The document provides an overview of the genitourinary system including the kidneys, nephrons, ureters, bladder, prostate gland, and urethra. It discusses common conditions like cystitis, benign prostatic hyperplasia, prostate cancer, urolithiasis, nephrolithiasis, and renal failure. Nursing interventions are outlined for various procedures and post-operative care related to these conditions.

1. GENITOURINARY SYSTEM Ma. Victoria Recinto, RN, USRN

2. OVERVIEW Fluid, e+ & acid-base balance Excretion of the nitrogenous waste products, bacterial toxins, water-soluble drugs & drug metabolites Secrete renin & erythropoetin (role in parathyroid hormones & Vit D)

3. OVERVIEW: KIDNEYS A pair of bean-shaped organs located retroperitoneally at the back of peritoneum at either side of the vertebral column Parts: medulla, cortex & renal pelvis

4. OVERVIEW: NEPHRON Basic functional unit Composed of glomerulus (network of capillaries that filters blood) & tubules (proximal, distal & loop of Henle) Urine flows from the pelvis of the kidney through ureters & empties into bladder

5. OVERVIEW Kidney Function Urine formation Stages Filtration: GFR: 125 ml/min Tubular reabsorption: 124 ml reabsorbed Tubular secretion: 1 ml excreted

6. OVERVIEW Ureters 25 cm long, prevent reflux of urine back to the kidneys Bladder Behind symphysis pubis, elastic & muscular tissue that makes it distensible Can hold up to 1.2-1.8 L urine 250-500 cc of urine can trigger micturition

7. OVERVIEW Prostate gland Surrounds the male urethra Contains a duct that opens into the prostatic portion of the urethra & secretes the alkaline portion of seminal fluid

8. OVERVIEW Urethra- extends to the exterior surface of the body F: 2-5 cm/ 1-1.5 in M: 20 cm/ 8 in Catheter: Pedia: 8-10F, Adult F 12-14F, Adult M 14-16 F

9. CYSTITIS (UTI) Inflammation of the bladder r/t microbial invasion or urethral obstruction

10. CYSTITIS (UTI) Predisposing Factors Microbial invasion (80%- E. coli, Enterobacter, Pseudomonas & Serratia) Urinary obstruction & stagnation F>M (shorter urethra that is close to the rectum)  estrogen levels (affecting vaginal flora) Sexually active & pregnant woman

11. CYSTITIS (UTI): Causes Allergens/irritants: soaps, sprays, bubble bath, perfumed sanitary napkins Bladder distention, renal stones Indwelling urethral cath Urinary stasis

12. CYSTITIS (UTI): Causes Invasive UT procedures Poor-fitting diaphragms, spermicides Sexual intercourse Synthetic underwear & pantyhose Wet bathing suits

13. CYSTITIS (UTI): S/Sx Flank pain & tenderness Urinary frequency & urgency (incomplete bladder emptying) Dysuria (painful urination), bladder spasms Burning sensation upon urination Cloudy, dark, foul-smelling urine, Hematuria Fever, chills, A/N/V, malaise

14. CYSTITIS (UTI): Diagnostic Procedure Urine C/S: determines the causative agent

15. CYSTITIS (UTI): Nursing Interventions Force fluids Heat on abdomen, Sitz bath as ordered Monitor for the color, odor, blood in urine Strict asepsis in foley cath. insertion, maintain close system Meticulous perineal care Avoid caffeine & alcohol

16. CYSTITIS (UTI): Nursing Interventions Administer meds as ordered Systemic Antibiotics (Cephalosporin, Tetracycline, Ampicillin) Sulfonamides (Cotrimoxazole: Bactrim, Gantricin): can cause crystals in concentrated urine Urinary analgesic: Pyridium Antispasmodics

17. CYSTITIS (UTI): Nursing Interventions Acid ash diet (maintaining urine pH of 5.5) Bread, cereals, whole grains Cheese, eggs Corns, legumes Cranberries, prunes, plums, tomatoes Meat, fish, oysters, poultry Pastries Prevent Cx: Pyelonephritis

18. Health Teaching: CYSTITIS (UTI) Prevention Good perineal care (wipe from front to back) Avoid bubble baths, tub baths, vaginal deodorants/sprays Void q 2-3 hrs (esp. for pregnant women) Void & drink a glass of water after intercourse

