NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: GENITOURINARY SYSTEM

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

I. PYELONEPHRITIS (PN): acute or chronic inflammation due to bacterial infection of the parenchyma and renal pelvis; 95% of cases caused by gram-negative
enteric bacilli (Escherichia coli); occurs more frequently in women.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: inflammation of renal medulla or lining of the renal pelvis → nephron destruction; hypertrophy of nephrons needed to maintain urine output → impaired sodium reabsorption (salt wasting); inability to concentrate urine; progressive renal failure; hypertension (two thirds of all cases).

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Urinary obstruction (tumors, prostate).
  • Cystitis.
  • Neurogenic bladder.
  • Pregnancy.
  • Catheterization, cystoscopy.

C. Assessment:

  • Subjective data:
    a. Pain: flank—one or both sides; back; dysuria; headache.
    b. Loss of appetite; weight loss.
    c. Night sweats; chills.
    d. Urination: frequency, urgency.
  • Objective data:
    a. Fever; shaking chills.
    b. Laboratory data:
    (1) Blood—polymorphonuclear leukocytosis greater than 11,000/mm3.
    (2) Urine—leukocytosis, hematuria, white blood cell casts, proteinuria (<3 gm in 24 hours), positive cultures; specific gravity—normal or increased with acute
    PN, decreased with chronic PN; cloudy; foul smelling.
    c. Intravenous pyelogram (IVP)—may manifest structural changes.

D. Analysis/nursing diagnosis:

  • Altered urinary elimination related to kidney disease.
  • Pain related to dysuria and kidney damage.
  • Hyperthermia related to inflammation.
  • Risk for fluid volume excess related to renal failure.

E. Nursing care plan/implementation:

  • Goal: combat infection, prevent recurrence, alleviate symptoms.
    a. Medications:
    (1) Antibiotics, urinary antiseptics, and/or sulfonamides appropriate for causative organism; also reduce pain.
    (2) Analgesics for pain—phenazopyridine (Pyridium); stronger if calculi present.
    (3) Antipyretics for fever—acetaminophen (Tylenol).
    b. Fluids: 1,500 to 2,000 mL/day to flush kidneys, relieve dysuria, reduce fever, prevent dehydration.
    c. Observe hydration status: I&O (output minimum 1,500 mL/24 hr); daily weight; urine—check each voiding for protein, blood, specific gravity; vital signs q4h to monitor for hypertension, tachycardia; skin turgor.
    d. Hygiene: meticulous perineal care; cleanse with soap and water; antibiotic ointment may be used around urinary meatus with retention catheter.
    e. Cooling measures: tepid sponging.
    f. Diet: sufficient calories and protein to prevent malnutrition; sodium supplement as ordered. Acid-ash to prevent renal calculus.
  • Goal: promote physical and emotional rest.
    a. Activity: bedrest or as tolerated—depends on whether anemia or fever is present; encourage activities of daily living as tolerated.
    b. Emotional support: encourage expression of fears (possible renal failure, dialysis); provide diversional activities; include family in care; answer questions.
  • Goal: health teaching.
    a. Medications: take regularly to maintain blood level; side effects.
    b. Personal care: perineal hygiene; avoid urethral contamination (by wiping perineum front to back); avoid tub baths.
    c. Possible recurrence with pregnancy.
    d. Monitoring daily weight.

F. Evaluation/outcome criteria:

  • Normal renal function (minimum 1,500 mL urine/24 hr).
  • Blood pressure within normal range.
  • No recurrence of symptoms.
  • Laboratory findings within normal limits.

II. ACUTE GLOMERULONEPHRITIS

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

III. ACUTE RENAL FAILURE (ARF): broadly defined as rapid onset of oliguria accompanied by a rising BUN and serum creatinine; usually reversible.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: acute renal ischemia → tubular necrosis → decreased urine output. Oliguric phase (<400 mL/24 hr)—waste products are retained →metabolic acidosis → water and electrolyte imbalances→ anemia. Recovery phase—diuresis → dilute urine → rapid depletion of sodium, chloride, and water → dehydration.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Types and risk factors:

  • Prerenal—due to factors outside of kidney; usually circulatory collapse—cardiovascular disorders, hypovolemia, peripheral vasodilation, renovascular obstruction, severe vasoconstriction.
  • Intrarenal—parenchymal disease from ischemia or nephrotoxic damage; nephrotoxic agents— poisons, such as lead (carbon tetrachloride); heavy metals (mercury); antibiotics (gentamicin); incompatible blood transfusion; alcohol myopathies; obstetric complications; acute rena1 disease—acute glomerulonephritis, acute pyelonephritis.
  • Postrenal—obstruction in collecting system: renal or bladder calculi; tumors of bladder, prostate, or renal pelvis; gynecological or urological surgery in which ureters are accidentally ligated.

