NCLEX: Renal and urologic disorders

Urine studies

Urine studies, such as urinalysis and urine osmolality, can indicate urinary tract infection (UTI) and other disorders.

Urinalysis
Performed on a urine specimen of at least 10 ml, urinalysis can
indicate urinary or systemic disorders, warranting further investigation.

Nursing considerations
• Collect a random urine specimen, preferably the first-voided morning specimen. Send the specimen to the laboratory immediately.
• Refrigerate the specimen if analysis will be delayed longer than 1 hour.

Urine osmolality
Urine osmolality evaluates the diluting and concentrating ability of the kidneys. It may aid in the differential diagnosis of polyuria, oliguria, or syndrome of inappropriate antidiuretic hormone secretion. To gather more information about the patient’s renal function, compare the urine specific gravity with urine osmolality.

Nursing considerations
• Obtain a random urine specimen.
• Keep in mind that urine osmolality typically ranges from 50 to 1,400 mOsm/kg, with the average being 300 to 800 mOsm/kg.

 

Other tests

Further diagnostic tests can help evaluate urologic structure and function. These include cystometry, percutaneous renal biopsy, and uroflowmetry.

Cystometry
Used to help determine the cause of bladder dysfunction, cystometry assesses the bladder’s neuromuscular function by measuring the efficiency of the detrusor muscle reflex, intravesicular pressure and capacity, and the bladder’s reaction to thermal stimulation. Abnormal test results may indicate a lower urinary tract obstruction.

Nursing considerations
• Explain to the patient the different steps of the test and what will happen in each. Let him know that a urinary catheter will need to be inserted.

• Tell the patient that, if no more tests are needed, the catheter will be removed after the test. Warn him that he may experience transient burning or urinary frequency after the test but that a sitz bath may alleviate discomfort.

Percutaneous renal biopsy
Histologic examination can help differentiate glomerular from tubular renal disease, monitor the disorder’s progress, and assess the effectiveness of therapy. It can also reveal a malignant tumor such as Wilms’ tumor. Histologic studies can help the doctor diagnose disseminated lupus erythematosus, amyloid infiltration, acute and chronic glomerulonephritis, renal vein thrombosis, and pyelonephritis.

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Nursing considerations
• Instruct the patient to restrict food and fluids for 8 hours before the test. Inform him that he’ll receive a mild sedative before the test to help him relax.
• After the test, tell him that pressure will be applied to the biopsy site to stop superficial bleeding and then a pressure dressing will be applied.
• Instruct him to lie flat on his back without moving for at least 12 hours to prevent bleeding.
• Tell him he should avoid strenuous activity for at least 2 weeks.

Uroflowmetry
Uroflowmetry measures the volume of urine expelled from the urethra in milliliters per second (urine flow rate) and determines the urine flow pattern. This test is performed to evaluate lower urinary tract function and demonstrate bladder outlet obstruction. Normal flow rate for males is 20 to 25 ml/second; for females, 25 to 30 ml/second.

Nursing considerations
• Advise the patient not to urinate for several hours before the test and to increase his fluid intake so that he’ll have a full bladder and a strong urge to void.

Treatments

If uncorrected, renal and urologic disorders can adversely affect virtually every body system. Treatments for these disorders include drug therapy, dialysis, nonsurgical procedures, and surgery.

Drug therapy

Ideally, drug therapy should be effective and not impair renal function. However, because renal disorders alter the chemical composition of body fluids and the pharmacokinetic properties of many drugs, standard regimens of some drugs may require adjustment. For instance, dosages of drugs that are mainly excreted by the kidneys unchanged or as active metabolites may require adjustment to avoid toxicity. In renal failure, potentially toxic drugs should be used cautiously and sparingly.
Drug therapy for renal and urologic disorders can include:
• antibiotics
• urinary tract antiseptics

• electrolytes and replacements
• diuretics.

Dialysis

Depending on the patient’s condition and, at times, his preference, dialysis may take the form of hemodialysis or peritoneal dialysis.

Hemodialysis
Hemodialysis removes toxic wastes and other impurities from the blood of a patient with renal failure. In this technique, the blood is removed from the body through a surgically created access site, pumped through a dialyzing unit to remove toxins, and then returned to the body. The extracorporeal dialyzer works through a combination of osmosis, diffusion, and filtration.

