Nursing Adult Health 2 Exam 2 study guide, Study notes of Nursing

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Nursing Adult Health 2 Exam 2 study guide

Renal Lab Values Renal Anatomy Overview

• Nephrons, located in parenchyma are composed of glomerulus and tubules. They either secrete or reabsorb ions and filtrates, fluid, waste products and electrolytes, acids and bases
• What does the kidney do? FUNCTIONS OF THE KIDNEYS o Acid/Base balance o Excrete waste/toxins o Fluid/electrolyte balance o Regulate BP-excrete renin o RBC production is controlled by erythropoietin, which is secreted by kidney and then it stimulates bone marrow to produce RBCs o Synthesize Vit D for calcium absorption/and regulate parathyroid hormones (pTH helps regulate calcium in the body) o Produce urine o Water homeostatis
• Diabetes and hypertension contribute to chronic kidney disease – major factors
• If you have a kidney issue the patient could be acidotic Fluid Balance
• Urine is produced as blood is filtered through kidneys
• Water/waste not reabsorbed=urine
• Antidiuretic hormone (ADH) prompts kidneys to reabsorb water
• ADH produced in hypothalamus
• Adh produced when: o 1. pt is dehydrated. 2. High sodium intake. 3. Decrease in Blood volume
• Lack of ADH = DI Potassium
• An increase in potassium=increase in aldosterone
• Aldosterone makes the distal convoluted tubules to secrete potassium, normalizing serum potassium levels
• Normal k level: ~3.5-
• Lowered in Diuretic use, raised in pts with kidney dz
• Hemodialysis will lower k level
• Kayexalate – can lower potassium; patient will drink it, pulls potassium in the patient’s bowel and they will have diarrhea and patient will get rid of the potassium
• CBIGKDIE?????
• Citrus fruits, leafy greens, bananas – good sources of potassium BUN
• Normal 8-25 mg/dl
• Blood Urea Nitrogen
• Blood test which measure nitrogenous urea (product of protein metabolism)

• Tells us how well the kidneys are clearing urea, if pt is dehydrated (hihgly affected by fluid volume), amount of protein in diet, muscle breakdown, gi bleed (digestion of protein in the gut could raise the BUN), lack of profusion of the kidneys
• When BUN and Creatinine levels increase together=possible renal dysfunction
• Patients on a tube feed may have a higher BUN because tube feeds are high in protein Creatinine
• Normal 0.6-1.3 mg/dl
• Measures creatinine in blood, which is another product of protein and muscle metabolism; found in skeletal muscles
• Increase is seen when 50% of renal function is gone
• Could be elevated d/t dehydration, but minimally affected by hydration
• Creatinine Clearance o Evaluates how well the kidneys are working to remove creatinine from the blood o Blood and urine are taken o 24 hour urine collection is done then blood is taken o This is the best estimate of glomerular filtration rate (GFR) o Normal GFR: 125 mL blood/MIN going through the kidney (95-135) o Best test to tell us about kidney function Specific Gravity
• Urine test
• Measurement of the kidney’s ability to concentrate urine
• Normal 1.016-1.
• Increased in poor intake of fluids, decreased kidney profusion, and increased ADH
• Decreased in high amount of fluid intake, DI, possible kidney dz Urine Culture and Sensitivity
• Culture of urine may reveal bacteria in the urine
• Sensitivity will tell us which antibiotics the bacteria are sensitive to
• Remember to collect via clean catch: clean meatus/peri-area, collect midstream sample
• Do not let sample sit-send it! Renal and Urologic Problems Chapter 46 Urinary Tract Infection
• Classification: upper or lower; complicated and uncomplicated infections; recurrent o Uncomplicated – occur in normal urinary tract o Complicated – present with a co-existing condition (obstruction, stones, catheters) o Recurrent – common
• Etiology: often caused by gram negative bacteria (sometimes e. coli)
• Clinical manifestations: LUTS: Emptying problems- weak urinary stream, hesitancy, post void dribbling, urinary retention or incomplete emptying, dysuria, pain on urination, suprapubic pain, hematuria, cloudy urine. Storage symptoms – urinary frequency, urgency, incontinence, nocturia, and nocturnal enuresis

