Chapter 10
Care of the Patient with a
Urinary Disorder
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and
Physiology
• Functions of the urinary system


Excretion of waste products
Regulation of water, electrolytes, and acid-base
balance
• Kidneys (two)

Nephron: Functional unit of kidneys
• Urine composition and characteristics

95% water; remainder is nitrogenous wastes and salts
• Urine abnormalities

Albumin; glucose; erythrocytes; ketones; leukocytes
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 2
Figure 10-2
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
Coronal section through right kidney.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 3
Figure 10-3
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
The nephron unit.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 4
Overview of Anatomy and
Physiology
• Ureters (two)

Passageway for urine from the kidneys to the urinary
bladder
• Urinary bladder (one)

Temporary storage pouch for urine
• Urethra (one)

Carries urine by peristalsis from the urinary bladder
out to its external opening
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 5
Figure 10-5
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
The male urinary bladder, cut to show the interior.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 6
Laboratory and Diagnostic
Examinations
• Urinalysis









Blood urea nitrogen (BUN)
Blood creatinine
Creatinine clearance
Prostate-specific antigen (PSA)
Osmolality
Kidney-ureter-bladder radiography (KUB)
Intravenous pyelogram (IVP)
Retrograde pyelography
Voiding cystourethrography
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 7
Laboratory and Diagnostic
Examinations
• Endoscopic procedures









Renal angiography
Renal venogram
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Renal scan
Ultrasonography
Transrectal ultrasound
Renal biopsy
Urodynamic studies
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 8
Medication Considerations
• Diuretics to enhance urinary output

Thiazide diuretics
 Loop (or high-ceiling) diuretics
 Potassium-sparing diuretics
 Osmotic diuretics
 Carbonic anhydrase inhibitor diuretics
• Medications for urinary tract infections




Quinolone
Nitrofurantoin
Methenamine
Fluoroquinolone
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 9
Maintaining Adequate Urinary
Drainage
• Types of catheters

Coudé catheter
 Foley catheter
 Malecot, Pezzer, or mushroom catheters
 Robinson catheter
 Ureteral catheters
 Whistle-tip catheter
 Cystostomy, vesicostomy, or suprapubic catheter
 External (Texas or condom) catheter
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 10
Figure 10-6
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Different types of commonly used catheters.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 11
Disorders of the Urinary System
• Urinary retention

Etiology/pathophysiology
• The inability to void despite an urge to void

Clinical manifestations/assessment
• Distended bladder
• Discomfort in pelvic region
• Voiding frequent, small amounts
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 12
Disorders of the Urinary System
• Urinary retention (continued)

Medical management/nursing interventions
•
•
•
•
•
Warm shower or sitz bath
Natural voiding position if possible
Urinary catheter
Surgical removal of obstruction
Analgesics
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 13
Disorders of the Urinary System
• Urinary incontinence

Etiology/pathophysiology
• Involuntary loss of urine from the bladder

Total incontinence; dribbling; stress incontinence
• Secondary

Infection; loss of sphincter control; sudden change in
pressure in the abdomen
• Permanent or temporary
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 14
Disorders of the Urinary System
• Urinary incontinence (continued)

Clinical manifestations/assessment
• Involuntary loss of urine


Leaking with coughing, sneezing, or lifting
Medical management/nursing interventions
•
•
•
•
•
Treat underlying cause
Surgical repair of bladder
Temporary or permanent catheter
Bladder training
Kegel exercises
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 15
Disorders of the Urinary System
• Neurogenic bladder

Etiology/pathophysiology
• Loss of voluntary voiding control
• Results in urinary retention or incontinence
• Lesion of the nervous system that interferes with normal
nerve conduction to the urinary bladder
• Two types


Spastic
Flaccid
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 16
Disorders of the Urinary System
• Neurogenic bladder (continued)

Clinical manifestations/assessment
• Infrequent voiding
• Incontinence
• Diaphoresis, flushing, nausea prior to reflex
incontinence

Medical management/nursing interventions
• Antibiotics; urecholine
• Intermittent catheterization
• Bladder training
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 17
Disorders of the Urinary System
• Urinary tract infections

Etiology/pathophysiology
• Type depends on location
• Pathogens enter the urinary tract






Nosocomial infection
Bladder obstruction
Insufficient bladder emptying
Decreased bactericidal secretions of the prostate
Perineal soiling in females
Sexual intercourse
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 18
Disorders of the Urinary System
• Urinary tract infections (continued)

Clinical manifestations/assessment
•
•
•
•

Urgency; frequency; burning on urination
Nocturia
Abdominal discomfort; perineal or back pain
Cloudy or blood-tinged urine
Medical management/nursing interventions
• Pharmacological management

Antibiotics; urinary antiseptics/analgesics
• Encourage fluids
• Perineal care
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 19
Obstructive Disorders of the
Urinary System
• Urinary obstruction

Etiology/pathophysiology
•
•
•
•

Strictures; kinks
Cysts; tumors
Calculi
Prostatic hypertrophy
Clinical manifestations/assessment
•
•
•
•
Continuous need to void
Voiding small amounts frequently
Pain
Nausea
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 20
Obstructive Disorders of the
Urinary System
• Urinary obstruction (continued)