Balancing act

By extracting by-products of protein metabolism — notably urea and uric acid — as well as creatinine and excess water, hemodialysis helps restore or maintain acid-base and electrolyte balance and prevent the complications associated with uremia.

Patient preparation
Before hemodialysis, take these steps:
• If the patient is undergoing hemodialysis for the first time, explain its purpose and what to expect during and after treatment. Explain that he first will undergo surgery to create vascular access.
• Assess the access site for the presence of a bruit and thrill, and keep the vascular access site supported and resting on a sterile drape or sterile barrier shield.

Monitoring and aftercare
After hemodialysis, take these steps:
• Monitor the vascular access site for bleeding. If bleeding is excessive, maintain pressure on the site and notify the practitioner.
• To prevent clotting or other problems with blood flow, make sure that the arm used for vascular access isn’t used for any other procedure, including I.V. line insertion, blood pressure monitoring, and venipuncture.
• At least four times per day, assess circulation at the access site by auscultating for bruits and palpating for thrills. Unlike most other circulatory assessments, bruits and thrills should be present here. Lack of a bruit at a venous access site for dialysis may indicate a blood clot, which requires immediate surgical attention.

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Home care instructions
Before discharge, instruct the patient to:
• care for his vascular access site by keeping the incision clean and dry
• notify the practitioner of pain, swelling, redness, or drainage in the accessed arm
• palpate the site for thrills
• refuse treatments or procedures on the accessed arm, including blood pressure monitoring or needle punctures
• avoid putting excessive pressure on the arm (such as sleeping on it, wearing constricting clothing on it, and lifting heavy objects or straining with it), showering, bathing, or swimming for several hours after dialysis.

Peritoneal dialysis
Like hemodialysis, peritoneal dialysis removes toxins from the blood of a patient with acute or chronic renal failure that doesn’t respond to other treatments. Unlike hemodialysis, it uses the patient’s peritoneal membrane as a semipermeable dialyzing membrane.

Waste away

In this technique, a hypertonic dialyzing solution (dialys ate) is instilled through a catheter inserted into the peritoneal cavity. Then, by diffusion, excessive concentrations of electrolytes and uremic toxins in the blood move across the peritoneal membrane into the dialysis solution. Next, through osmosis, excessive water in the blood does the same. After an appropriate dwelling time, the dialysate is drained, taking toxins and wastes with it.

Patient preparation
Before dialysis, take these steps:
• For the first-time peritoneal dialysis patient, explain the purpose of the treatment and what he can expect during and after the procedure.
• Tell him that first the doctor will insert a catheter into his abdomen to allow instillation of dialysate. Explain the appropriate insertion procedure.

Monitoring and aftercare
After dialysis, take these steps:
• Using sterile technique, change the catheter dressing every 24 hours or whenever it becomes soiled or wet.
• Watch closely for developing complications. Peritonitis can cause fever, persistent abdominal pain and cramping, slow or cloudy dialysis drainage, swelling and tenderness around the catheter, and increased white blood cell (WBC) count.

Home care instructions
Before discharge, instruct the patient to:
• participate in a training program before beginning treatment on his own
• wear medical identification jewelry or carry a card identifying him as a dialysis patient and keep the phone number of the dialysis center on hand at all times in case of an emergency
• watch for and report signs and symptoms of infection and fluid imbalance
• follow up regularly with the practitioner and dialysis team to evaluate the success of treatment and detect any problems.

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Nonsurgical procedures

Several nonsurgical procedures may be employed to treat renal
or urologic disorders, including calculi basketing, catheterization,
and extracorporeal shock-wave lithotripsy (ESWL).

Calculi basketing
When ureteral calculi are too large for normal elimination, removal with a basketing instrument is the treatment of choice, helping to relieve pain and prevent infection and renal dysfunction. In this technique, a basketing instrument inserted through a cystoscope or ureteroscope into the ureter captures the calculus and then is withdrawn to remove it.

Patient preparation
Before the procedure, take these steps:
• Tell the patient that after calculi removal, he’ll have an indwelling urinary catheter inserted to ensure normal urine drainage; the catheter will probably remain in place for 24 to 48 hours.
• Tell him that he’ll receive I.V. fluids during and immediately after the procedure to maintain urine output and prevent complications, such as hydronephrosis and pyelonephritis.

