Adult I review GU

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Adult I review GU
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  1. pyuria
    cloudy urine from infection
  2. Urine pH
    4.5 - 8.0

    • < 4.5 - acidosis - high meat protein - meds
    • > 8.0 - alkilosis - bacteriuria, UTI, antibiotics, meds
  3. Urine spectific gravity
    1.005- 1.030

    < 1.005 diabetes insipidus, overhydration, renal disease, hypokalemia

    > 1.030 dehydration, fever, diabetes mellitus, vomiting, diarrhea

    specific gravity is amount of formed elements in urine
  4. Urine protein
    2 - 8 mg/dL

    >8 proteinuria - exercise, fever, stress, acute infeciton, kidney disease
  5. Urine Glucose
    Negative

    >15 mg/dL or +4 - DM, stroke, cushings, anesthesia, glucose infusion, severe stress
  6. Urine Ketones
    Negative

    +1 -3 - ketoacidosis, starvation, high-protein diet

    ketones - by-product of fats being broken down for energy
  7. Urine RBC's
    Rare

    >2 kidney trauma, kidney disease, renal calculi, axcess asparin, anticoagulants
  8. Urine WBC's
    3-4

    >4 UTI, fever, strernuous activity, kidney disease
  9. Renin - angiotensin- aldosterone system
    renin released by the juxtaglomerular apparatus in the distal tubules in response to slow filtrate flow

    converts circulating angiotensinagin into angiotensin I

    Angiotensin I converted to angiotensin II by angiotensin converting enzyme, primarily in the lungs

    angiotensin II is a vasoconstrictor and activates vascular smooth muscle throughout body

    angiotensin II promote the release of aldosterone by the adrenal gland

    aldosterone acts upon the distal tubules to promote conservation of water and sodium and excretion of potassium

    Increases systemic blood pressure through vasoconstriction and fluid conservation
  10. B.U.N.
    • 5-25 mg/dL
    • (blood urea nitrogen)

    • Urea nitrogen, the end product of protein metabolism (amino acids)
    • Circulates in the bloodstream at normal levels of 5-25 mg/dL(abnormal > 25-50 mg/dL or higher)

    • Excreted in the urine
    • Elevated in dehydration, renaldisease, UGI bleed, steroids &tetracycline
  11. CREATININE
    creatinine clearance
    • 0.5 - 1.5mg/dL
    • Nitrogenous waste/product of muscle metabolism
    • Normal levels 0.5 - 1.5mg/dL(abnormal > 4 mg/dL)
    • Inversely proportional to GFR
    • Excreted by kidneys (almost all)
    • Elevated in renal disease,breakdown of muscle tissue, &trauma

    Test used to Dx kidney disfunction - when 50% nephrons destroyed creatinine starts to rise

    • creatinine clearance
    • 85 – 135/ min
    • 24-hour urine is collected and blood is drawn and the creatinine levels of both are compared
  12. URINALYSIS
    • pH 4.5 - 8.0 (6 average)
    • appearance: clear
    • color: amber, yellow
    • odor: aromatic
    • specific gravity: 1.005 - 1.030
    • protein: 2 - 8 mg/dL (trace)
    • glucose: negative
    • ketones: negative
    • blood RBC’s up to 2
  13. IVP
    • (intravenous pyelogram)
    • Position & size of kidneys, ureters, bladder
    • Can detect obstructions
    • Can determine bladder residual
    • Sequential films
    • IV contrast dye used (allergic reactions)
    • Client will experience groin “heat” or flushing
    • Enema or bowel prep
    • NPO (food only) X 8 hours
    • Nurse should assess Allergy to Shellfish or Iodine
    • Also watch for urticaria (hives), Resp. distress, ↓BP
    • Adrenaline & Benadryl should be on hand
  14. Renal ULTRASOUND
    • Uses high frequency sound waves; noninvasive
    • Bowel prep not needed
    • No fluid or food restrictions
    • Detects masses, obstruction, cysts
  15. RENAL SCAN
    • Visualize structures, perfusion, function of kidney Radioactive isotope is injected IV so wash hands after procedure when voiding
    • NPO, but no specific prep except drink water &empty bladder
    • Cold spots where nonfunctioning tissue
  16. GFR
    90-120 mL/minute