C. Assessment:

  • Subjective data:
    a. Sudden decrease or cessation of urine output (<400 mL/24 hr).
    b. Anorexia, nausea, vomiting from azotemia.
    c. Sudden weight gain from fluid accumulation.
    d. Headache.
  • Objective data:
    a. Vital signs (vary according to cause and severity):
    (1) BP—usually elevated.
    (2) Pulse—tachycardia, irregularities.
    (3) Respirationsincreased rate, depth, crackles.
    b. Neurological: decreasing mentation, unresponsive to verbal or painful stimuli, psychoses, convulsions.
    c. Halitosis; cracked mucous membranes; uremic odor.
    d. Skin: dry, rashes, purpura, itchy, pale.
    e. Laboratory data:
    (1) Blood: increased—potassium, BUN, creatinine, WBC count; decreased—pH, bicarbonate, hematocrit, hemoglobin.
    (2) Urine: oliguric renal failuredecreased volume; specific gravity fixed or ↑; increased—protein, casts, red and white blood cells, sodium. Non-oliguric renal
    failure—up to 2 L/day, ↓ specific gravity, dilute, isomolar.

D. Analysis/nursing diagnosis:

  • Altered urinary elimination related to kidney malfunction.
  • Fluid volume excess related to decreased urine output.
  • Altered nutrition, less than body requirements, related to anorexia.
  • Altered oral mucous membrane related to stomatitis.
  • Altered thought processes related to uremia.

E. Nursing care plan/implementation:

  • Goal: maintain fluid and electrolyte balance and nutrition.
    a. Monitor: daily weight (should not vary more than ±1 lb); vital signs—include CVP; blood chemistries (BUN 6 to 20 mg/dL; creatinine 0.6 to 1.5 mg/dL).
    b. Fluids: IV as ordered; blood: plasma, packed cells, electrolyte solutions to replace losses; restricted to 400 mL/24 hr if hypertension present or during oliguric phase to prevent fluid overload.
    c. Diet, as tolerated: high carbohydrate, low protein, may be low potassium and low sodium; hypertonic glucose (total parenteral nutrition [TPN]) if oral feedings not tolerated; intravenous L-amino acids and glucose.
    d. Control hyperkalemia: infusions of hypertonic glucose and insulin to force potassium into cells; calcium gluconate (IV) to reduce myocardial irritability from K+; sodium bicarbonate (IV) to correct acidosis; polystyrene sodium sulfonate (Kayexalate) or other exchange resins, orally or rectally (enema), to remove excess K+; continuous renal replacement therapy, peritoneal or hemodialysis.
    e. Medications—diuretics (mannitol, furosemide [Lasix]) to increase renal blood flow and diuresis.
  • Goal: use assessment and comfort measures to reduce occurrence of complications.
    a. Respiratory: monitor rate, depth, breath sounds, arterial blood gases; encourage deep breathing, coughing, turning; use incentive spirometer or nebulizer as indicated.
    b. Frequent oral care to prevent stomatitis.
    c. Observe for signs of:
    (1) Infection—elevated temperature, localized redness, swelling, heat, or drainage.
    (2) Bleeding—stools, gums, venipuncture sites.
  • Goal: maintain continual emotional support.
    a. Same caregivers, consistency in procedures.
    b. Give opportunities to express concerns, fears.
    c. Allow family interactions.
  • Goal: health teaching.
    a. Preparation for dialysis (indications: uremia, uncontrolled hyperkalemia, or acidosis). Continuous renal replacement therapy (CRRT) may be used in ARF with fluid overload or rapidly developing azotemia and metabolic acidosis. Continuous ultrafiltration (8 to 24 hours) of extracellular fluid and uremic toxins. Client’s BP powers system. Arterial and venous access required.
    b. Dietary restrictions: low sodium, fluid restriction.
    c. Disease process; treatment regimen.

F. Evaluation/outcome criteria:

  • Return of kidney function—normal creatinine level (<1.5 mg/dL), urine output.
  • Resumes normal life pattern (about 3 months after onset).