19. Health Teaching: CYSTITIS (UTI) Prevention Wear cotton pants, avoid tight clothes or pantyhose with slacks Avoid sitting in a wet bathing suit for prolonged periods of time Use estrogen vaginal creams to restore pH, use water-soluble lubricants for coitus (esp. for menopausal women)

20. BENIGN PROSTATIC HYPERTROPHY Slow enlargement of the prostate gland  urethral narrowing & obstruction Predisposing factors Male >40-50 y/o r/t hormonal influences

21. BENIGN PROSTATIC HYPERTROPHY S/Sx Urinary frequency, hesitancy, urgency,  urinary stream Terminal dribbling Backache Hematuria Dysuria, nocturia Burning sensation upon urination Urinary stasis, UTI

22. BENIGN PROSTATIC HYPERTROPHY Diagnostic Procedures Digital rectal exam: enlarged prostate gland Cystoscopy: urinary obstruction KUB- enlarged prostate gland U/A-  WBC,  RBC

23. BENIGN PROSTATIC HYPERTROPHY: Nursing Interventions Force fluids unless contraindicated Bladder drainage via urinary cath as ordered Prostatic massage Administer as ordered Terazosin- relaxes urinary sphincters Finasteride (Proscar)- promotes atrophy of BPH Avoid meds that can cause urinary retention (anticholinergics, antihistamines, decongestants)

24. BENIGN PROSTATIC HYPERTROPHY: Nursing Interventions Assist in surgery Prostatectomy (perineal, retropubic & suprapubic) Transurethral Resection of the Prostate (TURP) Cystoclysis: continuous bladder irrigation Irrigate the tube with pNSS to flush the clots WOF bleeding, hemorrhage Strict asepsis

25. PROSTATE CA: TURP Insertion of a scope into the urethra to excise prostatic tissue Bleeding is common post-op, WOF hemorrhage Continuous bladder irrigation (CBI) post-op to maintain the urine at a pink color

26. PROSTATE CA: TURP Bladder spasms are common post-op, give antispasmodics as ordered WOF dribbling & incontinence Sterility may or may not occur post-op

27. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal Technique Via abdominal & bladder incision Via low abdominal incision without opening the bladder Via incision bet. scrotum & anus Hemorrhage Yes No No Bladder spasms Yes Yes but less Urinary incontinence common

28. PROSTATE CA: Prostatectomy Point of comparison Suprapubic Retropubic Perineal CBI Yes Yes - Sterility Yes Yes Yes Remarks Abdominal dressing soaked frequently with urine, Longer healing time than TURP Minimal abdominal drainage WOF infection, (No rectal tubes, rectal temp. taking & enema) Teach perineal exercises

29. Nursing Interventions: s/p TURP Monitor VS, U.O., hematuria & clots, Hgb & Hct levels Force fluids Expect red to light pink urine for 24 hrs, turning to amber in 3 days (then encourage ambulation) WOF arterial bleeding (bright red urine with clots):  CBI & notify MD

30. Nursing Interventions: s/p TURP WOF venous bleeding (burgundy- colored urine): notify MD who will apply traction on the catheter Continuous urge to void is N but not encouraged to prevent bladder spasms Antibiotics, analgesics, stool softeners & antispasmodics as ordered

31. Nursing Interventions: s/p TURP Monitor 3-way foley catheter (for the balloon (30-45 cc), inflow & outflow) Use pNSS only to prevent water intoxication or hypoNa (  LOC,  HR,  BP)

32. Nursing Interventions: s/p TURP Maintain infusion rate as ordered, if (+) clots:  rate For obstructed catheter: turn off CBI, irrigate with 30-50 ml pNSS, notify MD if it does not resolve CBI is d/c usually after 1-2 days, WOF continence & urinary retention

33. Discharge Health Teaching: s/p TURP Avoid heavy lifting, stressful exercise, driving, Valsalva maneuver & sexual intercourse for 2-6 wks Drink 2.4-3L fluids/day before 8 pm

34. Discharge Health Teaching: s/p TURP Avoid alcohol, caffeine & spicy foods to prevent overstimulation of the bladder Pt may pass small clots & tissue debris for several days If urine becomes less in amount & bloody, rest & force fluids, notify MD if persistent

35. Nursing Interventions: s/p Suprapubic Prostatectomy Monitor foley catheter & suprapubic catheter drainage As ordered, clamp the suprapubic cath after foley cath is removed (2-4 days post-op) & instruct the pt to void, measure residual urine by unclamping the cath & measuring the U.O.

