What surgery may be performed in Tx of interstitial cystitis/painful bladder syndrome?
may have urinary diversions
may have pain in urinary diversions if urine contents was the cause of the pain
Assessment of interstitial cystitis/painful bladder syndrome?
1. pain: char., relief/exacerbating factors
2. bladder log or voiding diary for at least 3 days to det. voiding frequency/nocturia
3. monitor pt for UTI- can cause exacerbations
Nursing interventions/education for pt with interstitial cystitis/painful bladder syndrome?
1. reassure pt that it is a real condition
2. teach pt about nutrition & what to avoid
3. educate pt not to take multivitamin with more than recommended dietary allowance - can irritate bladder
4. teach pt to avoid clothing that can create suprapubic pressure: tight waste bands
What should signal nurse that pt with interstitial cystitis/painful bladder syndrome may have developed a UTI?
pt develops further s/s of UTI not associated with IC/PBS: dysuria, fever, etc
Renal tuberculosis (TB) is usually secondary to what condition?
When does onset occur?
TB of the lung
5 t0 8 years after primary infection
S/S of initial infection of renal TB?
1. often asymptomatic but may complain of fatigue & have low-grade fever
What is usually the initial s/s that occurs with renal TB?
4 s/s that typically occur?
s/s of a UTI - lesions will ulcerate and infection descends to lower urinary tract
2. frequent urination
3. burning on voiding
4. epidiymitis in men
What may happen to renal lesions as they heal?
What 3 s/s may occur r/t to this?
may calcify as they heal -> renal colic, lumbar & iliac pain, & hematuria may occur
Dx of renal TB?
localization of tubercle bacilli in the urine & IVP findings
Long-term complication of renal TB?
depends on duration of disease before Tx
scarring of renal parenchyma, ureteral strictures, & reduced bladder volume that may be irreversible
inflammation of the glomeruli r/t immunologic process that affects both kidneys equally
Glomerulonephritis is classified r/t what 3 factors?
1. extent of damage (diffuse or focal)
2. initial cause
3. extent of changes (minimal or widespread)
Etiology of glomerulonephritis?
caused by 2 types of antibody-induced injury r/t build-up of antigen-antibody complexes & complement deposited in glomeruli
2 types of antibody-induced injury that cause glomerulonephritis?
1. autoantibodies to own glomerular basement membrane occur -> immunoglobulins & complement are deposited along basement membrane (may be r/t virus or structural change in basement membrane)
2. antibodies react with a circulating antigen (bacteria/virus) & are randomly depositied as immune complexes along basement membrane -> accumulation of antigen/antibody & complement that releases chemotactoic factors -> inflammatory response-> glomerular injury
S/S of glomerulonephritis?
1. hematuria - microscopic to gross
2. urinary excretion of: RBC, WBC, casts, protein
3. elevated BUN & creatinine
Assessment for glomerulonephritis?
1. Hx - exposure to drugs, immunizations, infections (strep, hepatitis)
1. edema: ACE inhibitors, NSAIDs, low-Na/low to moderate protein diet, loop/thiazide diuretics
2. Tx of hyperlipidemia -
_____ restriction is a key to managing edema in NS.
How much Na is allowed on low-Na diet with NS?
2 - 3 g
Tx of hyperlipidemia in NS?
usually not successful
lipid lowering agents have some success
Tx of thrombosis in NS?
antigoagulant therapy may be needed for up to 6 months
Meds for NS?
2. anticoagulants prn
3. corticosteroids & cyclophosphamide prn
Tx of NS r/t DM?
mgmt of DM & Tx of edema
The major nursing interventions of NS are r/t what complication?
What are the nursing interventions needed?
1. daily weights
3. measureing abd or limb girth
4. skin care to prevent B/D: hygiene, avoid trauma
5. monitor effectiveness of diuretic therapy
How is effectiveness of Tx for edema in NS evaluated?
compare daily assessment of fluid status findings qd
Nutrition consideration in NS?
pt may become malnourished r/t protein lost in urine & anorexia
small, frequent meals following diet for NS - finding right balance of protein is hard
Major considerations with a pt with NS?