IV. CHRONIC RENAL FAILURE: as a result of progressive destruction of kidney tissue, the kidneys are no longer able to maintain their homeostatic functions; considered irreversible.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: destruction of glomeruli → reduced glomerular filtration rate → retention of metabolic waste products; decreased urine output; severe fluid, electrolyte, acid-base imbalances →uremia. Clinical picture includes:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Ammonia in skin and alimentary tract by bacterial interaction with urea → inflammation of mucous membranes.
  • Retention of phosphate → decreased serum calcium → muscle spasms, tetany, and increased parathormone release → demineralization of bone.
  • Failure of tubular mechanisms to regulate blood bicarbonate → metabolic acidosis → hyperventilation.
  • Urea osmotic diuresis → flushing effect on tubules → decreased reabsorption of sodium → sodium depletion.
  • Waste product retention → depressed bone marrow function → decreased circulating RBCs→ renal tissue hypoxia → decreased erythropoietin production → further depression of bone marrow → anemia.

B. Risk factors:

  • Diabetic retinopathy.
  • Chronic glomerulonephritis.
  • Chronic urinary obstruction, ureteral stricture, calculi, neoplasms.
  • Chronic pyelonephritis.
  • Hypertensive nephrosclerosis.
  • Congenital or acquired renal artery stenosis.
  • Systemic lupus erythematosus.

C. Assessment:

  • Subjective data: excessive fatigue, weakness.
  • Objective data:
    a. Skin: bronze colored, uremic frost.
    b. Ammonia breath.
    c. Symptoms gradual in onset.

D. Analysis/nursing diagnosis:

  • In addition to the following.
  • Fatigue related to severe anemia.
  • Risk for impaired skin integrity related to pruritus.
  • Ineffective individual coping related to chronic illness.
  • Body image disturbance related to need for dialysis.
  • Noncompliance related to denial of illness.

E. Nursing care plan/implementation:

  • Goal: maintain fluid, electrolyte balance and nutrition.
    a. Diet: low sodium; foods high in: calcium, vitamin B complex, vitamins C and D, and iron (to reduce edema, replace deficits, and promote absorption of nutrients).
    b. Medications: given to control BP, regulate electrolytes, control fluid volume; supplemental vitamins if deficient; electrolyte modifier (aluminum hydroxide [Alu-Cap, Amphojel]), calcium carbonate to bind phosphate.
    c. I&O; intake should be equivalent to previous daily output to prevent fluid retention.
  • Goal: employ comfort measures that reduce distress and support physical function.
    a. Activity: bedrest; facilitate ventilation; turn, cough, deep breathe q2h; ROM—active and passive, to prevent thrombi. b. Hygiene: mouth care to prevent stomatitis and reduce discomfort from mouth ulcers; perineal care.
    c. Skin care: soothing lotions to reduce pruritus.
    d. Encourage communication of concerns.
  • Goal: health teaching.
    a. Dietary restrictions: no added salt when cooking; change cooking water in vegetables during process to decrease potassium; read food labels to avoid Na+ and K+; protein restriction according to BUN/creatinine ratio (10:1).
    b. Importance of daily weight: same scale, time, clothing.
    c. Prepare for dialysis; transplantation.

F. Evaluation/outcome criteria:

  • Acceptance of chronic illness (no indication of indiscretions, destructive behavior, suicidal tendency).
  • Compliance with dietary restriction—no signs of protein excess (e.g., nausea, vomiting) or fluid sodium excess (e.g., edema, weight gain).

V. DIALYSIS: diffusion of solute through a semipermeable membrane that separates two solutions; direction of diffusion depends on concentration of solute in each solution; rate and efficiency depend on concentration gradient, temperature of solution, pore size of membrane, and molecular size; two methods available (Comparison of Hemodialysis and Peritoneal Dialysis).

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Indications: acute poisonings; acute or chronic renal failure; hepatic coma; metabolic acidosis; extensive burns with azotemia.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

B. Goals:

  • Reduce level of nitrogenous waste.
  • Correct acidosis, reverse electrolyte imbalances, remove excess fluid.

