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Nursing Care of Clients with Urinary Tract Disorders


Nursing Care of Clients with Urinary Tract Disorders ... a client comes into the clinic with signs of acute glomerulonephritis. ... Common affects children and adults. – PowerPoint PPT presentation

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Title: Nursing Care of Clients with Urinary Tract Disorders

Nursing Care of Clients with Urinary Tract
  • Chapter 29

The Renal System
The Client with Urinary Tract Infection
  • Cystitis- Women more likely aging any area of
    the urinary tract bladder most common.
  • inflammation of the bladder
  • Clinical Manifestations
  • dysuria
  • frequency
  • urgency
  • nocuria, pyuria, hematuria
  • supra pubic pain

Pathophysiology UTI
  • Urinary tract sterile above the urethra due to
  • Adequate urine volume
  • Unimpeded urine flow
  • Complete bladder emptying
  • Risk factors for UTI-discussion
  • Cystitis- bladder mucosa becomes inflamed and
    congested with blood ( from the bacteria).
    Purulent discharge forms and the mucosa bleeds.
    This creates the CM of cystitis.
  • Catheter-Associated UTI- The longer the catheter
    remains in place, the greater the risk for
    infection. Bacteria enter the bladder by
    migrating through urine within the catheter or by
    moving up the urethra outside the catheter.
    Bacteria enter the catheter system at the
    connection between the catheter and drainage
    system or through the emptying tube of the bag.

The Client with Urinary Tract Infection
  • Pyelonephritis
  • inflammation of renal pelvis,
  • Acute or chronic.
  • Clinical Manifestations
  • Are Systemic
  • Urinary - same as cystitis, with CVA tenderness
  • G.I. - vomiting, diarrhea
  • Cardio - tachycardia
  • Hematological - leukocytosis

  • Bacteria usually Ecoli enter the kidney from the
    lower urinary tract.
  • Risk Pregnancy, obstruction and congenital
    malformation, Vesicouretral reflex risk factor in
    children- urine moves from the bladder back
    toward the kidney, adults too.
  • Infection can spread from the renal pelvis to the
    cortex, the inflamed kidney becomes edematous.
  • Abscesses may form and kidney tissue can be
    destroyed by the inflammatory process.
  • CM- Older adults change in behavior, confusion,
    incontinence or deterioration in condition.
  • Chronic pyelonephritis leads to fibrosis and
    scarring of the renal pelvis. Chronic kidney
    disease and end-stage renal disease are possible

Treatment Pylonephritis
  • 10-21 days of antibiotic therapy, intravenous
    antibiotics may be necessary/ usual.
  • Encouraging health promotion behaviors
  • Generous fluid intake 1 liter per day
  • Void when urge is felt-3 hours at most 2 better.
  • Women cleanse the perineal area from front to
    back after void and defecating
  • Void before and after sexual intercourse- women
  • Avoid bubble baths feminine hygiene sprays and
    vaginal douches
  • Cotton briefs avoid underwear make of synthetic
  • Acidic urine cranberry juice, vitamin c.

The Client with Urinary Tract Infection
  • Systemic Symptoms
  • Musculosketetal - muscle tenderness
  • Metabolic - fever, chills, malaise
  • Interdisciplinary Care
  • Labs and Diagnostics
  • UA- identify blood cells and bacteria in urine
  • Gram Stain and culture- What organism?
  • Eliminate the cause
  • Prevent relapse
  • Identify contributing factors
  • CBC-systemic response

The Client with Urinary Tract Infection
  • Intravenous pylogram (IVP)
  • dye used to visual renal pelvis
  • check allergies - iodine
  • Voiding cystogram
  • x-ray while voiding dye solution
  • Cystoscopy
  • direct visualization of bladder

The Client with Urinary Tract Infection
  • Pharmacology
  • 7 to 10 days of oral anti-microbial therapy
  • bactrim, septra- Sulfa drugs
  • Cipro, Pyridium
  • Nursing Care
  • Pain
  • Assess
  • Relieving measures
  • Increase fluids

The Client with Urinary Tract Infection
  • Nursing Care
  • Altered Patters of Urinary Elimination
  • I O
  • color, clarity, character
  • Quick access
  • Avoid caffeine
  • Knowledge Deficit
  • Disease process

