Inspects interior of bladder with a tubular lighted scope (cystoscope) (Fig. 44-10). Can be used to insert ureteral catheters, remove calculi, obtain biopsy specimens of bladder lesions, and treat bleeding lesions. Lithotomy position is used. Procedure may be done using local or general anesthesia, depending on patient's needs and condition. Complications include urinary retention, urinary tract hemorrhage, bladder infection, and perforation of bladder. Before: Force fluids or give IV fluids if general anesthesia is to be used. Ensure consent form is signed. Explain procedure to patient. Give preoperative medication. After: Explain that burning on urination, pink-tinged urine, and urinary frequency are expected effects. Observe for bright red bleeding, which is not normal. Assist with ambulation because orthostatic hypotension may occur. Offer warm sitz baths, heat, mild analgesics to relieve discomfort. Obtains renal tissue for examination to determine type of kidney disease or to follow progress of kidney disease. Technique is usually done as a skin (percutaneous) biopsy through needle insertion into lower lobe of kidney. Can be performed with CT or ultrasound guidance. Absolute contraindications are bleeding disorders, single kidney, and uncontrolled hypertension. Relative contraindications include suspected renal infection, hydronephrosis, and possible vascular lesions. Before: Type and crossmatch patient for blood. Ensure consent form is signed. Assess coagulation status through patient history, medication history, CBC, hematocrit, prothrombin time, and bleeding and clotting time. Patient should not be taking aspirin or warfarin (Coumadin). After: Apply pressure dressing and keep patient on affected side for 30-60 min. Bed rest for 24 hr. Vital signs ever 5-10 min, first hour. Assess for flank pain, hypotension, decreasing hematocrit, ↑ temperature, chills, urinary frequency, dysuria, and gross or microscopic hematuria. Urine dipstick can be used to test for bleeding in urine. Inspect biopsy site for bleeding. Instruct patient to avoid lifting heavy objects for 5-7 days and to not take anticoagulant drugs until allowed by HCP. i. Acute:
1. Chills, fever, leukocytosis, bacteriuria, pyruria, low flank pain, nausea and vomiting, headache, malaise, painful urination
2. Physical assessment: pain and tenderness in the area of the costovertebral angle
3. Some patients may experience urinary frequency and urgency as well
4. Recurring symptoms may cause scarring and renal failure
1. Usually asymptomatic
2. If acute exacerbation occurs, the patient may experience fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss
· Type of pain is determined by location of stone
· Symptoms of stones: when stones block flow of urine, obstruction develops, producing an increase in hydrostatic pressure and distending the renal pelvis and proximal ureter. Pyelonephritis and cystitis can occur from constant irritation by stone.
1. Stone in renal pelvis-pain also results from movement of stone down the ureter. Intense, deep ache in costovertebral region, pyuria, hematuria, pain radiates anteriorly and downward toward bladder in female and toward testes in male; renal colic: pain, nausea, vomiting, tenderness in costovertebral area.
2. Stone lodged in ureter- acute, excruciating, colicky wavelike pain, radiating down the thigh to the genitalia; frequent desire to void but little passed; blood usually in urine because of abrasive action of stone; these symptoms are referred to as ureteral colic
3. Stone in bladder- s/s UTI; hematuria; possible sepsis if infection is present with stone
a. liberal fluid intake
b. reduce dietary protein, calcium and sodium
c. foods to limit or avoid
o milk, cheese, ice cream, yogurt, sauces containing milk, all beans (except green beans), lentils, fish with fine bones (e.g., sardines, kippers, herring, salmon); dried fruits, nuts; Ovaltine, cocoa, chocolate
o dairy products except cottage cheese and farmer's cheese
o restrict foods high in vitamin D
· Catheters and drains used to maintain a patent urinary tract, to remove drainage, and to keep an accurate output. Monitor urine output at least every 1 to 2 hours immediately post-op.
· Pain management
· Assist with turn, cough, and incentive spirometry. Deep breathing is also encouraged. Goal prevention of atelectasis and other pulmonary complications since a nephrectomy can be performed through a flank incision just below the diaphragm.
· Monitor for infection
· Patient and family support
· Discharge education
1. Care of incision
2. No lifting, pushing or pulling
3. No driving
4. Pain management
5. Symptoms to report: increased amounts of mucus, blood, or sediment (can occlude the drainage tubing or catheter) wound drainage, blood in urine, pain not relieved by medication, swelling in legs, respiratory difficulty.
6. Diet: adequate oral intake, balanced diet or specialty diet such as diabetic or heart
7. Emotional support
8. Community resources