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Urinary disorders watson (2)

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Urinary disorders watson (2)

  1. 1. Filamer Christian College<br />College of Nursing<br />Roxas City<br /> <br /> <br />NCM 102<br /> <br />RENAL and URINARY SYSTEM<br /> <br />Topics:<br /> <br />Benign Prostatic Hypertrophy<br />Urinary Incontinence<br />Nephrotic Syndrome<br /> <br />Prepared by<br />Group 4- WATSON<br /> <br />Aspera, Liza Marie<br />Buencuchillo, Kristine<br />Cesar, Roneil<br />Lacdo-o, Krisanta Camille<br />Montealegre, Lynmar Kaye<br />Nobleza, Argie<br />Tan, Jazel Cheene<br /> <br /> <br />Submitted to<br /> <br />Miss Shenell A. Delfin, RN<br />NCM 102 Lecturer<br /> <br /> <br /> <br /> <br />March 11, 2010<br />Benign Prostatic Hypertrophy<br /><ul><li> Enlargement of the prostate gland.
  2. 2. The term BPH is a misnomer because the actual change is a hyperplasia & not hypertrophy.
  3. 3. BPH becomes a disorder when enlargement obstructs the urinary channel and causes changes in the urinary tract with associated manifestations. </li></li></ul><li>The etiology of BPH is unclear.<br /><ul><li>Two factors necessary for BPH to occur are:</li></ul> (1) endocrine control (DHT)<br /> (2) aging<br /><ul><li>Hormonal Alteration: The relative roles of androgen & estrogen in inducing BPH, however , are complex & not completely understood.</li></ul>- Prostatic enlargement eventually occurs in 80% of men. By age 50, about 50% of men have some degree of BPH. <br />- Increased in African American men and is lower in Asians. <br />
  4. 4. PATHOPHYSIOLOGY<br />serum levels of Luteinizing hormone,<br />testosterone and luteinizing hormone – releasing hormone <br /> <br /> Pituitary gland stimulation to release of LH<br /> <br /> Testosterone production<br /> <br /> Combines with 5-alpha-reductase<br /> <br /> Dihydrotestosterone (DHT) formation<br /> <br /> Muscle contraction<br /> Restriction of urine flow<br /> <br /> Bladder outlet obstruction<br /> Detrusor muscle compensates<br /> <br />Trabeculation and bladder diverticula occur <br /> <br /> bladder wall elasticity<br />
  5. 5. ASSESSMENT<br />Progressive Hyperplasia<br /><ul><li>CIRCULATION
  6. 6. May exhibit:Elevated BP (renal effects of advanced enlargement)
  8. 8. May report:Decreased force/caliber of urinary stream; dribbling
  9. 9. Hesitancy in initiating voiding
  10. 10. Inability to empty bladder completely; urgency and frequency of urination
  11. 11. Nocturia, dysuria, hematuria, Sitting to void
  12. 12. Recurrent UTIs, history of calculi (urinary stasis)
  13. 13. Chronic constipation (protrusion of prostate into rectum) </li></li></ul><li>Cont. ASSESSMENT<br /><ul><li> Inguinal hernia; hemorrhoids (result of increased abdominal pressure required to empty bladder against resistance)
  14. 14. May exhibit:Firm mass in lower abdomen (distended bladder), bladder tenderness </li></ul>FOOD/FLUID <br /> May report:Anorexia; nausea, vomiting, Recent weight loss<br />PAIN/DISCOMFORT <br /> May report:Suprapubic, flank, or back pain; sharp, intense (in acute prostatitis), Low back pain <br />SAFETY <br /> May report:Fever <br />
  15. 15. Cont. ASSESSMENT<br />SEXUALITY <br /><ul><li>May report:Concerns about effects of condition/therapy on sexual abilities
  16. 16. Fear of incontinence/dribbling during intimacy
  17. 17. Decrease in force of ejaculatory contractions
  18. 18. May exhibit:Enlarged, tender prostate </li></ul>TEACHING/LEARNING <br /><ul><li>May report: Family history of cancer, hypertension, kidney disease
  19. 19. Use of antihypertensive or antidepressant medications, OTC cold/allergy medications containing sympathomimetics, urinary antibiotics or antibacterial agents
  20. 20. Self-treatment with saw palmetto or soy products </li></li></ul><li><ul><li>Obstructive Voiding symptoms
  21. 21. Weak stream
  22. 22. Prolonged micturition
  23. 23. Straining
  24. 24. Hesitancy
  25. 25. Intermittent stream
  26. 26. Feeling of incomplete bladder emptying
  27. 27. Irritative symptoms
  28. 28. Frequency
  29. 29. Nocturia
  30. 30. Urgency
  31. 31. Incontinence </li></ul>Systemic symptoms related to the UT:<br /> - Vesicoureteral reflux<br /> - Dilatation & hydronephrosis<br /> - Renal failure & symptoms of uremia<br />Symptoms unrelated to the UT:<br /> - hernias, hemorrhoids and vesical calculus<br /> - change in the caliber of bowl movements<br />Symptoms related to complications:<br /> - cystitis<br /> - pyelonephritis<br /> - bladder calculi <br /> - micro or gross hematuria.<br />
  32. 32. DIAGNOSTICS<br /><ul><li>Digital Rectal Examination (DRE) – smooth, firm, symmetric enlargement of the prostate
  33. 33. Urinalysis & microscopic examination: to R/O infection or the presence of hematuria.
