NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Genitourinary System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Diagnostic Procedures

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Renal Function Tests

Focus topic: Medical–Surgical Nursing

A. Renal concentration tests.

  • Underlying principles.
    a. Evaluate the ability of the kidney to concentrate urine.
    b. As kidney disease progresses, renal function decreases. Concentration tests evaluate this process.
    c. Renal concentration is measured by specific gravity readings (normal range 1.010–1.030).
    d. If specific gravity is 1.018 or greater, it may be assumed that the kidney is functioning within normal limits.
    e. Specific gravity that stabilizes at 1.010 indicates kidney has lost ability to concentrate or dilute.
  • Common tests.
    a. Urine osmolality—used to evaluate clients with renal disease (e.g., SIADH [syndrome of inappropriate antidiuretic hormone] and diabetes insipidus).
    b. Urinary sodium—24-hour test that determines amount of sodium excretion in urine. Used to determine clients with fluid volume deficits, acute renal failure, and acid–base imbalances.
  • Concentration and dilution tests.

B. Glomerular filtration test (endogenous creatinine clearance).

  • Kidney function is assessed by clearing a substance from the blood (filtration in the glomerulus).
  • Common test is the amount of blood cleared of urea per minute.
  • Test done on 12-hour or 24-hour urine specimen.
  • Normal range is approximately 100–120 mL/ min (1.67–2.0 mL/sec).
  • Blood urea nitrogen (BUN).
    a. Normal 10:1 ratio for BUN to creatinine.
    b. High BUN indicates severe catabolic state, GI bleeding, or use of corticosteroids.

C. Electrolyte tests.

  • Kidney function is essential to maintain fluid and electrolyte balance.
  • Tests for electrolytes (sodium, potassium, chloride, and bicarbonate) measure the ability of the kidney to filter, reabsorb, or excrete these substances.
  • Impaired filtration leads to retention, and impaired reabsorption leads to loss of electrolytes.
  • Tests are performed on blood serum, so venous blood is required.
Medical–Surgical Nursing

Analysis of Urine
A. Urinalysis is a critical test for total evaluation of the renal system and for indication of renal disease.
B. Specific gravity shows the degree of concentration in urine.

  • Indicates the ability of the kidney to concentrate or dilute urine.
  • Change from normal range indicates diabetes mellitus (> 1.030) or kidney damage (< 1.010).
  • Renal failure—specific gravity constant at 1.010. C. Analysis of the pH of urine—normal urine pH is 6–7. Lower than 6 is acidic urine, and higher than 7 is alkaline urine.

D. Urinary sodium—random sample used to identify renal failure.

Medical–Surgical Nursing: Renal Imaging

Focus topic: Medical–Surgical Nursing

A. Flat plate of abdomen without contrast dye.

  • Outlines size of kidney.
  • Outlines stone formation.

B. Intravenous pyelogram (IVP).

  • Contrast dye identifies changes in kidney structure.
  • Identifies presence of stones.
  • Outlines ureteral obstructions.

C. Voiding cystourethrogram (VCUG) x-ray (XR).

  • Contrast dye inserted through catheter into bladder.
  • Determines reflux, cancer on wall of bladder, and increased residual volume.

D. Retrograde pyelogram (XR).

  • Contrast inserted into ureters retrograde from bladder.
  • Visualizes collecting system.

E. Renal ultrasound.

  • Noninvasive and useful in identifying kidney size, hydronephrosis, and obstructions.
  • Used to guide percutaneous needle biopsies of kidneys.

Medical–Surgical Nursing: GU Examination

Focus topic: Medical–Surgical Nursing

Male Examination

A. Testicular self-exam (TSE).

  • Instruct client to perform monthly following warm bath or shower. (Between ages 15 and 25, third highest cause of cancer deaths in men.)
  • Stand before mirror and check for swelling on skin and scrotum.
  • Rotate each testicle between thumb and forefinger, feeling for a firm surface.
  • If painless lump is felt (not the epididymis), notify physician immediately.

B. Prostate evaluation.

  • Rectal exam annually beginning at age 40.
  • Blood chemistry for cancer.
    a. Prostatic acid phosphate (PAP)—elevated.
    b. Prostate-specific antigen (PSA)—elevated. Most sensitive tumor marker.
    c. May be false-positive readings.
  • Ultrasound with biopsy if indicated.

Female Examination
A. Pelvic examination.

  • Inspection of external genitalia for signs of inflammation, bleeding, discharge, and epithelial cell changes.
  • Visualization of vagina and cervix.
  • Bimanual examination.
  • Rectal examination.

