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Ch. 45-47: Renal & urologic problems

Terms in this set (61)

-past health history: presence or history of diseases that are r/t renal ot other urologic problems; HTN, diabetes, gout, or other metabolic problems

Healthperception-health management:
-have you ever smokes?
-person living in middle eastern countries or Africa can acquire certain parasites that can cause cystitis or bladder cancer

Nutritional-metabolic pattern:
-large intake of particular foods (dairy, or foods high in proteins) can cause calculi formation
-asparagus may cause the urine to smell musty
-beets may cause urine to turn red; mistake for bloody urine
-caffeine, alcohol, carbonated drinks, or spicy foods often aggravate urinary inflammatory diseases
-many herbal teas cause diuresis

Elimination pattern:
-investigate bowel function

Activity-exercise pattern:
-assess patients level of activity
-sedentary person is more likely to have stasis of the urine which can predispose to infection & calculi
-active person may find that increasing activity aggravates the urinary problem

Sleep-rest pattern:
-nocturia is common & bothersome lower urinary tract symptom
-leads to sleep deprivation, daytime sleepiness, fatigue
-up to 1 episode of nocturia is considered normal in younger adults
-up to 2 episodes are acceptable among adults 65 & older

Physical exam:
INSPECTION:
-SKIN: yellow-gray casts; changes in turgor; texture (rough dry skin)
-MOUTH: ammonia breath odor
-FACE/EXTREMITIES: generalized edema, peripheral edema
-ABDOMEN: unilateral mass
PALPITATION:
-costovertebral angle (CVA)
-normal sized left kidney is not palpable
-occasionally the lower pole of right kidney is palpable
PERCUSSION:
-tenderness in flank area may be detected bu fist percussion (kidney punch)
-Murphy's punch
-if CVA pain is present it may indicate an infection or polycystic kidney disease
-normal a bladder is not percussible until it contains 150 mL of urine.
AUSCULTATION:
-bell of stethoscope may be used to auscultate over both CVA's & in the upper abdominal quadrants
-bruit (abnormal murmor) indicates impaired blood flow to the kidneys
URINE STUDIES:
-urinalysis: examine w/in 1 hour of obtaining specimen
-creatinine clearance: waste product of protein breakdown (primarily body muscle mass); collect 24 hour specimen, discard 1st urination when test is started, add end of 24 hour specimen to collection
-urine culture: identifies causative organisms; clean catch of 5-10cc
-residual urine: left in bladder after urinating; cath patient immediately after urinating or use bladder scanner
-urine cytology: identifies abnormal cellular structures that occur w/ bladder cancer & to follow the progress of bladder cancer

BLOOD STUDIES:
-BUN: concentration of urea in blood is regulated by the rate at which kidney excretes urea
-electrolytes: sodium, potassium, calcium (total), phosphorus, bicarbonate (most patients in renal failure have metabolic acidosis & low serum HCO3 levels)

RADIOLOGIC PROCEDURES:
-kidneys, ureters, bladder (KUB): involves X-ray exam of abdomen & pelvis & delineates size, shape, & position of kidneys. Radiopaque stones & foreign bodies can be seen
-intravenous pyelogram (IVP): patient w/ significantly ↓ renal function should not have IVP (no renal failure patients)
-CT scan: kidney size can be evaluated; tumors, abscesses, supra-renal masses; distinguishes subtle differences in density. Use of IV administered contrast media during CT scan accentuate density of renal tissue & helps differentiate masses
-cystogram: vesicoureteral reflux; neurogenic bladder & recurrent urinary tract infections. can also delineate abnormalities of the bladder

ENDOSCOPY:
-cystoscopy: inspects interior of bladder w/ tubular lighted scope; lithotomy position; local or general anesthesia; after procedure observe for BRB which is not normal

RENAL RADIONUCLIDE IMAGING:
-renal scan: evaluates anatomic structures, perfusion, & function of the kidneys
-renal biopsy: obtains renal tissue for examination to determine type of renal disease or to follow progress of renal disease; absolute contradictions are bleeding disorders, single kidney, uncontrolled HTN
-most frequent malignant tumor of the urinary tract is transitional cell carcinoma of the bladder
-most common between 60-70 years old
-men > women

