Urinary Disorders

lab value of urine ph is
ph-4.6 to 8.0

each day the body forms 1000 to 2000ml of urine

Albumin- (albuminuria) 1.indication of possible kidney disease.
2. increased blood pressure.
3. toxicity of kidney cells from heavy metals.

Glucose- (glycosuria)
1. Indicates a high blood glucose level. Blood glucose level rises above the renal threshold and thte glucose spills into the urine.

erythrocytes- (hematuria)
1. indication of infection, tumors, or kidney disease.
Kidney stones and irritation also produce hematuria.

Ketone bodies- (ketoaciduria) or (ketonuria). occures when excessive quantities of fatty acids are oxidized. Seen with diabetes mellitus, starvation, or any other metabolic condition in which fats are rapidly catabolized.

Leukocytes.
White blood cells in urine occurs when there is an infection in the urinary tract.

750 to 1000 mL of urine.
250 mL of urine, the individual has a conscious desire to urinate.

the terminal portion of the urinary system. It is a small tube that carries urine by peristalsis from the bladder out of its external opening, the urinary meatus.

urethra is approximately 1/4 inch in diameter and 1½ inches long.

approximately 8 inches long

1.003 to 1.030
State of hydration, medications

The first voiding is discarded and the time noted at the beginning of the 24-hour urine collection. For the next 24 hours all urine is collected and placed in a special laboratory container. Common substances measured to monitor kidney function include total urine protein, creatinine, urea, uric acid levels, and catecholamines.

the patient's hydration status and gives information about the ability of the kidneys to concentrate urine. Specific gravity is decreased by high fluid intake, reduced renal concentrating ability, diabetes insipidus, and diuretic use; it is increased in dehydration due to fever, diaphoresis, vomiting, diarrhea, and medical conditions such as diabetes mellitus (diabetic ketoacidosis or hyperglycemic hyperosmolar nonketotic coma) and inappropriate secretion of antidiuretic hormone

a laboratory test used to determine the kidney's ability to rid the blood of the nonprotein nitrogen (NPN) waste and urea, which results from protein breakdown (catabolism).

10 to 20 mg/dL. For a more accurate test result, the patient should receive nothing by mouth (NPO) for 8 hours before blood sampling.

preventive nursing measures should be instituted to protect the patient from possible disorientation or seizures.

nonprotein nitrogen

which results from protein breakdown

Creatinine is a catabolic product of creatine, which is used in skeletal muscle contraction. The daily production of creatine, and subsequently creatinine, depends on muscle mass, which fluctuates very little.

Only renal disorders—such as glomerulonephritis, pyelonephritis, acute tubular necrosis, and urinary obstruction

dehydration, malnutrition, or hepatic function.

0.5 to 1.1 mg/dL (female), 0.6 to 1.2 mg/dL (male)

Levels are directly related to muscle mass and are usually measured for a 24-hour period. During the testing period, excessive physical activity should be avoided.

the onset of testing and another at the conclusion.

any deviation will alter test results

An elevation in serum levels with a decline in urine levels

serum, 0.5 to 1.1 mg/dL (female), 0.6 to 1.2mg/dL (male); urine, 87 to 107 mL/min (female), 107 to 139 mL/min (male)

Normal range is less than 4 ng (nanogram)/mL

prostate cancer, benign prostatic hypertrophy, and prostatitis.

assesses the general status of the abdomen and evaluates the size, structure, and position of the urinary tract structures. No special preparation is necessary.

explain that the procedure involves changing position on the radiography table, which may be uncomfortably firm.

tumors, calculi, glomerulonephritis, cysts, and other conditions.

structures of the urinary tract, filling of the renal pelvis with urine, and transport of urine via the ureters to the bladder.

the patient has an allergy to iodine (or iodine-containing foods such as iodized salt, saltwater fish, seaweed products, vegetables grown in iodine-rich soils) because it is the base of the radiopaque dye that will be injected into a vein for this and other radiologic examinations.

physician may order a corticosteroid or an antihistamine to be administered before testing or, as an alternative, may order ultrasonography.

a light supper, a non–gas-forming laxative, and NPO 8 hours before testing. In planning the testing regimen, the nurse should schedule urography before barium-based studies. When the dye is injected, the patient will experience a warm, flushing sensation and a metallic taste.

structural deviations, hydronephrosis, calculi within the urinary tract, polycystic kidney disease, tumors, and other conditions.

Radiopaque dye is injected through an indwelling catheter into the urinary bladder for visualization of the urinary bladder to evaluate its structure or to determine the cause of recurrent infections.