    • glomerular filtration rate
    • considered the most accurate means of detecting changes in kidney function
  17. dysuria
    painful urination
  18. AGING & the GU SYSTEM:
    • urinary incontinence is not a normal outcome of aging
    • Decreased ability to concentrate urine as decreased nephrons/glomeruli
    • Less tolerant of dehydration or water loads
    • Kidneys less able to eliminate drugs as decreased glomerular filtration rate
    • Decreased thirst leads to dehydration
    • Urine more alkaline so more UTI’s
    • Glycosuria from Type 2 DM leads to UTI’s
    • Incomplete bladder emptying/retention due to prostate hyperplasia & bladder prolapse
    • Urinary frequency/nocturia from relaxed pelvic muscles
    • Decreased ADH & aldosterone so fluid &electrolyte imbalances
  19. cystitis
    • inflammation of the urinary bladder
    • most common UTI
  20. pyelonephritis
    • inflammation of the kidney and renal pelvis
    • most common upper UTI
  21. Urinary Tract Infection(UTI) Risk Factors
    • Incidence – 8 mil./yr.
    • UTI Risk factors:
    • Age (decrease immunity with age)
    • Gender:
    • Females: short urethral close to vagina & anus; spermicidals alter flora; pregnancy retention
    • Males: uncircumcised or prostatehypertrophy
    • Urinary tract obstructions
    • Neurogenic bladder dysfunction
    • Vesicoureteral reflux from bladder to kidneys
    • Catheterization
  22. Protective Mechanisms Against UTI’s:
    • Adequate urine volume free flows from kidneys to urinary meatus (acid)
    • Complete bladder emptying prevents reflux
    • Bacteriostatic properties of bladder
    • Peristalsis of ureters
    • Males with long urethra & antibacterial effectof zinc from prostate
    • Mucous secreting glands in urethra that trap bacteria
    • Mechanical barrier of urethral sphincter
  23. catheter associated UTI
    • 10 to 15% of hospitalized patients with indwelling catheters
    • colonization of perineal skin by bowel flora is common source of infection in women

    • Often asymptomatic
    • gram-negative bateremia
    • must resolve quickly went catheter is removed with short course of antibiotics
    • intermittent catheterization carries less risk
    • nurses need to clean around entry point of catheter catheter tubing
  24. Types of UTI’s:
    • Cystitis = lower UTI of bladder
    • Pyelonephritis = upper UTI of kidney
    • Catheter-associated UTI’s:
    • -10-15% catheterized pts. develop UTI
    • -Migrates thru urine or around catheter sheath
    • Esp. E. coli, Proteus, Pseudomonas, Klebsiella, &Staph. saprophyticus

    Reinfection = reoccurs after 5-10 days with different bacterial (resistant)

    • Persistent/relapse = persistent infection despite treatment > 3 days due to resurgence of same organism
    • Nonbacterial or interstitial cystitis
  25. CYSTITIS
    S & S
    • (lower UTI)Inflammation of the bladder - most common type
    • S & S
    • Frequency/urgency
    • Dysuria (painful urination)
    • Nocturia (void at night)
    • Pyuria (cloudy/pus)
    • Suprapubic pain
    • Hematuria
    • Foul smelling urine

    • ELDERLY
    • Nonspecific manifestations
    • nocturia
    • incontinence
    • confusion
    • behavior change
    • lethargy
    • "just not feeling right."
  26. cystitis
    risk factors
    • risk factors for all UTI's plus
    • personal hygiene practices
    • voluntary urinary retention
  27. PYELONEPHRITIS
    • (upper UTI - kidney)
    • Signs / Symptoms
    • Fever/chills (rapid onset)
    • Vomiting
    • Flank pain (dull)
    • Costoverebral tenderness
    • Urine - cloudy, foul odor
    • Bacteria and WBC’s in urine
    • Dysuria and frequency
    • Inflammation/scarring with HTN, if chronic
  28. acute pyelonephritis
    chronic pyelonephritis
    acute pyelonephritis is a bacterial infection of the kidney- usually develops from an and infection in the lower urinary tract, that ascends to the kidneys

    • chronic pyelonephritis is associated with nonbacterial infections and inflammatory processes
    • common cause of chronic kidney disease
    • causes: UTIs or other conditions that damage the kidneys, such as HTN, vascular conditions, severe vesicoureteral reflux, or obstruction of the urinary tract

    • S & S
    • may be asymptomatic
    • urinary frequency
    • dysuria
    • flank pain
    • hypertension can develop as kidney tissue is destroyed
  29. Diagnostic Tests for UTI’s
    • Urinalysis with RBC,WBC, bacteria &casts - bacteria count >1000,000 as indicative of infection
    • - urine collected by clean catch method or straight cath

    Urine culture &gram stain-culture and sensitivity

    CBC with diff. (left shift of neutrophils)

    IVP - intravenous pyelography - used to evaluate for structural or functional abnormalties

    • Cystourethrography
    • Cystoscopy
  30. UTI – Meds
    • Treatment(Urinary Anti-infectives)
    • Single dose for 1 time infection
    • 3-day course for uncomplicated cystitis
    • Longer course of Tx (7-10 days) pyelonephritis

    • Prophylaxis
    • Trimethoprim-sulfamethoxazole/TMP-SMZ(Bactrim or Septra)
    • Nitrofurantoin (Macrodantin, stains teeth)
    • Ciprofloxicin (Cipro)
    • Cephalexin (Keflex)
    • FINISH ALL MEDS