Risk factors:
-smoking
-exposure to dyes used in rubber & cable industries
-chronic abuse of phenacetin-containing analgesics

Manifestations:
-microscopic or gross, painless hematuria = most common clinical finding

Surgical therapy:
-transurethral resection w/ fulguration: used for the diagnosis & treatment of superficial lesions w/ a low recurrence rate; used to control bleeding in the patient who is a poor operative risk or who has advanced tumors; blade is inserted through the cystoscope
-laser photocoagulation: treat superficial bladder cancers; bloodless destruction of the lesion, minimal risk of perforation, lack of need for a urinary catheter; disadvantage = destruction of the tumor, unable to pathological evaluation for grading & staging
-open loop resection w/ fulguration: used for the control of bleeding, for large superficial tumors, multiple lesions

Post op:
-drink large colume of fluid each day for the 1st week & avoid intake of alcohol
-approx 7-10 days after, patient may see dark red or rustic colored flecks in the urine (scabs from healing tumor)
-opioid analgesics & stool softeners
-15-20 min of sitz bath for 2-3 x per day to promote muscle relaxation
-help patient & family to cope w/ cancer
-f/u cystoscopies every 3-6 months for 3 years then yearly after

-partial cystectomy: resection of that portio of the bladder wall containing the tumor
-radical cystecotomy: removal of the bladder, prostate, seminal vesicles in men & the bladder, uterus, cervix, urethra & ovaries in women

Intravesical therapy:
-chemo w/ local instiliation of chemotherapeutic or immune0stimulating agents delivered directly into the bladder by a urethral catheter
-chemo are retained for about 2 hours; patient's position changed q 15 min.
-Thiotepa can ↓ WBC & platelet counts
-flu-like symptoms, ↑ urinary frequency, hematuria, systemic infection

Nursing responsibilities:
-↑ daily fluid intake
-quit smoking
-assessing for secondary UTI
-stressing need for routine urological f/u
-uremia: a syndrome in which kidney function declines to the point that the symptoms develop in multiple body systems → occurs when the GFR is < 10 mL/min

Urinary system:
-polyuria→oliguria→anuria

Metabolic disturbances:
-waste product accumulation
-altered carbohydrate metabolism
- ↑ triglycerides → hyperinsulinemia stimulates hepatic production of triglycerides

Electrolyte & acid-base imbalances:
-potasium → hyperkalemia
-sodium → normal or low; sodium along w/ water is retained resulting in dilutional hyponatremia
-calcium & phosphate
-magnesium → hypermagnesium generally is not a problem unless the patient is ingesting magnesium
-metabolic acidosis

Hematologic system:
-anemia → decreased production of erythropoietin by the kidneys
-bleeding tendencies → impaired platelet aggregation & impaired release of platelet factor III
-infection

Cardiovascular system:
-HTN
-LVH
-vascular changes
-cardiac dysrhythmias

Respiratory system:
-Kussmaul breathing → to compensate for metabolic acidosis
-dyspnea → fluid overload
-pulmonary edema
-uremic pleuritis
-pleural effusion
-predispostiion for respiratory infections

GI system:
-stomatitis w/ exudates & ulcerations
-metalic tast in mouth
-uremic fetor (urinous odor of breath)
-anorexia, nausea, vomiting
-gastroparesis (delayed gastric emptying)

Neurologic system:
-CNS depression
-peripheral neuropathy
-treatment is dialysis or transplantation

Musculoskeltal system:
-renal osteodystrophy
-less vitamin D is converted to its acting form

Integumentary system:
-pruritis
-skin discoloration
-uremic frost → rare; urea crystalizes on the skin & usually seen when BUN levels are extremely high

reproductive system:
-infertility
-decreased libido

Endocrine system:
-hypothyroidism

Psychologic changes:
-personality & behavioral changes
-anxiety
-depression
-emotional lability