Monitoring and aftercare
After the procedure, take these steps:
• Promote fluids to maintain a urine output of 3 to 4 L/day. Observe the color of urine drainage from the indwelling urinary catheter; it should be slightly blood-tinged at first, gradually clearing within 24 to 48 hours. Irrigate the catheter as ordered using sterile technique.
• Administer analgesics as ordered.
• Observe for and report any signs or symptoms of septicemia, which may result from ureteral perforation during basketing.

Home care instructions
Before discharge, instruct the patient to:
• follow prescribed dietary and medication regimens to prevent recurrence of calculi
• drink 3 to 4 qt (3 to 4 L) of fluid per day, unless contraindicated
• take prescribed analgesics as needed
• immediately report signs and symptoms of recurrent calculi (such as flank pain, hematuria, nausea, fever, and chills) or acute ureteral obstruction (such as severe pain and inability to void).

Catheterization
The insertion of a drainage device into the urinary bladder, catheterization may be intermittent or continuous. Intermittent catheterization drains urine remaining in the bladder after voiding. It’s used for patients with urinary incontinence, urethral strictures, cystitis, prostatic obstruction, neurogenic bladder, or other disorders that interfere with bladder emptying. It may also be used postoperatively.
Catheterization helps relieve bladder distention caused by such conditions as urinary tract obstruction and neurogenic bladder. It allows continuous urine drainage in patients with a urinary meatus swollen from local trauma or childbirth as well as from surgery. Catheterization also can provide accurate monitoring of urine output when normal voiding is impaired.

Patient preparation
Before catheterization, take these steps:
• Thoroughly review the procedure with the patient and reassure him that although catheterization may produce slight discomfort, it shouldn’t be painful. Explain that you’ll stop the procedure if he experiences severe discomfort.
• Assemble the necessary equipment, preferably a sterile catheterization package.

Monitoring and aftercare
During catheterization, note the difficulty or ease of insertion, any patient discomfort, and the amount and nature of urine drainage.

Keep fluids flowing

During urine drainage, monitor the patient for pallor, dia phoresis, and painful bladder spasms. If these occur, clamp the catheter tubing and call the practitioner.

In the thick of it

During the procedure, take these steps:
• Frequently assess the patient’s intake and output. Encourage fluid intake to maintain continuous urine flow through the catheter and decrease the risk of infection and clot formation.
• Maintain good catheter care throughout the course of treatment. Clean the urinary meatus and catheter junction at least daily, more often if you note a buildup of exudate.
• To help prevent infection, maintain a closed drainage system and discontinue the catheter as soon as possible.

Home care instructions
Before discharge, instruct the patient to:
• drink at least 2 qt (2 L) of water per day, unless the practitioner orders otherwise
• perform daily periurethral care to minimize the risk of infection
• perform thorough hand washing before and after handling the catheter and collection system
• take showers but avoid tub baths while the catheter is in place
• notify the practitioner if he notices urine leakage around the catheter or any signs and symptoms of UTI, such as fever, chills, flank or urinary tract pain, and cloudy or foul-smelling urine.

ESWL
A noninvasive technique for removing obstructive renal calculi, ESWL uses high energy shock waves to break up calculi and allow their normal passage.

Patient preparation
Before the procedure, tell the patient that he may receive a general or epidural anesthetic, depending on the type of lithotriptor and the intensity of shock waves needed. Also explain that he’ll have an I.V. line and an indwelling urinary catheter in place after ESWL.

Monitoring and aftercare
After treatment, take these steps:
• Encourage ambulation as early as possible and increase fluid intake as ordered to aid passage of calculi fragments.
• Strain all urine for calculi fragments and send these to the laboratory for analysis.
• Report frank or persistent bleeding to the practitioner. Keep in mind, however, that slight hematuria usually occurs for several days after ESWL.

Home care instructions
Before discharge, instruct the patient to:
• drink 3 to 4 qt (3 to 4 L) of fluid each day for about 1 month after treatment.
• strain all urine for the 1st week after treatment, save all fragments in the container provided, and bring the container with him on his first follow-up appointment
• report severe, unremitting pain; persistent hematuria; inability to void; fever and chills; or recurrent nausea and vomiting

• comply with any special dietary or drug regimen designed to reduce the risk of new calculi formation.