    • (Urinary Analgesic)
    • Decreases irritability of urinary mucosa
    • Phenazopyridine (Pyridium)
    • Turns urine yellow/orange
    • -Can stain undies, contacts
    • -Take with meals to decrease GI effects
    • Surgery if calculi or structure abnormalities

    • Complement therapy-
    • Lavender bath
    • Saw palmetto
  31. UTI Nursing Interventions
    • Prevention -
    • Front to back pericare
    • Fluids 3L per day
    • Urinate q 3-4 hrs
    • Urinate post intercourse
    • Cotton undies
    • Avoid hot tubs
    • No colored or perfumed TP or powders etc
    • Acidify urine (cranberry or apple juice)
    • Avoid milk products (alkaline)
    • Hormone replacement therapy (estrogen)
  32. lithiasis
    nephrolithiasis
    urolithiasis
    • lithiasis =stone formation
    • nephrolithiasis = stone formed in kidney
    • urolithiasis = stone formed somewhere else in the urinary tract (the bladder)
  33. Renal Calculi
    Risk Factors:
    Factors leading to stones
    • Men 2-3 x > women
    • Southeast & Southwest U.S.
    • Age 20-55 yrs.
    • Caucasians > African Americans
    • Family or personal history
    • During summer months (dehydration)
    • Immobility
    • Diet high in calcium, oxalate (salts), orproteins
    • Gout, hyperparathyroidism, repeat UTI’s

    • Factors contributing to stones:
    • Suprasaturation – high salts
    • Nucleation – form around mucoproteins
    • Lack of inhibitor substances (acid or alkaline urine
  34. Renal Calculi
    Causes
    • Dehydration
    • High pH – calcium & phosphate stones
    • Low pH – uric acid & cystine stones

    • Types of stones:
    • Calcium phosphate/oxalate (75-80% most common)
    • Sturvite (15-20%, urease-producing bacteria, Proteus)
    • Uric acid (5-10%)
    • Cystine (rare , 1% from genetic defect)
  35. Renal Calculi Signs &Symptoms
    • Asymptomatic
    • Nausea, vomiting
    • Pallor, cool, clammy
    • Flank pain (stone in kidney,usually severe)
    • Renal colic (stone in ureters,spasms)
    • Dull, suprapubic pain(stone in bladder)
    • Groin pain (stone in urethra,radiates to genitals)
    • Hematuria (microscopic or gross)
    • S/S UTI’s (dysuria, freq., fever)
  36. UROLITHIASIS
    Renal Calculi - Treatments
    • STONE REMOVAL -
    • Ureteral catheter to dislodge stone
    • Extracorporeal Shock Wave Lithotripsy (ESWL) or Laser
    • Shock or laser breaks up stones to tiny pieces
    • Cystoscopy, Ureteroscopy, or Nephroscopy
    • Chemolytic dissolution (potassium citrate to alkalinize uric acid)
    • Surgical Removal (only if other methods fail):
    • -Ureterolithotomy – stone from ureter
    • -Pyelolithotomy – stone from renal pelvis
    • -Nephrolithotomy – stone from renal parenchyma (Staghorn)
  37. UROLITHIASIS
    Renal Calculi - Treatments
    Nutrition Therapy
    • -(decrease amounts of nutrients depending on type of stone)
    • Calcium stones –controversial
    • Low calcium intake ↓ oxalate excretion or phos or vit D

    Oxalate stones – more often decreased(spinach, rhubarb, asparagus, cabbage, tomatoes, beets,nuts, celery, chocolate, instant coffee, ovalteen,)

    Acid stones – low purine diet (avoid sardines, herring,organ meats, moderate intake of chicken, veal, pork, beef,ham, crab, bacon, salmon)
  38. Renal Calculi - Treatments
    Medication Therapy
    • Analgesics (MSO4, Demerol, & NSAID)
    • Thiazide diuretics for calcium stones
    • Potassium citrate to alkalinize uric acid
    • Allopurinol (Zyloprim)
    • - - Decreases serum uric acid
    • - - Used for uric acid stones
    • IV fluids to decrease further stone formation
  39. UROLITHIASIS
    Renal Calculi
    Nursing Interventions
    • Pain control & alternatives
    • Fluid intake 3 liters/day
    • Intake and output
    • Prevent urinary stasis for clients on bedrest
    • Strain urine
    • Increase activity
  40. CANCER OF THE BLADDER
    RISK FACTORS
    • #1 cigarette smoking (2X nonsmokers)
    • Age > 60 yrs.
    • Gender: males 4 X > females
    • Race: Caucasians 2 X > African Americans
    • Environmental carcinogens
    • Dyes, rubber, plastics, paint, leather,ink
    • Coffee, cola, caffeine (irritate bladder)
    • Estrogen (diethylstilbestrol/DES)
    • Chronic inflammation (UTI’s, calculi)
  41. Urinary Tumors
    Signs & Symptoms
    • Painless hematuria (75%) -reoccurs
    • Manifestations of UTI (dysuria,freq., nocturia)
    • Colicky pain (ureteral tumors)
    • Flank pain if obstruction
    • Renal failure
  42. Treatments for Urinary Tumors
    • Chemotherapy as primary tx. or to prevent recurrence
    • - BCG live (TB); Mitomycin C intravesical

