Urinary System ( A-Z )
Subject: Adult Medical and Surgical nursing (I & II) (Basic and Diploma)
Comprehensive Nursing and Pathophysiology (post. Basic)
Topic: Acute Glumerulonehritis
Glomerulnephritis is an immunologic disease characterized by inflammation of the capillary loops in the glomeruli.
Etiologic factors are many and varied including.
- Immunologic reactions –systemic lupus erthematosus (SLE) streptococcal infection.
- Vascular injury-hypertension.
- Metabolic diseases (DM).
- Disseminated vascular coagulation (DIC).
The most common cause Gr A-beta streptococcal infection (1-3 weeks after the infection. The most common sites of primary infections are the pharynx or tonsils (URI) and the skin (impetigo).
There are several immunologic mechanisms that can cause acute glomerulonephritis. The most common, Gr.A streptococcal infection and its consequence is the development of AGN. Antigen and antibody reaction results in inflammation of the glomeruli and scar tissue forms. Glomerular permeability increases and leak into the urine. Glomerular filtration decreases and nitrogenous wastes accumulate in the blood and serum creatinine rise.
Repeated episodes of acute glomerulonephritis result in chronic glomerulonephritis .The kidneys are reduced to as little as one fifth their normal sizes. Bands of scar tissue distort the remaining cortex. Numerous glomeruli and their tubules become seared and the branches of renal artery are thickened. These result in end –stage renal disease (ESRD).
Signs and symptoms:
- Increased urine specific gravity.
- Elevated erythrocyte sedimentation rate (ESR).
- Elevated antistreptolysin titer.
- Circulatory congestion.
- End-stage kidney disease.
- Diagnostic tests-urine analysis for protienuria. Hematuria and cell debris. Urine creatinine and clearance: blood tests for BUN, Creatinine, and blood cell counts, ESR, antistreptolysin O titer.
- Medical treatment: antibiotics and prophylactic antibiotic, symptomatic treatment of water retention and diuretics, treatment of hyperkalemia, antihypertensive drugs.
- Dietary restriction: Low-protein diet (1-1,2g/kg/d).
- Activities restriction: Bed rest until the infection resolves.
- Hypertensive encephalopathy.
- Congestive heart failure.
- Pulmonary edema.
Assess signs and symptoms, recent infections (especially sore throat or skin lesions).and changes in urine characteristics.
- Inspect the area around the eyes, the extremities, and the abdomen for fluid accumulation.
- Assess skin turgor.
- Monitor vital signs for respiratory and cardiac function for evidence of excess fluid volume- dyspnoea, tachycardia, and hypertension.
- Accurate intake and output records and daily weights.
- Excess fluid volume related to renal dysfunction.
- Risk for infection.
- Activity intolerance related to retention of chemical wastes and fatigue.
- Bed rest lack of knowledge of treatment measures.
- Anxiety related to possibility of chronic illness.
- Promoting fluid balance by-
- Sodium and fluid restriction.
- Monitor signs and symptoms of fluid overload.
- Body weighing daily.
- Vital signs.
- Administer anti-hypertensive, diuretics as prescribes and monitor serum k+
- Preventing infection by:
- Universal precautions.
- Preventing the patient from URI (from visitors etc.) if indicated administer antibiotics as prescribed.
- Avoiding characterization.
- Facilitating self –care and coping to illness by –
- Explain the rational for bed rest and once me signs and symptoms subside, encourage the patient to ambulate.
- Offer diversional activities to prevent depression (e.g. talking with others listening to music etc.).
- Encourage the patient to plan activities as tolerated for his herself).
- Encourage family to get involve and plan the care together with the patient.
- Encourage them to express their feelings and concerns and provide supportive care.
- Patient and family education
- Nature of disease and effect of diet and fluids on fluid balance and sodium retention.
- Diet teaching.
- Medication regimen.
- Need to balance activities.
- Avoidance of infection.
- Signs and symptoms indicating need for medical attention.
- Importance of follow up care.
- Health promotion – can be attained by public education of prompt treatment of sore throats and URIs.
Topic: Nephrotic syndrome.
Nephrotic syndrome is not a single disease entity but a constellation of symptoms including albuminuria, hypoalbuminemia, hyperlipidemia, and lipuria.
Nephrotic syndrome is associated with.