1. dietary/nutrition - Na, protein intake
2. thrombus formation
3. infection risk
4. hypocalcemia - ECG, bone fractures
5. edema - monitor lungs, skin, & fluid status
6. altered body image r/t edema
Diet of a person with nephrotic syndrome?
1. Na restriction (2-3g per day)
2. low-moderate protein
3. may have increased protein if protein levels get very low (if urine protein exceeds 10g/day)
Where do damaging effects of urinary tract obstruction occur?
above the level of obstruction
What changes/complications occur when a urinary obstruction occurs at the level of the bladder neck (F) or prostate (M)?
bladder changes may occur
detrusor muscles of bladder need to contract harder to push out urine -> they hypertrophy -> will eventually lose ability to compensate for increased resistance & muscle bundles will separate & become less compliant (trabeculation) -> bladder mucosa may herniate b/t detrusor muscle bundles -> diverticula that drain poorly = high residual urine volume
Patho of urinary obstruction?
obstruction increases resistance & bladder muscles have to work harder & hypertrophy to get out urine (diverticula may form):
1. reflux of urine (backflow)/hydronephrosis (backflow from lower to upper urinary tract)
2. dilation of ureters
3. hydronephrosis- dilation of renal pelvis & calyces
these changes result in chronic pyelonephritis & renal atrophy
What will occur in urinary obstruction if only one kidney is affected?
the other kidney will try to compensate & become hypertrophied
In partial urinary obstruction there is an increased risk of ______ r/t urinary stasis & reflux.
Progressive urinary obstruction can lead to ____ or ____.
oliguria or anuria
Tx of urinary obstruction?
requires location & relief of the blockage
1. insertion of a tube
2. surgical correction
3. diversion of urinary stream above level of blockage
Risk factors for nephrolithiasis?
1. warm climates that cause increased fluid loss: live in Southeast, Southwest, or Midwest, summer months
3. abnormalities that result in increased urine levels of Ca, oxaluric acid, uric acid, or citric acid
4. diet: high in proteins (increase uric acid), high in tea/fruit juices (increase oxalae), lg intake of Ca & oxalate, & low fluid intake/increased urine concentration
5. family Hx or cystinuria (genetic condition)
7. renal acidosis
8. altered urine pH: increase or decrease
9. sedentary occupation or immobility
10. b/t 20 & 55 years old
11. more frequent in whites
12. had a stone before (50% recurrence)
13. urinary retention/stasis
14. UTI: some bacteria may cause urine to become more alkaline (struvite stones occur)
2 ways to reduce the risk of recurrent nephrolithiasis?
keep urine dilute & free flowing
Residual urine volume in a urinary obstruction indicates what?
bladder is no longer able to compensate for the resistance created by the obstruction
Complications that may occur in an infected urinary stone?
1. renal infection
3. loss of kidney function
4 risk factors for infection r/t urinary stones?
1. external urinary diversion
2. indwelling catheter
2. neurogenic bladder
4. urinary retention
genetic disorder characterized by marked increased excretion of cystine that may increase risk of kidney stones
5 major categories of kidney stones?
1. calcium phosphate
2. calcium oxalate
3. uric acid
5. struvite (Mg ammonium phosphate)
Predisposing factors for Ca oxalate kidney stones?
1. idiopathic hypercalciuria
3. family Hx
Tx of Ca oxalate kidney stones?
1. increase hydration
2. reduce dietary oxalate
3. thiazide diuretics
4. cellulose phosphate to chelate Ca & prevent GI absorption
5. K+ citrate to maintain alkaline urine
6. cholestyramine to bind oxalate
7. Ca lactate to precipitate oxalate in GI tract
8. reduce daily Na intake
Predisposing factors for Ca phosphate stones?