  34. 34. Serum U/E & creatinine: to provide baseline information on renal function & metabolic status.
  35. 35. Uroflowmetry: At a volume of 125-150ml, normal individuals have average flow rates of 12ml/sec & peak flow close to 20ml/sec.</li></ul>Mild 11-15 ml/sec<br /> Moderate  7 and  10 ml/sec<br /> Severe  7ml/sec<br />
  36. 36. <ul><li>Residual Urine: estimated by U/S or catheterizations. Volumes >150 ml are considered significant since they constitute approximately one-third of normal bladder volume
  37. 37. Serum Prostate-Specific Antigen (PSA) – to rule out cancer, but may also be elevated in BPH </li></ul>Optional diagnostics for further evaluation:<br /><ul><li>Urodynamics –measures peak urine flow rate, voiding time and volume, and status of the bladder’s ability to effectively contract.</li></li></ul><li><ul><li>Measurement of postvoid residual urine; by ultrasound or catheterization
  38. 38. Cystourethroscopy – to inspect urethra and bladder and evaluate prostatic size </li></li></ul><li>Ultrasonography:<br />In BPH, it is most useful for measuring bladder & prostate volume as well as residual urine.<br />Estimation of prostatic size is important because most urologists prefer to perform TURP for glands under 100g.<br />TRUS must be used as it is more accurate. <br />IVP:<br />For UTI & complications of BPH<br />
  39. 39. COMPLICATIONS<br /><ul><li> Acute urinary retention, involuntary bladder contractions, bladder diverticula, and cystolithiasis
  40. 40. Vesicourethral reflux, hydroureter, hydronephrosis
  41. 41. Gross hematuria, urinary tract infection
  42. 42. Renal impairment
  43. 43. Bladder stones
  44. 44. Bladder damage (trabeculations, cellules, diverticula)
  45. 45. Overflow incontinence </li></li></ul><li>Interventions:<br />Facilitating Urinary Elimination<br /><ul><li>Provide privacy and time for patient to void
  46. 46. Assist with catheter introduction with guidewire or by way of suprapubic cystostomy as indicated.
  47. 47. Monitor intake and output
  48. 48. Maintain patency of catheter
  49. 49. Administer medications as ordered, and monitor for and teach patient about side effects.
  50. 50. Assess for and teach patient to report hematuria, signs of infection</li></ul>Patient education and Health Maintenance<br />NURSING DIAGNOSIS<br />1. Impaired Urinary Elimination related to obstruction of urethra.<br />Rationale: BPH causes an enlargement that forms like a capsule in the urinary bladder that occludes urine flow causing changes in urinary elimination. The patient experiences manifestations such as frequency, urgency, hesitancy, change in stream, incontinence, retention and nocturia.<br />
  51. 51. 2. Acute Pain related to surgery and bladder spasms<br />Rationale: Bladder spasms frequently occur after prostate procedures, and incisional pain will occur if an open surgery is completed due to stimulating actions on nociceptors which are responsible for pain sensation. <br />Interventions: <br /><ul><li>Ensure that the drainage system is not blocked
  52. 52. Administer medications for relief of bladder spasms (Antispasmodic medications)</li></ul>-Belladonna and opium suppositories <br />-Propantheline bromide (Pro-Banthine) or immediate relase oxybutynin (Ditropan IR)<br /><ul><li>Have proper interventions for side effects of drugs </li></ul>Dry mouth, drowsiness, acute confusion in the older clients<br />Stool softeners such as docusate sodium (Colace) should be given for constipation since straining at stool can precipitate bleeding from the operative site.<br />
  53. 53. 3.Risk for Injury related to presence of urinary catheters, hematuria, irrigation, or suprapubic drains <br />Rationale: Medical and surgical management for BPH require irrigation drainage such as urinary catheter. Blockage of an irrigated bladder is always possible in such situations that lead to overdistention, secondary hemorrhage, and formation of blood clots or infection. <br />Interventions:<br /><ul><li>Maintain irrigation
  54. 54. Monitor for bleeding
  55. 55. Prevent catheter dislodgment
  56. 56. Prevent Infection
  57. 57. Monitor for retention
  58. 58. Manage temporary incontence</li></li></ul><li>INTERVENTIONS<br /><ul><li>Patients with mild symptoms (in the absence of significant bladder or renal impairment) are followed annually; BPH does not necessarily worsen in all men.