C. Hemodialysis: circulation of client’s blood through a compartment formed of a semipermeable membrane (polysulfone, polyacrylonitrile) surrounded by dialysate fluid.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Types of venous access for hemodialysis:
    a. External shunt (AV shunt (cannulae).
    (1) Cannula is placed in a large vein and a large artery that approximate each other.
    (2) External shunts, which provide easy and painless access to bloodstream, are prone to infection and clotting and cause erosion of the skin around the insertion area.
    (a) Daily cleansing and application of a sterile dressing.
    (b) Prevention of physical trauma and avoidance of some activities, such as swimming. b. Arteriovenous fistulas or graft (AV fistula).
    (1) Large artery and vein are sewn together (anastomosed) below the surface of the skin (fistula) or subcutaneous graft using the saphenous vein, synthetic prosthesis, or bovine xenograft to connect artery and vein.
    (2) Purpose is to create one blood vessel for withdrawing and returning blood.
    (3) Advantages: greater activity range than AV shunt and no protective asepsis.
    (4) Disadvantage: necessity of two venipunctures with each dialysis.
    c. Vein catheterization.
    (1) Femoral or subclavian vein access is immediate.
    (2) May be short- or long-term duration.
  • Complications during hemodialysis:
    a. Dysequilibrium syndrome—rapid removal of urea from blood → reverse osmosis, with water moving into brain cells → cerebral edema → possible headache, nausea, vomiting, confusion, and convulsions; usually occurs with initial dialysis treatments; shorter dialysis time and slower rate minimizes.
    b. Hypotension—results from excessive ultrafiltration or excessive antihypertensive medications.
    c. Hypertension—results from volume overload (water and/or sodium), causing dysequilibrium syndrome or anxiety.
    d. Transfusion reactions.
    e. Arrhythmias—due to hypotension, fluid overload, or rapid removal of potassium.
    f. Psychological problems:
    (1) Clients react in varying ways to dependence on hemodialysis.
    (2) Nurse needs to identify client reactions and defense mechanisms and to employ supportive behaviors (e.g., include client in care; continual repetition and reinforcement); do not interpret client’s behavior— for example, do not say, “You’re being hostile” or “You’re acting like a child”; answer questions honestly regarding quality and length of life with dialysis and/or transplantation; encourage independence as much as possible.
  • Commonly used medications:
    a. Antihypertensives (ACE inhibitors, beta blockers, diuretics).
    b. Phosphorus binders (calcium acetate, calcium carbonate, Renagel).
    c. B-complex vitamins with vitamin C and folic acid.
    d. Synthetic erythropoietin (Aranesp, Epogen).
    e. Iron.
    f. Activated vitamin D.

D. Intermittent peritoneal dialysis: involves introduction of a dialysate solution into the abdomen, where the peritoneum acts as the semipermeable membrane
between the solution and blood in abdominal vessels. Procedure:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Area around umbilicus is prepared and anesthetized with local anesthetic, and a catheter is inserted into the peritoneal cavity through a trocar; the catheter is then sutured into place to prevent displacement.
  • Warmed dialysate is then allowed to flow into the peritoneal cavity. Inflow time: 5 to 10 minutes; 2 L of solution are used in each cycle in the adult; solutions contain glucose, Na+, Ca++, Mg++, K+, Cl–, and lactate or acetate.
  • When solution bottle is empty, dwell time (exchange time) begins. Dwell time: 10 to 20 minutes; processes of diffusion, osmosis, and filtration begin to move waste products from bloodstream into peritoneal cavity.
  • Draining of the dialysate begins with the unclamping of the outflow clamp. Outflow time: usually 10 minutes; returns less than 2 L usually result from incomplete peritoneal emptying; turn side to side to increase return; multiple exchanges in 24 hours depending on client need.

E. Continuous ambulatory peritoneal dialysis (CAPD): functions on the same principles as peritoneal dialysis, yet allows greater freedom and independence for clients on dialysis. Procedure:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Dialysis solution is infused into peritoneum three times daily and once before bedtime.
  • Dwell time—≥4 hours for each daily exchange, and overnight for the fourth (8 to 12 hours).
  • Indwelling peritoneal catheter is connected to solution bag at all times—serves to fill and drain peritoneum; concealed in cloth pouch, strapped to the body during dwell time; client can move about doing usual activities.

F. Continuous cycling peritoneal dialysis (CCPD): same principles as CAPD, except uses an automated system to infuse and remove dialysate; reduces nursing care needs with clients who are hospitalized. Cumbersome equipment inhibits nighttime mobility. Procedure:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Long exchanges without an automated cycler during the day, and short exchanges with a cycler at night.
  • Dwell time—6 to 8 hours while sleeping.
  • Automatic alarms to prevent malfunction with home use.

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

VI. KIDNEY TRANSPLANTATION: placement of a donor kidney (from sibling, parent, cadaver) into the iliac fossa of a recipient and the anastomosis of its ureter to the bladder of the recipient; indicated in end-stage renal disease.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Criteria for recipient: irreversible kidney function; under 70 years of age; patent and functional lower urinary tract; and good surgical risk, free of serious cardiovascular complications. Contraindicated in those with another life-threatening condition.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Donor selection:

  • Sibling or parent—survival rate of kidney is greater; preferred for transplantation.
  • Cadaver—greater rate of rejection following transplantation, although majority of transplantations are with cadaver kidneys.

C. Bilateral nephrectomy: necessary for clients with rapidly progressive glomerulonephritis, malignant hypertension, or chronic kidney infections; prevents complications in transplanted kidney for nursing care.

D. Analysis/nursing diagnosis:

  • Altered urinary elimination related to kidney failure.
  • Fear related to potential transplant rejection.
  • Risk for infection related to immunosuppression.
  • Body image disturbance related to immunosuppression.