• Diagnostic studies: dipstick urinalysis, urinalysis, urine culture and sensitivity (C & S), clean catch, IVP, abd CT, renal ultrasound
• Collaborative care: antibiotics based on C & S; Bactrim and Macrodantin are common tx for UTI; OTC Pyridium can help to sooth discomfort of painful urination (urine dk. orange), Fluoroquinolone’s used in complicated UTI, Diflucan if fungal
• Nursing management: Relief from LUTS symptoms; prevention of upper urinary tract involvement. Health promotion- emptying bladder, hygiene, 1800 ml fluid intake/day, limit catheter use. Acute: fluid intake, local beat for discomfort, urinate every 3-4 hrs to avoid cystitis. Home care: drug therapy for full course. Evaluate expected outcomes Acute Pyelonephritis (Kidney Infection)
• Etiology: Begins in lower urinary track and ascends the urethra; unresolved bacterial infection can cause bacteremia that can lead to urosepsis (can be fatal)
• Clinical manifestations: mild fatigue to onset of chills, fever, vomiting, flank pain, and LUTS characteristics of cystitis, urinary urgency and frequency. Costovertebral angle (CVA) pain in the affected side CVA tenderness is a characteristic sign of polynephritis.
• Diagnostic studies: urinalysis, urine shows pyuria, bacteremia, and hematuria; CBC, urine cultures, IVP later
• Collaborative care: severe infections may require hospitalization; mild symptoms can be treated outpatient for 14-21 days of antibiotics,
• Nursing management: o Plan for: 1) return to normal renal function 2) pain relief, and 3)no recurring symptoms; early tx for cystitis to prevent polynephritis, educating on dx process and tx; evaluate expected outcomes. Encourage fluid intake of 8 glasses of fluid per day; encourage rest; educate about antibiotics
• Chronic: kidney that has shrunk, and lost function from scarring from frequent infections. Diagnosed with radiologic imaging. Often progress to end stage renal failure.
• Pyelonephritis-inflammation of the renal parenchyma and renal pelvis (collecting system)
• Risk for urosepsis, septic shock, dealth
• Place pt on broad spectrum abx until culture sensitivity is back from lab (24+ hours maybe)
• An abcess can even form in the kidney from pyelo
• Chronic pyelo=small, atrophic, fibrotic kidneys d/t recurrent infection that could progress to ESRD Urethritis
• Inflammation of the urethra
• Etiology: bacterial or viral infection, trichomonas, chlamydia, gonorrhea
• Clinical manifestations: difficult to diagnose in women
• Diagnostic studies: urine cultures
• Collaborative care: treatment for organism
• Nursing management: STD prevention; education for antibiotics; hygiene and abstention from sexual intercourse during treatment; suggest warm sitz baths; suggest that patient refer their partner for treatment also.
• In men this is usually an STI

o Purulent dc=gonococcal o Clear dc-non- gonococcal Urethral Diverticula

• The result of obstruction and rupture of the periurethral glands
• Etiology: urethral trauma from childbirth; infections from gonococcal;
• Clinical manifestations: dysuria, post void dribbling; urinary frequency and urgency, suprapubic discomfort, feeling of incomplete bladder emptying,
• Diagnostic studies: urine, voiding cystourethrography, MRI, ultrasound
• Collaborative care: surgical intervention
• Nursing management: education and care
• Urethral diverticula are localized outpouchings of the urethra from enlarged peri- urethreal glands. This is more common in women than men. Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS)
• Chronic, painful inflammatory disease of the bladder causing frequency and urgency (Painful bladder syndrome)
• Etiology: unknown but could be infection or autoimmune - Clinical manifestations: painful and bothersome LUTS. Suprapubic pain
• Diagnostic studies: diagnosis of exclusion- symptoms of a UTI without the presence of a positive urine culture, bacteremia, or pyuria. Cystoscopic exam may show a small bladder capacity and superficial ulcerations called glomerulations in interstitial cystitis.
• Collaborative care: avoid foods that are likely to stimulate the bladder. Take Prelief, reduce stress, Elavil to reduce pain.
• Nursing management: encourage bladder log/diary when voids and when pain comes on; eliminate bladder irritating foods i.e.- caffeine, alcohol, citrus, aged cheese, foods with vinegar, hot peppers and curry ; avoid high-potency vitamins as they irritate the bladder
• No bacteria will be found in the urine, so then you send them for a cysto and the bladder may have small filling capacity
• May be ulcerations in the bladder itself
• Can try to expand the bladder and make the muscle fibers longer
• Overactive bladder you will want to avoid caffeine and alcohol Glomerulonephritis
• Etiology: Immunologic processes involving the urinary tract predominantly affect the renal glomerulus. Two types of antibody-induced injury: 1) anti-GBM (glomular basement membrane) and 2) antibodies react with circulating nonglomerular antigens
• Caused By: Kidney infections, Post-strep (d/t antibodies depositing in the glomeruli; look for the strep rash on pt. skin), viral infections, SLE, scleroderma, IGA nephropathy, vasculitis, HTN, Diabetic nephropathy
• Clinical manifestations: hematuria-ranging from microscopic to gross and urinary secretion of various formed elements, including RBCs, WBCs, proteins, and casts.
• Diagnostic studies: urine, CBC
• Nursing Management: assess for exposure to drugs, immunizations bacterial and viral infections (hepatitis).

