NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Genitourinary System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Surgical Interventions for the Renal System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Cystostomy

Focus topic: Medical–Surgical Nursing

Definition: An opening into the bladder for suprapubic drainage.

Characteristics
A. Diverts urine flow from urethra.
B. Empties bladder (similar for Foley catheter, but catheter is inserted in suprapubic area rather than through urinary meatus).
C. Provides less risk of infection for client.
D. Used

  • For urethral stricture.
  • Following vaginal surgery.
  • For neurogenic bladder.
  • Following surgery on prostate and bladder.

Implementation
A. Provide care the same as for any client with indwelling catheter.
B. Clamp catheter when ordered and then have client void on his or her own (through urinary meatus).
C. Remove when able to void on own.

Medical–Surgical Nursing: Urolithiasis (Renal Calculi)

Focus topic: Medical–Surgical Nursing

Definition: The presence of stones in any portion of the urinary system.

Characteristics
A. Causes: dehydration; immobilization; hypercalcemia; excessive uric acid excretion; obstruction; deficiency of citrate, magnesium, nephrocalcin, and uropontin (prevent crystallization in urine); and urinary stasis.
B. Diagnostic tests.

  • Retrograde pyelography.
  • Renal ultrasound.
  • KUB x-ray.
  • CT scan.
  • Magnetic resonance imaging (MRI).
  • Blood chemistries.
  • Urinalysis.

C. Surgical interventions.

  • Ureterolithotomy: removal of stone from ureter.
  • Pyelolithotomy: removal of stone from kidney pelvis.
  • Lithotripsy.
    a. Extracorporeal shock-wave lithotripsy (ESWL): Under general anesthesia, client is immersed in water and shock waves disintegrate stones that are then excreted in urine.
    b. Percutaneous ultrasonic tract is formed; nephroscope inserted through tract, stone extracted or pulverized.
    c. Laser therapy.

D. Chemolysis.

  • Dissolves stones using infusion of chemicals: alkylating agents, acidifying agents.
  • Used for at-risk clients who could have complications with other procedures.
  • Use percutaneous nephrostomy to inject warm solution continuously onto stone until stone breaks up.
Medical–Surgical Nursing

Assessment
A. Evaluate pain (starts low in back and radiates around front and down the ureter).
B. Observe for nausea, vomiting, and diarrhea.
C. Observe for hematuria.
D. Assess for chills and fever.
E. Observe for pyuria.

Implementation
A. Manage pain with opioids or nonsteroidal anti- inflammatory drugs (NSAIDs).
B. Apply moist heat or provide warm bath if not vomiting.
C. Force fluids to at least 3000 mL/24 hr.
D. Record intake and output.
E. Strain all urine for stones.
F. Send stones to laboratory for chemical analysis.
G. Administer appropriate antibiotics (infections occur especially when stones block off a portion of kidney).
H. Place heating pad on affected area.
I. Watch vital signs for indication of infection.
J. Instruct client in methods to prevent urolithiasis.

  • Provide adequate fluid intake (8 glasses of 8 oz H2O/day).
  • Immediately treat urinary tract infection with appropriate antibiotics.
  • Ambulate clients to prevent urinary stasis (or reposition in bed frequently).
  • Dietary restrictions related to type of stone.

Medical–Surgical Nursing: Urinary Diversion

Focus topic: Medical–Surgical Nursing

Definition: Procedure that diverts urine from bladder to a new exit site, through an opening in the skin termed a stoma. Most common type is the ileal loop.

Characteristics
A. Cancer of neck of bladder or ureters.
B. Cancer of pelvic area.
C. Neurogenic bladder.

Medical–Surgical Nursing

Assessment
A. Assess type of urinary diversion.

  • Incontinent ileal conduit; cutaneous—urine continuously drains through an opening created in abdominal wall and skin. Requires an external collection device.
  • Continent—a portion of intestine is used to create a new reservoir for urine. Called Kock pouch or Indiana pouch—segment of small bowel or colon is used to create, holds urine without leakage, requires self-catheterization.

B. Assess client’s fluid balance.

  • Ensure output is 30 mL/hr.
  • Intake and output.
  • Daily weights.

C. Observe characteristics of urine. (Hematuria common in first 48 hours.)
D. Observe for complications related to surgical intervention.

  • Urinary fistula (urine around incision).
  • Bowel fistula (feces from incision).
  • Wound complications (dehiscence or evisceration).