E. Nursing care plan/implementation:

  • Preoperative:
    a. Goal: promote physical and emotional adjustment.
    (1) Informed consent.
    (2) Laboratory work completed—histocompatibility, CBC, urinalysis, blood type and crossmatch.
    (3) Skin preparation.
    b. Goal: encourage expression of feelings: origin of donor, fear of complications, rejection.                                                                                                                 c. Goal: minimize risk of organ rejection: give medications: begin immunosuppression (azathioprine, corticosteroids, cyclosporine); antibiotics if ordered.
    d. Goal: health teaching.
    (1) Nature of surgery; placement of kidney.
    (2) Postoperative expectations: deep breathing, coughing, turning, early ambulation; reverse isolation.
    (3) Medications: immunosuppressive therapy: purpose, effect.
  • Postoperative:
    a. Goal: promote uncomplicated recovery of recipient.
    (1) Vital signs; CVP; I&O—urine output usually immediate with living donor; with cadaver kidney may not work for a week or more and dialysis will be needed within 24 to 48 hours. Report less than 100 mL/hr immediately.
    (2) Isolation: strict reverse isolation with immunosuppression; wear face mask when out of room.
    (3) Position: back to nonoperative side; semi-Fowler’s to promote gas exchange.
    (4) Indwelling catheter care: strict asepsis; characteristics of urine—report gross hematuria, heavy sediment; clots; perineal care; bladder spasms may occur after removal of catheter.
    (5) Activity: ambulate 24 hours after surgery; avoid prolonged sitting.
    (6) Weigh daily.
    (7) Medications: immunosuppressives; analgesics as ordered (pain decreases significantly after 24 hours).
    (8) Drains: irrigate only on physician order; meticulous catheter care.
    (9) Diet: regular after return of bowel sounds; liberal amounts of protein; restrict fluids, sodium, potassium only if oliguric.
    b. Goal: observe for signs of rejection—most dangerous complication.
    (1)Three classifications:
    (a) Hyperacute—occurs within 5 to 10 minutes up to 48 hours after transplantation (rare).
    (b) Acute—most common 7 to 14 days; varies depending on living (1 week to 6 months) or cadaver (1 week to 2 years) donor.
    (c) Chronic—occurs several months to years.
    (2) Assessment:
    (a) Subjective data:
    (i) Lethargy, anorexia.
    (ii) Tenderness over graft site.                                                                                                                                                                                                                 (b) Objective data:
    (i) Laboratory data: Urine: decreased—output, creatinine clearance, sodium; increased— protein. Blood: increased—BUN, creatinine.
    (ii) Rapid weight gain; more than 3 lb/day.
    (iii) Vital signs: BP, temperature— elevated.
    c. Goal: maintain immunosuppressive therapy.
    (1) Azathioprine (Imuran)—an antimetabolite that interferes with cellular division. Side effects:
    (a) Gastrointestinal bleeding (give PO form with food).
    (b) Bone marrow depression; leukopenia; anemia.
    (c) Development of malignant neoplasms.
    (d) Infection.
    (e) Liver damage.
    (2) Prednisone—believed to affect lymphocyte production by inhibiting nucleic acid synthesis: anti-inflammatory action helps prevent tissue damage if rejection
    occurs. Side effects:
    (a) Stress ulcer with bleeding (give with food).
    (b) Decreased glucose tolerance (hyperglycemia).
    (c) Muscle weakness.
    (d) Osteoporosis.
    (e) Moon facies.
    (f) Acne and striae.
    (g) Depression and hallucinations.
    (3) Cyclosporine (Neoral, Sandimmune)—polypeptide antibiotic used to prevent rejection of kidney, liver, or heart allografts; PO dose given with room-temperature chocolate milk or orange juice in a glass dispenser. Side effects:
    (a) Nephrotoxicity (increased BUN, creatinine).
    (b) Hypertension.
    (c) Tremor.
    (d) Hirsutism, gingival hyperplasia.
    (e) GI—nausea, vomiting, anorexia, diarrhea, abdominal pain.
    (f) Infections—pneumonia, septicemia, abscesses, wound.
    (4) Additional drugs may include cyclophosphamide (Cytoxan), antithymocyte globulin (ATG), antilymphocyte globulin, muromonab-CD3 (OKT3), tacrolimus
    (Prograf), and mycophenolate mofetil (CellCept).                                                                                                                                                                                   d. Goal: health teaching.
    (1) Signs of rejection.
    (2) Drugs: side effects of immunosuppression.
    (3) Self-care activities: temperature, blood pressure, I&O, urine specimen collection.
    (4) Avoidance of infection.