A catheter is inserted and dye injected as with the cystography to assess the status of the urethral structure.

enhance urinary output. This action is achieved by increasing the kidney's filtration of sodium, chloride, and water at different sites in the kidney.

such as heart failure and hypertension.

chemical structure, as well as the site and type of action on the kidney.

act at the distal convoluted tubule to impair sodium and chloride reabsorption, leading to excretion of electrolytes and water.

in the ascending loop of Henle to inhibit tubular reabsorption of sodium and chloride. This group is the most potent of all diuretics and may lead to significant electrolyte depletion. These diuretics are effective to use for patients with impaired renal function.

effects electrolytes to cause hypokalemia, hypochloremia, hyponatremia, hypocalcemia (abnormally low blood calcium), and/or hypomagnesia (decreased magnesium in the blood). The effect on acid-base balance is the development of hypochloremic alkalosis.

nephrotic syndrome, heart failure, and pulmonary edema. Side effects are those associated with rapid fluid loss: vertigo, hypotension, and possible circulatory collapse.

the distal convoluted tubule to inhibit sodium reabsorption and potassium secretion. Potassium-sparing diuretics decrease the sodium-potassium exchange.

in combination with other diuretics.

hyperkalemia, because further retention of potassium could cause a fatal cardiac dysrhythmia.

aldosterone antagonists and nonaldosterone antagonists

acts to block aldosterone in the distal tubule to promote potassium uptake in exchange for sodium secretion. Although it can be used in combination with other diuretics primarily in the treatment of hypertension and edema, spironolactone is most frequently used for its potassium-sparing quality.

acts directly to reduce ion transportation in the tubule, though there is little diuretic effect. Triamterene is instead used to help limit the potassium-wasting effect of other diuretics.

Holds on to potassium. It Block the aldactone receptors in the distal convoluted tubles where they interfere with sodium and potassium exchange. Sodium and water are excreted yet potassium is spared.

Do not use salt sub due to the potassium in salt sub.

most frequently used for its potassium-sparing quality.

acts directly to reduce ion transportation in the tubule, though there is little diuretic effect.

used to help limit the potassium-wasting effect of other diuretics.

act at the proximal convoluted tubule to increase plasma osmotic pressure, causing redistribution of fluid toward the circulatory vessels.

edema, promote systemic diuresis in cerebral edema, decrease intraocular pressure, and improve renal function in acute renal failure. In acute renal failure, osmotics are used to attempt to prevent irreversible failure, but they are contraindicated in advanced states of renal failure.

acts by increasing osmolarity of glomerular filtrate; decreasing reabsorption of water electrolytes; and increasing urinary output, sodium, and chloride, which actually has minimal effect on acid-base balance.

the oliguric phase of acute renal failure, promote systemic diuresis in cerebral edema, and decrease intraocular pressure. Careful assessment of the cardiovascular system before the administration of mannitol is essential because of the high risk of inducing heart failure. Avoid extravasation (escape of the medication from the blood vessel into the tissues), which may lead to tissue irritation or necrosis.

interferes with the bonding of water and carbon dioxide by the enzyme carbonic anhydrase (an enzyme present in red blood cells) at the proximal convoluted tubule. Although it has limited usefulness as a diuretic, acetazolamide is used to lower intraocular pressure.

Because patients receiving diuretics often have complicated disease conditions such as heart failure and pulmonary edema, nursing interventions include monitoring for signs and symptoms of fluid overload: changes in pulse rate, respirations, cardiac sounds, and lung fields. Daily morning weights should be recorded for the patient receiving diuretics. Accurate intake and output (I&O) records should be kept, and blood pressure, pulse, and respirations should be documented 4 times a day until the medication is regulated and the vital signs stabilize.

Diet instruction to the patient and family should include a warning to avoid overuse of salt in cooking or as a table additive. A number of salt substitutes are currently on the market; however, the long-term effects of those potassium preparations are not known and could further complicate the renal patient's condition. The use of most diuretics, with the exception of the potassium-sparing diuretics, requires adding daily potassium sources (e.g., baked potatoes, raw bananas, apricots, or navel oranges). In some cases it is necessary for the physician to order potassium supplements to be taken in combination with the diuretic

Careful monitoring of this potentiating effect is essential for safe nursing management to prevent toxicity from other medications. For example, as diuretics effectively decrease the volume of extracellular fluid, the serum level of digoxin may increase proportionately, resulting in digitoxicity. Special considerations should be used in the selection and management of diuretics in the treatment of children, adolescents, and the older adult.

