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THE GENITOURINARY SYSTEM

Urological Assessment
Key Signs and Symptoms of Urological Problems
EDEMA - associated with fluid retention
- renal dysfunctions usually produce ANASARCA
PAIN
Suprapubic pain= bladder
Colicky pain on the flank= kidney
HEMATURIA
Painless hematuria may indicate URINARY CANCER!
Early-stream hematuria - urethral lesion
Late-stream hematuria - bladder lesion

DYSURIA - Pain with urination - lower UTI

POLYURIA - More than 2 Liters urine per day

OLIGURIA - Less than 400 mL per day

ANURIA - Less than 50 mL per day

Urinary Urgency

Urinary retention

Laboratory examination
1. Urinalysis
2. BUN and Creatinine levels of the serum
3. Serum electrolytes

Diagnostic examination
1. Radiographic
2. IVP
3. KUB x-ray
4. KUB ultrasound
5. CT and MRI
6. Cystography

Implementation Steps for selected problems

Provide PAIN relief


● Assess the level of pain
● Administer medications usually narcotic ANALGESICS
Maintain Fluid and Electrolyte Balance

●Encourage to consume at least 2 liters of fluid per day


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●In cases of ARF, limit fluid as directed
●Weigh client daily to detect fluid retention
Ensure Adequate urinary elimination
● Encourage to void at least every 2-3 hours
● Promote measures to relieve urinary retention:
1. Alternating warm and cold compress
2. Bedpan
3. Open faucet
4. Provide privacy
5. Catheterization if indicated

Urinary Tract Infection (UTI)

Bacterial invasion of the kidneys or bladder (CYSTITIS) usually caused


by Escherichia coli

Predisposing factors include


1. Poor hygiene
2. Irritation from bubble baths
3. Urinary reflux
4. Instrumentation
5. Residual urine, urinary stasis
6. Urinary Tract Infection (UTI)

PATHOPHYSIOLOGY
The invading organism ascends the urinary tract, irritating the mucosa
and causing characteristic symptoms
Ureter - ureteritis
Bladder - cystitis
Urethra - urethritis
Pelvis - pyelonephritis

Assessment findings
1. Low-grade fever
2. Abdominal pain
3. Enuresis
4. Pain/burning on urination
5. Urinary frequency
6. Hematuria

Assessment findings: Upper UTI


1. Fever and CHIILS
2. Flank pain
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3. Costovertebral angle tenderness

Laboratory Examination
1. Urinalysis
2. Urine Culture

Nursing interventions
1. Administer antibiotics as ordered.
2. Provide warm baths and allow client to void in water to alleviate painful
voiding.
3. Force fluids. Nurses may give 3 liters of fluid per day.
4. Encourage measures to acidify urine (cranberry juice, acid-ash diet).
 Provide client teaching and discharge planning concerning
1. Avoidance of tub baths
2. Avoidance of bubble baths that might irritate urethra
3. Importance for girls to wipe perineum from front to back
4. Increase in foods/fluids that acidify urine.

Pharmacology
1. Sulfa drugs
Highly concentrated in the urine
Effective against E. coli!

2. Quinolones
Nephrolithiasis/Urolithiasis

Presence of stones anywhere in the urinary tract


calcium
oxalate
uric acid

Nephrolithiasis/Urolithiasis
Predisposing factors
1. Diet: large amounts of calcium and oxalate
2. Increased uric acid levels
3. Sedentary life-style, immobility
4. Family history of gout or calculi
5. Hyperparathyroidism

Pathophysiology
Supersaturation of crystals due to stasis

Stone formation

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May pass through the urinary tract

OBSTRUCTION, INFECTION and HYDRONEPHROSIS

Assessment findings
1. Abdominal or flank pain
2. Renal colic radiating to the groin
3. Hematuria
4. Cool, moist skin
5. Nausea and vomiting

Diagnostic tests
1. KUB Ultrasound and X-ray: pinpoints location, number, and
size of stones
2. IVP: identifies site of obstruction and presence of non-
radiopaque stones
3. Urinalysis: indicates presence of bacteria, increased protein,
increased WBC and RBC (hematuria)

Medical management
1. Surgery
a. Percutaneous nephrostomy: tube is inserted through skin and
underlying tissues into renal pelvis to remove calculi.
b. Percutaneous nephrostolithotomy: delivers ultrasound waves
through a probe placed on the calculus.