F. Evaluation/outcome criteria:

  • No signs of rejection (e.g., no weight gain, oliguria).
  • No depression.
  • Client resumes role responsibilities.

VII. NEPHRECTOMY (radical or partial): removal of kidney through flank, retroperitoneal, abdominal, thoracic, or thoracic-abdominal approach; indicated with malignant tumors, severe trauma, or under certain conditions before renal transplantation.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Analysis/nursing diagnosis:

  • Pain related to surgical incision.
  • Risk for infection related to wound contamination.
  • Risk for fluid volume excess.
  • Risk for aspiration related to vomiting.
  • Constipation related to paralytic ileus.
  • Anxiety related to possible loss of function in remaining kidney.
  • Dysfunctional grieving related to perceived loss.

B. Nursing care plan/implementation:

  • Preoperative: Goal: optimize physical and psychological functioning.
  • Postoperative: Goal: promote comfort and prevent complications.
    a. Observe for signs of:
    (1) Paralytic ileus—abdominal distention, absent bowel sounds, vomiting (common complication following renal surgery).
    (2) Hemorrhage.
    b. Fluid balance: daily weight—maintain within 2% of preoperative level.

C. Evaluation/outcome criteria:

  • No complications (e.g., hemorrhage, paralytic ileus, wound infection).
  • Acceptance of loss of kidney.

VIII. RENAL CALCULI (UROLITHIASIS): formation of calculi (stones) in renal calyces or pelvis that pass to lower regions of urinary tract—ureters, bladder, or urethra; occurs after age 30, with greatest incidence in men, particularly over age 50.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: organic crystals form (most consist of calcium salts or magnesium and ammonium phosphate (struvite) →obstruction, infection; increased backward pressure in kidney →hydronephrosis → atrophy, fibrosis of renal tubules.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors (in over 50% of cases, cause is idiopathic):

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Urinary tract infection.
  • Urinary stasis—obstruction.
  • Metabolic factors—excessive intake of vitamin D or C, calcium carbonate.

C. Assessment (depends on size, shape, location of stone):

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:
    a. Pain: occasional, dull, in loin or back when stones are in calyces or renal pelvis; excruciating in flank area (renal colic), radiating to groin when stones are ureteral.
    b. Nausea associated with pain.
  • Objective data:
    a. Pallor, sweating, syncope, shock, and vomiting due to pain.
    b. Palpable kidney mass with hydronephrosis.
    c. Fever and pyuria with infection.
    d. Laboratory data:
    (1) Urinalysis: abnormal—pH (acidic or alkaline); RBCs (injury); WBCs (infection); increased—specific gravity; casts; crystals; other organic substances, depending on type of stone (i.e., calcium, struvite, uric acid, or cystine); positive culture.
    (2) Blood: increased calcium, phosphorus, total protein, alkaline phosphatase, creatinine, uric acid, BUN.
    e. Diagnostic tests:
    (1) IVP: reveals nonopaque stones, degree of obstruction.
    (2) X-ray; radiopaque stones seen.
    (3) Ultrasound may also be used.

D. Analysis/nursing diagnosis:

  • Pain related to passage of stone.
  • ltered urinary elimination related to potential obstruction.
  • Urinary retention related to obstruction of urethra.

E. Nursing care plan/implementation:

  • Goal: reduce pain and prevent complications.
    a. Medication: narcotics, antiemetics, antibiotics.
    b. Fluids: 3 to 4 L/day; IVs if nauseated, vomiting.
    c. Activity: ambulate to promote passage of stone, except bedrest during acute attack (colic).
    d. Reduce spasms: warm soaks to affected flank.
    e. Observe for signs of:
    (1) Obstruction—decreased urinary output, increased flank pain.
    (2) Passage of stone (90% will pass <5-mm size)—cessation of pain; filter urine with gauze.                                                                                                              f. Monitor: hydration status—I&O, daily weight; vital signs—particularly temperature for sign of infection; urine—color, odor.
  • Goal: health teaching.
    a. Importance of fluids: minimum 3,000 mL/day; 2 glasses during night.
    b. Diet: modify according to stone type.
    (1) Calcium oxalate and calcium phosphate stoneslow calcium, phosphorus, and oxalate (e.g., avoid tea, cocoa, cola, beans, spinach, acidic fruits).
    (2) Magnesium and ammonium phosphatelow phosphorus.
    (3) Uric acid stoneslow purine.
    (4) Cystine stoneslow protein.
    c. Acid-ash diet with calcium oxalate and calcium phosphate stones, magnesium and ammonium phosphate (struvite) stones.
    d. Alkaline-ash diet with uric acid and cystine stones.
    e. Signs of urinary infection: dysuria, frequency, hematuria; seek immediate treatment.
    f. Prepare for removal if indicated; 20% of stones require additional treatment: cytoscopy for small stones; cystolitholapaxy for soft stones; lithotripsy or surgical removal (nephroscopic, pyelolithotomy, or nephrolithotomy).