• Goodpasture syndrome – autoimmune where antibodies attack the glomerular membraens Acute Post Streptococcal Glomerulonephritis
• Etiology: Most common in children and young adults; develops 5 to 21 days after an infection of the tonsils, pharynx, or skin (e.g., streptococcal sore throat , impetigo) by nephrotoxic strains of group A 𝗉-hemolytic streptococci.
• Clinical manifestations: generalized body edema (anasarca) , periorbital edema , hypertension, oliguria, hematuria with a smoky or rusty appearance, and proteinuria; fluid retention d/t decreased glomerular filtration.
• Diagnostic studies: urine, CBC, and complete H & P
• Collaborative care: encourage early diagnosis and treatment of sore throats and skin lesions. Rest, sodium and fluid restriction, diuretics, anti-hypertensive medication, adjust protein as determined by BIN level; antibiotics and corticosteroids as needed
• Nursing management: rest, edema and hypertension management, and dietary protein restriction when an increase in nitrogenous wastes (e.g. elevated BUN value) is present. Nephrotic Syndrome
• Results when the glomerulus is excessively permeable to plasma protein, causing proteinuria that leads to low plasma albumin and tissue edema. o Decreased serum albumin, which can lead to edema, ascites, anasarca (which is massive generalized edema) o Decreased plasma oncotic pressure from decreased proteins=increased hepatic lipoprotein synthesis=HLD
• Etiology: glomerular disease, infections, neoplasm, allergens, drugs (NSAIDs), and multisystem diseases ( e.g.-DM).
• Clinical manifestations: edema; flank pain that indicates renal vein thrombosis ( risk for clots and possible PE)
• Diagnostic studies: urine, CBC. Monitor albumin levels (You will see a decrease in serum albumin and protein causing hypoalbuminemia. This cause fluid to shift out of the vascular system into surrounding tissue causing ascites and anasarca (massive edema).
• Collaborative care: Treatment is supportive and symptomatic. Edema- ACE inhibitors for edema, low protein and sodium diet, corticosteroid, lipid-lowering meds. Risk for clots due to loss of anticoag proteins in the urine – make sure patient is getting some kind of prophylactic treatment
• Nursing management: major nursing interventions for a patient with nephrotic syndrome are related to edema. Edema is assessed by weighing the patient daily, accurately recording intake and output, and measuring abdominal girth or extremity size. Restrict sodium in diet. Skin assessment and prevention of breakdown. Monitor dietary intake. Safety from infection. Urinary Tract Calculi
• Classification: Five (5) major categories of stones ( Lithiasis ) are (1) calcium phosphate, (2) calcium oxalate, (3) uric acid, (4) cystine, and (5) struvite.
• Etiology: Urinary stones cause clinical manifestations when they obstruct urinary flow. Common sites of complete obstruction are at the UPJ (the point where the ureter crosses the iliac vessels) and at the ureterovesical junction (UVJ).