36. Nursing Interventions: s/p Suprapubic Prostatectomy Prepare for removal of suprapubic cath if pt consistently empties bladder & residual urine is <75 ml

37. UROLITHIASIS AND NEPHROLITHIASIS Formation of stones elsewhere in the urinary tract (esp. in the kidneys)  obstruction  dilation (Hydroureter, Hydronephrosis)  RF Common type: Ca, oxalate, uric acid

38. UROLITHIASIS AND NEPHROLITHIASIS Predisposing Factors Diet:  Ca, Vit. D, milk, oxalate (chocolates), protein, purines or alkali Obstruction & urinary stasis, UTI, prolonged urinary catheterization Use of diuretics, Dehydration Obesity Sedentary lifestyle, Prolonged immobility Hyperparathyroidism (HyperCa), Gout Family hx

39. UROLITHIASIS AND NEPHROLITHIASIS: S/Sx Problems: pain, obstruction, tissue trauma, hemorrhage & infection Renal colic (dull, aching or sudden sharp severe pain) from lumbar region radiating to the testicles (M) & bladder (F) Ureteral colic radiating to the genitalia & thigh N/V, pallor, diaphoresis, cool, moist skin Alternating urinary frequency & retention S/Sx of UTI

40. UROLITHIASIS/NEPHROLITHIASIS: Diagnostic Procedures KUB film, CT scan, renal UTZ- locates stones IV Pyelogram- location & composition of stones Cystoscopy: urinary obstruction U/A:  WBC,  RBC, bacteria Stone analysis: type, no. & composition

41. UROLITHIASIS/NEPHROLITHIASIS: Nursing Interventions Monitor VS, I/O, S/Sx of infection Force fluids Strain all urine with gauze, WOF presence of stones, send to lab for analysis Warm sitz bath, warm compress on flank area Turn immobilized pt q2h Administer Narcotic analgesics, Antibiotics, Allopurinol as ordered

42. UROLITHIASIS/NEPHROLITHIASIS: Nursing Interventions (DIET) Acid ash diet (maintaining urine pH of 5.5) Cranberries, prunes, plums, tomatoes Bread, cereals, whole grains Cheese, eggs Corns, legumes Meat, fish, oysters, poultry Pastries Alkaline ash diet Fruits except cranberries, prunes, plums, tomatoes Milk Most vegetables Rhubarb Beef, halibut, veal, trout & salmon

43. UROLITHIASIS/NEPHROLITHIASIS: Nursing Interventions (DIET) Calcium Phosphate Stones Acid ash,  Ca,  Phosphate,  Vit D Calcium Oxalate Acid ash,  Ca,  Oxalate (tea, almonds, cashews, chocolate, cocoa, beans, spinach & rhubarb) Struvite/ Triple Phosphate (Mg & NH3) Caused by urea splitting by bacteria Acid ash,  Phosphate (dairy products, red & organ meats, whole grains)

44. UROLITHIASIS/NEPHROLITHIASIS: Nursing Interventions (DIET) Uric acid Alkaline ash,  purines (organ meats, gravies, red wines, sardines) Cystine Alkaline ash,  methionine (AA that forms cystine): meat, milk, cheese, eggs

45. UROLITHIASIS/NEPHROLITHIASIS: Nursing Interventions Assist in surgery Nephrectomy: removal of 1 kidney Extracorporeal Shockwave Lithotripsy: if stones are recurrent Prevent Cx: ARF

46. UROLITHIASIS/NEPHROLITHIASIS: Cystoscopy For stones located in the bladder or lower ureter No incision, 1 or 2 ureteral cath will be inserted & left X 24h, stones are manipulated & dislodged With continuous chemical irrigation to dissolve the stones

47. UROLITHIASIS/NEPHROLITHIASIS: Cystoscopy

48. UROLITHIASIS/NEPHROLITHIASIS: Extracorporeal Shockwave Lithotripsy Non-invasive mechanical procedure for breaking up stones located in the kidney or upper ureter No incision or drain Fluoroscopy is used to visualize the stones

49. UROLITHIASIS/NEPHROLITHIASIS: Extracorporeal Shockwave Lithotripsy Ultrasonic waves are delivered through bath of warm water Stones are passed in the urine within a few days NPO 8 hrs pre-procedure Force fluids & ambulation post-procedure WOF bleeding, pain, S/ of urinary obstruction