1. alkaline urine
2. primary hyperparathyroidism
Tx of Ca phosphate stones?
Tx underlying causes & other stones
Predisposing factors for struvite (Mg ammonium phosphate) kidney stones?
urea-splitting bacteria cause urine to become alkaline
Does pH affect the formation of Ca oxalate stones?
Some bacteria that cause increased alkalinity of the blood & struvite kidney stones?
4. some staphylococci
Tx of struvite kidney stones?
1. admin ABX
2. acetohydroxamic acid
3. surgical intervention to remove stone
4. measures to acidify the urine
Predisposing factors for uric acid kidney stones?
2. acid urine
3. inherited condition
Tx of uric acid kidney stones?
1.reduce urinary concentration of uric acid
2. alkalinize urine with K+ citrate
3. admin allopurinol
4. reduce dietary purines
Foods high in purine?
meats: especially fish, seafood, bird meat, and organ meats,
Predisposing factor for cystine kidney stones?
Tx of cystine kidney stones?
1. increase hydration
2. give a-penicillamine & tiopronin to prevent cystine crystallization
3. give K+ citrate to maintain alkaline urine
When do urinary stones cause s/s?
when they obstruct urinary flow
S/S of urinary/kidney stone?
1. abd or flank pain (usually severe)
3. renal colic
5. mild shock: cool, moist skin
6. pain in groin, labia, or testicles
7. may have s/s of UTI: fever, chills, etc
What is the cause of renal colic?
increase in ureteral peristalsis in response to the passage of small stones causes intense colicky pain
Dx of renal stones?
1. UA: hematuria
2. urine culture
3. CT scan
5. retrograde pyelogram
What test may be used to differentiate a nonopaque renal stone from a tumor?
What test may be used to localize degree & site of obstruction or to confirm the presence of a radiolucent stone (uric acid/cystine stones) or staghorn calculus?
IVP or retrograde pyelogram
IVP should not be performed in what pt?
pt with renal failure
What is important in the diagnosis of the underlying problem causing kidney stones?
retrieval & analysis of the stones
What labs are important with kidney stones?
1. CMP: Ca, phosphorus, Na, K+
3. uric acid
What should be included when getting a history in pt with kidney stones?
1. previous stones
2. meds Rx & OTC
3. dietary supplements
4. family Hx of stones
What test should be done on person with recurrent stones?
24h urinary measurement of Ca, phosphorus, Mg, Na, oxalate, citrate, sulfate, K+, uric acid, & total volume
Tx of kidney stones?
2 parts of Tx performed at same time:
1. mgmt of the acute attack
2. eval of the cause of the stone formation & prevention of further development of stones
Interventions in mgmt of acute attack of kidney stones?
1. pain mgmt: opiods given frequently
2. stones larger than 4mm may require insertion of ureteral stent to prevent obstruction r/t inability to pass through ureter
3. may require procedures to remove/break up the stone
Interventions to ID cause of kidney stones & prevent further kidney stones?
1. obtain subjective data from pt
2. teaching for ppl that have reoccurring stones
3. meds or other Tx based on cause of the stones
What subjective data is needed to help ID cause of kidney stones?
1. Hx & family Hx
2. geographic residence
3. nutritional assessment including: vit A & D use
4. activity pattern
5. Hx of periods of prolonged illness with immobilization or dehydration
6. Hx of disease or surgery involving the GI or genitourinary tract
Tx of ppl who are active stone formers?
teaching & therapy regimen
1. adequate hydration
2. dietary changes
3. meds: to alter urine pH, prevent excessive urinary excretion of a substance, or correct a primary disease
4. Tx of struvite stones involves controlling infection
Foods high in oxalate?
What type of stones may occur r/t increased oxalate consumption?
6 indications for procedures to remove/break up kidney stones?