- Allergic reactions (insect bites, pollen, and AGN).
- Infections (herpes infection).
- Systematic disease (SLE, DM).
- Circulatory problems (severe CHF and chronic constrictive pericarditis).
- Cancer (Hodgkin’s lung, colon, and breast).
- Renal transplantation.
Immune complex deposition, nephrotoxic antibodies, or other non-immune mechanisms damage to cells in the glomerular basement membrane that result in increased membrane porosity and permeability with significant protienuria. Serum albumin is then depleted; result in decreased serum osmotic pressure – generalized edema. As fluid is lost into the tissue the plasma volume decreases, stimulating secretion of aldosterone leading to even greater edema.
Signs and symptoms:
- Severe generalized edema.
- Pronounced proteinuria.
- Diagnostic tests – urine analysis (for protein casts and erythrocytes), serum test for protein and lipid analysis.
- Medication: Corticosteroids – prednisolone.
- Diet – high –protein, low-salt diet.
- Prevention of infection.
Health history physical examination and lab investigations to assess signs and symptoms described above.
May include but are not limited to:
- Imbalanced nutrition: less than body requirement due to anorexia, edema.
- Risk for infection related to decreased nutrition, immobility, edema.
- Deficient knowledge related to lack of knowledge / information.
- Promoting nutrition-
- Sodium restriction – 0.5-1g/day.
- Protein – high protein diet, supplement according to amount of protein loss.
- Small, frequent feeding.
- Vitamins supplement.
- Oral hygiene care.
- Weighing daily.
- Preventing infection (immune function becomes compromised of protein loss and steroid use.
- Monitor signs of any infection and notify physicians promptly.
- Administers antibiotics as prescribed.
- Monitor and prevent skin breakdown-using skin protective measures. E.g. scrotal support for men.
- Patient and family education:
- The effects of nephritic syndrome on the kidneys and the possibility of dialysis.
- Medical regimen-name dose, actions, side-effects and the need to finish antibiotics as appropriate.
- Nutritional support.
- Self-assessment of fluid status, including signs and symptoms of hypovolemia and hypervolemia.
- Signs and symptoms requiring medical attention.
- Promotion of and healthy life. Such as exercise. Adequate rest and sleep and avoidance of infection.
- Need for follow up care to monitor renal function.
Topic: Benign prostatic hyperplasia (BPH)
Benign prostatic hyperplasia (BPH) is an enlargement and change in the tissue consistency of portions of the prostate.
Although the cause is unknown, the condition is hormone dependent.
It occurs in at least 50% of all men over 50 years old and 75% of men over 70 years.
Male sex hormones stimulate growth and enlargement of the prostate. Prostatic gland enlargement or the enlarging tumor obstructs urine outflow, leading to urinary retention, stasis, and infection.
Signs and symptoms:
- Symptoms of urinary obstructions- urgency, frequency etc
- Palpation reveals an enlarged, firm prostate ( hematuria and a hard, fixed nodule indicate that cancerous tumor likely)
- Signs and symptoms of renal failure- Indicate advanced BPH.
- Diagnostic tests- test of renal function, prostate specific antigen (PSA), cystourethroscopy, etc.
- Medication- to reduce the size of the prostate or relax the bladder neck.
- Surgical management- to remove prostate gland for patients with recurrent, persistent UTIs and obstructive problems, transurethral prostatectomy is performed.
- Carefully assess coagulation parameters as the patient undergoing the vascular prostate gland is at risk of bleeding also a history of taking NSAIDs and anticoagulants must be reported.
- Constipation must treated preoperative to lessen discomfort and decrease straining during defecation postoperatively because it defecation can cause more pain and exacerbate bleeding.
- Inform the patient about post –operative retaining of Foley catheter, and the possibility of bladder irrigation procedure.
- Inform the patient that his urine may appear red or pink for several days after the surgery and that is a normal result of manipulation of the prostate.
- Instruct the patient about the discomfort associate with bladder spasms and the presence of large catheter and how this discomfort may be managed.
- Impaired urinary elimination related to surgery
- Acute pain related to bladder spasms
- Maintain urine output and characteristics to determine adequacy of urination
- Maintain constant bladder irrigation as prescribed to ensure urinary drainage and prevent the formation of clot.