Administer slow due to inner ear damage.
Available orally, po, iv.

quinolones, nitrofurantoins, methenamines, and fluoroquinolones. Examples of each group follow

UTIs caused by gram-negative microbes (e.g., Escherichia coli and Proteus mirabilis). The common side effects are drowsiness, vertigo, weakness, nausea, and vomiting. The use of nalidixic acid is contraindicated in renal impairment.

UTIs, gonorrhea, and gonococcal urethritis. Administration should be with a full glass of water 1 hour before or 2 hours after meals or the use of antacids.

1.Check all medications the patient is using for potential negative drug interactions.
2.Hydrate the patient to produce daily urine output of 2000 mL, unless contraindicated.
3.Instruct the patient to take all the medication, even though the symptoms may subside quickly.
4.Soothe skin irritations with cornstarch or a bath of bicarbonate of soda or dilute vinegar.
5.When indicated, teach the patient to use the acid-ash diet to help maintain a urine pH of 5.5.
6.Observe the patient receiving nalidixic acid (NegGram) for visual disturbances and offer appropriate assistance for ambulation or transfer.
7.Monitor the patient receiving nitrofurantoin (Macrodantin) for signs of allergic response (such as erythema, chills, fever, and dyspnea). If these signs or symptoms develop, medication should be discontinued and the physician notified (trial doses of this medication may be used to detect possible allergic reaction before administering full dosage).
8.Report continuing signs of infection

Meat, whole grains, eggs, cheese, cranberries, prunes, and plums.
Acid-ash diets should be supplemented with vitamins C and A and folic acid.

daily intake of 2000 mL of water, unless contraindicated.

Patients at risk for difficulty with urine elimination include patients who have undergone surgical procedures of the bladder, prostate, or vagina; patients with primary urological problems, such as urethral stricture; and those who are critically ill with multisystem problems

maintain urine flow, to divert urine flow to facilitate healing postoperatively, to introduce medications by irrigation, and to dilate or prevent narrowing of some portions of the urinary tract. Catheters may be used for intermittent or continuous urinary drainage.

determined by the location and cause of the urinary tract problem. Catheters are measured by the French (Fr) system. Urethral catheters range in size from 14 to 24 Fr for adult patients. Ureteral catheters are usually 4 to 6 Fr.

.Follow aseptic technique to avoid introduction of microorganisms from the environment. Never rest the collecting bag on the floor.
2.Record intake and output (I&O). For precision monitoring, such as hourly urine output, add a urometer to the drainage system. If urine output falls to less than 50 mL/hour, first check the drainage system for proper placement and function before contacting the physician.
3.Adequately hydrate the patient to flush the urinary tract.
4.Do not open the drainage system after it is in place except to irrigate the catheter, and then only with a specific order from the physician. It is important to maintain a closed system to prevent urinary infections.
5.Perform catheter care twice daily and as needed, using standard precautions. Each institution has a specific protocol for catheter care. Cleanse perineum with mild soap and warm water, rinse well, and pat dry. At times an antiseptic solution or ointment may be ordered to use at the catheter incision site.
6.Check the drainage system daily for leaks.
7.Avoid placement of the urinary drainage bag above the level of the catheter insertion, which would cause urine to reenter the drainage system and contaminate the urinary tract.
8.Prevent tension on the system or backflow of urine while transferring the patient.
9.Ambulate the patient if possible to facilitate urine flow. If the patient's activity must be restricted, turn and reposition every 1½ hours.
10.Avoid kinks or compression of the drainage tube that may cause pooling of the urine within the urinary tract. Gently coil excess tubing, secure with a clamp or pin to avoid dislodging the catheter, and release the tubing before transferring or repositioning the patient.
11.Gently inspect the entry site of the catheter for blood or exudate that may indicate trauma or infection. Observe the color and composition of the urine to note any blood or sediment. During drainage of the collection bag, note the presence of malodor.
12.Collect specimens from the catheter by cleansing the drainage port with alcohol, then withdrawing the urine by using a sterile adapter and a sterile 10-mL syringe, using standard precautions. Send the urine specimen immediately to the laboratory.
13.Report and record assessment findings and interventions initiated.

1.If necessary, urination may be stimulated by running water, placing the patient's hands in water, or pouring water over the perineum. If the last method is attempted, the amount of water used should be subtracted in calculating the correct amount voided.
2.If the patient's condition permits, it is preferable for a female to sit on a bathroom stool or commode, and preferable for a male to stand to void.