B. Papanicolaou (Pap) smear.

  • Diagnosis for cervical cancer.
  • Vaginal secretions and secretions from posterior fornix are smeared on a glass slide.
  • Pathological classifications.
    a. Class I: No abnormal or atypical cells present.
    b. Class II: Abnormal or atypical cells present but no malignancy found; repeat Pap smear and follow-up if necessary.
    c. Class III: Cytology suggests malignancy; additional procedures: biopsy, dilation and curettage (D&C).
    d. Class IV: Cytology strongly suggests malignancy; additional procedures: biopsy, D&C.
    e. Class V: Cytology conclusive of malignancy.

C. Breast self-examination (BSE).

  • Perform 5–7 days after menses, counting first day of menses as day 1. Less fluid is retained.
  • Instruct female client to place pillow under the shoulder and, using three fingers, compress breast tissue in a circular motion, beginning at outer edge and moving toward nipple.
    a. Examine entire breast including nipple area.
    b. Move pillow to other shoulder and repeat examination.
  • Remind client to immediately report any lump, irregularity, edema, skin changes, discharge, nipple changes, changes in contour of breasts.

D. Mammography.

  • X-ray of soft tissue to detect nonpalpable mass.
  • Baseline (one time) age 35–39; yearly after age 40.

Medical–Surgical Nursing: Cystoscopy

Focus topic: Medical–Surgical Nursing

Definition: The direct visualization of the bladder and urethra by means of a cystoscope.

Purpose
A. Inspect bladder and urethra for stones, etc.
B. Evaluate results of tissue examination obtained from biopsy.
C. Treat lesions of the bladder, urethra, and prostate.

Implementation
A. Measure vital signs.
B. Observe for urethral bleeding.
C. Chart intake and output, and consistency of urine.
D. Monitor for signs of infection.

  • Frequency.
  • Urgency.
  • Burning during urination.

E. Monitor for perforation of bladder.

  • Sharp abdominal pain.
  • Anuria.
  • Boardlike abdomen.

F. Maintain client on bed rest for 4–6 hours if indicated; then ambulate if no complications. (Many procedures are outclient and the client is released 1–2 hours after test if no complications.)
G. Monitor vital signs for shock and infection.

Medical–Surgical Nursing: System Implementation

Focus topic: Medical–Surgical Nursing

A. Monitor fluid intake at least every shift for clients with renal dysfunction.

  • Encourage fluids.
    a. Urinary tract infection.
    b. Cystitis.
    c. Pyelonephritis.
    d. Urolithiasis.
  • Restrict fluids.
    a. Glomerulonephritis.
    b. Renal failure.
    c. Nephrotic syndrome.

B. Provide appropriate diet for renal dysfunction.

  • Pyelonephritis—high calorie, vitamins, and protein; if oliguria is present, change diet to low protein.
  • Glomerulonephritis—low saturated fat, 0.8 g/kg/day protein, low sodium.
  • Nephrotic syndrome—0.8 g/kg/day protein, high calorie, low sodium, liberal potassium.
  • Renal failure—restricted protein to 40–60 mEq/day; low in nitrogen, potassium; 2 g/day sodium, phosphate, and sulfate.

C. Monitor client for complications associated with renal dysfunction, especially congestive heart failure, pulmonary edema, and hypertension.
D. Provide good skin care; edematous areas are easily broken down.
E. Encourage bed rest for clients in an acute stage of the disease.
F. Administer medications on time to keep blood levels stable and in therapeutic range.
G. Monitor vital signs for early detection of changes in client status.
H. Provide shunt care to maintain patency and prevent infection.
I. Instruct client on diet, fluid alteration, and shunt care as needed.
J. Encourage client to express feelings and concerns with altered body image.

Medical–Surgical Nursing: Renal Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Injuries to the Kidney

Focus topic: Medical–Surgical Nursing

Definition: Injury to the kidney includes any trauma that bruises, lacerates, or ruptures any part of the kidney organ.

Assessment
A. Assess for hematuria.
B. Assess for shock, if hemorrhage has occurred.
C. Evaluate pain over costovertebral area.
D. Observe for gastrointestinal symptoms of nausea and vomiting.

Implementation
A. Promote bed rest.
B. Monitor vital signs frequently for possible hemorrhage.
C. Monitor blood work and laboratory examination of urine to assess for hematuria.
D. Prevent infection.
E. Frequently monitor the total status of the client following injury.

  • Observe for pain and tenderness.
  • Observe any sudden change in status.