  59. 59. Pharmacologic management
  60. 60. a-Adrenergic blockers such as doxazosin (Cardura), tamsulosin (FLomax), terazosin (Hytrin) – relax smooth muscle of bladder base and prostate to facilitate voiding.
  61. 61. 5 alpha reductase inhibitor</li></ul>Finasteride (Proscar) – antiandrogen effect on prostate cells, reverses or prevents hyperplasia<br />
  62. 62. <ul><li>Surgery </li></ul>TURP, transurethral incision of the prostate (TUIP), or open prostatectomy for very large prostate, usually by suprapubic approach<br />Newer approaches – laser surgery, transurethral electrovaporization, transurethral needle ablation, insertion of intraurethral stents, hyperthermia, and thermotherapy.<br />
  63. 63.
  64. 64.
  65. 65. Nursing care<br /> <br />Pre – op<br /><ul><li>Obtain informed consent
  66. 66. Assess ability to empty bladder
  67. 67. The bladder should be palpated for distention
  68. 68. If the client cannot void, a urethral catheter may have to be placed
  69. 69. Stop anticoagulants medications before the procedure
  70. 70. Assess clients knowledge about surgery and its outcomes
  71. 71. Provide health teaching to lessen clients fear and anxiety
  72. 72. Restate explanations given by the surgeon and anesthetist</li></li></ul><li> <br />Post-op<br /><ul><li>Vital signs monitoring
  73. 73. Maintenance of urinary drainage
  74. 74. MIO
  75. 75. Document urine color
  76. 76. Proper positioning of the catheter and drainage system. </li></ul> <br /> <br />
  77. 77. URINARY INCONTINECE<br />Urinary incontinence is unintentional loss of urine that is sufficient enough in frequency and amount to cause physical and/or emotional distress in the person experiencing it.<br />Women are affected by the disorder more frequently than are men; one in 10 women under age 65 suffer from urinary incontinence. <br />Older Americans, too, are more prone to the condition. Twenty percent of Americans over age 65 are incontinent.<br />
  78. 78.
  79. 79.
  80. 80.
  81. 81.
  82. 82.
  83. 83. DIAGNOSTICS<br /><ul><li>Physical examination
  84. 84. Stress test - the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
  85. 85. Urinalysis - urine is tested for evidence of infection, urinary stones, or other contributing causes.
  86. 86. Blood tests - blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
  87. 87. Ultrasound - sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
  88. 88. Cystoscopy - a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
  89. 89. Urodynamics - various techniques measure pressure in the bladder and the flow of urine. </li></li></ul><li>COMPLICATIONS<br /><ul><li>Skin problems.
  90. 90. Urinary tract infections.
  91. 91. Changes in your activities.
  92. 92. Changes in your work life.