Medical management/nursing interventions
• Establish urinary drainage




Indwelling catheter
Suprapubic cystostomy
Ureterostomy
Nephrostomy
• Pharmacological management

Pain relief
o Narcotics
o Anticholinergics
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 21
Obstructive Disorders of the
Urinary System
• Hydronephrosis

Etiology/pathophysiology
• Dilation of the renal pelvis and calyces
• Unilateral or bilateral
• Obstruction of the urinary tract

Clinical manifestations/assessment
•
•
•
•
Dull flank pain (slow onset)
Severe stabbing pain (sudden onset)
Nausea and vomiting
Frequency, dribbling, burning, and difficulty starting
urination
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 22
Obstructive Disorders of the
Urinary System
• Hydronephrosis (continued)

Medical management/nursing interventions
• Pharmacological management


Antibiotics
Narcotic analgesics
• Surgery to relieve obstruction
• Nephrectomy

Severely damaged kidney
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 23
Obstructive Disorders of the
Urinary System
• Urolithiasis

Etiology/pathophysiology
• Formation of urinary calculi (stones)
• Develops from minerals
• Identified according to location


Nephrolithiasis; ureterolithiasis; cystolithiasis
Clinical manifestations/assessment
• Flank or pelvic pain
• Nausea and vomiting
• Hematuria
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 24
Obstructive Disorders of the
Urinary System
• Urolithiasis (continued)

Medical management/nursing interventions
•
•
•
•
•
Antibiotics
Encourage fluids
Ambulate
STRAIN ALL URINE
Surgical procedures

Cystoscopy; ureterolithotomy; pyelolithotomy;
nephrolithotomy
• Lithotripsy
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 25
Figure 10-7
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)
Location and methods of removing renal calculi from upper urinary tract.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 26
Renal Tumors
• Etiology/pathophysiology


Adenocarcinomas that develop unilaterally
Renal cell carcinomas arise from cells of the proximal
convoluted tubules
• Clinical manifestations/assessment


Early: Intermittent painless hematuria
Late
•
•
•
•
Weight loss
Dull flank pain
Palpable mass in flank area
Gross hematuria
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 27
Renal Tumors
• Medical management/nursing interventions



Radical nephrectomy
Radiation
Chemotherapy
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 28
Renal Cysts
• Etiology/pathophysiology


Cysts form in the kidneys
Polycystic kidney disease
• Cysts cause pressure on the kidney structures and
compromise function
• Clinical manifestations/assessment





Abdominal and flank pain
Voiding disturbances
Recurrent UTIs
Hematuria
Hypertension
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 29
Renal Cysts
• Medical management/nursing interventions


No specific treatment
Pharmacological management
• Analgesics
• Antibiotics
• Antihypertensives




Relieve pain
Heat (unless bleeding)
Dialysis
Renal transplant
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 30
Tumors of the Urinary Bladder
• Etiology/pathophysiology


Most common site of cancer in the urinary tract
Range from benign papillomas to invasive carcinoma
• Clinical manifestations/assessment


Painless intermittent hematuria
Changes in voiding patterns
• Medical management/nursing interventions


Localized—remove tissue by burning
Invasive lesions—partial or total cystectomy
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 31
Conditions Affecting the Prostate
Gland
• Benign prostatic hypertrophy

Etiology/pathophysiology
• Enlargement of the prostate gland
• Common in men 50 years old and older
• Cause is unknown
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 32
Conditions Affecting the Prostate
Gland
• Benign prostatic hypertrophy (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
Frequent urination
Difficulty starting urination
Dysuria
Frequent UTIs
Hematuria
Oliguria
Nocturia
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 33
Conditions Affecting the Prostate
Gland
• Benign prostatic hypertrophy (continued)

Medical management/nursing interventions
• Relieve obstruction—Foley catheter
• Prostatectomy
• Postoperative


TURP
o Bladder irrigations
o Urine will be pink to cherry red
Suprapubic or abdominal
o Assess dressings
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 34
Conditions Affecting the Prostate
Gland
• Cancer of the prostate

Etiology/pathophysiology
• Malignant tumor of the prostate gland

Clinical manifestations/assessment
• Initially

No symptoms
• Advanced stages

Urinary obstruction
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 35
Conditions Affecting the Prostate
Gland
• Cancer of the prostate (continued)

Medical management/nursing interventions
• Localized: radiation and/or surgery
• Men over 70 years old: Radiation and hormone therapy
• Advanced




Estrogen therapy
Orchiectomy
Radiation therapy
Chemotherapy
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 36
Urethral Strictures
• Etiology/pathophysiology

Narrowing of the lumen of the urethra that interferes
with urine flow; congenital or acquired
• Clinical manifestations/assessment



Dysuria; nocturia
Weak urinary stream
Pain with bladder distention
• Medical management/nursing interventions


Correction of stricture
Analgesics
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 37
Urinary Tract Trauma
• Urinary tract trauma

