Nursing Care of Patients with Genitourinary Problems

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KUB
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General diagnostic study: x-ray of the kidneys, ureter, and bladder – no contrast needed.
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Intravenous Pyelogram (IVP)
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General diagnostic study: Injection of contrast (can be nephrotoxic), and then films are taken sequentially; visualizes the entire urinary tract.
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Ultrasound, CT scan, MRI
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General diagnostic study: looks at structure.
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Arteriogram
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General diagnostic study: visualize the renal blood vessels.
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Cystogram
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General diagnostic study: visualize the bladder and evaluate vesicoureteral reflux.
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Cystoscopy
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General diagnostic study: Direct visualization of the urethra and bladder.
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Cystometrogram (CMG)
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General diagnostic study: evaluates neuromuscular function of the bladder; fluid is instilled in the bladder and pressure readings are taken.
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Urinary Flow Study
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General diagnostic study: Measures the volume voided over a time period (ml/second); assess amount of outflow obstruction and bladder or sphincter dysfunction.
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Urinalysis
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General diagnostic study: Physical, chemical, and microscopic analysis of urine; helpful to diagnose renal disease, UTI, and metabolic disorders; proteinuria is a sensitive indicator of renal disease.
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Agenesis
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Structural abnormality: complete failure of organ development.
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Dysgenesis
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Structural abnormality: failure of the organ to develop normally.
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Hypoplasia
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Structural abnormality: failure to develop to the normal size.
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Extrophy of the Bladder
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Structural abnormality: the bladder is essentially inside out and the inside is exposed on the outside towards the abdomen.
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Ambiguous Genitalia
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Structural abnormality: external genitalia appearance not typical for either sex.
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Hypospadias
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Structural abnormality: urethral opening not at the tip of the penis; commonly seen with chordee (abnormal downward curve of penis); surgical revision is often required; circumcision is not recommended.
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Epispadias
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Structural abnormality: urethral opening not at the tip of the penis; commonly associated with extrophy of the bladder; surgical revision is often required; circumcision is not recommended.
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Hydrocele
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Structural abnormality: collection of serous fluid around the testicles; scrotum is smaller in the morning and larger at the end of the day; surgery required if not resolved spontaneously by 1 yr.
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Hydrocele: non-communicating
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Structural abnormality: processus vaginalis obliterated and fluid is gradually absorbed.
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Hydrocele: communicating
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Structural abnormality: processus vaginalis remains open so peritoneal fluid is forced into the scrotum with increased intrabdominal pressure and gravity.
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Vesicoureteral Reflux
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Structural abnormality: urine goes back up the ureters and sometimes to the kidney; if it reaches the kidney it can cause infection, scarring, renal damage; Grades I-V (graded by how far up the urine goes), lower grades may resolve with growth.
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Vesicoureteral Reflux: Treatment and Diagnosis
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General treatment includes prophylactic (low-dose) antibiotics; higher grades require surgery to minimize renal damage; diagnosed with renal ultrasound, x-ray, and voiding cystourethrogram.
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Polycystic Kidney Disease (PKD): 1. Autosomal recessive – present at birth (rare); 2. Autosomal Dominant – most common, affects children and adults.
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Structural abnormality: Multiple cysts grow on the kidneys increasing the size and interfering with function; symptoms of AD type don’t usually appear until 30-40 yoa; can affect organs other than kidneys (liver and pancreatic cysts, abnormal heart valves, cerebral aneurysms, diverticulosis); diagnosed by ultrasound, CT/MRI, genetic testing.
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Renal Stones (Calculi): Urolithiasis – stones in the urinary tract; Nephrolithiasis – stones in kidney
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Obstructions: Most common in men 20-55 yoa (4:1); stones made of calcium are the most common; Risk factors: family hx, dehydration, excess Ca+/protein, sedentary; Manifestations: kidney – dull aching flank pain, ureter – pain radiating to suprapubic area*n/v*pallor*cool clammy skin*hematuria, bladder – dull suprapubic pain*hematuria.