F. Evaluation/outcome criteria:

  • Relief from pain.
  • No signs of urinary obstruction (e.g., increased flank pain, decreased urine output).
  • No recurrence of lithiasis (adheres to diet and fluid regimen).

IX. LITHOTRIPSY. Laser lithotripsy—newer treatment using laser and a ureteroscope; constant water irrigation because of heat. Extracorporeal shock wave—a
noninvasive mechanical procedure used to break up renal calculi so they can pass spontaneously, in most cases. The trunk of the client is submerged in distilled
water. In addition to being strapped to a frame, the client may also receive sedation and analgesia for pain from sound waves. The procedure takes 30 to 45 minutes, and remaining still is important. An underwater electrode generates shock waves that fragment the stone so it can be excreted in the urine a few days after the procedure. A degree of renal colic may occur, requiring narcotics for up to 3 days. Nursing measures should encourage ambulation and promote diuresis through forcing fluids. Percutaneous lithotripsy—nephrostomy tract above kidney region; nephroscope used to retrieve calculi. Urinary drainage from incision for 3 to 4 days is normal. May be required for large fragments remaining after extracorporeal lithotripsy. Nursing measures include: dressing changes to prevent infection and prevent skin breakdown, and administration of antibiotics and narcotics for pain.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

X. BENIGN PROSTATIC HYPERPLASIA (BPH): bladder outlet obstruction resulting from an enlargement of the prostate gland.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: prostate enlarges, bulges upward, blocks flow of urine from bladder into urethra → obstruction → hydroureter, hydronephrosis.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Changes in estrogen and androgen levels.
  • Men older than 50.

C. Assessment:

  • Subjective data—urination:
    a. Difficulty starting stream.
    b. Smaller, less forceful.
    c. Dribbling.
    d. Frequency.
    e. Urgency.
    f. Nocturia.
    g. Retention (incomplete emptying).
    h. Inability to void after ingestion of alcohol or exposure to cold.
  • Objective data:
    a. Catheterization for residual urine: 25 to 50 mL after voiding.
    b. Enlarged prostate on rectal examination.
    c. Laboratory data:
    (1) Urine—increased RBC, WBC counts.
    (2) Blood—increased creatinine, prostatespecific antigen (PSA).

D. Analysis/nursing diagnosis:

  • Urinary retention related to incomplete emptying.
  • Altered urinary elimination related to obstruction.
  • Urinary incontinence related to urgency, pressure.
  • Anxiety related to potential surgery.
  • Body image disturbance related to threat to masculine identity.

E. Nursing care plan/implementation:

  • Goal: relieve urinary retention.
    a. Catheterization: release maximum of 1,000 mL initially; avoid bladder decompression, which results in hypotension, bladder spasms, ruptured blood vessels in bladder; empty 200 mL every 5 minutes.
    b. Patency: irrigate intermittently or continually, as ordered.
    c. Fluids: minimum 2,000 mL/24 hr.
  • Goal: health teaching.
    a. Preparation for surgery (cystostomy, prostatectomy):
    (1) Expectations—indwelling catheter (will feel urge to void).                                                                                                                                                                 (2) Avoid pulling on catheter (this increases bleeding and clots).
    (3) Bladder spasms common 24 to 48 hours after surgery, particularly with transurethral resection and suprapubic approaches.
    (4) Threatening nature of procedure (possibility of impotence with perineal prostatectomy).

XI. PROSTATECTOMY: surgical procedure to relieve urinary retention and frequency caused by benign prostatic hyperplasia or cancer of the prostate.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Types

  • Transurethral resection (TUR)—removal of obstructive prostatic tissue surrounding urethra by an electrical wire (resectoscope) introduced through the urethra; hypertrophy may recur, and TUR repeated; little risk of impotence. Laser also being used.
  • Suprapubic—low midline incision is made directly over the bladder; bladder is opened and large mass of prostatic tissue is removed through incision in urethral mucosa.
  • Retropubic—removal of hypertrophied prostatic tissue high in pelvic area through a low abdominal incision; bladder is not opened; client may remain potent.
  • Perineal—removal of prostatic tissue low in pelvic area is accomplished through an incision made between the scrotum and the rectum; usually results in impotency and incontinence.

