May exhibit:Elevated BP (renal effects of advanced enlargement)
May report:Decreased force/caliber of urinary stream; dribbling
Hesitancy in initiating voiding
Inability to empty bladder completely; urgency and frequency of urination
Nocturia, dysuria, hematuria, Sitting to void
Recurrent UTIs, history of calculi (urinary stasis)
Chronic constipation (protrusion of prostate into rectum)
Inguinal hernia; hemorrhoids (result of increased abdominal pressure required to empty bladder against resistance)
May exhibit:Firm mass in lower abdomen (distended bladder), bladder tenderness
FOOD/FLUID May report:Anorexia; nausea, vomiting, Recent weight loss PAIN/DISCOMFORT May report:Suprapubic, flank, or back pain; sharp, intense (in acute prostatitis), Low back pain SAFETY May report:Fever
Cont. ASSESSMENT SEXUALITY
May report:Concerns about effects of condition/therapy on sexual abilities
Fear of incontinence/dribbling during intimacy
Decrease in force of ejaculatory contractions
May exhibit:Enlarged, tender prostate
May report: Family history of cancer, hypertension, kidney disease
Use of antihypertensive or antidepressant medications, OTC cold/allergy medications containing sympathomimetics, urinary antibiotics or antibacterial agents
Self-treatment with saw palmetto or soy products
Obstructive Voiding symptoms
Feeling of incomplete bladder emptying
Systemic symptoms related to the UT: - Vesicoureteral reflux - Dilatation & hydronephrosis - Renal failure & symptoms of uremia Symptoms unrelated to the UT: - hernias, hemorrhoids and vesical calculus - change in the caliber of bowl movements Symptoms related to complications: - cystitis - pyelonephritis - bladder calculi - micro or gross hematuria.
Digital Rectal Examination (DRE) – smooth, firm, symmetric enlargement of the prostate
Urinalysis & microscopic examination: to R/O infection or the presence of hematuria.
Serum U/E & creatinine: to provide baseline information on renal function & metabolic status.
Uroflowmetry: At a volume of 125-150ml, normal individuals have average flow rates of 12ml/sec & peak flow close to 20ml/sec.
Mild 11-15 ml/sec Moderate 7 and 10 ml/sec Severe 7ml/sec
Residual Urine: estimated by U/S or catheterizations. Volumes >150 ml are considered significant since they constitute approximately one-third of normal bladder volume
Serum Prostate-Specific Antigen (PSA) – to rule out cancer, but may also be elevated in BPH
Optional diagnostics for further evaluation:
Urodynamics –measures peak urine flow rate, voiding time and volume, and status of the bladder’s ability to effectively contract.
Measurement of postvoid residual urine; by ultrasound or catheterization
Cystourethroscopy – to inspect urethra and bladder and evaluate prostatic size
Ultrasonography: In BPH, it is most useful for measuring bladder & prostate volume as well as residual urine. Estimation of prostatic size is important because most urologists prefer to perform TURP for glands under 100g. TRUS must be used as it is more accurate. IVP: For UTI & complications of BPH
Acute urinary retention, involuntary bladder contractions, bladder diverticula, and cystolithiasis
Assist with catheter introduction with guidewire or by way of suprapubic cystostomy as indicated.
Monitor intake and output
Maintain patency of catheter
Administer medications as ordered, and monitor for and teach patient about side effects.
Assess for and teach patient to report hematuria, signs of infection
Patient education and Health Maintenance NURSING DIAGNOSIS 1. Impaired Urinary Elimination related to obstruction of urethra. Rationale: BPH causes an enlargement that forms like a capsule in the urinary bladder that occludes urine flow causing changes in urinary elimination. The patient experiences manifestations such as frequency, urgency, hesitancy, change in stream, incontinence, retention and nocturia.
2. Acute Pain related to surgery and bladder spasms Rationale: Bladder spasms frequently occur after prostate procedures, and incisional pain will occur if an open surgery is completed due to stimulating actions on nociceptors which are responsible for pain sensation. Interventions:
Ensure that the drainage system is not blocked
Administer medications for relief of bladder spasms (Antispasmodic medications)
-Belladonna and opium suppositories -Propantheline bromide (Pro-Banthine) or immediate relase oxybutynin (Ditropan IR)
Have proper interventions for side effects of drugs
Dry mouth, drowsiness, acute confusion in the older clients Stool softeners such as docusate sodium (Colace) should be given for constipation since straining at stool can precipitate bleeding from the operative site.