The patient may experience some dribbling of urine after voiding as a result of dilation of the sphincter from the catheter. The time, amount, and color of the urine output should be recorded.

Nursing diagnoses and interventions for the patient with a urinary catheter include but are not limited to the following:

spinal cord injury or other neurological disorders that interfere with urinary elimination. Intermittent self-catheterization promotes independent function for the patient. At home there is less risk of cross-contamination than in the hospital, so the catheterization procedure can be safely modified as a clean technique, although the nurse will instruct the patient using strict surgical asepsis in the hospital because of the risk of infection there. The need for the patient to be alert for signs and symptoms of infection and to have periodic evaluations by the physician should be emphasized. Institutional guidelines for catheter insertion technique should be followed.

developing the use of the muscles of the perineum to improve voluntary control over voiding; bladder training may be modified for different problems. In preparation for the removal of a urethral catheter, the physician may order a clamp/unclamp routine to improve bladder tone.

by tightening the muscles of the perineal floor. The patient can perhaps develop awareness of the appropriate muscle group by trying to stop the flow of urine during voiding. Having identified the correct muscles and the feeling of their contraction, the patient can be directed to tighten the muscles of the perineum, holding that tension for 10 seconds, then relaxing for 10 seconds. The exercises should be done initially in groups of 10, building to groups of 20, four times a day. Because muscle control develops gradually, it may take 4 to 6 weeks to develop control of leakage.

a voiding schedule is established. The nurse monitors the patient's voiding for a few days to identify patterns, or schedules voiding times to correlate with the patient's activities. Typical voiding times are on arising, before each meal, and at bedtime. The patient is assisted to void as scheduled. After a few days, the scheduled voiding pattern is evaluated by identifying its effectiveness in keeping the patient continent. The schedule is modified until continence is established. Fluid intake and medications may influence voiding patterns (i.e., the patient may need to void 30 minutes after the ingestion of coffee or furosemide in response to the diuretic effect). Reduction of fluid intake during the hours preceding bedtime may aid in keeping the patient dry during sleep.

the inability to void even with an urge to void. It may be acute or chronic. With urinary retention the patient may not be able to empty the bladder, creating urinary stasis and increasing the possibility of infection.

Establish urinary drainage.

Develop voiding schedule.

Teach Kegel exercises.

Assist with skin care.

Suggest use of protective clothing.

Engage patient in social activities.

Teach importance of adequate fluid intake.

Evaluation: Patient verbalizes understanding of factors that alter urinary pattern.

Patient reports return of normal urination pattern.

The incontinent patient may reduce fluid intake to decrease voiding, but without adequate fluids, urine may become more concentrated, irritating the bladder mucosa and increasing the urge to urinate. Bladder training exercises should be taught to improve the tone of the perineal muscles. Establish a 2-hour schedule for the patient to go to the bathroom. Once continence has been achieved, the schedule goal may be raised to 3 hours. Use of protective undergarments may help keep the patient and the patient's clothing dry. For the female patient, Kegel exercises are helpful; 10 repetitions, 5 to 10 times a day is suggested to improve muscle tone.

means the loss of voluntary voiding control, resulting in urinary retention or incontinence. Neurogenic bladder is caused by a lesion of the nervous system that interferes with normal nerve conduction to the urinary bladder.

The goal for management of the patient with neurogenic bladder is to establish urinary elimination and prevent complications. Because of the disturbance of neurological function, it may not be possible to reinstate normal voiding function. The patient with a spastic bladder may be placed on a bladder training program, with self-stimulation used every 2 hours to empty the bladder:

(blood in the urine)

pus in the urine

is septic poisoning due to retention and absorption of urinary products in the tissues.

should be supportive, with patient education for adequate hydration and hygiene. Because there is a strong tendency for these infections to recur by either reinfection or persistent infection, patient education must include early detection.

inflammation of the urethra, is classified by the presence or absence of gonorrhea.

These should focus on patient education: avoid sexual activity until the infection clears; take all medications, especially antibiotics, to ensure the infection is resolved; use condoms for protection from reinfection; and instruct sexual partners to be evaluated for urethritis to prevent continuing infections

an inflammation of the wall of the urinary bladder, usually caused by urethrovesical reflux, introduction of a catheter or similar instrument, or perhaps contamination from feces. Cystitis is most common in women, due to ease of entrance of pathogens through the short urethra, even during voiding.

usually occurs secondary to another infection, such as prostatitis or epididymitis.

dysuria, urinary frequency, and pyuria.

a clean-catch, midstream urinalysis that reveals a bacterial count greater than 100,000 organisms/mL.

short-term therapy with an antiinfective agent. If the treatment is effective, the patient should receive relief quickly. A repeat urinalysis 1 to 3 days after initiation of the medication confirms the effectiveness of the intervention.