Surgery

Surgery may be necessary when conservative treatments fail to control the patient’s renal or urologic disorder. Common surgeries include cystectomy, kidney transplantation, nephrectomy, suprapubic catheterization, transurethral resection of the bladder tumor (TURBT), and urinary diversion.

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Cystectomy
Partial or total removal of the urinary bladder and surrounding structures may be necessary to treat advanced bladder cancer or, rarely, other bladder disorders such as interstitial cystitis. In most patients with bladder cancer, the combined use of chemotherapy, radiation therapy, and surgery yields the best results. In metastatic bladder cancer, cystectomy and radiation therapy may provide palliative benefits and prolong life.

Take three

Cystectomy may be partial, simple, or radical.

Partial, or segmental, cystectomy involves resection of cancerous bladder tissue. Typically preserving bladder function, this surgery is most commonly indicated for a single, easily accessible tumor.

Simple, or total, cystectomy involves resection of the entire bladder, with preservation of surrounding structures. It’s indicated for multiple or extensive carcinoma, advanced interstitial cystitis, and related disorders.

Radical cystectomy is usually indicated for muscle-invading, primary bladder carcinoma. In men, the bladder, prostate, and seminal vesicles are removed. In women, the bladder, urethra and, usually, the uterus, fallopian tubes, ovaries, and a segment of the vaginal wall are excised. This procedure may involve bilateral pelvic lymphadenectomy. Because this surgery is so extensive, it typically produces impotence in men and sterility in women.

Diversionary tactics

A permanent urinary diversion is needed in both radical and simple cystectomy. A cutaneous diversion allows urine to drain through a newly created opening in the abdominal wall. In a continent diversion, a portion of the intestine is used to create a urinary reservoir.

Patient preparation
Before surgery, take these steps:
• If the patient will be undergoing simple or radical cystectomy, reassure him that urinary diversion need not interfere with his normal activities and arrange for a visit by an enterostomal therapist, who can provide further information.
• If the patient is scheduled for radical cystectomy, you’ll need to address concerns about the loss of sexual or reproductive function. As appropriate, refer the patient for psychological and sexual counseling.
• If the bowel will be used as a reservoir, perform bowel preparation before surgery.

Monitoring and aftercare
After surgery, take these steps:
• Periodically inspect the stoma and incision for bleeding, and observe urine drainage for frank hematuria and clots. Slight hematuria commonly occurs for several days after surgery but should clear thereafter.
• Observe the wound site and all drainage for signs of infection. Change abdominal dressings frequently, using sterile technique.
• Periodically ask the patient about incisional pain and, if he has had a partial cystectomy, ask about bladder spasms. Provide analgesics and an antispasmodic such as oxybutynin (Ditropan) as ordered.
• To prevent pulmonary complications associated with prolonged immobility, encourage frequent position changes, coughing and deep breathing and, if possible, early ambulation.

Home care instructions
Before discharge, instruct the patient to:
• watch for and report signs or symptoms of UTI and persistent hematuria
• learn how to care for his stoma and where to obtain needed supplies
• contact the local chapter of the United Ostomy Association for support
• follow up with the practitioner as recommended.

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Kidney transplantation
Ranking among the most commonly performed and most successful of all organ transplantations, kidney transplantation represents an attractive alternative to dialysis for many patients with otherwise unmanageable end-stage renal disease. It also may be necessary to sustain life in a patient who has suffered traumatic loss of kidney function or for whom dialysis is contraindicated. (See Kidney transplantation site and vascular connections.)

Patient preparation
The patient will understandably find the prospect of kidney transplantation confusing and frightening. Help him cope with such emotions by preparing him thoroughly for transplantation and a prolonged recovery period and by offering ongoing emotional support. To do so, take these steps:

• Describe the routine preoperative measures. Point out that he may need dialysis for a few days after surgery if his transplanted kidney doesn’t start functioning immediately.
• Review the transplantation procedure itself, supplementing and clarifying the practitioner’s explanations as necessary.
• Discuss the immunosuppressant drugs the patient will be taking and explain their possible adverse effects. Point out that these drugs increase his susceptibility to infection; as a result, he’ll be kept temporarily isolated after surgery.

Monitoring and aftercare
After surgery, take these steps:
• First and foremost, take special precautions to reduce the risk of infection. For instance, use strict sterile technique when changing dressings and performing catheter care. Also, limit the patient’s contact with staff, other patients, and visitors and have all people in the patient’s room wear surgical masks for the first 2 weeks after surgery.