    Radiation (not cure but shrinks tumor)

    • Surgery-
    • Transection - Transurethral tumor rescetion
    • - - fulguration - destriction of tissue using electric sparks
    • - - laser photocoagulation - use of light energy to destroy abnormal tissue

    • Cystectomy (partial or radical bladder removal if invasive cancer; ureterostomy) -
    • radical may include removal of reporductive organs - prostate and seminal vessels in men and hysterectomy, with removal of fallopian tubes and ovaries for women

    • Urinary diversions -
    • Ileal conduit with pouch & stoma - section of small intestine made into pouch - brought to surface as stoma

    • Continent urinary diversion with nipple valve (“Kock”)
    • -portion of stomach, colon, or small intestine used to form pouch
    • -client must be able to self-cath
    • -reservoir may absorb electrolytes resulting in imbalances
  43. Nursing Diagnoses for Bladder Cancer
    • Impaired urinary elimination
    • Risk for impaired skin integrity
    • Disturbed body image
    • Risk for infection
  44. BLADDER DYSFUNCTION
    • Incontinence = failure in storage
    • Retention = failure in emptying
    • Neurogenic Bladder = failure in control
  45. Urinary Retention
    Incomplete emptying of bladder with overdistention, poor muscle contraction, &inability to void

    Normally during micturition, parasympathetic stimuli cause detrusor muscle to contract with opening of internal sphincter & relaxation of external sphincter with voiding

    • Causes of retention:
    • Mechanical obstruction of urethra (prostate hypertrophy, scarring due to UTI’s)
    • Functional problems esp. drugs (antihistamines,tricyclic antidepressants, anticholinergics like Atropine, Robinul, anti-Parkinson’s),
    • or fail to go tobathroom

    Psychogenic (shy bladder)
  46. Urinary Retention
    Signs/Symptoms
    Home Care
    • S & S
    • Overflow voiding/incontinence 25-50 cc at frequent intervals
    • Firm distended bladder displaced midline
    • Dull percussion - caused by fluid - Tymphany is normal

    Tx. with cholinergic drugs like Urecholine that promotes detrusor muscle contraction

    Nursing Dx.: Urinary Retention or Impaired urinary elimination RT mechanical obstruction or functional problem AEB inability to void large amounts and large residual volumes with distended bladder that percusses dull

    • Vasovagal response - become pale, sweaty, and hypotensive if bladder is drained rapidly
    • -drain urine 500 ml at a time & clamp cath for a few mins if this happens

    • Home Care
    • -teach intermittient self-cath
    • -teach avoid anticholenergics (benedryl)
    • - double-voiding - void stay on toilet 2-5 mins and void again
    • - scheduled voiding
    • -indewlling cath- teach to use clean technique when switching overnight bag to leg bag
  47. Neurogenic Bladder
    Disruption of CNS or peripheral nervous system related to bladder filling & emptying

    • Spastic bladder dysfunction-spinal cord injury above S2-4 with freq. spontaneous detrusor muscle contractions & emptying
    • Low volume to moderate volume - involuntary contractions

    • Flaccid bladder dysfunction-damage to sacral spinal cord at or below reflex arc level causing loss of detrusor muscle tone & flaccid bladder
    • High Volume - Low Pressure- Absent contrations

    • Diagnosis:
    • Incontinence if spastic bladder
    • Post-void catheterization > 50 cc; retention/flaccid
    • Cystometrography evaluates filling & bladder tone
  48. Neurogenic Bladder Treatments:
    • Medications-
    • Urecholine (cholinergic) to stimulate detrusor muscle contraction if flaccid bladder/retention

    Anticholinergics to relax detrusor muscle if spasticbladder (Ditropan, Detrol, Urispas)

    • Diet-high fluid intake (cranberry & applejuices)
    • Bladder retraining-use of trigger points
    • Surgery- Rhizotomy = destroy nerve to detrusor muscle if hyer reflexia or spasticbladder; artificial sphincter

    Nursing Diagnoses- Urinary retention,Incontinence or Impaired urinary elimination
  49. Types of Incontinence:
    • Incontinence = involuntary urination due to
    • Increased bladder pressures, or
    • Decreased urethral resistance

    • 4 Types -
    • Stress Incontinence esp. cough/sneeze
    • Increased abdominal pressure → leaking
    • Weak perineal muscles

    Urge incontinence – invol. loss of urine with strong urge to void

    Overflow Incontinence – unable to empty bladder with overdistention/obstruction - dribbles

