Adult Genitourinary Disorders and Nursing Interventions

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Urine Formation
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glomerular
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Electrolyte balance
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tubular reabsorption by diffusion NA
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acid base balance
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tubular secretion, K, and H
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Renin
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vasoconstriction
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Prostaglandin
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go to site of injury or trauma
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Bradykinin
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vasodilate
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erythropoietin
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RBCs
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Vitamin D
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calcium uptake
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capsule
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fibrous tissue covering outer surface of kidney except for the hilum
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hilum
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the opening where vessels, nerves, and ureters exit
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medulla and cortex
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2 layers of functional kidney tissue
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pyramids
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Medulla fans into _____.
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Renal columns
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_____ _____ separated pyramids
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papillae
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tip of each pyramid
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major & minor calyx
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collect urine at end of each papillae, form together which narrows to make the renal pelvis then becomes the ureters
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Nephron
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form urine from blood – 2 types 1. Cortical – shorter and located in the renal cortex 2. juxtamedullary – makes up 20% of nephrons, loner, and extend deep in the medulla and function to concentrate urine in times of low urine
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Papillae
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drain urine into collection side
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Ureter
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pathway for urine to travel to bladder
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Assessment Nursing Hx
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1. Demographics ( 2. SES 3. Nutrition history 4. medications (prescriptions and OTC) 5. Evirnonmental exposures 6. previous kidney or urologic problems
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Physical Assessment
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1.Neurocognitive – memory, LOC, alertness may all be altered in geriatric patients with UTIs 2. Integumentary – reflection of fluid volume status; rashes, bruising, yellowing 3. Respiratory- reflection of fluid volume status 4. renal/GU: costovertebral angle tenderness, i&o’s comparison, bladder distension, urinary symptoms including: frequency, urgency, dysuria (pain when pee) 5. musculoskeletal- electrolytes 6. psychosocial – coping and support
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Kidney changes associated with aging
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1. reduced blood flow to kidneys 2. thickened glomerular and tubular basement membranes 3. decreased tubule length 4. decreased glomerular filtration rate 5. nocturnal polyuria 6. risk for dehydration
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medulla
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what is the only structure in the kidney that does not change with aging?
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Bladder
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w/ aging it has decreased capacity – it weakens – loss of urinary sphincter tone
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Urinary stasis
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incomplete bladder emptying
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enlarged prostate
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W/aging men will have an _______ ______.
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pessary
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W/ aging women will have cystocele and prolapse (decreased elasticity and tone of pelvic floor) shorten the urethra. they will need a ______ to support the bladder.
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Urethra changes with aging
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1. hypo-estrogenic states in older women adversely effects vagina and urethra due to atrophy, making them more susceptible to infections.
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Prostate gland changes with aging
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– enlargement causes urinary retention and difficult initiating urinary stream
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Urinary Tract Infections
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Can get urethritis, cystitis, prostatitis, or pyelonephritis – most common in women r/t urethral proximity to rectum – 90% caused by E. coli – less commonly caused by staphylococcus saprophytic, klebsiella pneumoniae, proteus and enterobacter species
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Symptoms of UTI
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1. painful burning post micturition (dysuria) 2. frequency and urgency 3. pelvic pain 4. fever 5. in elderly: confusion/ams 6. pregnant pts. my or may not have symptoms
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Assessment of Urine in a UTI
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will be 1. olfactory: malodorous 2. visual – concentrated, cloudy, hematuria (bloody)
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UTI Presentations in Elderly Pop.
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Will have behavioral symptoms 1. altered mental status 2. confusion 3. dizziness 4. falls 5. hallucinations 6. fatigue 7. lethargy
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may not
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In pregnant patients with a UTI, you may or _______ ______ see signs on a UTI
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Nursing Role w/Urinalysis (UA)
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1. clean catch (wipe, start stream, get pee) 2. catheterized – straight in and out catheter – indwelling catheter 3. 24 hr urine – interpret and understand UA
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Assessment of UA
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1. color, odor, turbidity 2. specific gravity should be: 1.005 – 1.030 3. pH should be around 6 4. glucose 5. ketone bodies 6. protein – should be minimal 7. leukoesterase (pyuria) – if + = infection 8. nitrites (bacteruria) – if they have e.coli will be positive 9. cells, casts, crystals, and bacteria
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pyuria
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presence of pus in the urine
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E. coli
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If a pt tests positive for nitrites (bacteria) than the patient has a UTI caused by ______.