The Client with Urinary Tract Infection
  • Nursing Care- health promotion
  • Follow treatment regimen
  • teach prevention- Void at least every
  • 2 hours. Well hydrated.
  • Limit caf. Beverages.
  • Women- void after intercourse
  • Hygiene practices
  • Clothing practices

  • These diseases involving the glomerulus are the
    leading cause of chronic kidney disease in the
  • Flitration which is the first step in urine
    formation occurs in the glomerulus.
  • Inflammatory condition that affects the
    glomerulus. Acute or chronic.
  • May be a primary disorder or may occur secondary
    to a systemic disease such as lupus.
  • -Damages the capillary membrane and allows blood
    cells and proteins to escape from the vascular
    compartment into the filtrate
  • CM- Hematuria, proteinuria, loss of plasma
    proteins in the blood which leads to
    hypoalbuminemia. Edema follows caused by reduced
    osmotic draw within blood vessels.
  • Glomerular filtration is disrupted, GFR falls and
    azotemia occurs.
  • Azotemia- increased blood levels of nitrogenous
    wastes, urea, creatinine.

  • Fall in GFR activates the renin-angiotensin-aldost
    erone system leads to water retention and
  • Acute glomerulonephritis follows an infection
    with group A beta Strep such as strep throat.
  • Protein complexes from the infection become
    trapped in the glomerular membrane causing an
    inflammatory response and drawing WBC to the
  • Inflammation damages the glomerular capillary
    walls and makes them more porous. Plasma proteins
    and blood cells escape into the urine.

  • CM- acute develop abruptly, 10-14 days after the
    initial infection
  • Nausea, malaise, arthralgias, proteinuria.
  • Hypertension and edema (periorbital)more often in
    children and young adults, not elderly
  • Symptoms may subside spontaneously, most people
    recover completely, some may develop chronic
    glomerulonephritis never regaining full kidney

Nephrotic Syndrome
  • Group of symptoms results when glomerular tissues
    are damaged and there is significant protein lost
    in the urine.
  • No one cause may result in adults from primary
    kidney disorder or systemic disease such as
    diabetes or lupus.
  • CM- proteinuria, low serum albumin levels, high
    blood lipids and edema, thromboemboli very
  • May resolve without effects, adults less likely
    to recover than children. May have persistent
    proteinuria and progressive renal impairment that
    leads to renal failure

Chronic Glomerulonephritis
  • Result of kidney damage by a systemic disease
    such as diabetes.
  • May occur with no previous kidney disease or
    apparent cause.
  • Slow progressive destruction of glomeruli and
    nephrons. Kidneys decrease in size and surfaces
    become granular as nephrons are destroyed.
  • CM- Develop slowly, renal failure may develop
    years to decades after the disease is diagnosed.
  • Diabetic nephropathy-impairs filtration and
    elimination. Damage in 15-20 yrs of diagnosis
  • Lupus nephritis- hematuria and proteinuria,
    inflammatory lesions in the glomerulus. Chronic
    or acute may progress rapidly.

Diagnostic test
  • Antistrepolysin (ASO)titer- Identifies antibodies
    to group A beta-hemolytic strep.
  • ESR- erythrocyte sedimantation rate will be
    elevated in glomerulonephritis. Indicator of
  • BUN and serum creatinine levels are increased in
    kidney disease.
  • Serum electrolytes- will be elevated in kidney
  • UA- blood and protein in the urine, 24 hour urine
    and creatinine
  • KUB to evaluate kidney size, kidney scan or

  • No specific drug tx for glomerulonephritis.
  • Glucocorticoids such as prednisone.
  • Penicillin or other antimicrobials for infection.
  • Antihypertensives and diuretics to lower BP and
    to reduce edema
  • NSAID for patients with nephrotic syndrome to
    reduce inflammation.

Dietary Management Glomerulonephritis
  • Sodium intake is restricted.
  • Dietary proteins may be increased when protein is
    being lost in the urine/if azotemia is present
    dietary protein is restricted.
  • When protein is restricted complete proteins such
    as meat, fish, eggs, soy or poultry should be
    given these supply all the essential amino acids
    required for growth and tissue maintenance.