    Functional Incontinence - due to physical,environmental or psycho-social causes
  50. Treatments for Incontinence
    • Medications (esp. stress & urge incont.)
    • Smooth muscle contractors (Contac, Acutrim,Allerest) for stress incontinence
    • Estrogen therapy if atrophic vaginitis (elderly)
    • Increase bladder capacity (Ditropan, Detrol) for urge incontinence

    • Surgery –
    • Bladder neck suspension
    • Prostatectomy
    • Other/implant artificial sphincter

    • Nursing Interventions –
    • Limit fluids at night, esp. caffeine & sweeteners
    • Kegel exercises to strengthen pelvic muscles
    • Bladder training q 2-4 hrs. pattern

    • Nuring Diagnoses:
    • Readiness for Enhanced Urinary Elimination
    • Toileting self-care deficit
    • Impaired Social Interaction
  51. hydroureter
    hydronephrosis
    hydroureter - distended ureters (caused by urinary retention)

    hydronephrosis - distended kidneys ( caused by urinary retention)
  52. Congenital Kidney Malformations
    • Congenital Kidney Malformations:
    • Agenesis = absence of kidney
    • Hypoplasia = underdevelopment of kidney
    • Horseshoe kidney = fused together at upper or lower poles; hydronephrosis of renal pelvis
  53. POLYCYSTIC KIDNEY DISEASE (“PKD”):
    • Hereditary disease(s) with cyst formation &massive kidney enlargement
    • 2 Types PKD:
    • Autosomal recessive (rare) – infants
    • Autosomal dominant (common) – adults - Renal cysts; floppy valves; cerebral bleeds
    • Diagnosis:
    • Renal ultrasound
    • IVP
    • CT scan
  54. Autosomal Dominant Polycystic Disease- Adults
    • S/S’s PKD:
    • Flank pain
    • Hematuria
    • Proteinuria
    • Polyuria/nocturia
    • UTI’s/calculi
    • Hypertension - starts as portal HT & ends as systemic
    • Renal failure

    • TX’s for PKD:
    • Fluids to avoid UTI’s & stones
    • Control HT (ACE inhibitor drugs)
    • Dialysis or transplantation
    • Genetic counseling
  55. Glomerulonephritis
    • Types of glomerular disorders:
    • Primary – involves kidneys
    • Idiopathic
    • Immunologic

    Secondary to multisystem disease (DM, Lupus/SLE, Goodpasture’s Syndrome)

    Rapid Progressive Glomerulonephritis (rapid renal failure); crescent lesions

    • Chronic Glomerulonephritis (ESRD decades)
    • Immunologic process causing inflammation of BOTH kidneys (antigen/antibody response)
    • Usually follows within 2-4 weeks after a STREP INFECTION
  56. Glomerulonephritis
    Signs & Symptoms
    • Edema-fluid retention esp. face & periorbital
    • Proteinuria (protein in urine due to damage to glomerulus)
    • Azotemia (increased nitrogen wastes in blood such as BUN & Creat.)
    • Hematuria (cola-colored/smokey from blood)
    • Oliguria (< 400 cc in 24 hrs.)
    • Fatigue/anorexia/N&V
    • Low serum albumin (hypoalbuminemia)
    • Hypertension/headache
    • (May also have hyperlipidemia)
  57. Glomerulonephritis Treatment
    • REST, REST, REST(allow kidneys to heal)
    • Treat hypertension (systemic, renal)
    • Dietary Treatment:
    • - Low sodium- because of fluid retention
    • - Low protein – if BUN is elevated
    • - Low fluids- because of fluid retention

    • Diuretics if needed
    • Corticosteroids (not strep as worsens it)
    • Immunosuppressants (Cytoxan, Imuran)
    • (Anti-infectives – ONLY if bacteria present)
    • Plasmapheresis / dialysis
  58. Glomerulonephritis Nursing Interventions
    • Education – early treatment of strep infections
    • Activity limits – space activities & assist with ADL’s; rest so kidneys can heal
    • Diet restrictions – Na, protein, fluids
    • Complete/essential vs. incomplete proteins
    • Monitor fluids – I&O, daily wts, grade edema
  59. GU Nursing Diagnoses
    • Acute pain RT UTI or calculi AEB dull suprapubic/flank pain or renal colic
    • Impaired urinary elimination RT cystitis,stone obstruction AEB dysuria or cystectomy
    • Ineffective health maintenance RT medications to treat UTI or diet to prevent calculi
    • Knowledge deficit about preventative information on UTI’s & calculi
    • Sleep deprivation RT UTI AEB nocturia
    • Risk for infection RT foley catheter or ureterosigmoidostomy
    • Disturbed body image RT urinary diversion
    • Sexual dysfunction RT new stoma
    • Risk for impaired skin integrity RT ileal conduit or ureterostomy
    • Urinary retention RT flaccid bladder
    • Urinary incontinence RT stress, urge,overflow
    • Self-care deficit in toileting
    • Social isolation RT shame of incontinence
    • Fluid volume excess RT renal failure or glomerulonephritis & low oncotic pressure
    • Anticipatory grieving RT loss of kidney function
    • Risk for ineffective coping RT PKD &genetic transmission
    • Fatigue RT glomerulonephritis & loss of plasma proteins
    • Ineffective role performance RT forced bedrest in glomerulonephritis
    • Ineffective protection RT immuno suppressant therapy in glomerulonephritis
    • Imbalance nutrition, less than required RT proteinuria
  60. Erectile Problems/Impotence
    • Inability to attain or maintain erection to permit satisfactory sexual intercourse
    • Due to:
    • Less elastic collagen (distensibility)
    • Leaking veno-occlusive mechanism
    • Reduced sensation
    • Hypogonadism from less testosterone
    • Chronic illness (70%, DM, ETOH, atherosclerosis)