3.Risk for Injury related to presence of urinary catheters, hematuria, irrigation, or suprapubic drains Rationale: Medical and surgical management for BPH require irrigation drainage such as urinary catheter. Blockage of an irrigated bladder is always possible in such situations that lead to overdistention, secondary hemorrhage, and formation of blood clots or infection. Interventions:
Monitor for bleeding
Prevent catheter dislodgment
Monitor for retention
Manage temporary incontence
Patients with mild symptoms (in the absence of significant bladder or renal impairment) are followed annually; BPH does not necessarily worsen in all men.
a-Adrenergic blockers such as doxazosin (Cardura), tamsulosin (FLomax), terazosin (Hytrin) – relax smooth muscle of bladder base and prostate to facilitate voiding.
5 alpha reductase inhibitor
Finasteride (Proscar) – antiandrogen effect on prostate cells, reverses or prevents hyperplasia
TURP, transurethral incision of the prostate (TUIP), or open prostatectomy for very large prostate, usually by suprapubic approach Newer approaches – laser surgery, transurethral electrovaporization, transurethral needle ablation, insertion of intraurethral stents, hyperthermia, and thermotherapy.
Pre – op
Obtain informed consent
Assess ability to empty bladder
The bladder should be palpated for distention
If the client cannot void, a urethral catheter may have to be placed
Stop anticoagulants medications before the procedure
Assess clients knowledge about surgery and its outcomes
Provide health teaching to lessen clients fear and anxiety
Restate explanations given by the surgeon and anesthetist
Vital signs monitoring
Maintenance of urinary drainage
Document urine color
Proper positioning of the catheter and drainage system.
URINARY INCONTINECE Urinary incontinence is unintentional loss of urine that is sufficient enough in frequency and amount to cause physical and/or emotional distress in the person experiencing it. Women are affected by the disorder more frequently than are men; one in 10 women under age 65 suffer from urinary incontinence. Older Americans, too, are more prone to the condition. Twenty percent of Americans over age 65 are incontinent.
Stress test - the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
Urinalysis - urine is tested for evidence of infection, urinary stones, or other contributing causes.
Blood tests - blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
Ultrasound - sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
Cystoscopy - a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
Urodynamics - various techniques measure pressure in the bladder and the flow of urine.
Urinary tract infections.
Changes in your activities.
Changes in your work life.
Changes in your personal life.
NURSING DIAGNOSIS 1. Acute Pain May be related to: Increased frequency/force of ureteral contractions,Tissue trauma, edema formation; cellular ischemia 2. Impaired Urinary Elimination related to uninhibited bladder contraction Rationale: Uninhibited bladder contraction as a result of insufficient bladder control causes unannounced need to void. This inability of a person to delay voiding cause a disturbance in thr normal pattern of his/her urinary elimination.
3. Situational low self-esteem related to functional impairment. Rationale: One’s self esteem is affected by the ability to function well and relate to others. Functional impairment such as Urinary incontinence could make a person becomes consciouson how pther people react
INTERVENTIONS A. Medical management:
Anticholinergics (oxybutynin, dicyclomine)
Tricyclic antidepressants (imipramine, doxepin)
B. Surgical management:
Bladder related (inhibiting bladder contractility/decreasing sensory input/ increasing bladder capacity)
Outlet related (Increasing outlet resistance)
Vesicourethral urethral suspension with or without prolapse repair (female)
TVT - tension free vaginal tape
Bladder outlet reconstruction
Artificial urinary sphincter
Closure of the bladder outlet
· Nursing Interventions:
Patient education on the prevention of URINARY INCONTINENCE : adequate fluid consumption, regular bladder emptying and proper perineal hygiene.
Avoid caffeine and alcohol
Avoid drinking a lot of fluids in the evening
Regular voiding by the clock
Gradual increase in time between voids
Maintain Adequate Renal Function
Establish Normal Voiding Pattern
Administer antibiotics, as ordered.
Monitor TPR every 4 hours and administer antipyretic drugs and antibiotics as prescribed
Instruct patient to complete full prescription of antibiotic and have a follow up urine culture 2weeks after completion of antibiotic therapy.
Careful monitoring of renal function with proper adjustment of dosages depending on renal clearance
Unless contraindicated, liberal fluid intake up to 3 to 4 li/day.
Establish Realistic Endpoints based on Improvement of Symptoms versus Cure
Is a set of clinical manifestations caused by protein wasting secondary to diffuse glomerular damage.