2. Extracorporeal shock-wave lithotripsy: delivers


shock waves from outside the body to the stone, causing
pulverization
a. Pain management : Morphine or Meperidine
b. Diet modification

Nursing interventions
1. Strain all urine through gauze to detect stones and crush
all clots.
2. Force fluids (3000—4000 cc/day).
3. Encourage ambulation to prevent stasis.
4. Relieve pain by administration of analgesics as ordered
and application of moist heat to flank area.
5. Monitor intake and output
6. Provide modified diet, depending upon stone consistency:
Calcium, Oxalate and Uric acid stones

Calcium stones
- limit milk/dairy products; provide acid-ash diet to
acidify urine (cranberry or prune juice, meat, eggs,
poultry, fish, grapes, and whole grains)
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Oxalate stones
- avoid excess intake of foods/ fluids high in oxalate
(tea, chocolate, rhubarb, spinach); maintain
alkaline-ash diet to alkalinize urine (milk;
vegetables; fruits except prunes, cranberries, and
plums)

Uric acid stones


- educe foods high in purine (liver, beans, kidneys,
venison, shellfish, meat soups, gravies, legumes);
maintain alkaline urine
7. Administer allopurinol (Zyloprim) as ordered, to decrease
uric acid production.
8. Provide client teaching and discharge planning
concerning:
● Prevention of Urinary stasis by maintaining
increased fluid intake especially in hot weather and during
illness; mobility; voiding whenever the urge is felt and at
least twice during the night
● Adherence to prescribed diet
● Need for routine urinalysis (at least every 3—4
months)
● Need to recognize and report signs/ symptoms of
recurrence (hematuria, flank pain).

Acute Renal Failure


Sudden interruption of kidney function to regulate fluid and electrolyte
balance and remove toxic products from the body

PATHOPHYSIOLOGY
● Pre-renal failure
● Intra-renal failure
● Post-renal failure

Prerenal CAUSE:
Factors interfering with perfusion and resulting in diminished
blood flow and glomerular filtrate, ischemia, and oliguria; include CHF,
cardiogenic shock, acute vasoconstriction, hemorrhage, burns,
septicemia, hypotension, anaphylaxis

Intrarenal CAUSE:
Conditions that cause damage to the nephrons; include acute
tubular necrosis (ATN), endocarditis, diabetes mellitus, malignant
hypertension, acute glomerulonephritis, tumors, blood transfusion

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reactions, hypercalcemia, nephrotoxins (certain antibiotics, x-ray dyes,
pesticides, anesthetics)

Postrenal CAUSE:
Mechanical obstruction anywhere from the tubules to the
urethra; includes calculi, BPH, tumors, strictures, blood clots, trauma,
and anatomic malformation

Three phases of acute renal failure


1. Oliguric phase
2. Diuretic phase
3. Convalescence or recovery phase
Four phases of acute renal failure (Brunner and Suddarth)
1. Initiation phase
2. Oliguric phase
3. Diuretic phase
4. Convalescence or recovery phase

Assessment findings: The Three Phases of Acute Renal Failure


1. Oliguric phase
Urine output less than 400 cc/24 hours
duration 1—2 weeks
Manifested by dilutional hyponatremia, hyperkalemia,
hyperphosphatemia, hypocalcemia, hypermagnesemia, and metabolic
acidosis
Diagnostic tests: BUN and creatinine elevated
2. Diuretic phase
Diuresis may occur (output 3—5 liters/day) due to partially
regenerated tubule’s inability to concentrate urine
Duration: 2—3 weeks; manifested by hyponatremia, hypokalemia, and
hypovolemia
Diagnostic tests: BUN and creatinine slightly elevated

3. Recovery or convalescent phase


Renal function stabilizes with gradual improvement over next 3—12
months
Laboratory findings:
● Urinalysis: Urine osmo and sodium
● BUN and creatinine levels increased
● Hyperkalemia
● Anemia
● ABG: metabolic acidosis
Nursing interventions
● Monitor fluid and Electrolyte Balance
● Reduce metabolic rate
● Promote pulmonary function
● Prevent infection