    • Diagnosis:Labs – testosterone, endocrine levels/thyroid
    • Nocturnal penile tumescence & rigidity monitor - #erections during REM sleep (psychogenic)
    • Cavernosometry - check blood flow
  61. Erectile Disorder Treatments
    • Medications -
    • Viagra, Levitra increase smooth muscle relaxation (enhance nitrous oxide)& increase blood flow - taken 1 hr before
    • -dont take more than once a day
    • -dont take with nirate-based medicaions - may cause severe hyoptension
    • -dont take with apha-blochers unless PB > 90/60

    • Cialis - smooth muscle relaxer - SR 36 hours or daily smaller doses - erection only occurs with sexual stimulation
    • -dont take with nitrates, alpha blockers, erythromycin, rifampicin, ketoconazole, itraconazole or protease inhibitors (for HIV) - if taking these call Dr if erection last longer than 4 hours

    Papaverine intracavernous injections - inject direactly into penis - erection last 30 mins to 4 hours

    Caverject injection or minisuppository -

    • Hormone replacement (testosterone IM)
    • Transdermal nitroglycerin paste to penis
    • Mechanical devices-vacuum pump & O-ring
    • Surgical protheses/penile implants
    • Semi-rigid rods
    • Self-contained implant with pump in head of penis
    • Inflatable implant with pump in scrotum
  62. Priapism
    • PRIAPISM = Invol. sustained painful erection(6+hrs) unassociated with sexual arousal
    • Due to:
    • Primary: tumors, infection, trauma that impairs blood outflow
    • Secondary: leukemia, thrombocytopenia, sicklecell, diabetes, spinal cord lesions
    • Can cause penile necrosis & permanent erectile problems (50%)

    • Treatment: Iced saline enemas
    • IV ketamine (anesthesia) or spinal anesthesia; analgesics
    • Surgery to decompress or shunt blood
  63. Ejaculatory Dysfunction:
    Delayed ejaculation: aging, hypogonadism,meds (HT, antidepress., opiates), sensation

    Retrograde ejaculation: seminal fluid into bladder from prostate problems or testicular cancer

    • Premature ejaculation: most treatable
    • -Condoms to reduce sensation
    • -Relaxation & guided imagery
    • -Constrictive rings at base of penis
  64. Phimosis/Paraphimosis
    • Phimosis =Constriction of penile foreskin so cannot be retracted
    • Congenital or from repeated infections
    • Prevents cleaning under foreskin (leads to cancer) & interferes with elimination & sex

    • Paraphimosis = Foreskin is tight & cannot cover glans penis → ischemia of glans penis (edema, engorged, painful)
    • Risk factor = Long-term retraction of foreskin (as in use of Foley cath in uncircumcised male)
    • Treatment:
    • Antibiotics if due to infection
    • Surgical circumcision
  65. CANCER OF PENIS
    • Squamous cell carcinoma (95%)
    • Risk factors: (rare in U.S.)
    • Phimosis
    • Uncircumcised men ages 45-60
    • Human papillomavirus (HPV) & HIV
    • Ultraviolet light (shield tanning booth)

    • S/S: red, velvety penile lesion (bleeds)
    • Purulent, foul-smelling discharge
    • Enlarged inguinal lymph nodes

    • Treatment: fluorouracil (5-FU) cream
    • External beam radiation or laser treatment
    • Surgery/partial or total penectomy
    • Chemotherapy if metastasis
  66. Benign Scrotal Masses:
    Hydrocele=fluid in tunica vaginalis testis;Dx. transilluminate,; Tx. aspirate or sclerose

    Spermatocele=mobile painless mass/cyston epididymis from sperm leakage; no Tx.

