BSN-4H Med-Surg Lec

URINARY TRACT DISORDERS

A. NEPHROLITHIASIS - Refers to stone formation in the kidneys - May vary in size CLASSIFICATION OF STONES (according to composition) 1. Infection stones - urea-splitting bacteria such as proteus, produce a more alkaline urine that favors precipitation; - 15% incidence 2. Magnesium ammonium phosphate (struvite) and calcium phosphate (apatite). - prone to staghorn calculi - may lead to COMPLICATIONS: *bleeding *pain *UTI *sepsis 3. Calcium Stones - 75% of kidney stones contain calcium, mostly calcium oxalate and calcium phosphate , Calcium oxalate stone, Calcium Stones CAUSES: - Idiopathic - Hypercalciuria >4 MKD - Hyperuricosuria - uric acid crystals act as a nucleus around Ca stones - Increased absorption of Oxalate ( end product of CHON metabolism - d/t inflammatory bowel disease, SI bypass 4. Uric Acid Stones - 10% incidence - occur in patients with and without gout, - develop in patients with diseases where there is a high rate of cell turnover such as leukemias, - radiolucent (not visualized on x-rays). Calcium containing stones are radiopaque. 5. Cystine Stones uncommon; 10% incidence caused by genetic defects in renal reabsorption of cystine, they form at a low pH

6. gravel within calyces GRAVEL - very fine gritty material less than 1 mm in diameter CLASSIFICATION OF STONES (according to location) 1. Upper Urinary Tract (kidney & ureter) 1

BSN-4H Med-Surg Lec - common in developed countries, hot weather, diet rich in oxalate, textile industry ( Calcium oxalate in cotton dust) 2. Lower Urinary Tract (urinary bladder) - 10% incidence - caused by Lower urinary tract obstruction (BPH), bladder diverticuli, or urine stasis - increased incidence in Asia due to CHON deficiencies ETIOLOGY / RISK FACTORS 1. Heredity 2. Environmental influence - sedentary occupation, industrial areas 3. Age 20-55 years old 4. Sex males 5. Race - Whites CLINICAL MANIFESTATIONS 1. Pain - depend on the size & location of the stone o Staghorn calculi asymptomatic 2. Hydronephrosis - indicates obstruction 3. Fever, chills, pyuria indicates infection 4. Renal Colic - group of symptoms associated with the movt of a calculus thru a narrow anatomical point usually in the ureter s/s: severe costovertebral angle pain radiating to the flank; N & V DIAGNOSIS 1. Urinalysis 2. Blood Chemistry SUA, Phosphorous, Calcium 3. Renal Function Tests 4. BUN, Creatinine 5. Ultrasound of KUB 6. Intravenous Pyelogram TREATMENT A. MEDICAL MANAGEMENT - Decrease the concentration of substances

B. PHARMACOLOGIC TREATMENT - PO4 decreases urinary Ca - Thiazides increases urinary Ca excretion - Allopurinol prevents formation of uric acid nidus C. DIETARY - Limit Vitamin C supplements (converts half of ingested Ascorbate to Oxalic Acid) - Increase OFI - Low purine diet D. SURGICAL MANAGEMENT 2

BSN-4H Med-Surg Lec Indications: 1. 2. 3. 4. Nephrolithotomy Ureterolithotomy Presence of infection Progressive renal damage Obstruction to urine flow Severe pain

NURSING INTERVENTIONS 1. Monitor I & O 2. Assess BUN & Creatinine 3. Increase OFI 4. Administer antibiotics or pain relievers 5. Encourage mobility B. PYELONEPHRITIS Bacterial invasion of the renal calyces, parenchyma, & renal pelvis which is usually an ascending infection from the lower urinary tract ETIOLOGY 1. Bacterial inflammation - results to scarring, fibrosis, & tubular dilatation 2. Repeated bouts of infection in the lower urinary tract DIAGNOSIS 1. 2. 3. 4.

Urinalysis Urine GSCS CBC IVP for chronic cases

C. CYSTITIS It is an inflammation of the bladder from any cause but is often secondary to bacterial infection specifically E.coli CLINICAL MANIFESTATION 1. Urinary frequency, urgency 2. Dysuria 3. Feeling of incomplete emptying of the bladder 4. fever INCIDENCE Higher in women: 1. Coitus may manipulate urethra to allow bacteria to enter 2. Shorter urethra 3. Pregnancy & childbirth 4. Damage to pelvic floor muscles Men- not susceptible due to bactericidal properties of prostatic secretions DIAGNOSIS Based on the symptoms: CBC leukocytosis Urine culture 3

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TREATMENT 1. Antibiotic 2. Fluids D. RENAL FAILURE Loss of kidney function May be acute or chronic S/S: due to retention of wastes & fluid, and inability of the kidneys to regulate electrolytes *ACUTE RENAL FAILURE* Sudden loss of kidney function caused by renal cell damage from ischemia or toxic substances Abrupt & reversible Leads to hypoperfusion, cell death & decompensation in renal function Prognosis is dependent on the cause & the condition of the client Near-normal or normal kidney function may resume gradually Acute renal failure CAUSES 1. 2. 3. 4. 5. 6.