• Clinical manifestations: pain, costovertebral flank pain or colicky
• Diagnostic studies: CBC, Chemistry, urine, x-ray, CT, IVP
• Collaborative care: treatment of the symptoms of pain, infection, or obstruction. Lithotripsy is used to eliminate calculi from the urinary tract. Outcome for lithotripsy is based on stone size, stone location, and stone composition. Open surgery for obese patient to remove stone, stent placement if need. - Nursing management: (1) relief of pain, (2) no urinary tract obstruction, and (3) an understanding of measures to prevent further recurrence of stones. fluids, Dietary modifications based on the stone type (purine, calcium or oxalate)
• Educate on straining urine at home to return to clinic with stones for evaluation.
• Lithotripsy o Strictures
• A stricture is a narrowing of the lumen of the ureter or urethra. Ureteral strictures can affect the entire length of the ureter. - Etiology: A urethral stricture is the result of fibrosis or inflammation of the urethral lumen. Causes of urethral strictures include scarring, trauma, urethritis, iatrogenic, or a congenital defect. Urethritis after gonococcal infection.
• Clinical manifestations: diminished force of the urinary stream, straining to void, sprayed stream, postvoid dribbling, or a split-urine stream.
• Diagnostic studies: retrograde urethrography(RUG), voiding cystourethrography (VCUG)
• Collaborative care: stent placement
• Nursing management: Post treatment surgical care, monitor I & O, pain management
• Iatrogenic means related to medical exam or treatment, repeated catheterization, for example Renal trauma
• Majority occur in men under the age of 30.
• Sports injuries, traffic accidents, falls, penetrating wounds from gunshots or stabbing.
• Findings : gross hematuria
• Diag : UA, IVP with cystography and ultrasound, CT and MRI. Renal arteriography may also be used.
• Tx: bedrest, fluids, analgesia, prep for surgery if necessary.

• Nsg : Monitor for shock, assess, I & O, monitor urine for hematuria, fluids, comfort and pain mgmt, monitor for nephrotoxic antibiotics or any medications that are impaired due to renal injury.
• IVP=intravenous pyelogram
• Contrast with xray Renal Vascular Problems: Sclerosis, Stenosis, and Thrombosis
• Vascular problems involving the kidney include: o (1) Nephrosclerosis- treat with antihypertensives aggressively. o (2) Renal artery stenosis- treat with surgery to restore vascular flow with angioplasty and stent; control HTN; surgical intervention may be possible. o (3) Renal vein thrombosis- treat with anticoagulants. Hereditary Renal Diseases
• Etiology: Polycystic kidney disease (PKD) is a life-threatening genetic disease. It is characterized by cysts that enlarge and destroy surrounding tissue by compression.
• Manifests between 30-40 years; no treatment; nephrectomy may be necessary with dialysis or kidney transplant Polycystic Kidney Disease
• Most common life threatening genetic disease in the world.
• Etiology: Genetic - autosomal recessive and dominant traits. Offspring have a 50% chance of getting if one parent has.
• Clinical manifestations: palpable large kidneys, no early symptoms, HTN, hematuria, UTI, chronic pain
• Diagnostic studies: CT Diagnosis is based on clinical manifestations, family history, IVP, ultrasound (best screening measure), or CT scan.
• Collaborative care: prevent infections esp. UTIs; nephrectomy and eventually kidney transplant
• Nursing management: diet modification, fluid restriction, drugs, assist with chronic Disease process, counseling because of the Genetic nature of the disease. Urinary Instrumentation Review
• Review types of instrumentation: o Urethral catheterization- inserted through external meatus o Ureteral catheterization- through renal pelvis o Suprapubic catheterization- inserted under general anesthesia o Nephrostomy tubes- inserted into the pelvis of the kidney o Intermittent catheterization- straight cath or “in-and-out cath”. Used often with patients with neurogenic bladder who have spinal cord injuries and neurologic diseases (or bladder outlet obstruction for men). Procedure for home care : cath 3-5 hours, hand hygiene with soap and water only**, lubricant, dry and place in a pouch and change catheter every 7 days. **Use sterile technique for acute or extended care facilities. Urinary Diversion

• Diversion to the skin that requires an appliance. Most common is an ileal conduit. Continent urinary diversions and orthotropic bladder reconstruction. Ca of the bladder, neurogenic bladder, congenital anomalies, chronic infections, strictures
• Pre-op mgmt: educate on procedure, fear, and anxiety; living with appliance; sexual activity.
• Post-op mgmt: atelectasis, shock, increased risk for thrombosis, SBO, and UTI. Keep NPO, mgmt of NG, maintain urine output, encourage fluid intake when able to take in clear liquids. Educate on catheterization and pouch and skin care.
• Could be urinary stoma, construction of a new bladder is the orthotopic neobladder
• Ileal conduit-use ileum of bowel to create a collection site, needs a stoma
• Nephrostomy is inserted into the pelvis of the kidney Male Reproductive Problems Benign Prostate Hyperplasia (BPH)
• Enlargement of prostate gland resulting from increase in number of epithelial cells and connective tissue
• Most common urologic problem in male adults
• About 50% of all men will develop BPH in their lifetime.
• Of the men who develop BPH, almost half of them will have bothersome lower urinary tract symptoms.
• Research is not clear if having BPH leads to an increased risk of developing prostate cancer.
• Etiology/Patho o BPH is not completely understood but is thought to result from hormonal changes from aging process o Excessive accumulation of dihydroxytestosterone DHT in the prostate cells that can stimulate overgrowth of prostate tissue o Increased proportion of estrogen over testosterone in blood so decreased testosterone in the blood; decrease in testosterone but they continue to produce and accumulate high levels of DHT in the prostate; higher amount of estrogen within the gland increases the activity of substances that promote cell growth o Decrease in amount and force of the urinary stream due to compressed urethra. o Typically BPH develops in the inner part of the prostate.