1. too lg to pass
2. occur r/t infection
3. cause impaired renal function
4. causing persistent pain, N, or ileus
5. inability of pt to be Tx medically
6. pt with 1 kidney
If a urinary stone is located in the bladder , a ____ is done to remove small stones.
For lg stones a ______ is done.,
lg stones are broken up with an instrument called a lithotrite (stone crusher) then the bladder is irrigated to wash out crushed stones
uses ultrasonic lithotrite to pulverize stones
Complications associated with cystoscopic precedures to remove stones from the bladder? (cystoscopy, cystolitholapaxy, & cystoscopic lithotripsy)
2. retained stone fragments
How may stones be removed from the renal pelvis & upper urinary tract?
flexible ureteroscopes inserted via a cystoscope & used to remove stones
may need to use ultrasonic laser or electrohydraulic lithotripsy to break up stones before removing with ureterscope
nephroscope inserted through skin into renal pelvis -> kidney stones fragmented -> stone fragments are removed -> renal pelvis is irrigated -> percutaneous nephrostomy tube is usually left in place to make sure ureter is not obstructed
Methods of breaking up kidney stone during percutaneous nephrolithotomy?
3. laser lithotripsy
Complications of percutaneous nephrolithotomy?
2. injury to adjacent structures
procedure used to eliminate calculi from the urinary tract
Contraindication for lithotripsy?
staghorn or partial staghorn cystine stones
4 types of lithotripsy procedures?
1. percutaneous ultrasonic
4. extracorporeal shock-wave
Percutaneous ultrasonic lithotripsy?
small incision made in flank-> ultrasonic probe place in renal pelvis via a nephroscope -> probe placed against the stone -> produces ultrasonic waves that break stone in to sandlike particles
What type of anesthesia is used in percutaneous ultrasonic lithotripsy?
general or spinal anesthesia
When will percutaneous ultrasonic lithotripsy be used?
when stone is large & other lithotripsy procedrues have failed
same as percutaneous ultrasonic except stones are broken into small fragements & removed byu forceps or by suction & a continuous saline irrigation flushes out the stone particles
How are fragments collected during electrohydraulic lithotripsy?
drainage that occurs during irragation is strained to cathc particles to be analyzed
fragments may also be removed via basket extraction
pt placed in water bath (if electrohydraulic used) -> fluoroscopy or ultrasound used to focus a lithotripter on the affected kidney -> high-energy acoustic shock waves shatter stone without damaging surrounding tissues-> broken into fine sand & excreted within urine
other methods may be used that do not require submersion: electromagnetic & piezoelectric
What type of anesthesia is required for extracorporeal shock-wave lithotripsy?
general or spinal
needed to ensure pt position is maintained during procedure
Post-procedure considerations with extracorporeal shock-wave lithotripsy?
1. pain: some sedation/analgesia required
3. self-retaining ureteral stent may be placed after procedure to facilitate passage of sand & prevent sand build-up in ureter - will be removed within 2 weeks
2 types of pt that may require open surgery for kidney stones?
1. obese pt
2. complex abnormalities in the calyces or at the UPJ
incision into the kidney to remove a stone
incision into the renal pelvis for stone removal
removal of stone in ureter
removal of stone in bladder
Where is incision made for open lithotomy procedures?
flank incision directly below diaphragm & across side
Interventions for prevention of urinary stones/recurrence of stones?
2. self monitoring of urinary pH
3. measure UO
Complication of open lithotomy procedures?
Nutritional therapy r/t urinary stones?
1. adequate fluids: after stone episode need about 3L/day (excessive fluids may increase pain)
3. ambulate pt when possible to help stone pass from upper to lower urinary tract
Consideration when ambulating a pt that has a urinary stone?
if pt is experiencing renal colic or taking opioids -> risk for fall
***should not ambulate alone
Cause of ureteral strictures?
usually unintended complication of surgical intervention r/t adhesions or scar formation
s/s of ureteral strictures?