F. Prepare for surgery (nephrectomy) if health status deteriorates (shock indicating severe hemorrhage).

Medical–Surgical Nursing: Urinary Tract Infections

Focus topic: Medical–Surgical Nursing

Definition: A term that refers to a wide variety of conditions affecting the urinary tract in which the common denominator is the presence of microorganisms. Classified as infections involving the upper or lower urinary tract. Most common healthcare problem in United States. More common in women.

Characteristics
A. Urine is sterile until it reaches the distal urethra.
B. Any bacteria can be introduced into the urinary tract, resulting in infection, which may then spread to any other part of the tract. Escherichia coli is most frequent organism causing about 80% of all cases; 5–15% are caused by Staphylococcus.
C. The most important factor influencing ascending infection is obstruction of free urine flow.

  • Free flow, large urine output, and pH are antibacterial defenses.
  • If defenses break down, the result may be an invasion of the tract by bacteria.

D. Microscopic examination is completed for an accurate identification of the organism (especially important in chronic infections).

Assessment
A. Determine location of infection.

  • Lower urinary tract infection (UTI)—cystitis, urethritis, or prostatitis.
  • Upper UTI—pyelonephritis, interstitial nephritis.

B. Evaluate urine cultures and chemical tests to determine presence and number of bacteria.
C. Evaluate urine colony count. Colony count over 100,000/mL indicates urinary tract infection.
D. Assess for location, type, and precipitating factors leading to pain.
E. Observe urine for color, consistency, specific gravity.
F. Assess for frequency, urgency, nocturia, incontinence, and suprapubic or pelvic pain.
G. Blood or urine test to rule out sexually transmitted diseases (STDs), which produce similar symptoms.

Implementation
A. Encourage fluids to 3000 mL provided there are no cardiac or renal contraindications.
B. Administer urinary antimicrobials as ordered.

  • Standard treatment—therapy for lower tract infection.
    a. Single-dose therapy effective in 80% of cases (Monurol [fosfomycin] antibiotics—one packet of granules dissolved into 90–120 mL of water [not hot]. May be taken with or without meals.)
    b. Primsol (trimethoprim), sulfamethoxazole, Bactrim, Septra (sulfamethoxazole and trimethoprim), or quinolones (Cipro [ciprofloxacin] or Noroxin [norfloxacin]) may be used.
  • Short-course therapy—3 or 4 days, more commonly prescribed.
  • Longer course—10–14 days, for upper tract infections.
    a. Antibacterial may be prescribed with single- dose therapy.
    b. Urinary antiseptics may be used with antimicrobials.
  • Action of antimicrobials—inhibits cell-wall mucopeptide synthesis; interferes with enzyme needed for bacterial metabolism.
  • Adverse effects—hypersensitivity, nausea, vomiting, diarrhea, rash.

C. Administer antiseptics—interfere with vital processes of the bacteria.

  • Medications: Furadantin (nitrofurantoin); Hipres, Urised (methenamine salts).
  • Adverse effects—anorexia, nausea, vomiting.
  • Avoid foods that increase urinary pH.

D. Antispasmodics and analgesics may be used to relieve pain, frequency, urgency, and burning.
E. Encourage client to void every 2 to 3 hours and to empty bladder—reduces urinary stasis and risk of reinfection
F. Avoid beverages that irritate bladder—alcohol, coffee, carbonated beverages.
G. Teach women hygiene measures to prevent reoccurrence (wipe front to back, keep perineum clean and dry, do not douche, and avoid tight-fitting pants; also, voiding after sexual intercourse helps).

Medical–Surgical Nursing: Cystitis

Focus topic: Medical–Surgical Nursing

Definition: Inflammation of the bladder from infection or obstruction of the urethra is the most common cause.

Assessment
A. Observe for frequency, urgency, and burning sensation on urination.
B. Evaluate lower abdominal discomfort.
C. Observe for dark and odorous urine (often a manifestation), hematuria.
D. Assess laboratory findings for presence of bacteria and hematuria.
E. Bacterial counts exceeding 105 colonies/mL of urine indicate infection using clean catch technique for urine sample.

Implementation
A. Assist physician in identifying and removing the cause of the condition (infection, obstruction, etc.).
B. Administer antibiotics on time. Drugs usually administered—Bactrim, Septra (sulfamethoxazole with trimethoprim) are drugs of choice. May use Macrodantin (nitrofurantoin macrocrystals).
C. Instruct client on how to prevent infection. Empty bladder completely and frequently.
D. Instruct client on measures for symptomatic relief of chronic conditions. Antispasmodics are used for pain and bladder irritability.
E. Collect an uncontaminated urine specimen (midstream specimen) for laboratory test.
F. Maintain adequate fluid intake.