Nursing- Health Promotion
  • Advise to the effective treatment of
    streptococcal infections in all age groups.
  • Complete the full course of antibiotic therapy to
    eradicate the bacteria.
  • Effectively managing diabetes, treating
    hypertension and avoid drugs and substances that
    are potentially damaging to the kidneys.
  • Changes in urine output, rising serum creatinine
    and BUN levels should be reported to charge
  • Monitor for increased wt, increase in blood
    pressure or edema

Nursing Diagnosis
  • Excess fluid volume related to plasma protein
    loss and sodium and water retention.
  • Risk for infection r/t medication regeime
  • Risk for imbalanced nutrition less than body
    requirements related to anorexia
  • Deficient knowledge Glomerulonephritis related
    to lack of information
  • Anxiety related to prescribed activity restriction

Renal Calculi
The Client with Urinary CalculiObstructive
  • Urolithisasis
  • development of stone in urinary system
  • nephrolithiasis - stone in kidney
  • Most common in US- Kidney.
  • formed by crystals - calcium, magnesium, uric
  • Clinical Manifestations
  • depends on where stone is
  • Renal colic- Pain from obstructed urine flow,
    tissue damage, distention and rough edged stone.
    Discussion, book.
  • CVA-

The Client with Urinary Calculi
  • Diagnosis
  • KUB, IVP, Renal Ultrasound, UA
  • Treatment
  • Pharmacology Vital! - narcotic analgesic - M.S.,
    demerol, after analysis- thiazide diuretics for
    ca stones reduce urinary calcium excretion, can
    prevent future stones.
  • Dietary - increase fluid 3 liters/day, reduce
    calcuim and uric acid intake. Foods that lower
    the urinary pH. Acidic! Discussion.
  • Risk Factors personal or family history,
    dehydration, excess calcium, oxalate or protein
    intake, gout, hyperparathyroidism or urinary
    stasis, immobility(calcium out of bone into the

Types of Calculi
Pathophysiology- Calculi-(Stones)
  • Stones are masses of crystals formed from
    materials normally excreted in the urine.
  • Most are made of calcium
  • Stones form when a poorly soluble salt (calcium
    phosphate) crystallizes.
  • When fluid intake is adequate, no stone growth
  • Stone development is also affected by the pH of
    the urine and the naturally occurring compounds
    that inhibit stone development.

The Client with Urinary Calculi
  • Treatment
  • Surgery
  • lithotrispy
  • crushing of calculi
  • cystoscopy
  • Nursing Care
  • Pain management
  • Altered Urinary Elimination - strain urine,
    patent catheter tubing

Kidney Stones
  • An abnormal dilation of the renal pelvis and
  • Results from urinary tract obstructions or
    vesicoureteral reflux. (backflow of urine from
    bladder to ureters)
  • When urine outflow is obstructed pressure in the
    renal pelvis increases and it dilates. The
    nephrons and collecting tubules may be damaged
    thus affecting kidney function.
  • CM- Acute renal failure may develop. Discussion.
  • Diagnosed by ultrasound or CT scan. Cystoscopy to
    identify the cause.

  • Prompt treatment is vital to preserve kidney
  • Reestablishing urine flow from the affected
  • Nephrostomey tube, ureteral stent or indwelling
    catheter may be required.
  • Stents- used to keep ureters open and promote
    healing, surgery or cystoscopy. Temporary or
    longer periods if necessary.

Nursing Care Hydronephrosis
  • Preventing hydronephrosis and ensuring urinary
  • Monitor intake and output
  • Monitor bladder emptying to identify impaired
    urine outflow. Pelvic or abdominal tumors,
    urinary calculi, adhesions and scarring from
    previous surgeries or neurologic deficits.

Bladder tumor (Congenital disorders)
Bladder Cancer
The Client with Urinary Tumor
  • Bladder most common site. 10th cause of cancer
  • Death.
  • Risk Factors
  • gt50 years old
  • male
  • cigarette smoking
  • Chronic inflammation of the bladder.
  • Symptoms - painless hematuria, urgency and

  • Most are polyp like structures attached by a
    stalk to the bladder mucosa. Superficial or
  • Prognosis for full recovery is good.
  • Metastasis to pelvic lymph nodes. Lungs, bones
    and liver are common.
  • Kidney tumors anywhere in the kidney invade the
    renal vein. Often metastasized to other organs
    include brain.