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● Provide skin care
● Provide emotional support

Nursing interventions
1. Monitor and maintain fluid and electrolyte balance.
a. Measure l & O every hour. note excessive losses in diuretic phase
b. Administer IV fluids and electrolyte supplements as ordered.
c. Weigh daily and report gains.
d. Monitor lab values; assess/treat fluid and electrolyte and acid-base
imbalances as needed
2. Monitor alteration in fluid volume.
a. Monitor vital signs, PAP, PCWP, CVP as needed.
b. Weigh client daily.
c. Maintain strict I & O records.
3. Assess every hour for hypervolemia
a. Maintain adequate ventilation.
b. Restrict FLUID intake
c. Administer diuretics and antihypertensives
4. Promote optimal nutritional status.
a. Weigh daily.
b. Administer TPN as ordered.
c. With enteral feedings, check for residual and notify physician if
residual volume increases.
d. Restrict protein intake to 1 g/kg/day
e. Restrict POTASSIUM intake
d. HIGH CARBOHYDRATE DIET, calcium supplements
5. Prevent complications from impaired mobility (pulmonary
embolism, skin breakdown, and atelectasis)
6. Prevent fever/infection.
a. Assess for signs of infection.
b. Use strict aseptic technique for wound and catheter care.
7. Support client/significant others and reduce/ relieve anxiety.
a. Explain pathophysiology and relationship to symptoms.
b. Explain all procedures and answer all questions in easy-to-
understand terms
c. Refer to counseling services as needed
8. Provide care for the client receiving dialysis.
9. Provide client teaching and discharge planning concerning
a. Adherence to prescribed dietary regimen
b. Signs and symptoms of recurrent renal disease
c. Importance of planned rest periods
d. Use of prescribed drugs only
e. Signs and symptoms of UTI or respiratory infection need to report to
physician immediately

Chronic Renal Failure


Gradual, Progressive irreversible destruction of the kidneys causing
severe renal dysfunction.
The result is azotemia to UREMIA
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Predisposing factors:
a. DM= worldwide leading cause
b. Recurrent infections
c Exacerbations of nephritis
d. urinary tract obstruction
e. hypertension

Pathophysiology
STAGE 1= reduced renal reserve, 40-75% loss of nephron
function
STAGE 2= renal insufficiency, 75-90% loss of nephron function
STAGE 3= end-stage renal disease, more than 90% loss.
DIALYSIS IS THE TREATMENT!

Assessment findings
1. Nausea, vomiting; diarrhea or constipation; decreased urinary
output
2. Dyspnea
3. Stomatitis
4. Hypertension (later), lethargy, convulsions, memory
impairment, pericardial friction rub

Diagnostic tests:
a. 24 hour creatinine clearance urinalysis
b. Protein, sodium, BUN, Crea and WBC elevated
c. Specific gravity, platelets, and calcium decreased
D. CBC= anemia

Medical management
1. Diet restrictions
2. Multivitamins
3. Hematinics and erythropoietin
4. Aluminum hydroxide gels
5. Anti-hypertensive
6. Anti-seizures
7. DIALYSIS
Nursing interventions
1. Prevent neurological complications.
a. Assess every hour for signs of uremia (fatigue, loss of
appetite, decreased urine output, apathy, confusion, elevated
blood pressure, edema of face and feet, itchy skin, restlessness,
seizures).
b. Assess for changes in mental functioning.
c. Orient confused client to time, place, date, and persons;
institute safety measures to protect client from falling out of
bed.
d. Monitor serum electrolytes, BUN, and creatinine as ordered

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2. Promote optimal GI function.
a. Assess/provide care for stomatitis
b. Monitor nausea, vomiting, anorexia
c. Administer antiemetics as ordered.