  • Force fluids only if specifically ordered.
  • Check and record intake and output.

G. Encourage bed rest or a decrease in activity during the acute stage.
H. Avoid urinary tract irritants—coffee, tea, citrus.

Medical–Surgical Nursing: Pyelonephritis

Focus topic: Medical–Surgical Nursing

Definition: An acute or chronic infection and inflammation of one or both kidneys that usually begins in the renal pelvis. Women are more commonly affected. Gram-negative organisms are most often responsible, especially Escherichia coli.

Assessment
A. Observe for attacks of chills, fever, malaise, gastrointestinal upsets.
B. Evaluate for tenderness and dull, aching pain in back.
C. Assess for fatigue, headache, poor appetite, excessive thirst, and weight loss.
D. Identify frequent and burning urination (more common in lower tract involvement).
E. Evaluate pus and bacteria in urine.
F. Evaluate renal function. May have normal renal function except for inability to concentrate urine.
G. Evaluate for renal insufficiency.

  • Progressive destruction of renal tubules and glomeruli.
  • Inability of kidneys to excrete large amounts of electrolytes.
  • Ultrasound or computed tomography (CT) scan is used to locate any obstruction in urinary tract.

H. Assess for hypertension in presence of bacterial pyelonephritis.
I. Identify if overt symptoms disappear in a few days but urine is still infected.

Implementation
A. Administer and monitor drug therapy.

  • Antibiotic therapy usually for 2 weeks (organism-specific for infection).
  • Usual drugs—Bactrim, Septra (trimethoprim and sulfamethoxazole), Cipro (ciprofloxacin), Garamycin (gentamicin), or a third-generation cephalosporin.
  • Analgesics and sedatives as needed.
  • May be on antibiotics up to 6 months.

B. Maintain bed rest until asymptomatic.
C. Force fluids to flush kidneys and maintain urine output of 1500 mL/day (3–4 L/day).
D. Continue monitoring for presence of bacteria.
E. Instruct client in methods to prevent chronic renal insufficiency.
F. Monitor urinalysis.

  • Check urine concentration (specific gravity), blood, protein.
  • Check electrolytes.

G. Provide diet high in calories and vitamins, and low in protein if oliguria is present.
H. Monitor temperature every 4 hours.
I. Instruct to empty bladder regularly.
J. Observe for edema and signs of renal failure.
K. Instruct client in good hygiene to prevent further infections.

Medical–Surgical Nursing: Glomerulonephritis

Focus topic: Medical–Surgical Nursing

Definition: A group of kidney diseases caused by inflammation of the capillary loops in the glomeruli of the kidney.

Characteristics
A. The kidney’s glomeruli are affected by an immunological disorder.
B. Most frequently follows infections with group A beta-hemolytic Streptococcus.
C. Upper respiratory infections, skin infections, other autoimmune processes (systemic lupus), and acute infections predispose to glomerulonephritis.
D. Glomerulonephritis symptoms appear 2–3 weeks after original infection.

Assessment
A. Initially, symptoms may be mild—assess for pharyngitis as it can occur after a strep infection, fever, malaise.
B. Assess urine.

  • Evaluate for hematuria—first symptom.
  • Urine may be dark, smoky, cola-colored.
  • Assess urine for persistent and excessive foam caused by protein.
  • Assess specific gravity for high values.
  • Observe for oliguria, anuria.
  • Observe for hypoalbuminemia due to increased loss via urine. (Proteinuria 2–8 g daily.)

C. Observe for weakness, anorexia, mild anemia.
D. Evaluate edema—leg, face, or generalized.
E. Assess abdominal pain, nausea, vomiting.
F. Flank pain.
G. Identify if hypertension, headache, or convulsions are present.
H. Assess for congestive heart failure.
I. Evaluate presence of increased BUN and creatinine.
J. Reduced visual acuity.
K. Observe for signs of encephalopathy.

Implementation
A. Administer penicillin for residual infection.
B. Administer loop diuretics and antihypertensives if necessary.
C. Administer corticosteroids and immunosuppressive agents if disease is progressing rapidly.
D. Provide appropriate diet.

  • Protein restriction if oliguria is severe; otherwise, protein allowed at low normal range (normal 40–60 g/day).
  • BUN level watched for protein determination.
  • Protein should be of the complete type (milk, eggs, meat, fish, poultry).
  • High carbohydrate to provide energy and spare protein.
  • Potassium usually restricted.
  • Sodium restriction for hypertension, edema, and congestive heart failure (CHF). If diuresis is great, sodium replacement may be necessary.
  • Fluid restriction: Replacement is based on insensible loss plus measured sensible loss of previous day or hour.
  • Vitamin replacement.