The Client with Urinary Tumor
  • Diagnosis
  • UA for cytology
  • IVP, Renal Ultrasound, CT Scan, Cystoscopy with
  • Treatment
  • Pharmacology - chemotherapy
  • Radiation therapy
  • Surgery

The Client with Urinary Tumor
  • Surgery
  • cystectomy - removal of bladder
  • ileal conduit - creation of urinary diversion
  • portion of ilium from small intestine is formed
    into a pouch the end brought to skin surface to
    form a stoma
  • wears a pouch, empty frequently
  • good skin care
  • urine has mucous flecks

Stoma for ileal conduit
Radical nephrectomy
  • Removal of the affected kidney and surrounding
  • Open technique to allow inspection of surrounding
  • HP- No smoking!!, UA and cytology
  • Assess painless hematuria!

Nursing Care - Review
  • Urinary Tract infections?
  • Signs/symptoms, diagnostic studies, treatment
  • Renal Calculi?
  • Bladder Cancer?

The Client with Urinary Retention
  • Occurs when bladder does not fully empty
  • Benign prostatic hypertrophy
  • 25-50cc considered overflow
  • leads to UTI
  • Treatment
  • catheterization - intermittent or indwelling
  • Cholinergic meds - urecholine

Benign Prostatic Hypertrophy
The Client with Neurogenic Bladder
  • Spinal Cord injury
  • frequent spastic contraction of the bladder
  • involuntary bladder emptying
  • Treatment
  • self catheterization
  • surgery - urinary diversion

The Client with Urinary Incontinence
  • Impaired bladder control
  • impacts skin breakdown, infections, rashes,
    embarrassment, isolation, withdrawal, depression
  • Stress - associated with intrabdominal pressure
  • Urge - cant inhibit flow long enough to reach
  • Overflow - inability to fully empty bladder,
    over-distended and loss small amounts of urine
  • Reflex - involuntary loss of large amount
  • Functional - physical or environmental

The Client with Urinary Incontinence
  • Treatment
  • Correct underlying problem - cysocele,
    urethrocele, enlarged prostate gland
  • Toileting schedule
  • to bathroom
  • diaper change

Polycystic Kidney Disease
Polycystic Kidney Disease
  • Hereditary disease in which cysts form on the
    kidneys, the kidneys enlarge and their function
    is gradually destroyed.
  • Common affects children and adults.
  • Cysts in the nephrons microscopic to several
    centimeters in size, they destroy functional
    kidney tissue.
  • Adult is slow and progressive, CM in 30-40.
  • CM- flank pain, micorscopic or frank
    hematuria,proteinuria, polyuria, nocturia. UTI
    and stones are common. Hypertension and renal
  • DX- Renal ultrasound. Tx- fluids, Ace inhibitors,
    preserve kidney function avoid UTIs. Will have
    renal failure and need dialysis or kidney
  • Offspring of clients with polycystic kidney
    disease have 50 chance of of inheriting the
    disorder. Genetic counseling!

Renal Failure
  • Kidneys are unable to remove accumulated waste
    products from the blood.
  • Acute
  • Chronic or end stage chronic
  • Azotemia and fluid and electrolyte and acid-base
    imbalances are the defining characteristics.

  • Acute renal failure is a rapid decline in renal
    function with an abrupt onset.
  • Often reversible with prompt treatment.
  • 10,000 affected per year in the US
  • Risk factors Critically ill, major trauma,
    surgery, infection, hemorrhage, severe heart
    failure, lower urinary tract obstruction.

Pathphysiology ARF
  • Common cause
  • Ischemia of the kidney
  • Nephrotoxins- agents that damage kidney tissue.
  • Prerenal- Most common results from conditions
    that affect the blood supply to the kidney.
    Hemorrhage. Shock or heart failure.
  • Intrarenal- damage to the nephrons by
    inflammation (acute glomerulonephritis, HTN)
  • Postrenal- obstruction of urine outflow. (calculi
    or urethral obstruction).

  • Oliguria less than 400 mL per day.
  • Increased BUN and creatinine levels.
  • GFR falls, tubular cells become necrotic and
    slough and the nephron is unable to eliminate
    wastes effectively. ATN
  • ATN
  • Initiation phase-hrs to days, initiating event.
  • Maintenance phase- sharp drop in GFR. 1-2 weeks.
    Azotemia, edema, anorexia, oliguria
  • Recovery phase- improving kidney function,UO
    increases, may last one year.