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additional renal tests
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1. urine for culture and sensitivity (C&S) – takes 48 hrs. Tells you what kind of bacteria and they have and what kind of med they are sensitive to 2. composite urine culture 3. creatinine clearance – best indication of overal kidney function 4. Urine electrolytes 5. urine osmolarity – concentration 6. bedside sonography/bladder scanners 7. imaging assessment – CT ( with no contrast)or MRI
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dye
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If the patient is getting a CT for any renal tests, then never do ______ on it b/c can make infection worse.
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creatinine clearance
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The best indication of overall kidney function is ______.
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Cystitis
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inflammation of the bladder commonly caused by opportunistic bacteria moving up the urinary tract from external urethra to bladder due to foley catheter
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high risk
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Foley catheters present a _______ _______ for developing nosocomial cystitis.
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Intestinal Cystitis (IC)
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chronic inflammatory not infectious – pt’s will void 60 times daily (more intense urinary preceding urination) – suprapubic or pelvic pain sometimes radiating to the groin, vulva, or rectum – voiding relieves – results from urinalysis and urine culture are negative for infection
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Treatment for Cystitis
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– chronic ongoing symptom management in clinic and prevention of exacerbation – pt. education : 1. drink water 2. avoid 4 C’s – caffeine, coffee, citrus, and chocolate – can be one or all that trigger inflammatory response
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Vesicoureteral Reflux
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– the backwards flow of urine from the bladder into the kidneys (retrograde flow) – causes excruciating pain – symptoms like those of UTI
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who is at increased risk for vesicoureteral reflux
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patients that are chronically lying on the supine position and those that have a genetic link
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Diagnosis of Vesicoureteral Reflux
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1. radiology study 2. voiding cystouretholgram (VCUG) – study done 3-6 wks after active infection resolved
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Pyelonephritis
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bacterial infection in kidney and renal pelvis (upper urinary tract)
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Acute symptoms of Pyelonephritis
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1. fever 2. chills 3. tachycardia 4. tachypnea 5. flank back or CVT loin pain 6. nocturia 7. abdominal discomfort 8. n/v 9. urinary retention and frequency 10. general malaise or fatigue 11. Hx of recent cystitis
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UTI & Pyelonephritis Nursing Management
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1. for acute voiding pain – pyridium 200 mg PO TID prn ( educate that it turns pee neon orange or red) 2. for acute infection – bacterium DS160 mg, trimethoprim 800 mg, sulfamethoxazole BID x 3 days or ciprofloxacin 250 mg PO BID for 7 days
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Long Term Treatment for UTI and Pyelonephritis
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Minimize risk to the kidney 1. avoid/minimize NSAIDs 2. renal dosing of medications 3. avoid contrast dyes 4. limit dietary protein 5. optimize calorie nutrition 6. increase fluid intake
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Client Education
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1. Increase fluid intake to increase fluid volume 2. urinate with regular frequency – void at first urge 3. complete emptying of bladder 4. Perineal hygiene (females wipe from front to back) 5. void after intercourse ( post-coital micturition) 6. avoid bubble bathes – irritants 7. cranberry juice, apple cider vinegar good for urinary pH
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Urosepsis
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life threatening (20-40% mortality) infection originated in the urinary tract (uro) that spreads to the blood stream (sepsis)
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Populations susceptible to Urosepsis
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1. old 2. DM 3. Immunosuppressed pts. ( transplant recipients, long term steroid use for RA)
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Causes of Urosepsis
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1. congenital- ureteric or urethral strictures, polycystic kidney disease 2. acquired – calculi, prostatic hypertrophy, tumors of the urinary tract, trauma, pregnancy, radiation therapy 3. instrumentation – indwelling catheter, ureteric stent, nephrostomy tube, urological procedures
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Prostatitis signs and symptoms
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Acute onset and accompanied by all or some flu-like symptoms 1. fever 2. chills 3. malaise 4. N/V/Anorexia 5. dysuria 6. frequency 7. urgency 8. pain (low back, perineum, upper thighs)
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Benign Prostatic Hypertrophy (BPH)
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– common urological condition in aging males over 50 yrs of age
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Etiology of Benign Prostatic Hypertrophy
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-advancing age – functioning testicles – androgen production contribute to the development of the disorder
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Symptoms of Benign Prostatic Hypertrophy
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-urgency & frequency of urination – abdominal straining to be able to empty bladder – dysuria, nocturia due to incomplete bladder emptying – impairment of size and force of stream – terminal dribbling
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Diagnosis of Benign Prostatic Hypertrophy
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prostatic specific antigen (PSA) < 4.0 mg/mL is normal, trend is more significant