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Renal Stones: Unrelieved Obstruction
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Obstructions: can cause hydroureter, hydronephrosis; S/sx – colicky flank pain (may radiate to groin), hematuria, fever, n/v, abdominal pain; Dx with x-ray, ultrasound, IVP, CT/MRI; Tx – let stones pass (strain urine to catch stones for analysis), stent placement to maintain urine flow, Lithotripsy – break up the stone, Cystoscopy – scope inserted via urethra and stone removed, Nephrolithotomy – incision into kidney to remove the stone, dietary modification depending on stone composition.
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Ureteral Stent
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Double-J stents have opposing “J” hooks on the ends; “J” reduces the chance of the stent migrating; end and side holes allow urine to drain all along the stent. (For kidney stones)
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Renal Stones and Stent: Nursing Care Post-Op
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Label the drainage tubes and stents if outside the body; check urine for blood (color and “diptest); strain for stones after lithotripsy.
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Renal Stones and Stent: Surgical Post-Op
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Maintain catheter patency; manage pain; strict I&O; encourage fluids; monitor for s/sx of UTI.
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Renal Stones and Stent: Nursing Care Post Stent Placement
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Monitor for bleeding, infection, flank pain; encourage regular voiding, instruct to avoid overexertion; teach s/sx of UTI; stress importance of follow-up care.
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Benign Prostatic Hypertrophy (BPH): Definition
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Prostate gland continues to grow through lifetime; not a predisposition to cancer; no correlation btwn size and symptoms
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BPH: S/sx
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Prostate gland presses against urethra and can cause: weak stream, difficulty starting voiding, starting/stopping several times, incomplete bladder emptying/dribbling, urgency, frequency, nocturia, dysuria, bladder pain; sever BPH can cause urinary retention that can lead to UTI, kidney damage, bladder stones, incontinence.
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BPH: Diagnosis
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Obstructions: Diagnosis made by: digital rectal exam, PSA (prostate specific antigen) test, transrectal ultrasound, urine flow study, cystoscopy.
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BPH Medications: 1. Dutasteride (Avodart), Finasteride (Proscar)
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Inhibits the production of the hormone DHT (dihydrotestosterone), shrinks the prostate, takes several weeks to months for full effect. Side effects: pregnant women should not handle the drug, men taking the drug should not give blood.
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BPH Medications: 2. Terazosin (Hytrin), Doxazosin (Cardura), Tamsulosin (Flomax)
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Cause relaxation of smooth muscle tone in bladder neck and urethra; rapid effect (given first).
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BPH Medications: 3. Saw palmetto – herbal supplement
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Anti-inflammatory, anti-proliferation, takes 1-2 months for effectiveness, may increase the effects of anticoagulants.
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Transurethral Microwave (TUMT)
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Microwaves heat and destroy excess prostate tissue
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Transurethral Needle Ablation (TUNA)
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Low-level radio-frequency energy burns away tissue.
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Transurethral Resection of the Prostate (TURP)
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Prostate tissue cut away.
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Laser Surgery
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Vaporizes prostate tissue.
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Nursing care after BPH surgery
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Maintain catheter patency (NS continuous bladder irrigation – subtract from output; encourage fluid intake; traction); bladder spasm – give belladona and opium suppository first, then pyridium; educate that sexual function may take up to a year to fully return, retrograde ejaculation may occur (drink plenty of fluid and it will wash out).
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Bladder Cancer: Risk Factors
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Smoking, chemical exposure, cytoxan, pelvic irradiation, chronic/recurrent stone, lower UTIs.
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Bladder Cancer: Manifestations
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Hematuria, frequency, urgency, dysuria, incomplete emptying
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Bladder Cancer: Diagnosis
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Urine for cytology; Intravenous Pyelogram (IVP) – including retrograde; cystoscopy.