Chronic Kidney DiseaseChronic Renal Failure
  • Slow gradual process of kidney destruction.
  • May go on for years as nephrons are destroyed and
    functional kidney tissue is lost.
  • Eventually the kidney is unable to excrete
    metabolic wastes and regulate fluid and
    electrolyte balance, this is ESRD. Which is the
    final stage of chronic renal failure.
  • Highest in African Americans.
  • Diabetes is the leading cause of ESRD,
    hypertension, glomerulonephritis.

  • Nephrons are destroyed by disease, those that
    remain hypertrophy to compensate for the lost
    tissue. The increased demand on these nephrons
    increased their risk for damage and destruction.
  • Stage1- free of symptoms, early stage
  • Stage2- GFR falls sightly
  • Stage3- GFR decreased moderately
  • Stage4- uremia symptoms develop- transplant or
    dialysis are necessary.

  • Uremia- nausea, apathy, weakness, fatigue.
  • Vomiting, lethargy and confusion
  • Cardiovascular disease is the leading cause of
    death in client with chronic kidney disease, HTN
    is common.
  • Most meds are excreted by the kidneys.
    Antihypertensive drugs are used to decrease BP
    Lasix and ACE inhibitors.
  • Fluids and sodium intake are restricted. CHO are
    increased. TPN may be initiated.

Renal replacement Therapy
  • Dialysis- Diffusion of solutes across a membrane
    from an area of higher concentration to one of
    lower concentration.
  • Used to remove excess fluid and waste products in
    renal failure.
  • Blood is separated from a dialysis solution by a
    semipermeable membrane. Water and solutes such
    as urea and electrolytes diffuse across this
    membrane, but proteins do not.
  • Dialysis compensates for the kidneys inability to
    eliminate excess water and solutes.
  • 2 or 3 sessions per week. Outpatient center.

  • Hemodialysis- Electrolytes, waste products and
    excess water are removed from the body by
    diffusion and filtration. The clients blood is
    pumped through a dialyzer.
  • Peritoneal Dialysis- The peritoneum serves as the
    dialyzing surface. Warmed dialysate is instilled
    into the peritoneal cavity through a peritoneal

Case Study
  • A 82 year old male resident in a nursing home who
    is usually talkative and out-going stays in his
    room during lunch. The nurse notices while
    administering his medications that he appears
    listless and is slightly confused about the date.
  • Assessment reveals that he has slight tenderness
    in the right flank areas. He states he is tired
    and does not feel like eating. Vital signs are T
    99 P 88 R 20 B/P 118/62

  • The nurse asked him to void in a cup. The client
    has some difficultly urinating and stands to
    void. He voids 90mls of dark yellow concentrated
    urine, it is cloudy and has a strong odor.
  • The nurse instructs him to
  • The nurse then

  • UA results are
  • Color yellow
  • S.G. 1.030
  • pH 7
  • Glucose negative
  • Ketones moderate
  • RBC 10
  • WBC 10
  • Bacteria moderate/ could be contamination
  • Nitrates- moderate- Always indicates infection

  • What findings are considered abnormal?
  • What about a C S?
  • Treatment?

  • Nursing Care- discussion
  • Kidney transplant- discussion
  • Fistula or graft for hemodialysis.
  • Differences from hemodialysis and peritoneal

  • A client is diagnosed with chronic
    pyelonephritis. The nurse realizes that this
    client is prone to developing
  • A. cystitis
  • B. chronic renal failure
  • C. acute renal failure
  • D. renal calculi

  • A male client comes into the emergency department
    with symptoms of renal colic. The nurse realizes
    that this client most likely has a calculi that
    is obstructing the
  • A. renal pelvis
  • B. bladder
  • C. ureter
  • D. urethra

  • A male client has a history of calcium calculi.
    Which of the following medications can be
    prescribed to help this client?
  • A. furosemide (Lasix)B. chlorothiazide (Diuril)
  • C. allopurinol (Alloprim)
  • D. NSAIDs

  • While being catheterized for urinary retention,
    the client becomes diaphoretic and pale. Which
    of the following can be implemented to help this
  • A. Nothing, this is a normal response
  • B. Provide the client with fluids
  • C. Clamp the catheter after draining 500cc of
  • D. Pull the urinary catheter

  • Three weeks after being treated for strep throat,
    a client comes into the clinic with signs of
    acute glomerulonephritis. Which of the following
    manifestations will the nurse most likely find
    upon assessment of this client?
  • A. periorbital edema
  • B. hunger
  • C. polyuria
  • D. polyphagia
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