    Varicocele=abnormal dilation of vein within spermatic cord esp. L side after puberty; can decrease blood flow & cause infertility; Tx. byligating or sclerosing/balloon

    Testicular torsion=twisting of spermaticcord with scrotal swelling & pain; Dx scan for blood flow; Tx detorsion or orchiectomy (surgical removal of testes)
  67. Epididymitis =
    Infection/inflammation of epididymis - structure on posterior border of testes

    • Due to:
    • Sexually transmitted urethritis (gonorrhoeae,chlamydia)
    • Anal sex (E. coli, H. influenza, TB)
    • UTI or prostatitis > 35 yrs. old
    • Chemical epididymitis from urine reflux

    • S/S: pain & scrotal edema on 1 side
    • TX: (treat sexual partner too)
    • Antibiotics
    • Ice packs
    • Scrotal support
  68. Orchitis =
    • Infection/inflammation of testes
    • Due to:
    • Epididymitis
    • Systemic illness complication
    • Trauma, vasectomy or scrotal surgery
    • Mumps

    • S/S: High fever
    • Increased WBC’s
    • Unilat. Or bilat. Scrotal redness, swelling & pain
    • 30% develop atrophy & sterility
    • TX: BR, scrotal support & elevation
    • Hot or cold compresses
    • Analgesics
  69. Testicular Cancer Treatments:
    • Orchiectomy and retroperitoneal lymph node dissection
    • Consider sperm banking
    • Postop irradiation of lymph nodes from iliac region to diaphragm
    • Chemotherapy - BEP
    • Body image disturbance
    • Preventative testicular exams q mo. - starting at 15 years of age (CA most common 15 -40)
    • in shower,
    • soapy hands
    • roll each testicle between thumb and finger
    • -compare size
    • -feel for hard lumps on the testicle - even if painless
  70. PROSTATITIS TREATMENT
    Prostatitus -Inflammatory disorders of the prostate - can be bacterial or autoimmune

    S & S Enlarged prostate, urgency, frequency, fever, chills

    • Medications
    • – Antibiotics up to 4 months
    • – Analgesics/NSAID’s
    • – Anticholinergics
    • – Alpha-adrenergic blockers/muscle relaxants

    • Comfort measures
    • – Sitz baths/local heat
    • – 3 L/day fluids & void often

    • Prevent Complications
    • – Urinary retention
    • Epididymitis
    • – Pyelonephritis
  71. BENIGN PROSTATIC HYPERPLASIA (“BPH”)
    Nonmalignant prostate enlargement due to aging esp. > 50 yrs.

    • Signs/Symptoms:
    • Urinary obstruction/retention or incontinence
    • Feeling of incomplete emptying of bladder
    • Nocturia/frequency esp. noc.
    • Small urine stream
    • Difficulty in voiding/dysuria
    • Dribbling post void
    • UTI’s
    • Hyperplasia or prostate feels smooth, firm &rubbery (asymmetrical & enlarged)
  72. DIAGNOSIS OF BPH:
    • Digital Rectal Exam (DRE) - prostate is asumetrical and enlarged
    • Urinalysis - WBC's, RBC's, bacteria
    • Serum Creatinine - assess kidney damage
    • PSA/Prostate-Specific Antigen > 10 ng/ml - (normal is 0-4.0 ng/ml)
    • Residual Volume > 100 ml
    • Uroflowmetry < 10 ml/sec (normal> 14 ml/sec)
  73. BENIGN PROSTATIC HYPERPLASIA
    COMPLICATIONS
    • Benign hyperplasia - increase number of cells - age 40 - ?
    • half of men over 60 have it
    • hypertrophy - earlagement of cells

    • UTI
    • Renal calculi
    • Obstruction with renal insufficiency
    • Distended ureters - hydroureter
    • Pyelonephritis – hydronephrosis leading to renal failure
  74. TURP/TUIP
    • Transurethral Resection of the Prostate
    • Monitor continuous bladder irrigation (“CBI”)
    • Monitor urine output – color &amount
    • Increase fluid intake
    • Treat bladder spasms
    • -make sure catheter is not kinked
    • -(B & O Suppository) - belladonna & Opium - high abuse potential - get directly from pharmacy
    • Education
    • avoid straining (6 – 8 wks.)
    • - high fiber diet
    • - laxatives
  75. TURP Post-op Care
    • Clots (small) in urine for 24-36 hr are normal(continuous irrigation done)
    • Grossly bloody urine is not normal (indicates hemorrhage)
    • Hemorrhage may require a pulling tension on the balloon of catheter for a short time
    • Put pressure on bleeding site
    • Too long of tension on catheter may lead to necrosis
    • Bladder spasms from irritation of the bladder & clots block catheter making urine leak around it (hand irrigate)
    • Client with dribbling for a few wks post-op - teaching
    • Kegel exercises & practicing starting &stopping urine flow - teaching

    • CBI - 3 way lumen
    • Balloon - 30-40 cc (large)
    • If no clamp on CBI regulate flow my adjusting height of balloon
  76. Prostatectomy
    • Simple prostatectomy (TURP/TUIP) – scope
    • - ED for 3 month - 2 years