This should focus on teaching because there is a strong tendency for these infections to recur by either reinfection or persistent infection. The patient should be encouraged to drink 2000 mL of fluid per day. Accurate I&O should be recorded

is a chronic pelvic pain disorder with recurring discomfort or pain in the urinary bladder and surrounding region. Because IC cannot be diagnosed with a urine test, other urinary conditions are ruled out. Small bleeding sites may be visualized via endoscopy.The pathophysiology is unknown, but bacteria do not trigger it.

Teach the female to cleanse perineal area anteriorly to posteriorly to prevent contamination of pathogens (especially Escherichia coli) from the rectum to the short urethra.
•Encourage drinking 2000 mL of liquids per day unless contraindicated.
•Instruct the patient to take all the prescribed medications even though symptoms may subside quickly.
•Teaching must include early detection. Currently available is a sample urine test, ChemStrip LN, which allows the patient to test the urine at the first sign of infection of the bladder and call the physician for a prescription.
Teach patients, particularly females, to drink cranberry juice to help prevent urinary infections

as inflammation and/or infection of the prostate gland, is actually a group of diseases.

is caused by infectious organisms such as Pseudomonas and Streptococcus faecalis traveling up the urethra.

may result from a variety of reasons related to occlusion of the urethra (e.g., enlargement of the prostate gland).

pain in the prostate gland) presents with neither inflammation nor infection but demonstrates the other symptoms typical of prostatitis.

Regardless of the pathologic basis, comfort measures used are analgesics, sitz baths, and stool softeners to reduce pain, edema, spasm, and straining pressure in the pelvis.

Teaching includes the medication regimen. Sexual arousal and intercourse should be avoided in acute prostatitis so the prostate can rest; however, intercourse may be beneficial in the treatment of chronic prostatitis.

an inflammation of the structures of the kidney—the renal pelvis, renal tubules, and interstitial tissue. Pyelonephritis is almost always caused by E. coli.

contain pus urine

be unilateral or bilateral, causing chills, fever, prostration, and flank pain.

chronic disease pattern, with atrophy of the kidney as the nephrons are destroyed. Studies have also shown that chronic pyelonephritis may develop in association with other renal diseases unrelated to infection processes.

the retention in the blood of excessive amounts of nitrogenous compounds

become acutely ill, with malaise and pain in the costovertebral angle (CVA) (one of two angles that outline a space over the kidneys). CVA tenderness to percussion is a common finding in pyelonephritis. In the chronic phase the patient may show unremarkable symptoms, such as nausea and general malaise.

elevated blood pressure and gastrointestinal irritation such as vomiting and diarrhea.

Monitor urine character, malodor.Encourage oral fluids.
Instruct to void when urge is felt.Encourage perineal hygiene.Assess knowledge level concerning measures to prevent recurrence of symptoms.Discuss personal health habits: diet, exercise.
Discuss treatment plan with patient and family.

Obstruction at any point within the urinary tract can adversely affect function and alter structure. Causes of obstruction include strictures, kinks, cysts, tumors, calculi, and prostatic hypertrophy. Obstruction may lead to alterations in blood chemistry; infection that thrives as a result of urine stasis; ischemia due to compression; or atrophy of renal tissue.

(the dilation of the renal pelvis and calyces) may be congenital or may develop at any time. It can occur either unilaterally or bilaterally. Hydronephrosis is caused by obstructions in the urinary tract. An obstruction may be located in the lower urinary tract, in the ureters, or in the kidneys. The location of the obstruction will determine whether one or both kidneys are affected.

include administering medications as ordered, monitoring intake (intravenous and oral) and output, observing for signs and symptoms of infection, and monitoring vital signs.Any drainage tubes will need to be kept open and anchored to avoid inadvertent displacement. If a catheter is present, catheter care will be necessary. If surgery has been performed, the dressing must be observed, because drainage of urine may continue for some time. The area should be kept clean and dry to avoid excoriation of the skin.

formation of urinary calculi) can develop in any area of the urinary tract. Urolithiasis is a general term that encompasses all urinary calculi, but they are also named specifically to indicate where they are located or formed: nephrolithiasis (stones in the kidney), ureterolithiasis (stones in the ureter), and cystolithiasis (stones in the bladder). Other descriptive terms are lithiasis, and calculi (the formation

Stones are more likely to be passed if the patient remains active and increases fluid intake. If pain is so severe as to require opioid medication, the nurse must exercise discretion in allowing the patient out of bed. If nausea inhibits oral intake, the physician may order supplemental intravenous fluids. All urine will be strained. Because stones may be any size, even the smallest speck must be saved for assessment. The nurse should encourage fluids and administer analgesics as ordered. Urine is assessed for possible hematuria. BUN and creatinine are monitored for indications of continuing urinary obstruction.