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Bladder Cancer: Treatment
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Transurethral resection of the bladder tumor (TURBT); radiation and chemo; laser; cystectomy: partial/radical; Incontinent urinary diversion: ileal conduit; continent urinary diversion: Kock’s pouch; clean intermittent self-catheterization.
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Ileal Conduit
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A small section of the ileum is connected to the ureters and then a stoma is made. An ostomy bag is attached to the stoma.
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Kock’s Pouch
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A pouch made from the ileum that is then connected to the outside of the body with a small stoma. The pouch holds the urine and the patient will cath the stoma to release the stored urine.
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Bladder Cancer: Post Op care
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Standard post-op care; monitor for DVT; monitor for paralytic ileus; increase fluid intake (intestine still secretes mucous); meticulous skin care around stoma; keep urine acidic; teach self-cath, maintenance, and s/sx of infection.
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Urinary Tract Infections (UTI)
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Usually caused by gram-negative bacilli found in the GI tract; nosocomial UTIs are usually caused by E. coli; majority in women; also in older men and girls.
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UTI: Cystitis (inflammation of the bladder)
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Most common; manifestations: frequency, urgency, suprapubic pain, foul-smelling urine, pyruia, hematuria, dysuria; Asymptomatic: usually in the elderly – manifest as nocturia, new incontinence, confusion, change in behavior, lethargy, anorexia.
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UTI: Cystitis – Diagnosis
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urinalysis, gram stain, C&S
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UTI: Cystitis: Treatment
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3 days of trimethoprim-sulfamethoxazole (Bactrim, Septra); teach female patients proper hygiene after toileting, increase fluid intake, importance of urinating after intercourse.
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Pyleonephritis (acute)
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Inflammation of the renal pelvis and parenchyma. Ascends from the lower urinary tract (caused most often by E. coli), may be a preexisting factor, destruction of kidney tissue can occur from fibrosis and scarring.
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Pyleonephritis: Manifestations
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Chills, fever, malaise, vomiting, flank pain, urgency with pain and burning.
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Pyelonephritis: Diagnosis
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urinalysis, C&S, CBC with differential, blood culture.
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Pyelonephritis: Treatment
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7 days of oral fluroquinolone (Cipro)
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Urosepsis
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Bacteriuria and bacteremia – goes into the blood; can lead to spetic shock if not promptly diagnosed. (Have to use nephrotoxic anti-infectives).
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Glomerulonephritis: definition
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Most caused by immune mechanisms – injury from antigen, antibodies, and complement in the glomeruli causing an inflammatory reaction – Increased capillary permeability from inflammation allows proteins to cross and be excreted.
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Glomerulonephritis: Characterization and s/sx
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Commonly caused by group A B-hemolytic streptococcus infection; occurs 1-3 weeks after strep infection; s/sx: cola-colored urine (protein and RBCs in the urine), decrease in the GFR (oliguria and azotemia); hypertension, edema.
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Glomerulonephritis: Treatment
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Acute symptoms subside in 2 weeks; most recover – some may develop chronic glomerulonephritis or renal failure; diuretics, anti-hypertensives, low-protein, low-sodium, low-fluid diet.
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Nephrotic Syndrome: Definition
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Can be a primary disorder or secondary to another Dx (DM, Systemic lupus erythmus). Damage to the glomerular membrane causing increased capillary permeability; hyperlipidemia caused by liver compensating to increase albumin production. Can disrupt the coagulation system leading to DVT, renal vein thrombosis, PE.
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Nephrotic Syndrome: S/sx
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Generalized edema (loss of serum albumin reduces the ability to maintain normal colloid osmotic pressure) – can become severe enough to cause ascites and anasarca; massive proteinuria; lipiduria; hypoalbuminemia; altered immune response puts patient at risk for infection.
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Nephrotic Syndrome: Treatment
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Cure or control primary disease; relieve edema (diuretics, ACE inhibitors, steroids, low Na+ diets, low-protein diet); lipid-lowering drugs; anticoagulation therapy.

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