    Radical prostatectomy - removal of prostate, prostate capsule, seminal vesicles, and a portion of the bladder

    • Open radical prostatectomy-3 approaches:
    • Retropubic prostatectomy – abd. incision - most common - able to spare nerves to limit ED

    Suprapubic prostatectomy – bladder - not used often

    Perineal prostatectomy - posterior - used for older men - less invasive
  77. BPH Non-Surgical Treatments
    • Urethral Stents (used if person poor surgical candidate)
    • Prostatic Balloon Dilation (decreases impingement of urethra) -Doesn’t last forever
    • Heat (Microwave) treatment
    • - Heat prostate 113 degrees with tissue necrosis

    TUNA low level radio freq. so no impotence

    • Meds:
    • Proscar - Anti-androgen - blocks conversion ofo testosterone to DHT - shrinks prostate
    • SE/ADR - impotence, decreased libido, decreased ejaculate - should not be handled by pregnant women

    • Flomax - Alpha-adrenergic antagonist blocks smooth muscle contractions (Hytrin, Cardura, Uroxatral)
    • SE/ADR - orthostatic hypotension -
    • teach - make position chages slowly
    • - how to take and record blood pressure
    • - check with Dr before taking OTC cold or allergy meds

    • Phytotherapy (plants) -
    • Saw palmetto
    • Echinacea root
  78. PROSTATE CANCER
    Androgen-dependent adenocarcinoma

    • Risk factors:
    • Family history
    • African American 2 x > whites
    • High fat diet & excess Vitamin A
    • Age > 60 yrs.
    • Vasectomy as increases free testosterone

    • Spreads by:
    • Direct extension lymphatics
    • Direct extension bladder mucosa/wall
    • Later to bones, esp. vertebrae with fxs.

    • S & S -
    • like BPH - urgency, frequency, hesitency, dysuria, and nocturia
    • -may be asymptomatic
  79. Diagnosis CA Prostate:
    • PSA(Prostate Specific Antigen)
    • Normal levels less than 4 ng/ml (up to 6.5@70yr)
    • Elevated usually means Cancer
    • Elevations may not be CA (BPH)
    • Done yearly after 40-50 yr

    • DRE – (Digital Rectal Exam) prostate felt through the rectum (hard, fixed, nontender)
    • Biopsy via rectal needle
    • Ultrasound with transrectal guided bx.
  80. Treatments for CA Prostate
    Surgery – radical prostatectomy- with removal of prostate & bladder neck

    • Radiation – cure or palliative if metast.
    • -External beam
    • -Interstitial implants iodine, gold, palladium

    • Hormone manipulation-CA androgendependent so get rid of it
    • Estrogen/diethylstilbestrol (DES)
    • Luteinizing hormone (LH)
    • Steroidal or nonsteroidal antiandrogens(Megace)
  81. CANCER OF THE PROSTATE
    Pre and Postop Teaching
    • Perineal/Kegel exercises
    • Psychological support
    • Pain management
    • Chemotherapy or radiation
    • Altered sexual functioning (ED)
    • Altered sexual image

    • Post op
    • avoid rectal temp, enemas, perineal tubes
  82. Prostate CA
    Preventative intervetions
    • Teaching
    • -diet - lower red meat & increase fuits and veggies
    • - tomatoes, pink grapefruit, watermelon - high in lycopenes that help prevent damage to DNA and may help lower prostate CA risks

    Men at High risk - African american or first degree relative with prostate CA -should beging testing at 45

    PSA and DRE anually after 48 for all men who have life expectancy of at least 10 years- until age 75
  83. Cystectomy
    Postop care of stoma
    surgical removal of the bladder

    • continuous drainage necessitates appliance
    • risk for infection
    • risk for reflux
    • -good skin care vital due to contact with urine
  84. Nursing Diagnoses for Male GU Disorders:
    • Sexual dysfunction RT erectile disorder
    • Ineffective sexual pattern RT ejaculatory dysfunction
    • Disturbed body image RT gynecomastia
    • Situational low self-esteem RT feeling “lessthan a man”
    • Acute pain RT surgery & postop
    • Chronic pain RT cancer of penis/prostate, etc.
    • Knowledge deficit RT treatments for male cancers
    • Anticipatory grieving RT male cancers/loss of testes
  85. Nephrotoxins
    • Antibiotics:
    • Aminoglycosides
    • Amphotericin B
    • Tetracycline
    • Cephalosporins
    • Sulfonamides
    • Vancomycin

    • Anesthetics
    • Contrast dyes
    • Solvents
    • Gasoline
    • Kerosene
    • Turpentine

    • Other drugs
    • Tylenol, ASA, NSAIDS
    • Heroin
    • Amphetamines

    • Heavy Metals
    • Arsenic, lead, copper, gold,Lithium

    • Mushrooms –poisonous
    • Insecticides, Herbicides
    • Snake bites

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