization on the skin) and bathe
in plain water
6. Provide care for client receiving
dialysis.
 Chronic Renal Failure
Nursing Interventions
7. Monitor for bleeding
complications, prevent injury to
client.
Monitor Hgb, hct, platelets, RBC.
Hematest all secretions.
Administer hematinics as ordered
(precautions for hypertension).
Avoid lM injections
 Chronic Renal Failure
Nursing Interventions
8. Promote/maintain maximal
cardiovascular function.
Monitor blood pressure and report
significant changes.
Auscultate for pericardial friction rub.
Perform circulation checks routinely.
Administer diuretics as ordered and
monitor output.
Modify drug doses
 Chronic Renal Failure
Nursing Interventions
9. Control Hyperkalemia
• Infusion of hypertonic glucose and insulin to
force potassium into cells; calcium gluconate
(IV) to reduce myocardial irritability from
potassium.
• Sodium bicarb (IV) to correct acidosis
• Kayexalate
- Orally or rectally (enema) to remove
excess potassium
• Diuretics - mannitol, furosemide
 Chronic Renal Failure
Nursing Interventions
10. Maintain fluid and electrolyte
balance and nutrition
Monitor daily weight & include CVP
Fluid D5 ½ NSS, blood products
Know how to calculate fluid replacement
Diet high in carbohydrates, low protein
and low potassium based on values
 Chronic Renal Failure
Nursing Interventions

11. Maintain fluid and electrolyte

balance and nutrition
Diet
Medications
Input & 0utput
 Chronic Renal Failure
Nursing Interventions
12. Employ comfort measures that
reduce distress and support physical
function
Activity
Hygiene
Skin Care
Communication
 Chronic Renal Failure
Nursing Interventions
13. Goal: Health Teaching
Dietary restrictions
Daily weight
Dialysis
Transplant
 Chronic Renal Failure
Treatment Options for Renal Failure

Hemodialysis

Peritoneal dialysis

Continuous renal replacement

therapies (CRRT)
 Chronic Renal Failure
Evaluation
Return of kidney function- normal
creatinine levels (< 1.5 mg/dL)
Normal urine output
Resume normal life pattern
– Takes about 3 months after onset
 Chronic Renal Failure
Evaluation
Compliance with dietary restriction- no
signs of protein excess (nausea &
vomiting)
No signs fluid / sodium excess (edema,
weight gain)
Acceptance of chronic illness (no
indication of indiscretion, destructive
behavior, suicidal tendency)
Polycystic Kidney
Disease
Polycystic Kidney Disease
Description:
• Is a cystic formation and hypertrophy of
the kidneys, which lead to cystic rupture,
infection, the formation of scar tissue,
and damaged nephrons
• No way is known to arrest the progress
of the destructive cysts
• The ultimate result of this disease is
renal failure
Polycystic Kidney Disease
Types of Polycystic Kidney Disease
Infantile Polycystic Disease
An inherited autosomal recessive trait
that results in the death of the infant
within a few months after birth
Adult Polcystic Disease
An autosomal dominant trait that results
in end-stage renal disease
Polycystic Kidney Disease
Assessment:
Flank, lumbar, or abdominal pain
Fever and chills
UTIs
Hematuria, proteinuria, pyuria
Calculuses
Hypertension
Palpable abdominal masses and
enlarged kidneys
Polycystic Kidney Disease
Nursing Interventions:
• Monitor for gross hematuria which
indicates cyst rupture
• Increase sodium and water intake
because sodium loss rather than
retention occurs
• Prepare the client for percutaneous cyst
puncture for relief of obstruction or for
draining an abscess
Polycystic Kidney Disease
Nursing Interventions:
Provide bed rest if ruptured cysts and
bleeding occur
Administer antihypertensives as
prescribed
Prepare the client for dialysis or renal
transplantation
Encourage the client to seek genetic
counseling
Renal Tumors
 Renal Tumors
• Kidney tumors may be benign or malignant,
bilateral or unilateral
• Common sites of metastasis include the:
bone
lungs
liver, spleen
other kidney
The exact cause of renal carcinoma is unknown
Accounts for 3% of U.S. cancer deaths
 Renal Tumors
Risk Factors
Male sex
Increased BMI
Tobacco use
Manifestations
Painless gross hematuria
Dull flank pain
Palpable renal mass in flank
 Renal Tumors
Surgical and Medical Management
• Radical nephrectomy, involve removal of
the entire kidney, adjacent adrenal gland,
and renal artery and vein
• Laparoscopic nephrectomy, and partial
nephrectomy
• Renal artery embolization
• Palliative radiation therapy
• Use of chemotherapy is limited
 Renal Tumors
Kidney Surgery
Preoperative considerations
Perioperative concerns
Postoperative management
– Potential hemorrhage and shock
– Potential abdominal distention and paralytic
ileus
– Potential infection
– Potential thromboembolism
 Renal Tumors
Postoperative Nursing Management
• Assessment: include all body systems, pain,
fluid, and electrolyte status; patency and
adequacy of urinary drainage system
• Nursing Diagnoses: ineffective airway
clearance, ineffective breathing pattern, acute
pain, fear and anxiety, impaired urinary
elimination, and risk for fluid imbalance
• Complications: bleeding, pneumonia,
infection, and DVT
 Renal Tumors
Postoperative Nursing Management
• Monitor vital signs
• Monitor abdomen for distention caused by
bleeding
• Monitor for hypotension, decreases in urinary
output, and alterations in level of
consciousness as indicating signs of
hemorrhage
• Monitor for signs of adrenal insufficiency
• In clients with adrenal insufficiency, a large
urinary output followed by hypotension and
subsequent oliguria occurs
 Renal Tumors
Postoperative Nursing Management
Administer fluids and packed red blood cells
intravenously as prescribed
Monitor intake and output and daily weight
Monitor for a urinary output of 30 to 50 ml an
hour to ensure adequate renal function
Monitor urine for specific gravity
Maintain semi-Fowler position
Monitor for signs of respiratory complications
related to surgery
 Renal Tumors
Postoperative Nursing Management
Encourage coughing and deep-breathing
exercises
Monitor bowel sounds for paralytic ileus
Apply antiembolism stockings as prescribed
Do not irrigate (unless specifically prescribed)
or manipulate the nephrostomy tube if in place
Administer pain medications as prescribed
 Renal Tumors
Patient Teaching
Instruct both patient and family about:
Care of drainage system
Strategies to prevent complications
Signs and symptoms
Follow-up care
Fluid intake
Health promotion and health screening
Renal and Bladder
Trauma
 Renal & Bladder Trauma
May be classified on the basis of the
Mechanism of the injury
1. Blunt injuries
2. Penetrating injuries (stabbing, gunshot
wound or other objects piercing)
Location or severity of the injury.
6. Minor renal and bladder trauma
7. Major renal and bladder trauma
8. Critical renal and bladder trauma
 Renal and Bladder Trauma