1. mild to moderate colic - may be worse if pt consumes lg volume of fluids
2. infection may occur
Tx for discomfort & obstruction of ureteral strictures?
may be temporarily bypassed by placing a stent under endoscopic control or by diverting urinary flow via a nephrostomy tube
Permanent correction of ureteral strictures?
What will be done if this fails or strictures reoccur?
dilation with a balloon or catheter
may be incised under endoscopic control - endoureterotomy
Open surgery for ureteral strictures?
excise stenotic area & reanastomose the ureter to the contralateral ureter (ureteroureterostomy) or to the renal pelvis
reimplantation of the ureter into the bladder wall
fibrosis or inflammation of the urethral lumen
4 causes of urethral strictures?
2. urethritis - esp caused by gonococcal infection
3. iatrogenic (following surgery or repeated catheterization
4. congenital defect
Patho of urethral strictures?
inflammation/fibrosis occurs -> lumen of urethra narrows -> compliance is compromised (ability to open/close) -> meatal stenosis may occur
When do s/s of urethral strictures occur?
s/s of urethral strictures?
occur when it creates voiding dysfunction of bladder outlet obstruction
1. diminished force of urinary stream
2. straining to void
3. sprayed stream
4. postvoid dribbling
5. split urine stream
6. feeling of incomplete bladder emptying
7. urinary frequency & nocturia
Urethral strictures may lead to acute ____ ____.
4 things pt may report in their Hx that may be r/t urethral strictures?
2. difficulty with insertion of catheter
3. trauma involving penis or perineum
4. may also have Hx of UTI
What 2 tests are used to determine length, location, & caliber of urethral strictures?
1. retrograde urethrography (RUG)
2. voiding cystourethrography (VCUG)
Initial mgmt of a urethral stricture?
Problem with these procedures?
dilation with a urethral sound or filiforms & followers
urethral sound - metal instrument placed to dilate
filiforms & followers - series of progressivley enlarging stents placed in urethra to expand lumen
work initially but usually stenosis reoccurs
How are urethral stricture recurrances managed?
teaching pt to repeatedly dilate urethra by self-catheterization using a soft coude-tip catheter every few days
endoscopic or open surgical procedure (urethroplasty) may be performed to provide a more durable solution to an obstructive urethral stricture: may do reanastomosis or substitute segment with autotransplantation of skin flap
Clinical findings that support kidney trauma?
1. Hx of trauma to the area: abd, flank, back
2. gross or microscopic hematuria
2. IVP with cystography
3. ultrasound, CT, or MRI
4. renal arteriography
should eval injured and nonaffected kidney
Tx for kidney trauma?
range from bed rest, fluids, & analgesia to surgical exploration & repair/nephrectomy
Nursing interventions r/t kidney trauma?
1. assess CV status
2. monitor for shock (penetrating injury)
3. ensure increased fluid intake
4. monitor I&O
5. provide comfort measures
6. observe for hematuria
7. determine the presence of myoglobinuria
8. monitor potentially nephrotoxic ABX
3 vascular problems involving the kidneys?
2. renal artery stenosis
3. renal vein thrombosis
sclerosis of the small arteries and arterioles of the kidney
Patho of nephrosclerosis?
sclerosis of arteries & arterioles -> decreased BF -> patchy necrosis of the renal parenchyma & necrosis & fibrosis of the glomeruli
Benign nephrosclerosis cause?
vascular changes resulting from HTN & atherosclerosis process
There is a direct relationship between the degreee of nephrosclerosis & the severity of ____.
Accelerated nephrosclerosis is associated with ____ _____.
Accelerated nephrosclerosis is AKA?
Who usually gets it?
complication of HTN characterized by a sharp increase in BP with a diastolic pressure >130
usually occurs in young adults - more in males
Progression of accelerated nephrosclerosis?
renal insufficiency progresses rapidly
The only detectable abnormality in benign nephrosclerosis may be ____.