o Prostate cancer is most likely to develop in the outer part. o This enlargement gradually compresses the urethra, eventually leading to partial or complete obstruction. It is the compression of the urethra that ultimately leads to the development of clinical symptoms.

• Risk Factors o Aging o Obesity o Especially increased waist circumference o Lack of physical activity o Alcohol consumption o Erectile dysfunction o Smoking o Diabetes
• Clinical Manifestations o Irritative symptoms ▪ Symptoms associated with inflammation or infection: - Urinary frequency and urgency - Dysuria - Bladder pain - Nocturia - Incontinence o Obstructive Symptoms ▪ Symptoms due to urinary retention - Decrease in caliber and force of urinary stream - Difficulty in initiating urination - Intermittency o Starting and stopping stream several times while voiding - Dribbling at end of urinating
• Other findings and complications o Nocturia often the first symptom noticed. o Acute urinary retention (EMERGENCY) ▪ Complication with sudden, painful inability to urinate ▪ Treatment involves catheter insertion and possible surgery. o UTI and sepsis- Incomplete bladder emptying causes bacterial growth o Calculi may develop in bladder o Renal failure o Pyelonephritis o Potential for bladder damage
• Diagnostic Studies o History and Physical o Urinalysis with culture

▪ A urinalysis with culture is routinely done to determine the presence of infection. The presence of bacteria, white blood cells, or microscopic hematuria is an indication of infection or inflammation. o PSA level ▪ A prostate-specific antigen (PSA) blood test may be done to rule out prostate cancer. However, PSA levels may be slightly elevated in patients with BPH. Serum creatinine levels may be ordered to rule out renal insufficiency. Because symptoms of BPH are similar to those of a neurogenic bladder, a neurological examination may also be performed. ▪ Always draw PSA before during a DRE ▪ There is no specific normal or abnormal level of PSA in the blood, and levels may vary over time in the same man. In the past, most doctors considered PSA levels of 4.0 ng/mL and lower as normal. Therefore, if a man had a PSA level above 4.0 ng/mL, doctors would often recommend a prostate biopsy to determine whether prostate cancer was present. ▪ o Serum creatinine ▪ to R/O kidney problems o Neurologic exam o Digital rectal exam ▪ Abnormal DRE and PSA will require a TRUS ▪ Using DRE, the health care provider can estimate the size, symmetry, and consistency of the prostate gland. In BPH the prostate is symmetrically enlarged, firm, and smooth. o Uroflometry o Cystoscopy o Transrectal ultrasound (TRUS) scan o Age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years. o Age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than age 65). o Age 40 for men at even higher risk (those with more than one first- degree relative who had prostate cancer at an early age). o If no prostate cancer is found as a result of screening, the time between future screenings depends on the results of the PSA blood test: o Men who choose to be tested who have a PSA of less than 2.5 ng/mL may only need to be retested every 2 years. o Screening should be done yearly for men whose PSA level is 2.5 ng/mL or higher.

• Collaborative Care o Goals: ▪ Restore bladder drainage. ▪ Relieve symptoms.