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Transurethral Resection of Prostate (TURP) Nursing Management
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1. treats benign prostatic hypertrophy 2. monitor I&Os: 1-2 hours – hematuria fades to pink with 3 way irrigation 3. Measure BP and HR b/c hypotension or tachycardia may be a sign of excessive blood loss 4. Preform gentle irrigation with saline solution through urinary catheter if blood clots 5. remover urinary catheter by 72 hrs – measure and asses UOP q 4 hrs 6. encourage intake of 2-3 L of fluids daily to relieve initial dyspnea & resolve hematuria b/c body needs to do flushing 7. manage pain & dicomfort ass. w. bladder distention, irrigation from the catheter, or irrigation solution or bladder spasm 8. manage bladder spasm with belladonna suppositories – smooth muscle relaxants 9. minimize catheter manipulation and promote rest
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Alternative Benign Prostatic Hypertrophy
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– at this point, TURP is being used for patients with BPH, but there is a large shift in using penile implants instead – Flomax is used in the beginning
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Urolithiasis
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stones in urinary tract – different types depending on location 1. Nepholithiasis – kidney stones 2. ureterolithiasis – stone in ureter 3. Cystolithiasis – stone in bladder *** stones will harbor bacteria
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urolithiasis Pharm Treatment
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1. pain relief measures 2. drug therapy 3. CAM therapies
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Urolithiasis Treatment
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1. Lithotripsy 2. Surgical management: A. Laparoscopic – minimally invasive B. Exploratory or Open Removal – open surgical procedures
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Urolithiasis Assessment
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1. Health Hx & Physical Assessment
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Urolithiasis Symptoms
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1. flank pain (CVA area) radiating to groin area 2. urine color change – resembles coca-cola 3.
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Urolithiasis Diagnostic
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– Imaging studies: Non-contrasted (no dye) CT scan of abdomen and pelvis – sterile urinalysis and culture – 24 hr urine stone analysis – +/- UTI presence – serum (blood) test – BUN and Creatinine
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Laboratory Assessment
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– a reflection of kidney function – kidneys filter waste products normally found in blood – serum creatinine normal range: 0.5 – 1.5 mg/dL – Blood Urea Nitrogen: 5-25 mg/dL
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Normal Blood Urea Nitrogen Count
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5-25 mg/dL
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Increased levels of BUN > 25
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indicates kidney impairment
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decreased levels of BUN < 5
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can be caused by decreased muscle mass
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Kidney Function
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to filter waste products normally found in blood
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Serum Creatinine Normal Range
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0.5 – 1.5 mg/dL
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Male’s Normal Uric Acid
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3.5 – 8.0 mg/dL
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Female’s Normal Uric Acid
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2.8 – 6.8 mg/dL
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Nursing Management of Urolithiasis
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1. Pain Management – opioids 2. Infection Prevention – increase fluids to decrease urinary stasis, dilute urine and pass stone 3. Urinary Obstruction Prevention – may include alpha blocker (ie. Flowmax – relaxes ureter and promotes stone secretion 4. Future stone prevention / Risk reduction – diet decrease oxalate containing foods (spinach, chocolate, iced tea, nuts, coffee, soy, selected fruits and vegetables 5. Patient/Family teaching n non-surgical vs. surgical management of stones 6. strain urine – catch stone and save for urinalysis 7. stone evaluation – type of stone guides management
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Flomax
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In treatment of urolithiasis, ________ relaxes the ureter and promotes stone secretion
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Lithotripsy
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uses sound, laser, or dry shock wave energy to break stones not small fragments – patient undergoes conscious sedation – topical anesthetic cream applied to skin site – continuous ECG monitoring
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Most common cause of urethritis in males
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1. STIs- Gonorrhea or chlamydia
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Most common cause of Urethritis in females
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– post-menopausal women caused by tissue changes related to low estrogen
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Treatment of urethritis in males
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1. ceftriaxone 250 mg IM 2. Azithromycin 1 G PO single dose
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Treatment of urethritis in females
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– estrogen vaginal cream – Premarin 1% syringe intravaginally at bedtime
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Noninfectious Urethritis
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caused by urethral structure from trauma from urethral stent placement or catheter trauma
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Treatment of noninfectious Urethritis
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– Surgical removal of affected area with or without a graft
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Types of urinary incontinence (4)
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1. Stress incontinence 2. urge incontinence 3. overflow/reflex incontinence 4. functional incontinence