_____ ____ _____ account for most of the loss of renal function associated with aging.
atherosclerotic vascular changes
Tx for benign nephrosclerosis?
same as Tx for essential HTN:
aggressive antihypertensive therapy
2 major complications of HTN?
renal dysfunction & renal failure
Renal artery stenosis?
partial occlusion of one or both renal arteries & their major branches r/t atherosclerotic narrowing or fibromuscular hyperplasia
When should renal artery stenosis be considered as a Dx?
when HTN develops abruptly especially if pt is under 30 or over 50 with no family Hx of HTN
Best Dx tool for IDing renal artery stenosis?
Goals of therapy for renal arterial stenosis?
control BP & restore perfusion to the kidney
First choice procedure for Tx of renal artery stenosis
When is surgery indicated?
percutaneous transluminal renal angioplasty
when BF decreased enough to cause renal ischemia & evidence indicates renovascular HTN & surgical intervention may result in the pt becoming normotensive
How is blood normally rerouted during percutaneous transluminal renal angioplasty?
What other surgery may be performed & when is it indicated?
normally involves anastomoses b/t kidney & another major artery - usually splenic artery or aorta
in some cases of unilateral renal invovement with high renein production may do unilateral nephrectomy
What 6 conditions are associated with renal vein thrombosis?
2. extrinsic compression (tumor, aortic aneurysms
3. renal cell carcinoma
5. contraceptive use
6. nephrotic syndrome
s/s of renal vein thrombosis?
1. flank pain
4. nephrotic syndrome & its s/s may be present
Tx of renal vein thrombosis?
1. anticoagulants -
2. corticosteroids (if has nephrotic syndrome)
3. surgical thrombectomy may be performed instead of or along with anticoagulation therapy
What are anticoagulants important in the Tx of renal vein thrombosis?
there is a high incidence of pulmonary embolism
Polycysti kidney disease (PKD)?
life-threatening autosomal dominant disease involving both kidneys where the cortex & medulla of the kidney are filled with lg, thin-walled cysts filled with fluid/blood/pus that enlarge & destroy surrounding tissue by compression
2 types of PKD?
one occurs in childhood & one in adulthood
adulthood occurs in 30's or 40's
When do s/s of PKD begin to appear?
First s/s of PKD?
What other s/s may occur?
when cysts begin to enlarge
2. hematuria (from cyst rupture)
3. feeling of heaviness in back, side, or abd
1. chronic pain that may be constant/severe
2. bilat enlarged kidneys palpated
some ppl have no s/s
Dx of PKD?
1. H&P & s/s
2. family Hx
5. CT scan
Best screening measure for PKD?
Usual progression of PKD?
usually progresses to ESRD by age 60
What other body organs my be affected by PKD?
1. liver - liver cysts
2. heart - abnormal heart valves
3. blood vessels - aneurysms
4. intestines - diverticulosis
Most serious complication of PKD?
cerebral aneurysm - can rupture
Tx of PKD?
no specific Tx
1. prevent UTI &/or Tx with ABX as infections occur
2. nephrectomy if pain, bleeding, or infection becomes a chronic serious problem
3. dialysis & kidney transplant may be needed to treat ESRD
Nursing interventions for PKD?
those used for ESRD
1. diet modifications
2. fluid restriction
3. drugs: antiHTN
4. assisting pt to accept chronic disease process
5. assisting pt & family to deal with finances
6. counceling for pt who has children (usually Dx after have children) & genetic counceling for children b/c have 50% chance of having it
Medullary cystic disease?
Characteristics of meduallary cystic disease?
hereditary disorder that occurs in 2 forms
1. most cysts located in medulla
2. kidneys are asymmetric & significantly scarred
3. defects in conc. ability of the kidneys
s/s of medullary cystic disease?
2. progressive renal failure
3. severe anemia
4. metabolic acidosis
5. poor Na conservation
What can occur with HTN in medullary cystic disease?