E. Assess skin.

Implementation
A. If nasogastric tube is inserted, irrigate when necessary.
B. Provide routine abdominal postoperative care.
C. Provide stoma and skin care.
D. Provide psychological support for altered body image, change in lifestyle, chronic disease.
E. Refer to enterostomal therapist or cancer society for help with ostomy care.
F. Provide range-of-motion exercise.
G. Ensure tight-fitting ostomy bag around opening to prevent skin irritation.

H. Provide home care teaching regarding appliance change, odor control, and skin care.

Medical–Surgical Nursing: Nephrectomy

Focus topic: Medical–Surgical Nursing

Definition: Surgical removal of a kidney.

Assessment
A. Evaluate possible cause.

  • Polycystic kidneys.
  • Stones.
  • Preparation for transplantation.
  • Injury.
  • Infection that has destroyed kidney function.

B. Assess urine output for hematuria, cells, pus.
C. Observe for signs of hemorrhage and shock.
D. Evaluate intake and output (anuria can result if remaining kidney is damaged).
E. Check for bowel sounds and abdominal distention (paralytic ileus may be a complication).
F. Assess nasogastric tube drainage, both amount and consistency, if inserted.

Implementation
A. Obtain urine specimens as ordered to detect renal function of remaining kidney.
B. Force fluids after bowel sounds return.
C. Monitor intake and output frequently.
D. Monitor blood replacement therapy as needed.
E. Turn, cough, and deep-breathe every 2 hours (turn to operative side and back).
F. Encourage use of incentive spirometer.
G. Begin range-of-motion exercises immediately.
H. Encourage early ambulation.
I. Observe that Foley or suprapubic catheter is draining adequately.

  • Tape catheter to thigh or abdomen to prevent trauma to bladder.
  • Position catheter bag below bed level to facilitate drainage.

J. If nephrostomy tube is inserted, measure drainage and record characteristics of drainage (drains kidney after surgery).

  • Do not clamp tubes unless ordered.
  • Do not irrigate tubes unless ordered.

K. Administer antibiotics as ordered.
L. Administer low-dose heparin to reduce risk of thrombophlebitis.

Medical–Surgical Nursing: Renal Failure

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Acute Renal Failure

Focus topic: Medical–Surgical Nursing

Definition: The sudden loss of kidney function caused by failure of renal circulation or damage to the tubules or glomerulus. Condition reversible with spontaneous recovery in a few days to several weeks.

Categories of Acute Renal Failure
A. Prerenal—condition decreasing blood flow.

  • Decreased glomerular filtration rate (GFR).
  • Severe dehydration; diuretic therapy.
  • Circulatory collapse: hypovolemia, shock.

B. Intrarenal—disease process, ischemic or toxic conditions.

  • Acute glomerulonephritis.
  • Vascular disorders.
  • Toxic agents (e.g., carbon tetrachloride, sulfonamides, arsenic).
  • Severe infection.
  • Burns, crushing injuries.

C. Postrenal obstruction to urine flow caused by calculi or tumors, accidental ligation of ureters during GU or gynecological (GYN) surgery.

Assessment
A. Clinical phases—an initial period of oliguria (< 400 mL in 24 hours) followed by period of diuresis, and a period of recovery.

  • Evaluate urine output often. If less than 20 mL/hr, measure at least every 2–4 hours.
  • Observe lab reports for increased BUN and creatinine.

B. Evaluate serum levels of potassium, sodium, pH, PCO2, and HCO3—indication of complications.
C. Observe urinalysis for proteinuria, hematuria, casts.
D. Note if specific gravity fixed at 1.010–1.016 (normal is 1.025).
E. Evaluate for hyperkalemia.
F. Assess for signs of infection—client may not demonstrate fever or increased white blood cells (WBC).

Implementation
A. Monitor urinary output.

  • Record intake and output (oliguria followed by diuresis).
  • Weigh daily; lack of weight loss (½–1 pound daily) indicates retention of too much fluid.

B. Monitor fluid intake (observe for signs of CHF).
C. Monitor for complications of electrolyte imbalances.

  • Acidosis (treated with sodium bicarbonate).
  • Serum potassium levels (above 6 mEq/L together with peaking T waves and shortening QT interval) for hyperkalemia.

D. Allow client to verbalize concerns and effect of altered body image.
E. Encourage the prescribed diet: moderate protein restriction (1 g/kg/day); high carbohydrate; restrict foods high in K+ and phosphorus (coffee, bananas, juices).

  • Elevated potassium reduced by exchange resins (Kayexalate).
  • High level of serum potassium may require dialysis.
  • Restrict sodium to 2 g daily.

