Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 46 & 47: Nursing Management: Urinary Incontinence and Chronic Kidney
Disease
URINARY INCONTINENCE AND RETENTION

Urinary incontinence (UI) is an uncontrolled leakage of urine. The prevalence of

incontinence is higher among older adults, but it is not a natural consequence of
aging.

Causes of UI include confusion or depression, infection, atrophic vaginitis,

urinary retention, restricted mobility, fecal impaction, or drugs.

Type of UI: Table 46-18

Urinary retention is the inability to empty the bladder despite micturition or the
accumulation of urine in the bladder because of an inability to urinate.

Urinary retention is caused by two different dysfunctions of the urinary system:

bladder outlet obstruction, and deficient detrusor (bladder muscle) contraction
strength.

Evaluation for UI and urinary retention includes a focused history, physical

assessment, urinalysis, and a bladder log or voiding record.

Several strategies are used to manage UI (Table 46-19):

o Lifestyle interventions include an adequate volume of fluids and reduction
or elimination of bladder irritants from the diet.
o Behavioral treatments include scheduled voiding regimens, bladder
retraining, and pelvic floor muscle training.
o Drug therapy (Table 46-21) and surgery play a role in treating certain
types of UI.

Acute urinary retention is a medical emergency that requires prompt recognition

and bladder drainage.

INSTRUMENTATION

Short-term urinary catheterization may be performed to obtain a urine specimen

for laboratory analysis. Complications from long-term use (>30 days) of
indwelling catheters include bladder spasms, periurethral abscess, pain, and
urosepsis. Table 46-22

Nursing actions should include maintaining patency of the catheter, managing

fluid intake, providing for the comfort and safety of the patient, and preventing
infection.

The ureteral catheter is placed through the ureters into the renal pelvis as a stent,
often following a lithotripsy procedure or in case of obstruction.
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The suprapubic catheter is used in temporary situations such as bladder, prostate,

and urethral surgery. The suprapubic catheter is also used long term in selected
patients.

Nephrostomy tubes are inserted to maintain patency when complete obstruction

of a ureter is present. Make sure is never compressed, kinked, or clamped.

Intermittent catheterization is being used with increasing frequency in conditions

characterized by neurogenic bladder or bladder outlet obstruction in men.

URINARY DIVERSION
Require collection devices: Table 46-23

Urinary diversions are performed to treat cancers of the urinary tract, congenital
anomalies, strictures, trauma, and chronic infections.

Numerous urinary diversion techniques and bladder substitutes are possible,

including an incontinent urinary diversion, a continent urinary diversion (Kock
pouch) catheterized by the patient, or an orthotopic bladder so that the patient
voids urethrally.

The patient awaiting a urinary diversion must be given a great deal of

information. The nurse plays a critical role in the education of the patient and
caregivers.

Common peristomal skin problems associated with an ileal conduit include

dermatitis, yeast infections, product allergies, and shearing-effect excoriations.

Discharge planning after an ileal conduit includes teaching the patient symptoms
of obstruction or infection and care of the ostomy. Nursing Care Plan page 1158,
Patient Teaching Guide page 1159.

CHRONIC KIDNEY DISEASE

Chronic kidney disease (CKD) involves progressive, irreversible loss of kidney

function. Stages Table 47-6, causes

CKD usually develops slowly over months to years and necessitates the initiation
of dialysis or transplantation for long-term survival. The prognosis of CKD is
variable depending on the etiology, patients condition and age, and adequacy of
follow-up.

In the early stage of renal insufficiency, polyuria results from the inability to
concentrate urine. As the GFR decreases, the BUN and serum creatinine levels
increase. Calculated GFR is a mosre accurate indicator of kidney function.

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Uremia is a syndrome that incorporates all the signs and symptoms seen in the
various systems throughout the body in CKD.
o Fatigue, lethargy, and pruritus are often the early symptoms. Hypertension
and proteinuria are often the first signs. Hyperglycemia, hyperinsulinemia,
hyperlipidemia, and abnormal glucose tolerance tests may be seen.
o Common electrolyte imbalances include hyperkalemia, hyponatremia, and
metabolic acidosis.

o Normocytic anemia is due to decreased production of erythropoietin.

The most common cause of death is cardiac-related disease, including
cardiac dysrhythmias, pulmonary edema, and dyspnea. Other complications
include infections, neurologic changes, peripheral neuropathy, CKD-mineral
and bone disease, pruritus, infertility, personality and behavioral changes,
lethargy, and depression.

Hypertension and diabetes mellitus are contributing risk factors for the
development of vascular complications. Vascular changes from long standing
hypertension and accelerated atherosclerosis from elevated triglyceride levels
contribute to the high rate of CV disease. LVH is present in about 75% of
dialysis patients, eventually leads to cardiomyopathy and heart failure.

Diabetes, CKD, and insulin

The focus in CKD is on the prevention and early identification of potentially

reversible causes of renal failure to deter the progression of kidney disease.

The overall goals of CKD therapy are to preserve existing kidney function, treat
cardiovascular disease, prevent complications, and provide for the patients
comfort.
o Conservative therapy is attempted before maintenance dialysis begins.

o Multiple strategies are used to maintain serum calcium levels and reduce
potassium and phosphorus levels. (Kayexalate, calcium-based phosphate
binders, aluminum and magnesium)
o CKD progression can be delayed by using drug therapy to control
hypertension. Know side effect of ACE inhibitor and ARBs.
o Erythropoietin is used for the treatment of anemia. Monitor hct. Target is
between 10 and 12.
o Statins (HMG-CoA reductase inhibitors) are the most effective drugs for
lowering low-density lipoprotein (LDL) cholesterol levels.

o Prior to dialysis, dietary protein is restricted to some extent; once the

patient starts dialysis, protein intake can be increased.
o Water intake depends on the daily urine output.

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NURSING MANAGEMENT: CHRONIC KIDNEY DISEASE

The overall goals are that a patient with CKD will demonstrate knowledge and
ability to comply with treatment, participate in decision making, demonstrate
effective coping strategies, and continue with activities of daily living within
limitations. Look at teaching guide on page 1179 good summary of disease
management for these patients.

Most persons with CKD are cared for in an ambulatory care setting; hospital
care is required for the management of complications.

Nursing care for the patient revolves around the nursing diagnoses of excess fluid
volume, risk for injury, imbalanced nutrition, and grieving.

GERONTOLOGIC CONSIDERATIONS: CHRONIC KIDNEY DISEASE

Approximately 35% to 65% of patients who have CKD are 65 or older.

Physiologic changes in the older CKD patient include diminished
cardiopulmonary function, bone loss, immunodeficiency, altered protein
synthesis, impaired cognition, and altered drug metabolism.

Most elderly end-stage renal disease (ESRD) patients select home dialysis.
However, establishing vascular access for HD may be challenging because of
atherosclerotic changes.

The most common cause of death in the elderly ESRD patient is cardiovascular
disease (MI, stroke), followed by withdrawal from dialysis.

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.