▪ Prevent/treat complications. o Treatment based on ▪ symptoms and presence of complications o Conservative Therapy ▪ Active surveillance

• Lack of presence of symptoms
• Mild symptoms (AUA score of 0-7) ▪ Symptoms may disappear. ▪ Lifestyle changes may result in improvement. o American Urological Associate Symptoms Index ▪ Seven questions used to determine severity of prostate problems
• Drug Therapy o finasteride (Proscar)- risk ortho hypotenstion; pregnant women avoid touch meds ▪ dutasteride (Avodart) ▪ Jalyn (finasteride + tamsulosin) ▪ ↓ Size of prostate gland ▪ Takes 3 to 6 months for improvement ▪ Side effects: decreased libido, decreased volume of ejaculation, ED ▪ May lower the risk of prostate cancer ▪ Not recommended in the prevention of prostate cancer due to an increased risk of developing an aggressive form of prostate cancer ▪ The drug must be taken on a continuous basis to maintain therapeutic results. ▪ Serum PSA levels are decreased by almost 50% when taking finasteride. ▪ Therefore PSA levels should be doubled when comparing the patient’s current levels to pre-medication levels. o tamsulosin (Flomax) o doxazosin (Cardura) o silodosin (Rapaflo) ▪ Promotes smooth muscle relaxation in prostate, facilitates urinary flow ▪ Improvement in 2 to 3 weeks ▪ Offer symptomatic relief but do not treat hyperplasia o Erectogenic (erection causing) Drugs ▪ Tadalifil (Cialis) effectively reduces symptoms of both BPH and ED. o Herbal Therapy ▪ Saw palmetto has been used but no research supporting success ▪ Score ▪ Mild 0- ▪ Moderate 8- ▪ Severe 20-

▪ Saxifrage, betasitosterol, Pyguem africanum, and Cernilton are also promoted but varied success

• Collaborative Care Invasive (Surgery) Therapy o Invasive therapy is indicated when: ▪ Decrease in urine flow sufficient to cause discomfort ▪ Persistent residual urine ▪ Acute urinary retention ▪ Hydronephrosis- swelling and damage to one or both kidney d/t retention. Not a primary disease; secondary to obstruction. o The choice of treatment approach depends on the size and location of prostatic enlargement, as well as on patient factors such as age and surgical risk. o Intermittent catheterization or insertion of an indwelling catheter can temporarily reduce symptoms and bypass the obstruction. However, avoid long- term catheter use because of the increased risk of infection. o TURP – Transurethral Resection ▪ Removal of obstructing prostate tissue using resectoscope inserted through urethra ▪ Outcome for 80% to 90% is excellent. ▪ Relatively low risk ▪ Performed under spinal or general anesthesia and requires hospital stay ▪ Bladder irrigated for first 24 hours to prevent mucous and blood clots ▪ Complications include bleeding, clot retention, hyponatremia, retrograde ejaculation. ▪ Patients must stop anticoagulants before surgery. ▪ TURP has long been considered the “gold standard” surgical treatment for obstructing BPH. Although this procedure remains the most common operation performed, the number of TURP procedures done in recent years has decreased because of the development of less invasive technologies.

• Nursing Diagnosis and Planning o Acute pain o Risk for infection o Goals for patient having invasive procedures ▪ Restoration of urinary damage ▪ Treatment of UTI ▪ Understanding of - Upcoming procedure - Implications for sexual functioning - Urinary control
• Goals for Postoperative Care o No complications o Restoration of urinary control o Complete bladder emptying o Satisfactory sexual expression o Postop care: ▪ Postoperative bladder irrigation to remove blood clots and ensure drainage or urine ▪ Administer antispasmodics. ▪ Teach Kegel exercises.
• Preoperative Care for TURP o Restore urinary drainage o Coude – curved-tip catheter o Filiform – rigid catheter o Aseptic technique very important in preventing infection o Administer antibiotics o Treat UTIs o Provide patient opportunity to express concerns over alterations in sexual function. o Inform patient of possible complications of procedures. o In many health care settings, 10 mL of sterile 2% lidocaine gel is injected into the urethra before insertion of the catheter.
• Postoperative Care for TURP o Assess for complications ▪ Hemorrhage and clots in urine

▪ Bladder spasms ▪ Urinary incontinence ▪ Infection

• Nursing Implementation TURP o Postoperative care for TURP ▪ Observe patient for signs of infection. ▪ Dietary intervention ▪ Stool softeners to prevent straining o Instructions after prostate surgery ▪ Care of indwelling catheter ▪ Managing incontinence ▪ Maintaining adequate fluid intake ▪ Observing for signs and symptoms of UTI, wound infection
• Ambulatory and Home Care TURP o Instructions after prostate surgery ▪ Preventing constipation ▪ Avoiding heavy lifting - Not more than 10 lb or 4.5 kg ▪ Refraining from driving, intercourse after surgery as directed o Sexual counseling if erectile dysfunction becomes a problem o Avoiding bladder irritants o Yearly digital rectal examination (DRE)
• Newer Procedure: Urolift o Prostatitis
• Diagnostics o UA and culture o CBC o PSA
• Nursing and Collaborative Management o Antibiotics : trimethoprim/sulfamethoxozole, ciprofloxin, carbachol, carbenicillin, cephalexin, doxycycline o Anti-inflammatory: NSAIDs, indomethacin

o Possible urinary catheter o Encourage fluids o Manage fever Problems of the Penis