- Maintain patency of urinary catheter to ensure bladder emptying.
- Encourage high fluid intake
- After catheter removal, monitor for signs of retention and /or infection
- Pain management- assesses and administers prescribed pain medication, informs the patient to avoid trying to urinate around the catheter because it induces more spasms and pain.
- Patient and family education- discharge planning.
- Avoid heavy lifting and climbing more than two flights of stairs.
- Avoid sexual activity for at least 3 weeks
- Avoid driving for 2 weeks
- Monitor for infection and notify as soon as possible
- Avoid the use of alcohol and antihistamines
- Follow-up care.
Topic: calculi in the urinary tract (Urolithiasis)
Obstruction of any part of urinary system from the urethra to the kidney generates backflow of urine and pressure on the renal tubules causing tubular dysfunction. Causes of urinary obstruction include benign prostatic hypertrophy (BPH), calculi, urethral, stricture, tumors, trauma, and congenital anomaly. Urinary calculus, one of the common problems in the urinary system, is discussed.
Urolithiasis is the term used for stones or calculi in the urinary tract.
Stones are formed when urinary concentration of substances (super saturation) such as calcium phosphate, and uric acid increase.
- Inadequate hydration.
- Hyper- calciurea
- High protein and sodium intake.
- Excess intake of dietary purine found in red meat, fish and poultry and a disorder in purine metabolism (i.c.gout).
- Three major steps involved in the process of stone formation: nucleation, growth and aggregation.
- Stones obstruct urine flow and cause pain and vary depending on the location of the obstruction, for example, renal stones cause pain at the flank area which is called renal colic.
- Hydroureter and hydronephrosis occur as result of backflow of urine. Pressure build up to the kidney leads to destruction of kidney tissue and eventually kidney failure. With obstruction, urine flow is decreased contributing to infection.
Several risk factors are recognized to increase the potential of a susceptible individual to develop stones. These include:
- Anatomical anomalies in the kidneys and/or urinary tract – eg, horseshoe kidney, urethral stricture.
- Family history of renal stones.
- Relative dehydration.
- Metabolic disorders which increase excretion of solutes – eg, chronic metabolic acidosis, hypercalciuria, hyperuricosuria.
- Deficiency of citrate in the urine.
- Cystinuria (an autosomal-recessive aminoaciduria).
- Drugs – eg, diuretics such as triamterene and calcium/vitamin D supplements.
- More common occurrence in hot climates.
- Increased risk of stones in higher socio-economic groups.
- Contamination – as demonstrated by a spate of melamine-contaminated infant milk formula.
Sign and symptoms: Vary depending on the presence of obstruction, Infection and edema.
- The patient’s chief complaint usually pain.
- The location of pain may provide clues to the site of the calculus.
- Dull flank pain suggests the renal pelvis or stretching of the renal capsule from urine retention.
- If a calculus lodges in a ureter the patients usually has excruciating pain in the abdomen that radiates to groin or the perineum.
- Nauseas, vomiting.
- The patient may show signs and symptoms of UT.
- Basic analysis should include:
- Stick testing of urine for red cells (suggestive of urolithiasis), white cells and nitrites (both suggestive of infection) and pH (pH above 7 suggests urea-splitting organisms such as Proteus whilst a pH below 5 suggests uric acid stones).
- Midstream specimen of urine for microscopy (pyuria suggests infection), culture and sensitivities.
- Blood for FBC, CRP, renal function, electrolytes, calcium, phosphate and urate, creatinine.
- Prothrombin time and international normalised ratio if intervention is planned.
- Non-enhanced CT scanning is now the imaging modality of choice and has replaced Intravenous pyelogram (IVP). Ultrasound scanning may be helpful to differentiate radio-opaque from radiolucent stones and in detecting evidence of obstruction.
- Plain X-rays of the kidney, ureter and bladder (KUB) are useful in watching the passage of radio-opaque stones (around 75% of stones are of calcium and so will be radio-opaque).
- The European Association of Urology’s guidelines on urolithiasis recommend stone analysis for:
All first-time stone formers.
- All patients with recurrent stones who are on pharmacological preventing therapy.
- Patients who have had early recurrence after complete stone clearance.
- Late recurrence after a long stone-free period (stone composition may change).
- Encourage the patient to try to catch the stone for analysis. This may mean urinating through a tea strainer, filter paper such as a coffee filter, or gauze.