3. Monitor/prevent alteration in fluid and electrolyte balance


4. Assess for hyperphosphatemia (paresthesias, muscle cramps, seizures,
abnormal reflexes), and administer aluminum hydroxide gels
(Amphojel) as ordered
5. Promote maintenance of skin integrity.
a. Assess/provide care for pruritus.
b. Assess for uremic frost (urea crystallization on the skin) and
bathe in plain water
6. Monitor for bleeding complications, prevent injury to client.
a. Monitor Hgb, hct, platelets, RBC.
b. Hematest all secretions.
c. Administer hematinics as ordered.
d. Avoid lM injections
7. Promote/maintain maximal cardiovascular function.
a. Monitor blood pressure and report significant changes.
b. Auscultate for pericardial friction rub.
c. Perform circulation checks routinely.
7. Promote/maintain maximal cardiovascular function.
a. Administer diuretics as ordered and monitor output.
b. Modify drug doses
8. Provide care for client receiving dialysis.

DIALYSIS
a procedure that is used to remove fluid and uremic wastes from
the body when the kidneys cannot function

Two methods
1. Hemodialysis
2. Peritoneal dialysis
Nursing management
1. Meet the patient's psychosocial needs
2. Remember to avoid any procedure on the arm with the
fistula (HEMO)
3. Monitor WEIGHT, blood pressure and fistula site for
bleeding
4. Monitor symptoms of uremia
5. Detect complications like infection, bleeding (Hepatitis
B/C and HIV infection in Hemodialysis)
6. Warm the solution to increase diffusion of waste products
(PERITONEAL)
7. Manage discomfort and pain
8. To determine effectiveness, check serum creatinine, BUN
and electrolytes

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Male reproductive disorders
DIGITAL RECTAL EXAMINATION- DRE
• Recommended for men annually with age over 40 years
• Screening test for cancer
• Ask patient to BEAR DOWN

TESTICULAR EXAMINATION
• Palpation of scrotum for nodules and masses or inflammation
• BEGINS DURING ADOLESCENCE

Prostate specific antigen (PSA)


• Elevated in prostate cancer
• Normal is 0.2 to 4 nanograms/mL
• Cancer - over 4

BENIGN PROSTATIC HYPERPLASIA


- Enlargement of the prostate that causes outflow obstruction
- Common in men older than 50 years old

Assessment findings
1. DRE: enlarged prostate gland that is rubbery, large and
NON-tender
2. Increased frequency, urgency and hesitancy
3. Nocturia, DECREASE IN THE VOLUME AND FORCE OF
URINE STREAM

Medical management
1. Immediate catheterization
2. Prostatectomy
3. TRANSURETHRAL RESECTION of the PROSTATE (TURP)
4. Pharmacology: alpha-blockers, alpha-reductase inhibitors.
SAW palmetto

Nursing Intervention
1. Encourage fluids up to 2 liters per day
2. Insert catheter for urinary drainage
3. Administer medications – alpha adrenergic blockers and
finasteride
4. Avoid anticholinergics
5. Prepare for surgery or TURP
6. Teach the patient perineal muscle exercises. Avoid
valsalva until healing
Nursing Intervention: TURP
1. Maintain the three way bladder irrigation to prevent
hemorrhage
2. Only initially the drainage is pink-tinged and never
reddish
3. Administer anti-spasmodic to prevent bladder spasms
PROSTATE CANCER
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- a slow growing malignancy of the prostate gland
- Usually an adenocarcinoma
- This usualy spread via blood stream to the vertebrae
Predisposing factor
➢ Age
Assessment Findings
1. DRE: hard, pea-sized nodules on the anterior rectum
2. Hematuria
3. Urinary obstruction
4. Pain on the perineum radiating to the leg

Diagnostic tests
1. Prostatic specific antigen (PSA)
2. Elevated SERUM ACID PHOSPHATASE indicates SPREAD or
Metastasis

Medical and surgical management


1. Prostatectomy
2. TURP
3. Chemotherapy: hormonal therapy to slow the rate of
tumor growth
4. Radiation therapy

Nursing Interventions
1. Prepare patient for chemotherapy
2. Prepare for surgery

Nursing Interventions: Post-prostatectomy


1. Maintain continuous bladder irrigation. Note that drainage
is pink tinged w/in 24 hours
2. Monitor urine for the presence of blood clots and
hemorrhage
3. Ambulate the patient as soon as urine begins to clear in
color

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