Genito Urinary System

The Genito-Urinary System Medical Surgical Nursing Review

Outline of review
Recall the anatomy and physiology of the Renal System
Renal Assessment
Renal Laboratory Procedure
Common Conditions:
UTI
Kidney Stones
ARF and CRF

Outline of review
BPH
Prostatic cancer

Kidney function HYPERKALEMIA Excretes excess POTASSIUM Metabolic ACIDOSIS Produces bicarbonate and secretes acids Calcium and Phosphate imbalances Metabolism of Vitamin D ANEMIA Secretes Erythropoietin to increase RBC Impaired urine production and azotemia The Nephron produces urine to eliminate waste

Urological Assessment
Nursing History
Reason for seeking care
Current illness
Previous illness
Family History
Social History
Sexual history

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
Urinary frequency

PHYSICAL EXAMINATION
Inspection
Auscultation
Percussion
Palpation

Laboratory examination
Urinalysis
BUN and Creatinine levels of the serum
Serum electrolytes

Laboratory examination
Radiographic
IVP
KUB x-ray
KUB ultrasound
CT and MRI
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
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:
Alternating warm and cold compress
Bedpan
Open faucet
Provide privacy
Catheterization if indicated

Urinary Tract Infection (UTI)
Bacterial invasion of the kidneys or bladder (CYSTITIS) usually caused by Escherichia coli

Predisposing factors include
Poor hygiene
Irritation from bubble baths
Urinary reflux
Instrumentation
Residual urine, urinary stasis

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
Low-grade fever
Abdominal pain
Enuresis
Pain/burning on urination
Urinary frequency
Hematuria

Assessment findings: Upper UTI
Fever and CHIILS
Flank pain
Costovertebral angle tenderness

Laboratory Examination
Urinalysis
Urine Culture

Nursing interventions
Administer antibiotics as ordered
Provide warm baths and allow client to void in water to alleviate painful voiding.
Force fluids. Nurses may give 3 liters of fluid per day
Encourage measures to acidify urine (cranberry juice, acid-ash diet).

Provide client teaching and discharge planning concerning
a. Avoidance of tub baths
b. Avoidance of bubble baths that might irritate urethra
c. Importance for girls to wipe perineum from front to back
d. 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
and uric acid

Pathophysiology
Predisposing factors
a. Diet: large amounts of calcium and oxalate
b. Increased uric acid levels
c. Sedentary life-style, immobility
d. Family history of gout or calculi
e. Hyperparathyroidism

Pathophysiology
Supersaturation of crystals due to stasis
Stone formation
May pass through the urinary tract
OBSTRUCTION, INFECTION and HYDRONEPHROSIS

Assessment findings
Abdominal or flank pain
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.

Medical management
2. Extracorporeal shock-wave lithotripsy: delivers shock waves from outside the body to the stone, causing pulverization
Pain management : Morphine or Meperidine
Diet modification

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)

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
reduce 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

Acute renal failure
PATHOPHYSIOLOGY
Pre-renal failure
Intra-renal failure
Post-renal failure

Acute renal failure
PATHOPHYSIOLOGY
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

Acute renal failure
PATHOPHYSIOLOGY
Intrarenal CAUSE:
Conditions that cause damage to the nephrons; include acute tubular necrosis (ATN), endocarditis, diabetes mellitus, malignant hypertension, acute glomerulonephritis, tumors, blood transfusion reactions, hypercalcemia, nephrotoxins (certain antibiotics, x-ray dyes, pesticides, anesthetics)

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

Acute renal failure
Three phases of acute renal failure
Oliguric phase
Diuretic phase
Convalescence or recovery phase

Acute renal failure
Four phases of acute renal failure (Brunner and Suddarth)
Initiation phase
Oliguric phase
Diuretic phase
Convalescence or recovery phase

Acute renal failure
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

Acute renal failure
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

Acute renal failure
3. Recovery or convalescent phase:
Renal function stabilizes with gradual improvement over next 3—12 months

Acute renal failure
Laboratory findings:
Urinalysis: Urine osmo and sodium
BUN and creatinine levels increased
Hyperkalemia
Anemia
ABG: metabolic acidosis

Acute renal failure
Monitor fluid and Electrolyte Balance
Reduce metabolic rate
Promote pulmonary function
Prevent infection
Provide skin care
Provide emotional support

Acute renal failure
1. Monitor and maintain fluid and electrolyte balance.
Measure l & O every hour. note excessive losses in diuretic phase
Administer IV fluids and electrolyte supplements as ordered.
Weigh daily and report gains.
Monitor lab values; assess/treat fluid and electrolyte and acid-base imbalances as needed

Acute renal failure
2. Monitor alteration in fluid volume.
Monitor vital signs, PAP, PCWP, CVP as needed.
Weigh client daily.
Maintain strict I & O records.