Nephrotic syndrome is a protein wasting disease
The nephrotic syndrome is a clinical complex characterized by a number of renal and extra renal features the most prominent of which are:
heavy proteinuria(in practice >3.0 to 3.5 g/1.73 m2 per 24 hours), which leads to hypoproteinemia
decreased levels of serum albumin (albumin < 3 g/dl -hypoalbuminemia),
elevated serum lipids (hyperlipidemia),
It is important to realize that the NS is not a disease; it is a syndrome caused by many different renal diseases
When a clinician encounters a patient with the NS it is important for him to determine the underlying condition, because the course and prognosis will depend on the underlying disease
SECONDARY DISEASE ASSOCIATED WITH THE NEPHROTIC SYNDROME
NEPHROTIC SYNDROME GLOMERULAR DAMAGE Protein loss Reduced GFR Activation of the renein-angiotensin system Hypoalbuminemia Proteinuria Increased aldosterone Reduced blood oncotic pressure Hepatic lipoprotein synthesis Sodium/water retention Systemic edema Hyper-lipidemia Hyper-coaguability
SYMPTOMS AND SIGNS
SYMPTOMS AND SIGNS
An early sign of NS is frothy urine.
At presentation, proteinuria is usually > 2 gm/m2/day, or a urine protein/creatinine ratio is > 2
Symptoms and signs include anorexia, malaise, puffy eyelids, retinal sheen, abdominal pain, wasting of muscles, and edema.
Focal edema may be the reason for seeking help for such complaints as:
difficulty breathing (pleural effusion or laryngeal edema),
substernal chest pain (pericardial effusion),
swollen knees (hydroarthrosis),
swollen abdomen (ascites),
and (in children) abdominal pain from edema of the mesentery.
SIGNS AND SYMPTOMS
Most often, the edema is mobile - detected in the eyelids in the morning and in the ankles after ambulation.
Orthostatic hypotension and even shock may develop in children.
Adults may be hypo-, normo-, or hypertensive.
Oliguria and even acute renal failure may develop because of hypovolemia and diminished perfusion.
Patients present with increasing edema over a few days or weeks, lethargy, poor appetite, weakness, and occasional abdominal pain.
The initial episode and the subsequent relapses may follow an apparent viral upper respiratory tract infection.
Edema is the predominant feature and initially develops around the eyes and lower extremities.
With time, the edema becomes generalized and may be associated with an increase in weight, the development of an ascitic or pleural effusion, and a decline in urine output.
Hematuria and hypertension are unusual but manifest in a minority of patients.
Complete medical history and physical examination
kidney infection (pyelonephritis)
urinary tract infection
High blood cholesterol and elevated blood triglycerides
High blood pressure
Acute kidney failure
Chronic kidney failure
Altered Nutrition: Less Than Body Requirements related to Increased Metabolic Demands
Risk for Fluid Volume Deficit related to disease process
Risk for Infection Related to Altered Immune Response Secondary to Treatment
Potential Impairment of Skin Integrity related to Edema
Fatigue related to Increased Metabolic Demands
Treatment of causative glomerular disease
ACE inhibitors( in combination with loop diuretics – Proteinuria), anti hypertensives
Low-sodium diet, liberal amounts of Potassium(no hyperkalemia)
High CHON diet and cholesterol(lipidemia), Restrict Fluids
MIOW, Monitor Urine Sp.Gravity
Monitor Serum BUN and creatinine to assess renal function
Infuse IV albumin as ordered
Encourage Bed Rest for a few days to help mobilize edema; however some ambulation is necessary to reduce risk of thromboembolic complications
Fluid Restriction if edema is severe
High Protein Diet
References: SMELTZER, BARE, ET.AL BRUNNER AND SUDDARTH’S MEDICAL-SURGICAL NURSING, VOLUME 2 , 2008, 11th edition , PP. 1520-1525, 1578-1581, 1751-1573 PORTH,PATHOPHYSIOLOGY-Concepts of Ltered Health States, 2002, 6th Ed, pp.768, 805-809,977-979 Joyce M Black,Medical Surgical Nursing, 2002 ,6th Edition,pp.805-806, 856-867 Langford & Thompson,Handbook of Diseases,3rd Edition,pp.674-676 Gulanick, Myers, Nursing Care Plans,2007, 6th Ed. pp.75-77, 974 Doenges, et al., Nursing Care Plans, 2006, 7th Ed. pp.541-620 http://www. en.wikipedia.org/wiki/Urinary_system http://www . kidney.niddk.nih.gov/kudiseases/pubs/utiadult http://www. emedicinehealth.com/urinary_tract_infections/article_em.htm http://www. lab.anhb.uwa.edu.au/mb140/CorePages/Urinary/urinary.htm http://www. answers.com/topic/urinary-system http://www. faqs.org/health/Body-by-Design-V2/The-Urinary-System.html "View a negative experience in your life like you'd look at a photo negative. A single negative can create an unlimited number of positive prints."