Long-term management may include dietary adjustments to influence the urine pH or to decrease availability of certain substances to discourage stone formation. Moderate reduction of calcium phosphorus and purine-containing foods may be beneficial when stones are caused by metabolic abnormalities. Some foods to be avoided include cheese, greens, whole grains, carbonated beverages, nuts, chocolate, shellfish, and organ meat. Adequate daily fluid intake of 2000 mL will help cleanse the urinary tract (unless clinically contraindicated)

common in men than in women, renal tumors are primarily adenocarcinomas that develop unilaterally and are often quite large when first detected. Renal cell carcinoma as a primary malignant tumor appears to arise from cells of the proximal convoluted tubules.

Risk factors include smoking; familial incidence; and preexisting renal disorders, such as adult polycystic kidney disease and renal cystic disease secondary to renal failure.

Encourage patient to express feelings. Assist patient to identify personal strengths and coping skills. Actively listen. Support realistic hope: answer questions honestly.
Plan activities when pain control is greatest.Encourage active/passive range of motion exercises.Assess need for assistive devices.

The most significant problems arise with polycystic kidney disease (PKD). PKD is a genetic disorder characterized by the growth of numerous fluid-filled cysts, which can slowly replace much of the kidney. A patient with long-standing renal insufficiency or a dialysis patient may develop polycystic disease. Kidney function is compromised by the pressure of the cysts on kidney structures, secondary infections, and tissue scarring caused by rupturing of the cysts. The patient may progress to end-stage renal disease (ESRD).

Diagnosis is established by family history, physical examination, excretory urography, and imaging of cysts on radiographic examination or sonography. Blood chemistry results, such as urea and creatinine levels, are used to monitor the level of kidney function.

The bladder is the most common site of cancer in the urinary tract, occurring more often in men than in women. Papillomas have the potential to become cancerous and are removed when detected.

Benign prostatic hypertrophy (BPH), enlargement of the prostate gland, is common in men older than 50 years of age. The cause is unclear but may be influenced by hormonal changes. The prostate enlarges, exerting pressure on the urethra and vesicle neck of the urinary bladder, which prevents complete emptying.

any condition of the prostate gland that causes retention of urine in the bladder

Initial management is aimed at relieving the obstruction, usually by insertion of a Foley catheter. Care must be taken to avoid rapid decompression of the bladder to prevent rupture of mucosal blood vessels. Usually no more than 1000 mL of urine should be removed from a distended bladder initially.

transurethral resection of the prostate

Transurethral prostatectomy is done by approaching the gland through the penis and bladder using a resectoscope, a surgical instrument with an electric cutting wire for resection and cautery to resect the lobes away from the capsule (Figure 50-8, A).
2.Suprapubic prostatectomy is accomplished by an incision through the abdomen; the bladder is opened, and the gland is removed from above with the finger (Figure 50-8, B).
3.Radical perineal prostatectomy requires an incision through the perineum between the scrotum and the rectum (Figure 50-8, C).
4.Retropubic prostatectomy is the method in which a low abdominal incision is made, but the bladder is not opened. The gland is removed by making an incision into the capsule encasing the gland (Figure 50-8, D).

continuous closed bladder irrigation or intermittent irrigation to prevent occlusion of the catheter with blood clots, which would cause bladder spasms. Vital signs and urine color will be monitored every 2 hours for the first 24 hours to detect early signs of complications. With continuous bladder irrigation (CBI) the urine will be light red to pink, and with intermittent irrigation the urine will be a clear, cherry red

y using a three-way catheter (one lumen for irrigation fluid, one for urine drainage, and one to the retention balloon) or by using two catheters (Foley and suprapubic—one for irrigation fluid and one for urine drainage). The irrigant is an isotonic solution.

the nurse will subtract the amount of irrigation fluid used from the Foley catheter output to calculate urine output. This is reported as “actual urine output.”

are helpful to relieve bladder spasms but are not used in the retropubic approach because rectal stimulation is contraindicated.

because the resulting increased intraabdominal pressure may cause the operative site to bleed. The catheter is removed when the urine becomes clear. The patient is informed that initially he may experience frequency, voiding small amounts with some dribbling. He should be instructed to void with the first urge to prevent increased bladder pressure against the operative site.