Feeling rejected

• Throughout the recovery period, watch for signs and symptoms of tissue rejection. Observe the transplantation site for redness, tenderness, and swelling.
• Monitor the patient for signs of diabetes mellitus.

• Carefully monitor urine output; promptly report output of less than 100 ml/hour. A sudden decrease in urine output could indicate thrombus formation at the renal artery anastomosis site.

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Home care instructions
Before discharge, instruct the patient to:
• carefully measure and record intake and output to monitor kidney function
• weigh himself at least twice per week and report any rapid gain (any gain of 21/2 lb [1.1 kg] or more in a single day)
• watch for and promptly report signs and symptoms of infection
or transplant rejection, including redness, warmth, tenderness, or swelling over the kidney; fever; decreased urine output; and elevated blood pressure
• avoid crowds and contact with people with known or suspected infections for at least 3 months after surgery
• continue immunosuppressant therapy for as long as he has the transplanted kidney to prevent rejection.

Nephrectomy
Nephrectomy is the surgical removal of a kidney. It’s the treatment of choice for advanced renal cell carcinoma that’s refractory to chemotherapy and radiation, although radiofrequency ablation can treat small renal masses. It’s also used to harvest a healthy kidney for transplantation. When conservative treatments fail, nephrectomy may be used to treat renal trauma, infection, hypertension, hydronephrosis, and inoperable renal calculi.

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One kidney or two?

Nephrectomy may be unilateral or bilateral. Unilateral nephrectomy, the more commonly performed procedure, usually doesn’t interfere with renal function as long as one healthy kidney remains. However, bilateral nephrectomy (or the removal of a lone kidney) requires lifelong dialysis or transplantation to support renal function.
Four major types of nephrectomy are performed:

partial nephrectomy — resection of only a portion of the kidney

simple nephrectomy — removal of the entire kidney

radical nephrectomy — resection of the entire kidney and the surrounding fat tissue

nephroureterectomy — removal of the entire kidney, the perinephric fat, and the entire ureter.

Patient preparation
If the patient is having unilateral nephrectomy, reassure him that one healthy kidney is all he’ll need for adequate function. If the surgery is bilateral or will remove the patient’s only kidney, prepare him for radical changes in his lifestyle, most notably the need for regular dialysis.

Monitoring and aftercare
After nephrectomy, take these steps:
• Carefully monitor the rate, volume, and type of I.V. fluids. Keep in mind that mistakes in fluid therapy can be particularly devastating for a patient who has only one kidney.
• Check the patient’s dressing and drain every 4 hours for the first 24 to 48 hours, then once every shift to assess the amount and nature of drainage. Maintain drain patency.

Home care instructions
Before discharge, instruct the patient to:
• monitor intake and output; explain how this helps assess renal function
• follow the practitioner’s guidelines on fluid intake and dietary restrictions
• attend follow-up examinations to evaluate kidney function and assess for possible complications

• notify the practitioner immediately if he detects any significant decrease in urine output or develops fever, chills, hematuria, or flank pain
• avoid strenuous exercise or heavy lifting and sexual activity until his practitioner grants permission.

Suprapubic catheterization
Suprapubic catheterization is a type of urinary diversion connected to a closed drainage system that involves transcutaneous insertion of a catheter through the suprapubic area into the bladder.

A diverting procedure

Typically, suprapubic catheterization provides temporary urinary diversion after certain gynecologic procedures, bladder surgery, or prostatectomy and relieves obstruction from calculi, severe urethral strictures, or pelvic trauma. Less commonly, it may be used to create a permanent urinary diversion, thereby relieving obstruction from an inoperable tumor.

Patient preparation
Explain the procedure to the patient. Tell him that the doctor will insert a soft plastic tube through the skin of the abdomen and into the bladder and then connect the tube to an external collection bag. Also explain that the procedure is done under local anesthesia, causes little or no discomfort, and takes 15 to 45 minutes.