F. Be cautious when using antibiotics and other drugs.
G. Continually assess status of client for potential complications: dyspnea, tachycardia, increased blood pressure.
H. Evaluate slow return of decreased serum BUN, creatinine, phosphorus, and potassium to normal after diuresis phase begins.
I. Maintain bed rest to decrease exertion and metabolic state.

Medical–Surgical Nursing: Chronic Renal Failure

Focus topic: Medical–Surgical Nursing

Definition: The progressive loss of kidney function that occurs in three stages and, without intervention, ends fatally in uremia.

Characteristics
A. First stage: diminished renal reserve.

  • 40–75% loss of nephron function.
  • Abnormal renal function tests.
  • No accumulation of metabolic waste.

B. Second stage: renal insufficiency.

  • 75–90% loss of nephron function.
  • Metabolic waste begins to accumulate.
  • Increase in BUN and creatinine (10:1 ratio).
  • Polyuria and nocturia occur.
  • Stress poorly tolerated (e.g., infection).
  • Chemical abnormalities resolve slowly.
  • Anemia occurs.

C. Third stage: end-stage renal failure or uremia.

  • Less than 10% functioning nephrons.
  • Normal regulatory, excretory, and hormonal functions of kidneys are impaired severely.
  • Hypertension; edema.
  • Poor urine output.
  • Severe alterations of electrolytes.
  • Moderately increased BUN and creatinine.
  • Anemia common with this condition.
  • Metabolic acidosis.

Assessment
A. Assess for weakness, fatigue, and headaches.
B. Assess for anorexia, nausea, vomiting, and hiccups.
C. Evaluate for hypertension, heart failure, and pulmonary edema.
D. Evaluate for anemia, azotemia (nitrogen retention in the blood), and acidosis.
E. Observe for personality changes (e.g., anxiety, irritability, hallucinations, convulsions, and coma).
F. Evaluate for low and fixed specific gravity of urine of 1.010.
G. Respirations may become Kussmaul, with deep coma following.
H. Observe for severe skin itching.

Implementation
A. Provide diet (low protein with supplemented vitamins and amino acids) and fluids (500–600 mL/day) for acute renal failure.
B. Provide electrolyte replacement.

  • Sodium supplements provided.
  • Potassium and phosphorus restricted.
  • Acidosis replacement of bicarbonate stores.

C. Monitor and plan nursing care for hypertension and heart failure.
D. Prepare client for dialysis or kidney transplant.
E. Administer medications with caution—impaired renal function may require adjustment.

  • Administer antihypertensives, Epogen, iron supplements, phosphate-binding agents, and calcium supplements.
  • Antacids are used to treat hyperphosphatemia and hypocalcemia.

Medical–Surgical Nursing: Uremic Syndrome (Uremia)

Focus topic: Medical–Surgical Nursing

Definition: The accumulation of nitrogenous waste products in blood due to inability of kidneys to filter out waste products.

Characteristics
A. May occur after acute or chronic renal failure.
B. Increased urea, creatinine, uric acid.
C. Extensive electrolyte imbalances (increased K+, increased Na+, decreased Cl–, decreased Ca++, increased phosphorus).
D. Acidosis—bicarbonate cannot be maintained at adequate level.
E. Urine concentration ability lost.
F. Anemia caused by decreased rate of production of RBCs.
G. Metabolic acidosis accumulation affects all body systems.
H. Disorders of calcium metabolism with secondary bone changes.

Assessment
A. Observe for signs of oliguria for 1–2 weeks (produces less urine than 400 mL/day).
B. Assess changes in urine characteristics.

  • Urine contains protein, red blood cells, casts.
  • Specific gravity of 1.010.
  • Rise in urine solutes (e.g., urea, uric acid, potassium, magnesium).

C. Assess for metabolic acidosis.
D. Observe for hypotension or hypertension.
E. Assess for gastrointestinal problems: stomatitis, nausea, vomiting, and diarrhea or constipation.
F. Assess for respiratory complications.
G. Evaluate coma—with alterations of blood chemistry and acid load.

Implementation
A. Monitor restoration of blood volume.
B. Monitor fluid and electrolyte balance.
C. Provide dietary regulation.

  • Limit protein (0.8 g/kg) unless on peritoneal dialysis.
  • Reduce nitrogen, potassium, phosphate, and sulfate.
  • Limit sodium intake.
  • Provide glucose to prevent ketosis.
  • Control potassium balance to prevent hyperkalemia.
  • Carbohydrate intake 100 g daily.

FURTHER READING/STUDY:

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