  93. 93. Changes in your personal life.</li></li></ul><li>NURSING DIAGNOSIS<br />1. Acute Pain<br />May be related to: Increased frequency/force of ureteral contractions,Tissue trauma, edema formation; cellular ischemia <br />2. Impaired Urinary Elimination related to uninhibited bladder contraction<br />Rationale: Uninhibited bladder contraction as a result of insufficient bladder control causes unannounced need to void. This inability of a person to delay voiding cause a disturbance in thr normal pattern of his/her urinary elimination.<br />
  94. 94. 3. Situational low self-esteem related to functional impairment.<br />Rationale: One’s self esteem is affected by the ability to function well and relate to others. Functional impairment such as Urinary incontinence could make a person becomes consciouson how pther people react<br />
  95. 95. INTERVENTIONS<br />A. Medical management: <br /><ul><li>Anticholinergics (oxybutynin, dicyclomine)
  96. 96. Tricyclic antidepressants (imipramine, doxepin)
  97. 97. Pseudoephedrine (Sudafed)
  98. 98. Estrogen </li></ul>B. Surgical management: <br /><ul><li>Bladder related (inhibiting bladder contractility/decreasing sensory input/ increasing bladder capacity)
  99. 99. Augmentation cystoplasty </li></ul>Outlet related (Increasing outlet resistance) <br /><ul><li>Vesicourethral urethral suspension with or without prolapse repair (female)
  100. 100. Sling procedures </li></li></ul><li><ul><li>TVT - tension free vaginal tape
  101. 101. Bladder outlet reconstruction
  102. 102. Artificial urinary sphincter
  103. 103. Closure of the bladder outlet
  104. 104. Urinary diversion </li></ul>· Nursing Interventions:<br /><ul><li> Patient education on the prevention of URINARY INCONTINENCE : adequate fluid consumption, regular bladder emptying and proper perineal hygiene.
  105. 105. Avoid caffeine and alcohol
  106. 106. Avoid drinking a lot of fluids in the evening
  107. 107. Regular voiding by the clock
  108. 108. Gradual increase in time between voids
  109. 109. Maintain Adequate Renal Function </li></li></ul><li><ul><li>Establish Normal Voiding Pattern
  110. 110. Administer antibiotics, as ordered.
  111. 111. Monitor TPR every 4 hours and administer antipyretic drugs and antibiotics as prescribed
  112. 112. Analgesics PRN
  113. 113. Instruct patient to complete full prescription of antibiotic and have a follow up urine culture 2weeks after completion of antibiotic therapy.
  114. 114. Careful monitoring of renal function with proper adjustment of dosages depending on renal clearance
  115. 115. Unless contraindicated, liberal fluid intake up to 3 to 4 li/day.
  116. 116. Establish Realistic Endpoints based on Improvement of Symptoms versus Cure </li></li></ul><li>NEPHROTIC SYNDROME<br /><ul><li>Is a set of clinical manifestations caused by protein wasting secondary to diffuse glomerular damage.</li></li></ul><li>ETIOLOGY<br /><ul><li>Nephrotic syndrome is a protein wasting disease</li></ul>Caused by:<br /><ul><li>glomerulonephritis
  117. 117. diabetes mellitus
  118. 118. Lupus erythematosus
  119. 119. Amylodidosis
  120. 120. Carcinoma</li></li></ul><li>The nephrotic syndrome is a clinical complex characterized by a number of renal and extra renal features the most prominent of which are:<br /><ul><li>heavy proteinuria(in practice >3.0 to 3.5 g/1.73 m2 per 24 hours), which leads to hypoproteinemia
  121. 121. decreased levels of serum albumin (albumin < 3 g/dl -hypoalbuminemia),
  122. 122. severe edema,
  123. 123. elevated serum lipids (hyperlipidemia),
  124. 124. lipiduria,
  125. 125. and hypercoagulability</li></li></ul><li>NEPHROTIC SYNDROME<br /><ul><li>It is important to realize that the NS is not a disease; it is a syndrome caused by many different renal diseases
  126. 126. When a clinician encounters a patient with the NS it is important for him to determine the underlying condition, because the course and prognosis will depend on the underlying disease</li></ul>NS<br />
  128. 128. NEPHROTIC SYNDROME<br />GLOMERULAR DAMAGE<br />Protein loss<br />Reduced GFR<br />Activation of the renein-angiotensin system<br />Hypoalbuminemia<br />Proteinuria<br />Increased aldosterone<br />Reduced blood oncotic pressure<br />Hepatic lipoprotein synthesis<br />Sodium/water retention<br />Systemic edema<br />Hyper-lipidemia<br />Hyper-coaguability<br />
  129. 129. SYMPTOMS AND SIGNS <br />
  130. 130. SYMPTOMS AND SIGNS <br /><ul><li>An early sign of NS is frothy urine.
  131. 131. At presentation, proteinuria is usually > 2 gm/m2/day, or a urine protein/creatinine ratio is > 2
  132. 132. Symptoms and signs include anorexia, malaise, puffy eyelids, retinal sheen, abdominal pain, wasting of muscles, and edema.