E. Prolonged bed rest is of little value and does not improve long-term outcomes.
F. Monitor vital signs continuously.
G. Allow client to verbalize feelings on body image changes (due to edema), loss of health, fear of death.
H. Monitor fluid intake.

  • Measure fluids according to urinary output.
  • Record intake and output.
  • Weigh daily.

I. Monitor for signs of overhydration.
J. Take blood pressure frequently and observe for hypertension, signs of congestive failure, and pulmonary edema.
K. Evaluate for symptoms of renal failure.

  • Oliguria.
  • Azotemia.
  • Acidosis.

Medical–Surgical Nursing: Nephrotic Syndrome

Focus topic: Medical–Surgical Nursing

Definition: A term that refers to renal disease characterized by massive edema and albuminuria, high cholesterol, and low-density lipoproteins. Considered a disease of childhood.

Characteristics
A. The syndrome is seen in any renal condition that has damaged glomerular capillary membrane: glomerulonephritis, lipoid nephrosis, syphilitic nephritis, amyloidosis, or systemic lupus erythematosus.
B. There is a loss of plasma proteins, especially albumin, in the urine.
C. A specific form of intercapillary glomerulosclerosis is associated with diabetes mellitus (Kimmelstiel– Wilson syndrome).
D. Occurrence thought to be related to thyroid function.

Assessment
A. Evaluate edema (at first, dependent; later, generalized).
B. Identify if proteinuria (3–3.5 g/day) is present.
C. Identify if decreased serum albumin is present.
D. Identify if elevated serum cholesterol, triglycerides, hyperlipemia are present.
E. Assess hypertension (related to function of renin– angiotensin system).
F. Evaluate decreased cardiac output (secondary to fluid loss).
G. Observe for pallor, malaise, anorexia, lethargy.

Implementation
A. Provide nursing care directed toward control of edema.

  • Sodium restriction in diet.
  • Avoidance of sodium-containing drugs.
  • Diuretics (Lasix and Edecrin [ethacrynic acid]) that block aldosterone formation.
  • Salt-poor albumin.

B. Provide dietary instruction.

  • High protein (100 g or 0.8 g/kg/day) to restore body proteins.
  • High calorie, low saturated fat. 3. 500 mg sodium if edema present.

C. Administer drug therapy.

  • Adrenocortical therapy (Deltasone [prednisone]) to reduce proteinuria.
  • Immunosuppressives (Imuran [azathioprine]) or antineoplastic agents (Cytoxan [cyclophosphamide]).
  • .Angiotensin-converting enzyme (ACE) inhibitors with diuretics to reduce proteinuria (4–6 weeks).

D. Client education for home care is necessary.
E. Instruct client in the maintenance of general health status, as the disorder may persist for months or years.

  • Avoiding infections.
  • Nutritious diet (low sodium, high protein).
  • Activity as tolerated.

F. Maintain fluid balance.

  • Daily weights.
  • Monitor intake and output.

Medical–Surgical Nursing: Tuberculosis of the Kidney

Focus topic: Medical–Surgical Nursing

Definition: Tuberculosis of the kidney is an infection caused by Mycobacterium tuberculosis, which is usually bloodborne from other foci such as the lungs, lymph nodes, or bone.

Assessment
A. Identify frequency and pain on urination.
B. Evaluate burning, spasm, and hematuria.
C. Assess for slight afternoon fever, weight loss, night sweats, loss of appetite, and general malaise.
D. Evaluate findings of physical examination. Tuberculosis nodules may be present in the prostate.
E. Evaluate outcome of diagnostic studies.

  • Urine cultures to isolate the tubercle bacilli.
  • X-ray to reveal lesions.
  • Cystoscopic examination.
  • Erythrocyte sedimentation rate (ESR) elevation.

Implementation
A. Administer medications on time to maintain constant blood levels.

  • Drug therapy aimed at treating the original focus of infection as well as the genitourinary involvement.
  • Combinations of isoniazid, Myambutol (ethambutol), or Rifadin (rifampin) are used for 4 months.
  • Usually given together in a single daily dose.
  • Observe for side effects.

B. Instruct client on methods to improve general health status.

  • Good dietary habits.
  • Adequate rest.

C. Prepare the client for possible nephrectomy if kidney is extensively diseased.

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