B. Nursing care plan/implementation:

  • Preoperative.
  • Postoperative:
    a. Goal: promote optimal bladder function and comfort.
    (1) Urinary drainage: sterile closed-gravity system—maintain external traction as ordered.
    (2) Reinforce purposes, sensations to expect.
    (3) Bladder irrigation to control bleeding, keep clots from forming.
    (4) Suprapubic catheter care (suprapubic prostatectomy)—closed-gravity drainage system; observe character, amount, flow of drainage.
    (5) After removal:
    (a) Observe for urinary drainage q4h for 24 hours.
    (b) Skin care.
    (c) Report excessive drainage to physician.
    (6) Dressings: keep dry, clean; reinforce if necessary (may need to change suprapubic dressing if urinary drainage); notify physician of excessive bleeding.
    (7) Observe for signs of:
    (a) Bladder distention—distinct mound over pubis, slow drip in collecting bottle; irrigate catheter as ordered.
    (b) Increased bleeding—expect and report frank bleeding (if venous bleeding, increase traction on catheter); if bright-red drainage, and clots (arterial bleeding), may need surgical control; cool, clammy, pale skin and increased pulse rate indicate shock.
    b. Goal: assist in rehabilitation. Emotional support: fears of incontinence, loss of masculine identity, impotence.
    c. Goal: health teaching.
    (1) Expectations: mild incontinence, dribbling for a while (several months) after surgery; need to void as soon as urge is felt; push fluids.
    (2) Exercises: perineal (Kegel) 1 to 2 days after surgery—buttocks are tightened for a count of ten, 20 to 50 times daily.
    (3) Avoid:
    (a) Long auto trips, vigorous exercise, heavy lifting (anything heavier than 10 lb), and sexual intercourse for about 3 weeks or until medical permission, because they may increase tendency to bleed.
    (b) Alcoholic beverages for 1 month, because this may cause burning on urination; caffeine, because it causes diuresis.
    (c) Tub baths, because of increase chance of infection.
    (4) Medications: stool softeners or mild cathartics to decrease straining.

C. Evaluation/outcome criteria:

  • Relief of symptoms.
  • No complications (e.g., hemorrhage, impotence).

XII. URINARY DIVERSION: Incontinent—ileal conduit: anastomosis of ureters to a small portion of the ileum; stoma is called urostomy; urine flow is constant; requires external collection device. ContinentKock pouch, Indiana pouch: segment of small bowel or colon is used to create a pouch; holds urine without leakage; requires self-catheterization.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Indications:

  • Congenital anomalies of bladder.
  • Neurogenic bladder.
  • Mechanical obstruction to urine flow (e.g., bladder cancer).
  • Chronic progressive pyelonephritis.
  • Trauma to lower urinary tract.

B. Analysis/nursing diagnosis:

  • Altered urinary elimination related to surgical diversion.
  • Risk for impaired skin integrity related to leakage of urine.
  • Risk for infection related to contamination of stoma.
  • Constipation related to absence of peristalsis.
  • Body image disturbance related to stoma.

C. Nursing care plan/implementation:

  • Preoperative: optimal bowel and stoma site preparation.
    a. Diet: low residue 2 days followed by clear liquids for 24 hours.
    b. Medications:
    (1) Neomycin (for bowel sterilization).
    (2) Cathartics (GoLYTELY), enemas.
    c. Site selection: appliance faceplate (incontinent diversion) must bond securely; avoid areas of pressure from clothing (waistline); usual site is right or left lower abdominal quadrant.
  • Postoperative:
    a. Goal: prevent complications and promote comfort.
    (1) Observe for signs of:
    (a) Paralytic ileus (common complication)—keep NG tube patent.
    (b) Stoma necrosis—dusky or cyanotic color (emergency situation).
    (2) Skin care: check for leakage around ostomy bag.
    (3) Urinary drainage—stents or catheter in stoma; blood in urine in immediate postoperative period; mucus normal.
    b. Goal: health teaching.
    (1) Self-care activities:
    (a) Peristomal skin care—prevent irritation, breakdown; proper cleansing— soap and water; adhesive remover, if needed.
    (b) Appliance application and emptying; pouch opening 2 to 3 mm larger than stoma; do not remove each day; change appliance every 3 to 5 days or when
    leaking.
    (c) Odor control—dilute urine, hygiene, acid-ash diet; avoid asparagus, tomatoes.
    (d) Use of night drainage system if necessary for uninterrupted sleep.
    (2) Signs of complications: change in urine color, clarity, quantity, smell; stomal color change (normal is bright pink or red).

D. Evaluation/outcome criteria:

  • Acceptance of new body image.
  • Regains independence.
  • Demonstrates confidence in management of self-care activities.
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