When the tumor causes urinary symptoms, the cancer is in advanced stages. At this point, metastasis is common; frequent sites are the pelvic lymph nodes and bone.

is increasing considerably the odds of early diagnosis. PSA, normally secreted and disposed of by the prostate, increases in the bloodstream in cancer of the prostate as well as in the harmless condition of BPH.

0 to 4 ng/mL

Rectal temperature-taking, enemas, and use of rectal tubes are therefore forbidden. Extreme care must be taken not to create tension on the Foley catheter, which would disturb the surgical area. The nurse observes the color of the urine for signs of bleeding. The patient will also have a tissue drain inserted during surgery to promote drainage from the wound in the perineum. Initially there may be some small amount of urine from the drain, but this should cease in 1 or 2 days.

to rank cell differentiation. A low score of 2 through 4 is good; a high score of 7 through 10 is not. The treatment goal for the localized disease process is a cure; palliation is used for the extended disease process.

Renal failure is characterized by the inability of the kidneys to remove wastes, concentrate urine, and conserve or eliminate electrolytes. Diabetes mellitus is the most common cause of kidney failure, accounting for more than 40% of new cases. Other predisposing concurrent illnesses include burns, trauma, heart failure, volume depletion, and renal disease. Nursing interventions to prevent the development of renal failure include adequate hydration, prevention of infections, monitoring for signs and symptoms of shock, and teaching drug side effects to report immediately

such as hemorrhage, trauma, infection, and decreased cardiac output. The course of ARF is divided into phases.

BUN and serum creatinine levels rise while urine output decreases. The oliguric phase may last from several days to 4 to 6 weeks

blood chemistry levels begin to return to normal and urine output increases.

Return to normal or near-normal function

Diet should be protein sparing, high in carbohydrates, and low in potassium and sodium

remove potassium through the gastrointestinal tract; sodium polystyrene sulfonate (Kayexalate) is administered orally, per NG tube or as a retention enema.

Accurate documentation of urine output is necessary to identify the level of renal function. Azotemia may be revealed by blood chemistry studies. The patient with azotemia must be observed for changes in level of consciousness. Fluid status, vital signs, and response to therapies must be closely monitored. Frequent skin care with tepid water to remove urea crystals will be comforting

Reinforce explanation of dialysis procedure

Inform of community resources

Explain dietary restrictions

Self-care, general

Maintain asepsis and universal precautions

Weigh before and after treatment

Obtain vital signs every 30 to 60 minutes (BP in arm without fistula)

Maintain orientation (thought processes may be altered)

Assess for hemorrhage resulting from heparin use during dialysis

Monitor equipment (interruption of procedure)

Chronic renal failure, or end-stage renal disease (ESRD), exists when the kidneys are unable to regain normal function. ESRD develops slowly over an extended period as a result of kidney disease or other disease processes that compromise renal blood perfusion. As much as 80% of nephrons may be severely impaired before loss of renal function is detected.

pyelonephritis, chronic glomerulonephritis, glomerulosclerosis, chronic urinary obstruction, severe hypertension, diabetes mellitus, gout, and polycystic kidney disease. Whatever the cause, dialysis or kidney transplantation will be needed to maintain life.

Nursing interventions focus on restoring homeostasis. Measures to control fluid and electrolyte balance vary greatly, according to unique needs of the individual patient. Nutritional therapy is aimed at preserving protein stores and preventing production of additional protein waste products that the kidney would have to clear. High biologic proteins are used to provide the essential amino acids

The diet is high in calories from carbohydrates and fats from polyunsaturated sources (to maintain weight and spare protein), at least 2500 to 3000 calories daily. Other dietary restrictions are related to the patient's degree of acidosis. Potassium is retained, so foods high in potassium are restricted. Sodium is controlled at a level sufficient to replace sodium loss without causing fluid retention.

Hemodialysis requires an access to the patient's circulatory system to route blood through the artificial kidney (dialyzer) for removal of wastes, fluids, and electrolytes and then return the blood to the patient's body. Temporary methods include subclavian or femoral catheters or an external shunt placed in the nondominant forearm (Figure 50-9). In ESRD, access can be achieved by constructing a direct or a graft arteriovenous fistula (Figure 50-10). The AV fistula is preferred for permanent access. Hemodialysis is usually scheduled three times a week for 3 to 6 hours. Patients can be maintained on dialysis therapy indefinitely. Other patients may be maintained while waiting for kidney transplantation

Nurses have a key responsibility for maintaining access sites and preventing and/or managing infection. Optimally, a structured teaching program will be used, with individualization of patient teaching strategies to accommodate culture and knowledge level.