Monitoring and aftercare
After the procedure, take these steps:
• To ensure adequate drainage and tube patency, check the suprapubic catheter at least hourly for the first 24 hours after insertion. Make sure the collection bag is below bladder level to enhance drainage and prevent back flow, which can lead to infection.
• Tape the catheter securely in place on the abdominal skin to reduce tension and prevent dislodgment. To prevent kinks in the tube, curve it gently but don’t bend it.
• Check dressings often and change them at least once per day or as ordered. Observe the skin around the insertion site for signs of infection and encrustation.

Home care instructions
Before discharge, instruct the patient to:
• change the dressing, and empty and reattach the collection bag
• drink plenty of fluids
• follow up with the practitioner as recommended
• meet with the enterostomal therapist to help manage the urinary diversion

• notify the practitioner promptly of signs or symptoms of infection or encrustation, such as discolored or foul-smelling discharge, impaired drainage, and swelling, redness, and tenderness at the tube insertion site.

TURBT
A relatively quick and simple procedure,TURBT involves insertion of a resectoscope through the urethra and into the bladder to remove lesions. (It can also be performed using an Nd:YAG laser.) Most commonly performed to treat superficial and early bladder carcinoma, TURBT may also be used to remove benign papillomas or to relieve fibrosis of the bladder neck. This treatment isn’t indicated for large or infiltrating tumors or for metastatic bladder cancer.

Patient preparation
Tell the patient that he’ll receive either a local or general anesthetic. If he receives a local anesthetic, explain that he’ll be awake during treatment. Also inform him that he’ll have an indwelling urinary catheter in place for 1 to 5 days after the procedure to ensure urine drainage.

Monitoring and aftercare
After TURBT, take these steps:
• Maintain adequate fluid intake and provide meticulous catheter care, including frequent irrigation. (The practitioner may prescribe continuous or intermittent irrigation, especially if the removal of a large vascular lesion has compromised hemostasis).
• Observe urine drainage for blood. Remember that slight hematuria usually occurs directly after TURBT. However, notify the practitioner immediately of any frank bleeding or if the hematuria seems excessive.
• Assess for signs and symptoms of bladder perforation, including abdominal pain and rigidity, fever, and decreased urine output despite adequate hydration.

Home care instructions
Before discharge, instruct the patient to:
• report bleeding or hematuria that lasts longer than several weeks, fever, chills, or flank pain, which may indicate UTI
• drink plenty of water (10 glasses daily) and void every 2 to 3 hours to reduce the risk of clot formation, urethral obstruction, and UTI
• heed the urge to urinate
• refrain from sexual or other strenuous activity, avoid lifting anything heavier than 10 lb (4.5 kg), and continue taking a stool softener or other laxative until the practitioner orders otherwise
• follow up with the practitioner as recommended.

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Urinary diversion
A urinary diversion provides an alternate route for urine excretion when a disorder or abnormality impedes normal flow through the bladder. Most commonly performed in patients who have undergone total or partial cystectomy, diversion surgery may also be performed in patients with a congenital urinary tract defect or a severe, unmanageable UTI that threatens renal function; an injury to the ureters, bladder, or urethra; an obstructive malignant tumor; or a neurogenic bladder.
Several types of urinary diversion surgery can be performed. The two most common are ileal conduit and continent ileal diversion.

Patient preparation
Before the procedure, take these steps:
• Prepare the patient for the appearance and general location of the stoma. If he’s scheduled for an ileal conduit, explain that the stoma will be located somewhere in the lower abdomen, probably below the waistline. If he’s scheduled for a continent vesicostomy, explain that the exact stoma site is commonly chosen during surgery, based on the length of the patent ureter available.
• Review the enterostomal therapist’s explanation of the urine collection device that the patient will use after surgery.

Monitoring and aftercare
After the procedure, take these steps:
• Carefully check and record urine output. Report any decrease, which could indicate obstruction from postoperative edema or ureteral stenosis.
• Perform routine ostomy maintenance. Make sure the collection device fits closely around the stoma; allow no more than a 1/8 (0.3 cm) margin of skin between the stoma and the device’s faceplate. Regularly check the appearance of the stoma and peristomal skin.

Home care instructions
Before discharge, instruct the patient to:
• properly perform stoma care or ostomy self-catheterization
• watch for and report signs and symptoms of complications, such as fever, chills, abdominal pain, and pus or blood in the urine
• keep scheduled follow-up appointments with the practitioner and enterostomal therapist to evaluate stoma care and make any necessary changes in equipment
• contact a support group such as the United Ostomy Association.

 

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