Etiology and pathophysiology
• Injury to the urinary tract may result from accidents,
surgical intervention, and fractures

Clinical manifestations
• Hematuria
• Abdominal pain and tenderness

Medical management/nursing interventions
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 38
Immunological Disorders of the
Kidney
• Nephrotic syndrome

Etiology/pathophysiology
• Physiologic changes of the glomeruli interfere with
selective permeability

Clinical manifestations/assessment
•
•
•
•
•
Proteinuria; hypoalbuminemia
Generalized edema
Anorexia
Fatigue
Oliguria
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 39
Immunological Disorders of the
Kidney
• Nephrotic syndrome (continued)

Medical management/nursing interventions
• Pharmacological management


Corticosteroids
Diuretics
• Diet


Low sodium
High protein
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 40
Immunological Disorders of the
Kidney
• Nephritis (acute glomerulonephritis)

Etiology/pathophysiology
• Previous infection with β-hemolytic streptococcus
(2-3 weeks prior)
• Preexisting multisystem diseases
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 41
Immunological Disorders of the
Kidney
• Nephritis (acute glomerulonephritis) (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Edema of the face
Pallor
Malaise
Anorexia
Dyspnea with exertion
Hematuria
Changes in voiding patterns
Oliguria; dysuria
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 42
Immunological Disorders of the
Kidney
• Nephritis (acute glomerulonephritis) (continued)

Medical management/nursing interventions
• Pharmacological management



Antibiotics
Diuretics
Antihypertensives
• Supportive management
• Diet


Protein and sodium restrictions
Increase calories
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 43
Immunological Disorders of the
Kidney
• Nephritis (chronic glomerulonephritis)

Etiology/pathophysiology
• Slow, progressive destruction of glomeruli
• Commonly caused by other chronic illnesses


Diabetes mellitus
Systemic lupus erythematosus
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 44
Immunological Disorders of the
Kidney
• Nephritis (chronic glomerulonephritis) (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
•
Malaise; morning headaches
Dyspnea with exertion
Visual and digestive disturbances
Generalized edema
Weight loss
Fatigue
Hypertension
Anemia
Proteinuria
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 45
Immunological Disorders of the
Kidney
• Nephritis (chronic glomerulonephritis) (continued)

Medical management/nursing interventions
• Same as acute glomerulonephritis
• Renal dialysis
• Kidney transplant
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 46
Renal Failure
• Acute renal failure

Etiology/pathophysiology
• Kidney function altered


Interference with ability to filter blood
Decrease in blood flow to the kidney
• Three phases



Oliguric phase
Diuretic phase
Recovery phase
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 47
Renal Failure
• Acute renal failure (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
Anorexia
Nausea
Vomiting
Edema
Dry mucous membranes
Poor skin turgor
Urine output less than 400 mL/24 hours (oliguric phase)
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 48
Renal Failure
• Acute renal failure (continued)

Medical management/nursing interventions
• Pharmacological management



•
•
•
•
Diuretics
Antibiotics
Kayexalate
Administer fluids
Assess for and treat electrolyte imbalances
Dialysis
Diet: High in carbohydrates; low in protein, potassium,
and sodium
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 49
Renal Failure
• Chronic renal failure

Etiology/pathophysiology
•
•
•
•
End-stage renal failure
Kidneys are unable to regain normal function
Develops slowly over an extended period of time
Result of kidney disease or other disease process that
compromises renal blood flow
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 50
Renal Failure
• Chronic renal failure (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
•
Headache
Lethargy; decreased strength
Anorexia
Pruritus
Anuria
Muscle cramps or twitching
Dusky yellow-tan or gray skin color
Disorientation and mental lapses
Anemia
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 51
Renal Failure
• Chronic renal failure (continued)

Medical management/nursing interventions
•
•
•
•
Dialysis
Renal transplant
Medications to treat symptoms
Diet: High in calories; restricted protein,
potassium, and sodium
• Restricted fluids

300 to 600 mL above urine output
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 52
Care of the Patient Requiring
Dialysis
• A medical procedure for the removal of certain
elements from the blood through a semi-permeable
membrane (external or peritoneum)
• Mimics kidney function
• Two types


Hemodialysis
Peritoneal dialysis
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 53
Surgical Procedures for Urinary
Disorders
•
•
•
•
Nephrectomy
Nephrostomy
Kidney transplantation
Urinary diversion


Ileal conduit
Continent ileal urinary reservoir or Kock pouch
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 54
Figure 10-12
(From Belcher, A.E. [1992]. Cancer nursing. St. Louis: Mosby.)
Renal transplantation.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 55
Figure 10-13
Ileal conduit or ileal loop.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 56
Figure 10-14
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. (13th ed.). St. Louis: Mosby.)
Kock pouch.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 57
Nursing Process
• Nursing diagnoses







Urinary elimination, impaired
Tissue perfusion: renal, ineffective
Pain, acute and chronic
Infection, risk for
Fluid volume excess
Sexuality patterns, ineffective
Knowledge, deficient
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 58