• A fractured pelvis that causes bone

fragments to puncture the bladder is the
most common cause of bladder trauma

• A blunt trauma causes compression of

the abdominal wall causing hemorrhage
and destruction of kidney, ureter and
bladder
 Renal and Bladder Trauma
Assessment:
Anuria, hematuria
Pain over the costovertebral area
(kidney trauma)
Pain over the lower abdomen radiating
to the shoulder (Bladder trauma)
Nausea and vomiting
 Renal and Bladder Trauma
Nursing Interventions:
Monitor vital signs
Monitor for hematuria, hemorrhage, and
signs of shock
Promote bed rest
Monitor pain level
Prepare the client for insertion of a
suprapubic catheter to aid in urinary drainage
if prescribed
Prepare the client for surgical repair of the
laceration if prescribed
Bladder Cancer
 Bladder Cancer
Most common site of cancer of the
urinary tract (72%)
Occurs in men 3 times more often than
women
Peak age 50-70 years old
54,000 new cases/year….12,000
deaths/year
Multi-focal and recurrent: 75% chance
will reoccur
Bladder Cancer
 Bladder Cancer
Hallmark sign:
- Painless hematuria immediately on
voiding
Predisposing Factors:
Strong correlation with cigarette smoking
Exposure to chemicals (especially
aniline dyes, chemicals used in paint,
rubber, textiles, electrical cables)
Chronic bladder infections
 Bladder Cancer
Assessment Findings:
Intermittent painless hematuria
Dysuria
Frequent urination
Diagnostic Tests:
Cystoscopy with biopsy reveals
malignancy
Cytologic exam of the urine reveals
malignant cells
 Bladder Cancer
Medical Management:
Dependent on the staging of cell type
1. Radiation Therapy
Usually in combination with surgery
Radiation involves several cycles until
the mass shrinks to almost normal size
Recurrence is common after a few
months to years of completing therapy
 Bladder Cancer
Medical Management:
2. Chemotherapy
A. Methods include direct bladder
instillations, intra-arterial infusions, IV
infusion, oral ingestion
B. Agents include 5-fluorouracil,
methotrexate, bleomycin, mitomycin-C
hydroxyurea, doxorubicin,
cyclophosphamide, cisplatin
 Bladder Cancer
Medical Management:
3. Bladder Surgery
Superficial: treated with excision and
chemotherapy
Invasive: treated with cystectomy
(removal of bladder) with radiation and
chemotherapy
 Bladder Cancer
Medical Management:
4. Prophylactic immunotherapy:
instillation of bacille Calmette-Guerin
(used to vaccinate for TB in some
countries) used to prevent tumor
recurrence of superficial tumors
Nursing Interventions:
Provide care for the client receiving
radiation therapy or chemotherapy and
bladder surgery
 THE END
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