- Most calculi are passed spontaneously .Ambulation and adequate hydration facilitates the passage of many calculi.
- Opioid analgesics and antispasmodics are ordered to relieve intense colicky pain.
Antibiotics are ordered.
- If the calculus is dose not pass and symptoms continue, several procedures may be used to destroy or remove it. These procedures are:
Health history, physical examination and diagnostic tests to assess history and the presence of signs and symptoms described above.
- Acute pain related to obstruction, trauma, and renal colic.
- Impaired urinary elimination related to obstruction.
- Risk for deficient fluid volume related to anorexia, nausea and vomiting.
- Ineffective management of therapeutic regimen related to lack of knowledge of prevention and treatment of calculi.
Post –operative nursing diagnosis of the patient undergoing nephrostomy.
- Decreased cardiac output related to blood loss.
- Ineffective breathing patterns related to splinting of painful incision.
- Acute pain related to surgical wound and the placement of nephrostomy tube.
- Anxiety related to home management of nephrostomy tube.
- Describe patient’s usual fluid intake and diet including vitamin and mineral supplements.
- If pain is present, describe location, severity and nature of pain and provide pain relief measures (administer pain medication as prescribed etc.)
- Record any changes in urine amount or characteristics.
- Vital signs-take the temperature, to detect fever. A nurse who is trained in physical examination palpates and percusses the flanks and the abdomen, noting the presence of pain tenderness, or distended bladder.
- Monitor and management signs and symptoms of infection, obstruction.
- Educate the patient to observe and report decreased urine volume, bloody and cloudy urine, the spontaneous passage of a stone.
- Encourage the patient to increase fluid intake.
- Complete blockage of the urinary flow from a kidney decreases glomerular filtration rate (GFR) and, if it persists for more than 48 hours, may cause irreversible renal damage.
- If ureteric stones cause symptoms after four weeks, there is a 20% risk of complications, including deterioration of renal function, sepsis and ureteric stricture.
- Infection can be life-threatening.
- Persisting obstruction predisposes to pyelonephritis.
Recurrence of renal stones is common and therefore patients who have had a renal stone should be advised to adapt and adopt several lifestyle measures which will help to prevent or delay recurrence:
- Increase fluid intake to maintain urine output at 2-3 liters per day.
- Reduce salt intake.
- Reduce the amount of meat and animal protein eaten.
- Reduce oxalate intake (foods rich in oxalate include chocolate, rhubarb, nuts) and urate-rich foods (eg, offal and certain fish).
- Drink regular cranberry juice: increases citrate excretion and reduces oxalate and phosphate excretion.
- Maintain calcium intake at normal levels (lowering intake increases excretion of calcium oxalate).
- Depending on the composition of the stone, medication to prevent further stone formation is sometimes given – eg, thiazide diuretics (for calcium stones), allopurinol (for uric acid stones) and calcium citrate (for oxalate stones).
Topic: Renal Failure
Renal failure results when the kidneys are unable to remove the body’s metabolic wastes or perform their regulatory functions. There are two types of renal failure and chronic renal failure.
Acute renal failure is an – abrupt decline in kidney function as defined by increases in BUN and plasma creatinine levels. Urine output is generally decreased (less than 40 ml / hr – oliguria) but may be normal or even increased. Depending on cause, acute renal failure is classified by prerenal (e.g. hypovolemia), intrarenal (e.g. tubular necrosis, nephrotoxicity), or postrenal (obstruction of urine flow e.g. calculi, BPH, cancer of bladder)
Chronic renal failure or ERSD is a progressive, irreversible deterioration in kidney function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting uremia or azotemia.
Uremia – a syndrome of renal failure characterized by elevated blood urea nitrogen (BUN) and creatinine levels.
Azotemia – asymptomatic elevated BUN and creatinine.
Chronic renal failure
- Earlier acute renal failure.
- Diabetes mellitus.
- Recurrent infection and exacerbation’s of nephritis and other urinary diseases.
The interaction of tubular and vascular events results in ARF. The primary cause of ATN is ischemia. Ischemia for more than two hours results in severe and irreversible damage to the kidney tubules. Significant reduction in glomular filtration rate (GFR) is a result of (1) ischemia, (2) activation of the renin-angiotensin system, and (3) tubular obstruction by cellular debris. As nephrotoxins damage the tubular cells and these cells are lost through necrosis, the tubules become more permeable. This results in filtrate absorption and a reduction in the nephrons ability to eliminate waste.