  133. 133. Focal edema may be the reason for seeking help for such complaints as:
  134. 134. difficulty breathing (pleural effusion or laryngeal edema),
  135. 135. substernal chest pain (pericardial effusion),
  136. 136. scrotal swelling,
  137. 137. swollen knees (hydroarthrosis),
  138. 138. swollen abdomen (ascites),
  139. 139. and (in children) abdominal pain from edema of the mesentery. </li></li></ul><li>SIGNS AND SYMPTOMS<br /><ul><li>Most often, the edema is mobile - detected in the eyelids in the morning and in the ankles after ambulation.
  140. 140. Orthostatic hypotension and even shock may develop in children.
  141. 141. Adults may be hypo-, normo-, or hypertensive.
  142. 142. Oliguria and even acute renal failure may develop because of hypovolemia and diminished perfusion.</li></li></ul><li>PHYSICAL: <br /><ul><li>Patients present with increasing edema over a few days or weeks, lethargy, poor appetite, weakness, and occasional abdominal pain.
  143. 143. The initial episode and the subsequent relapses may follow an apparent viral upper respiratory tract infection.
  144. 144. Edema is the predominant feature and initially develops around the eyes and lower extremities.
  145. 145. With time, the edema becomes generalized and may be associated with an increase in weight, the development of an ascitic or pleural effusion, and a decline in urine output.
  146. 146. Hematuria and hypertension are unusual but manifest in a minority of patients.</li></li></ul><li>Diagnostics:<br /><ul><li>Complete medical history and physical examination
  147. 147. Urinalysis
  148. 148. Blood analysis
  149. 149. Kidney biopsy</li></li></ul><li>Complications<br /><ul><li>kidney infection (pyelonephritis)
  150. 150. urinary tract infection
  151. 151. Blood clots
  152. 152. High blood cholesterol and elevated blood triglycerides
  153. 153. Poor nutrition
  154. 154. High blood pressure
  155. 155. Acute kidney failure
  156. 156. Chronic kidney failure </li></li></ul><li>Nursing Diagnosis<br /><ul><li>Altered Nutrition: Less Than Body Requirements related to Increased Metabolic Demands
  157. 157. Risk for Fluid Volume Deficit related to disease process
  158. 158. Risk for Infection Related to Altered Immune Response Secondary to Treatment
  159. 159. Potential Impairment of Skin Integrity related to Edema
  160. 160. Fatigue related to Increased Metabolic Demands</li></li></ul><li>MANAGEMENT<br />A.Medical<br /><ul><li>Treatment of causative glomerular disease
  161. 161. Diuretics(edema)
  162. 162. ACE inhibitors( in combination with loop diuretics – Proteinuria), anti hypertensives
  163. 163. Glucocorticoids
  164. 164. Antineoplastic agents(cyclophosphamide-Cytoxan)
  165. 165. Immunosuppresants(cyclosporine- Neoral)
  166. 166. Low-sodium diet, liberal amounts of Potassium(no hyperkalemia)
  167. 167. High CHON diet and cholesterol(lipidemia), Restrict Fluids</li></li></ul><li>Nursing Management<br /><ul><li>MIOW, Monitor Urine Sp.Gravity
  168. 168. Patient Education
  169. 169. Monitor Serum BUN and creatinine to assess renal function
  170. 170. Infuse IV albumin as ordered
  171. 171. Encourage Bed Rest for a few days to help mobilize edema; however some ambulation is necessary to reduce risk of thromboembolic complications
  172. 172. Fluid Restriction if edema is severe
  173. 173. High Protein Diet</li></li></ul><li>References:<br />SMELTZER, BARE, ET.AL<br />BRUNNER AND SUDDARTH’S MEDICAL-SURGICAL NURSING, VOLUME 2 , 2008, 11th edition , PP. 1520-1525, 1578-1581, 1751-1573<br />PORTH,PATHOPHYSIOLOGY-Concepts of Ltered Health States, 2002, 6th Ed, pp.768, 805-809,977-979<br />Joyce M Black,Medical Surgical Nursing, 2002 ,6th Edition,pp.805-806, 856-867<br />Langford & Thompson,Handbook of Diseases,3rd Edition,pp.674-676<br />Gulanick, Myers, Nursing Care Plans,2007, 6th Ed. pp.75-77, 974<br />Doenges, et al., Nursing Care Plans, 2006, 7th Ed. pp.541-620<br />http://www. <br />http://www . <br />http://www. <br />http://www. <br />http://www. <br />http://www. <br />"View a negative experience in your life like you'd look at a photo negative. A single negative can create an unlimited number of positive prints."<br />
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