50. UROLITHIASIS/NEPHROLITHIASIS: Percutaneous Lithotripsy Done via cystoscopy (no incision) or nephroscopy (with small flank incision) to break stones located in the KUB Fluoroscopy is used to visualize the stones

51. UROLITHIASIS/NEPHROLITHIASIS: Percutaneous Lithotripsy Ultrasonic waves are aimed at the stone to break it into fragments Stones are passed via indwelling cath or nephrostomy tube (for chemical irrigation) left X 1-5 days Force fluids post-procedure WOF bleeding, infection, extravasation of fluid in the peritoneal cavity

52. UROLITHIASIS/NEPHROLITHIASIS: Surgery Ureterolithotomy: incision through lower abdominal or flank area With Penrose drain, ureteral stent & indwelling cath post-op Pyelolithotomy: via large flank incision With Penrose drain & indwelling cath post-op Nephrolithotomy: via large flank incision With nephrostomy tube & indwelling cath post-op

53. UROLITHIASIS/NEPHROLITHIASIS: Partial/Total Nephrectomy For extensive kidney damage, renal infection or severe obstruction & to prevent stone recurrence Focus of care: maintain patency of tubes (but never irrigate unless ordered), prevent infection Force fluids, monitor I/O

54. UROLITHIASIS/NEPHROLITHIASIS: Partial/Total Nephrectomy Determine stone composition, special diet as ordered Long-term medication to prevent stone recurrence For Ca stones: Phosphates, Thiazide diurectics, Allopurinol (for oxalate & uric acid stones also) For Oxalate stones: Pyridoxine or Mg oxide For Struvite & Cystine stones: Antibiotics

55. RENAL FAILURE Loss of kidney function S/Sx r/t retention of waste & fluids & inability to regulate e+ Causes Prerenal: DHN, hypovolemic shock,  C.O., vasodilation or vascular obstruction Intrarenal: ATN, nephrotoxicity, altered renal blood flow Postrenal: obstruction of urine flow

56. ARF: Oliguric Phase Duration: 8-15 days (if longer, less chance of recovery Sudden  U.O. (<400 ml/day)  GFR,  USG  K, N or  Na (Fluid overload):  LOC, S/Sx of CHF, pericarditis, dysrythmias, acidosis  BUN, crea A/N/V, HTN Pruritus, tingling extremities

57. ARF: Diuretic Phase Slow  U.O. then diuresis (4-5L/day)  GFR  K,  Na Hypovolemia,  BP,  HR, LOC improves Gradual  BUN, crea

58. ARF: Recovery (Convalescent) Phase Complete recovery: 1-2 yrs N U.O. Stable & N BUN Pt may develop Chronic RF

59. CHRONIC RENAL FAILURE Stage 1: Diminished Renal Reserve  renal function (-) accumulation of metabolic wastes Healthier kidney compensates Nocturia & polyuria r/t  ability to concentrate urine

60. CHRONIC RENAL FAILURE Stage 2: Renal Insufficiency Metabolic wastes begin to accumulate Oliguria & edema r/t  responsiveness to diuretics Stage 3: End Stage (Uremia) Excessive accumulation of metabolic wastes Kidneys unable to maintain homeostasis Dialysis or other renal replacement tx required

61. CHRONIC RENAL FAILURE: S/Sx A/N, HA, weakness & fatigue HTN  LOC, sz, coma Kussmaul’s respiration Diarrhea or constipation Muscle twitching, paresthesia

62. CHRONIC RENAL FAILURE: S/Sx  U.O.  or fixed USG Proteinuria, azotemia, anemia Fluid overload, CHF Uremic frost: urea crystals from evaporated perspiration on the face, eyebrows, axilla & groin (advanced uremic syndrome)

63. SPECIAL PROBLEMS IN RENAL FAILURE Anemia Vit. B9/Folic acid instead of iron (not well absorbed by the GIT of pt with CRF), Epogen, BT as ordered GI bleeding (r/t ammonia irritation) Bleeding precautions HTN & Hypervolemia Propranolol (Inderal):  renin release, diuretics, fluid restriction,  Na diet as ordered

64. SPECIAL PROBLEMS IN RENAL FAILURE Infection & injury Minimize urinary catheterization, strict hand washing, asepsis Insomnia & fatigue Adequate rest, mild CNS depressant as ordered