Acute renal failure
2. Assess every hour for hypervolemia
Maintain adequate ventilation.
Restrict FLUID intake
Administer diuretics and antihypertensives

Acute renal failure
3. Promote optimal nutritional status.
Weigh daily.
Administer TPN as ordered.
With enteral feedings, check for residual and notify physician if residual volume increases.
Restrict protein intake to 1 g/kg/day
Restrict POTASSIUM intake
HIGH CARBOHYDRATE DIET, calcium supplements

Acute renal failure
4. Prevent complications from impaired mobility (pulmonary embolism, skin breakdown, and atelectasis)
5. Prevent fever/infection.
Assess for signs of infection.
Use strict aseptic technique for wound and catheter care.

Acute renal failure
6. Support client/significant others and reduce/ relieve anxiety.
Explain pathophysiology and relationship to symptoms.
Explain all procedures and answer all questions in easy-to-understand terms
Refer to counseling services as needed
7. Provide care for the client receiving dialysis

Acute renal failure
8. Provide client teaching and discharge planning concerning
Adherence to prescribed dietary regimen
Signs and symptoms of recurrent renal disease
Importance of planned rest periods
Use of prescribed drugs only
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

Predisposing factors:
DM= worldwide leading cause
Recurrent infections
Exacerbations of nephritis
urinary tract obstruction
hypertension

PATHOPHYSIOLOGY
As renal functions decline
Retention of end-products of metabolism

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

Chronic Renal Failure loss of strength, foot drop, osteodystrophy Musculoskeletal Anemia Hema Uremic lungs Pulmo Acute MI, edema, hypertension, pericarditis CVS seizures, altered LOC, anorexia, fatigue CNS dry skin , pruritus, uremic frost Dermatologic

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
DIALYSIS

1. Prevent neurological complications.
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).

1. Prevent neurological complications.
Assess for changes in mental functioning.
Orient confused client to time, place, date, and persons; institute safety measures to protect client from falling out of bed.
Monitor serum electrolytes, BUN, and creatinine as ordered

2. Promote optimal GI function.
Assess/provide care for stomatitis
Monitor nausea, vomiting, anorexia
Administer antiemetics as ordered.
Assess for signs of Gl bleeding

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.
Assess/provide care for pruritus.
Assess for uremic frost (urea crystallization on the skin) and bathe in plain water

6. Monitor for bleeding complications, prevent injury to client.
Monitor Hgb, hct, platelets, RBC.
Hematest all secretions.
Administer hematinics as ordered.
Avoid lM injections

7. Promote/maintain maximal cardiovascular function.
Monitor blood pressure and report significant changes.
Auscultate for pericardial friction rub.
Perform circulation checks routinely.

7. Promote/maintain maximal cardiovascular function.
Administer diuretics as ordered and monitor output.
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

DIALYSIS
Two methods
1. Hemodialysis
2. Peritoneal dialysis

DIALYSIS
Diffusion
Osmosis
Ultrafiltration

DIALYSIS
Nursing management
Meet the patient's psychosocial needs
Remember to avoid any procedure on the arm with the fistula (HEMO)
Monitor WEIGHT, blood pressure and fistula site for bleeding

DIALYSIS
Nursing management
3. Monitor symptoms of uremia
4. Detect complications like infection, bleeding (Hepatitis B/C and HIV infection in Hemodialysis)
5. Warm the solution to increase diffusion of waste products (PERITONEAL)
6. Manage discomfort and pain

DIALYSIS
Nursing management
7. To determine effectiveness, check serum creatinine, BUN and electrolytes

Male reproductive disorders
BPH
Prostatic cancer

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

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

BPH
NURSING INTERVENTION
Encourage fluids up to 2 liters per day
Insert catheter for urinary drainage
Administer medications – alpha adrenergic blockers and finasteride
Avoid anticholinergics
Prepare for surgery or TURP
Teach the patient perineal muscle exercises. Avoid valsalva until healing

BPH
NURSING INTERVENTION: TURP
Maintain the three way bladder irrigation to prevent hemorrhage
Only initially the drainage is pink-tinged and never reddish
Administer anti-spasmodic to prevent bladder spasms

Prostate Cancer
a slow growing malignancy of the prostate gland
Usually an adenocarcinoma
This usualy spread via blood stream to the vertebrae

Prostate Cancer
Predisposing factor
Age

Prostate Cancer
Assessment Findings
DRE: hard, pea-sized nodules on the anterior rectum
Hematuria
Urinary obstruction
Pain on the perineum radiating to the leg

Prostate Cancer
Diagnostic tests
Prostatic specific antigen (PSA)
Elevated SERUM ACID PHOSPHATASE indicates SPREAD or Metastasis

Prostate Cancer
Medical and surgical management
Prostatectomy
TURP
Chemotherapy: hormonal therapy to slow the rate of tumor growth
Radiation therapy

Prostate Cancer
Nursing Interventions
Prepare patient for chemotherapy
Prepare for surgery

Prostate Cancer
Nursing Interventions: Post-prostatectomy
Maintain continuous bladder irrigation. Note that drainage is pink tinged w/in 24 hours
Monitor urine for the presence of blood clots and hemorrhage
Ambulate the patient as soon as urine begins to clear in color

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Genito Urinary System

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