Infection Renal Artery Occlusion Obstruction Dehydration/Diuretic Therapy Ischemia Antibiotics

PHASES OF ACUTE RENAL FAILURE A. OLIGURIC PHASE - Duration- 8-15 days - Sudden drop in urine output<400ml/day - Urine specific gravity of 1.010-1.016 - Anorexia, nausea, vomiting - Hypertension B. C. DIURETIC PHASE Urine output rises slowly, then diuresis occurs (4-5L/day) Excessive urine output indicates recovery of damaged nephrons Hypotension, tachycardia, improvement in LOC RECOVERY PHASE Slow process: complete recovery may take 1-2 years Urine volume is normal Increase LOC; BUN is stable & normal; May progress to chronic renal failure

DIAGNOSIS: History & physical examination LABS: 4

BSN-4H Med-Surg Lec o Urinalysis o S. creatinine o S. electrolytes o BUN o Renal Biopsy: if renal dysfunction persists for 3 or more weeks TREATMENT Goals -

to prevent further damage to the kidneys to promote recovery of renal function To prevent complications

Blood Transfusion Correction of fluid & electrolyte imbalance Early dialysis maybe advocated MEDICATIONS -

diuretics, kayexalate (cation exchange resin), Ca, antacids

*CHRONIC RENAL FAILURE* Progressive loss & ongoing deterioration in kidney function that occurs slowly over a period of time Occurs in 4 stages, irreversible, & results in uremia or end-stage renal disease Requires dialysis or kidney transplant to maintain life Hypervolemia or hypovolemia may also occur CAUSES 1. May follow acute renal failure 2. Renal artery occlusion 3. Chronic urinary obstruction 4. Recurrent infections 5. Hypertension 6. Metabolic disorders DM 7. Autoimmune disorder SLE CLINICAL MANIFESTATIONS Anorexia, nausea, vomiting Headache, weakness, fatigue Hypertension Confusion, lethargy followed by convulsion & coma Decreased urine output STAGES OF CHRONIC RENAL FAILURE A. Diminished Renal Reserve - Renal function is mildly to moderately impaired - Serum urea & creatinine, urine output is normal - Polyuria, nocturia, polydipsia B. Renal Insufficiency renal function is approximately 10% of normal 5

BSN-4H Med-Surg Lec C. serum urea & creatinine levels begin to rise Renal Failure Also known as end stage renal disease Renal function is approximately 5% of normal Serum urea & creatinine levels rise rapidly Urine output is <500ml/day Symptoms of uremia develop

DIAGNOSIS 1. Blood Studies BUN, creatinine, electrolytes, ABG, CBC 2. ECG peak T waves, Prolonged PR interval TREATMENT MEDICATIONS: o PO4 binding agents ( aluminum hydroxide) o Antihypertensives o Kayexalate o Sodium Bicarbonate o Erythropoietin injections Dialysis Kidney transplant NURSING MANAGEMENT - Monitor VS - Diet : Low protein, low Na, Low PO4, avoid potassium rich foods - I&O - Weigh daily E. EPIDIDYMITIS - Most common intrascrotal infection generally associated with chronic UTI - Due to coliform or Pseudomonas bacteria - Rare before puberty - Males<35 yo, due to N. gonorrhea & C. trachomatis FUNCTION OF THE EPIDIDYMIS consists of coiled tubules carrying sperm from the testicles & participates in sperm capacitation CLINICAL MANIFESTATION - Acute onset of scrotal swelling - Fever - If due to chlamydia: urethritis, with discharges - Scrotal edema and erythema in severe cases DIAGNOSIS 1. History & PE 2. CBC 3. Urinalysis / Urine GSCS 4. Blood CS 6

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TREATMENT 1. Bedrest for 3-4 days 2. Elevate scrotum with support & application of ice bags to decrease the inflammation & to increase comfort 3. Antibiotics Tetracycline for Chlamydia 4. Complications 5. Abscess 6. Sepsis 7. Testicular necrosis, testicular atrophy 8. Infection of the testicle F. PROSTATITIS - Inflammation of the prostate gland - Maybe acute or chronic - Maybe bacterial & nonbacterial *Bacterial: associated with UTI or catheter indwelling *Nonbacterial: Chlamydia, Trichomonas, Ureaplasma CLINICAL MANIFESTATIONS Acute perineal & lowback pain Fever, chills & dysuria Urinary frequency, urgency,decrease in the force & size of urinary strea DIAGNOSIS 1. History & PE tender prostate gland, boggy or edematous 2. CBC 3. Urinalysis, GSCS 4. TREATMENT 5. Bedrest 6. Analgesics & antibiotics cephalosporins 7. Non-bacterial metronidazole 8. Fluids G. BENIGN PROSTATIC HYPERTROPHY - Nonmalignant increase in proliferation of glandular & intercellular tissue of the prostate BPH ETIOLOGY unclear but usually due to changes in estrogen & androgen and the aging process Common in men>40 yo Incidence increases with age CLINICAL MANIFESTATIONS Urinary problems: decreased frequency, nocturia, incontinence, hematuria Vague epigastric discomfort Fever Costovertebral angle tenderness

BSN-4H Med-Surg Lec DIAGNOSIS DRE nonfixed, enlarged, firm & smooth mass in the prostate USD IVP Urinalysis, GSCS Serum creatinine, BUN TREATMENT Conservative therapy: prostatic massage & hot sitz bath Medications: anti androgen(estrogens), progestins Catheterization TURP TUIP NURSING RESPONSIBILITIES - Assess for urinary obstructions, distended bladder, low urine output - I&O - Increase OFI - Avoid straining - Avoid prolonged sitting, strenuous exercise