65. SPECIAL PROBLEMS IN RENAL FAILURE HypoCa, Hyperphosphatemia, HyperK Diet, dialysis Metabolic acidosis NaHCO3 as ordered (pt with CRF adjusted to low HCO3 levels without getting acutely ill) Muscle cramps e+ replacement, heat & massage as ordered Pruritus (r/t uremic frost) Skin care, avoid soaps, antipruritics as ordered

66. SPECIAL PROBLEMS IN RENAL FAILURE Neuro changes Monitor LOC, side rails up, calm & restful env’t, comfort measures & backrubs Occular irritation (r/t Ca deposits in conjunctiva) Ca & Phosphate binders, Eye drops as ordered Psychosocial problems

67. HEMODIALYSIS: FUNCTIONS Cleanses the blood with accumulated waste products (urea, crea & uric acid) Removes excessive fluids Restores buffer system & e+ levels of the body

68. HEMODIALYSIS: PRINCIPLES Semipermeable membrane: thin, porous cellophane (only water, urea, crea & uric acid can pass through) Proteins, bacteria & some blood cells are too large to pass through Blood flows into the dialyzer & into the dialysate

69. HEMODIALYSIS: PRINCIPLES Diffusion: mov’t of particles from greater to lesser concentration Osmosis: mov’t of fluids across a semipermeable membrane from lesser to greater concentration Ultrafiltration: mov’t of fluids across a semipermeable membrane due to artificial pressure gradient

70. HEMODIALYSIS: Nursing Interventions Monitor VS, lab values before, during & after HD Weigh the pt before & after HD to determine fluid loss/overload Hold antiHTN meds & other water soluble vit. & antibiotics before HD as ordered

71. HEMODIALYSIS: Nursing Interventions Provide adequate nutrition (pt may eat before HD) WOF hypovolemic shock Assess the patency of blood access device

72. HEMODIALYSIS: Blood Access Subclavian or femoral vein catheter For temporary use Check site for hematoma, bleeding, dislodging & infection Do not use for any other reason EXCEPT HD Maintain sterile, occlusive dressing Good for 6 weeks if complications do not occur

73. HEMODIALYSIS: Blood Access External AV shunt Surgical insertion of 2 Silastic cannulas into an artery & a vein (U-shaped) in the forearm or leg to form an external blood path Can be used immediately after creation No venipuncture is necessary for HD Shunt may be disconnected or dislodged WOF hemorrhage, infection, clotting (tingling or discomfort on the extremity) & skin erosion at the cath site

74. HEMODIALYSIS: Blood Access

75. HEMODIALYSIS: Blood Access External AV shunt Keep the shunt dressing dry & intact Prepare cannula clamps at bedside No BP taking, blood extraction, injection & venipunctures in the shunt extremity A patent shunt is warm to touch Auscultate for bruit & palpate for thrill WOF circulatory impairment in the shunt extremity

76. HEMODIALYSIS: Blood Access Internal AV shunt For chronic dialysis pt Can be used 1-2 wks after creation (subclavian/femoral cath, external AV shunt or PD can be used while the fistula is maturing) Venipuncture is necessary for HD Less risk of clotting, bleeding & infection Fistula can be used indefinitely No external dressing is required

77. HEMODIALYSIS: Blood Access Internal AV shunt Infiltration of needles  hematoma Aneurysm can form in the fistula CHF can occur from  blood flow to the venous system WOF arterial steal syndrome : compromised arterial perfusion r/t  blood diverted to the vein & refer to MD

78. HEMODIALYSIS: Blood Access Internal AV graft For chronic dialysis pt who do not have adequate blood vessels for fistula creation Artificial graft (Gore-Tex or bovine carotid artery) is used Can be used 2 wks after creation Dis/Advantages: same as in internal AV fistula

79. HEMODIALYSIS: Complications Disequilibrium syndrome Dialysis encephalopathy Electrolyte changes Muscle cramping Blood loss, hypoTN & shock Hepatitis Sepsis

80. HEMODIALYSIS: Disequilibrium syndrome Solutes are removed from the blood faster than from the CSF & brain  cerebral edema S/Sx: N/V, HA, HTN,  LOC, sz Prepare to dialyze the pt for a shorter pd. at  blood flow rates  env’tal stimuli Refer to MD

81. HEMODIALYSIS: Dialysis Encephalopathy Al toxicity r/t water source of the dialysate & ingestion of Al-containing antacids (phosphate binders) S/Sx:  LOC, sz, speech disturbance, dementia, bone pain Refer to MD Al-chelating agents as ordered