Peritoneal dialysis can be performed with a minimum of equipment and by the patient who is ambulatory. Unlike hemodialysis, peritoneal dialysis is performed 4 times a day, 7 days a week. One exchange cycle usually requires 30 to 40 minutes.

for those individuals with systemic inflammatory disease, previous abdominal surgery, and chronic back pain, among others.

Common complications associated with peritoneal dialysis guide nursing interventions. Hypotension may occur with excessive sodium and fluid removal. Peritonitis may arise from sepsis. Pain and hemorrhage may accompany instillation of the dialysate. Box 50-5 lists nursing intervention guidelines for peritoneal dialysis.

Encourage verbalization of self-concept. Assist in identifying personal strengths. Assist patient and significant others with clarifying expected roles and those that must be relinquished or altered. Support grief work if loss of role has occurred.Avoid taking BP and venipuncture in arm with fistula/cannula.Auscultate for bruits.Observe access site for skin color and condition.
After dialysis, inspect needle puncture sites for bleeding.

This includes instructing the patient to avoid heavy lifting, maintain hydration of 2000 mL each day unless contraindicated, monitor output, avoid use of alcohol, and avoid respiratory infections and hazardous activities that may cause assault to the remaining kidney.

Meticulous skin care, assessment for hemorrhage, accurate I&O

Assessment for hemorrhage, promotion of respiratory effort, accurate I&O

Promotion of urinary drainage via ileal conduit, I&O

Meticulous skin care, monitoring of electrolyte imbalance, assessment of signs and symptoms of infection

Meticulous skin care, assessment of urinary obstruction, accurate I&O

an incision to drain the pelvis of the kidney.

Never clamp acute pyelonephritis may result.

performed using strict aseptic technique. Gentle instillation of no more than 5 mL of sterile saline solution at one time prevents renal damage.

Postoperative management for surgical removal of the kidney is based on the prevention and detection of hemorrhage by monitoring vital signs, especially pulse and blood pressure; observation for restlessness and for GI complications of nausea, vomiting, and abdominal distention; and establishment of adequate urinary drainage. I&O are recorded. If the thoracic cavity is opened during surgery, the patient will have chest tubes (see Chapter 59). Pain may compromise respiratory efficiency.

Preoperative nursing intervention is complicated by the patient's fear and anxiety about transplantation and about possible rejection of the implanted organ. The patient is dialyzed until surgery can be satisfactorily completed. In surgery the nonfunctioning kidney remains in place and the donor kidney is positioned in the iliac fossa anterior to the crest of the ileum.

apprehension, generalized edema, fever, increased blood pressure, oliguria, edema, and tenderness over the graft site.

such as cyclosporine (Sandimmune), is used alone or in conjunction with steroids. Cyclosporine is considered an effective drug in suppressing the immune system's efforts to reject tissue while leaving the recipient sufficient immune activity to combat infection. Mycophenolate (CellCept) and tacrolimus (Prograf) are drugs now used to prevent rejection of kidney transplants; they are used in combination with corticosteroids. Immunosuppressive therapy increases the risk for infection and possible steroid-induced bleeding.

Home follow-up becomes a life pattern for the transplantation patient. Patient education is extensive: diet, fluids, daily weights, strict I&O measurements, prevention of infection, and avoidance of activities that may compromise the integrity of the urinary tract.

Several types of procedures are used to divert the flow of urine when required for treatment of bladder cancer, invasive cancer of the cervix, neurogenic bladder, and congenital anomalies. Often a cystectomy, which is the surgical removal of the bladder, is performed.

(Bricker's procedure or ileal loop). In an ileal conduit procedure the ureters are implanted into a loop of the ileum that is isolated and brought to the surface of the abdominal wall

are wound infection, dehiscence, urinary leakage, ureteral obstruction, small bowel obstruction, stomal gangrene, atrophy of the stoma, pyelonephritis, renal calculi, and/or a compromised respiratory status secondary to incisional pain.

is created by implantation of the ureters into a segment of the small intestine that has been surgically removed from the rest of the bowel and anastomosed to the abdominal wall. Control of urine flow is achieved by the use of a nipplelike valve that prevents leakage of urine.