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urinary incontinence
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– leakage of drainage related to bladder or sphincter dysfunction
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Stress incontinence
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– caused by sneezing, coughing, laughing, jumping jacks – most common type post part – weakened pelvic flood muscles cannot tighten the urethra enough to overcome the increased bladder pressure caused by contraction of the detrusor muscles
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Urge incontinence
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involuntary spasm of detrusor muscles, AKA overactive bladder
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Overflow/reflex incontinence
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– mechanical obstruction from enlarged prostate or bladder prolapse in women
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Functional incontinence
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– CNS disorder leading to neurogenic bladder (damage to nerves innervating the urinary bladder) – occurs in spina bidifa and dementia
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Nursing Management of Incontinence
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1. voiding dairy- may help guide management 2. behavioral interventions – timed and double voiding 3. medications- timing of diuretics 4. pelvic flood strengthening – kegel exercises 5. Nutrition – avoid bladder irritants (spicy and acidic foods, chocolate) 6. Fluids (type and timing) – avoid caffeinated beverages, stop fluid intake at least 2 hours before bedtime 7. hygiene and personal care – depends, undergarment 8. psychosocial impact – resources and support
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Urothelial Cancer
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– malignant tumors of urtothelium (lining of the transitional cells in kidney, renal pelvis, ureters, urinary bladder, and urethra – testicular cancer = rare – prostate cancer = common
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Symptoms of urothelial cancer
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1. hematuria – may be pink, red, or cola colored 2. back pain just below the ribs that doesn’t go away 3. wt. loss (w/o trying) 4. fatigue 5. intermittent fever
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Polycystic Kidney Disease
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– genetically acquired autosomal dominant – more common in white ppl
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Polycystic Kidney Disease characterized by:
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1. multiple cysts in nephrons 2. compromised function 3. larger than average kidneys
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rupture
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With polycystic kidney disease, there is a high risk for _________ of the cysts leading to bleeding and infection.
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HTN
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If a polycystic patient has ______, it must be under control.
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Most common complication of polycystic Kidney Disease
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Chronic UTIs
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Most serious complication of polycystic Kidney Disease
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end stage renal disease
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decrease
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With polycystic kidney disease as cysts enlarge there is a ____ in kidney function.
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Polycystic Kidney Disease Signs and Symptoms
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1. Abdominal or flank pain (1st manifestation) 2. distended abdomen or increased abdominal girth 3. bloody/cloudy urine 4. constipation 5. nocturia 6. HTN 7. kidney stones
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Nursing Care of Polycystic Kidney Disease
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1. BP daily 2. Take temp if pt. feels feverish 3. daily weights 4. dietary restriction of NA and protein 5. if urine small foul, notify provider 6. visual disturbances or HA , notify provider 7. prevent constipation – 2500 ml/ 24 hrs 8. exercise 9. increase fiber intake
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Glomerulonephritis
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– inflammation of glomerular – acute or chronic – streptococcal pharyngitis – causes by a variety of disease entities – Immunological reaction – causing inflammatory changes in glomerular structure = decreased GFR, edema, HTN – scar tissue replaces glomerular tissue causing irreversible damage
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Signs and Symptoms of Glomerulonephritis
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1. generalized edema 2. decreased UOP 3. proteinuria 4. hematuria 5. increased specific gravity 6. HTN 7. elevated HUN 8. elevated Cr 9. decreased GFR 10. elevated erythrocyte sedimentation rate 11. decreased serum albumin
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Nursing Management of Glomerulonephrititis
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1. measure strict I&Os w/ daily wt. checks 2. monitor for signs and symptoms of fluid volume overload (increase BP, HR, Resp. rate, dyspnea, adventitious lung sound, 3. urine color change – cola colored, smokey reddish brown, rusty 4. may obtain 24 urine collection 5. Dialysis if fluid volume overload cannot be controlled
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Pharm Management of Glomerulonephritis
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1. Antibiotics 2. Immunosuppressants (inflammation) 3.diuretics (fluid overload)
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Diet for Glomerulonephritis
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1. Sodium restriction w/ fluid retention 2. Possible fluid restriction 3. Possible Potassium restriction 4. possible protein restriction
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Imaging Studies for future reference
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1. KUB – abdominal x-ray looking at kidneys, ureters, and bladder 2. IVP: intravenouspyelography, essentially a KUB with contrast 3. renal ultrasound 4. CT scan(w/ or w/o contrast) 5. MRI (w/ or w/o contrast) 6. cystoscopic exam with bilateral retrograde uretopyelography

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