Signs and symptoms:
- Azotemia, uremia.
- Hyperkalemia – the patient may become apathetic and confused and may have nausea, vomiting, abdominal cramps, muscle weakness and number of the extremities.
- Hypervolemia, hypertension, decreased urine output.
- Dysrrhythmias (failure of cardiac function).
- Metabolic acidosis – tachypnea, kussmal’s respiration.
- Impaired immunologic function – General immune response is suppressed and antibody production is declined. Therefore the patient has reduced ability to resist infection.
- Lethargy, confusing.
- Infertility, decreased libido.
Health history, physical examination, and lab investigations to assess signs and symptoms described above.
May include but are not limited to:
- Excess fluid volume.
- Imbalanced nutrition less then body requirement.
- Risk for infection related to compromised immune response.
- Risk for injury related to decreased level of conscious.
- Fatigue related to uremia, anemia.
- Acute pain related to sodium depletion, uremia, muscle cramping.
- Ineffective coping related to situational crisis.
- Situational low self-esteem.
- Deficient knowledge.
- Maintaining fluid and electrolyte balance.
- Facilitating nutrition.
- Preventing infection and injury.
- Promoting comfort rest and sleep.
- Facilitating coping with changes in lifestyle and feeling regarding self.
- Patient and family education including:-
Nursing management of patients undergoing urologic surgery is regarded as similar to other types of surgery however. There are several issues require specific attentions and are addressed in this session.
- Standard pre-op care.
- Bleeding is a major complication of urologic surgery .especially kidney surgery. Thus can assessment of bleeding disorders is essential.
Adequate blood components required for the surgery must be confirmed.
- Pre-op teaching includes all standard patient information and focus on care of urinary drain including urinary catheter. tube drains ( e.g. nephostomy tube. ureterostomy .cystostomy tube, perose drains etc).
Post – operative nursing diagnosis:
The nursing diagnosis or collaborative problem developed based on the assessment data. These include but are not limited to –
- Risks for respiratory complicating relate surgical incision and anesthesia.
- Acute pain.
- Fluid volume disturbance.
- Risk for bleeding / hemorrhage.
- Anxiety related to home management nephrostomy tube (if retained).
- Performing standard post – operative care.
- Turning, deep breathing, incentive spiro early ambulation must be encouraged as possible.
- Positioning—semi-Fowler’s position (assist natural lung expansion)
- Ausculting lung sounds and encouraging all pulmonary hygiene routines.
- Managing pains–assess pain regularly and provide pain medication as prescribed.
- Maintain NPO status urine peristalsis resumes-> monitor bowel sounds and encourage early ambulation.
- Monitor and keep patency of tube drainage (nephrostomy or
Ureterostomy or cystostomy)-the presence of bright-red blood .excessive bloody drainage must be reported to the surgeon or if it stops draining must be immediately notified (because the obstruction of tube drain can result in rupture or dislodgment at the suture line).
- Fluid replacement via IV line until peristalsis resumes.
- Monitoring signs and symptoms of hypovolemic shock from bleeding at surgical line.
- Providing surgical wound care – observe signs of wound infection monitor wound discharge and drainage secretions for colour, odor, amount.
- Assessing anxiety.
- Patient education and discharge planning—
- must be individualized to the patient and family needs and appropriate to family and community context.
- Provide informative information and ensure that they can perform some specific skills (such as nephrostomy care, care of wound with retainage denec.)
- Medication use.
- Follow –up care.
- Bleeding from the stomach or intestines
- Bone, joint, and muscle pain
- Changes in blood sugar
- Damage to nerves of the legs and arms (peripheral neuropathy)
- Fluid buildup around the lungs (pleural effusion)
- Heart and blood vessel complications
- Congestive heart failure
- Coronary artery disease
- High blood pressure
- High phosphorous levels
- High potassium levels
- Increased risk of infections
- Liver damage or failure
- Miscarriages and infertility
- Swelling (edema)
- Weakening of the bones and increased risk of fractures
Md. Lothfur Rahman,
(BSN, RN, MPH)