• Congenital Problems o Hydrospadias - urethra is located on the ventral side of the penis. o Surgical repair may be necessary with chordee (downward curvature of penis during erection)
• Prepuce (Foreskin) Problems o Phimosis- tightening or constriction off the foreskin; cause by poor hygiene. Ice pack for edema, topical corticosteroid 2-3 x day. o Paraphimosis - tightening of the foreskin in the retracted position. Warm soaks, cleaning glans and foreskin, antibiotics, and possible circumcision Problems with Erectile Mechanism
• Priapism o A painful erection that lasts more than 6 hours. o Is a medical emergency o Risks/causes: DM, sickle cell, spinal cord trauma, medications, sildenafil (Viagra) o Tissue necrosis
• Peyronie’s Disease o Curved or crooked penis cause by plaque formation of the cavernosa of the penis or possible trauma. May have pain. o Not dangerous o Can cause pain during erections, ED, or embarrassment o Tx: med- collagenase Clostridium histolyticum to break down collagen o Surgical correction may be scheduled after 1 year of med tx. Problems of the Scrotum and Testes
• Epididymitis o Acute , painful inflammation of the epididymis o Men under 40 cause often gonorrhea or chlamydial infection; older men often UTI and prostatitis o Antibiotics both partners o Tx: Elevate scrotum, ice packs, and analgesics. o Ambulation increases pain
• Orchitis o Acute inflammation of the testis o Painful, swollen, and tender o Can be bacterial or viral infection (mumps, pneumonia, TB, syphilis. Also trauma, influenza, complicate UTI, and catheterization o Mumps orchitis could cause sterility if contracted as a child; encourage immunizations o Tx: antibiotics specific to bacteria, pain meds, and elevate scrotum Acquired Problems of Scrotum and Testes

• Hydrocele o Non-tender, fluid filled mass. Lumph interference o Diagnosis: Transillumination with a flashlight can display mass o Tx: none unless scrotum becomes large and uncomfortable then aspiration or surgical drainage
• Spermatocele o Sperm filled cyst in epididymis o Diagnosis: Transillumination o Unknown cause o Tx: surgical removal o Monitor for scrotal lumps that could indicate testicular CA
• Testicular Cancer o The incidence rate of testicular cancer has been increasing in the US and many other countries for several decades. The increase is mostly in seminomas. Experts have not been able to find reasons for this. Lately, the rate of increase has slowed. o Testicular cancer is not common: about 1 of every 250 males will develop testicular cancer at some point during their lifetime. o The average age at the time of diagnosis of testicular cancer is about 33. This is largely a disease of young and middle-aged men, but about 6% of cases occur in children and teens, and about 8% occur in men over the age of 55. o Because testicular cancer usually can be treated successfully, a man’s lifetime risk of dying from this cancer is very low: about 1 in 5,000.” o Self Exam
• Varicocele

▪

▪ The best time for you to examine your testicles is during or after a bath or shower, when the skin of the scrotum is relaxed. ▪ Hold your penis out of the way and examine each testicle separately. ▪ Hold your testicle between your thumbs and fingers with both hands and roll it gently between your fingers. ▪ Look and feel for any hard lumps or nodules (smooth rounded masses) or any change in the size, shape, or consistency of your testicles.

o Dilation of veins that drain testes o Scrotum feels wormlike with palpation o Tx: Surgery if patient is sterile

• Testicular Torsion o Twisting of the spermatic cord that supplies blood to testes and epididytimis o Common in men < age 20; trauma, or anatomic abnormalities o S/S: pain, tender, swelling, N/V o Diag: scan of testes or Doppler US o Surgical emergency within 4-6 hours or ischemia to testes Sexual Function
• Vasectomy o Bilateral surgical or ligation of the vas deferens to cause sterility. Some reversal have been successful. o Outpatient: 15-30 min under local anesthesia o Monitor for hematoma and swelling o Total of 10 ejaculations or 6 weeks to evacuate sperm. Advise contraception
• Erectile Dysfunction o Inability to maintain erection o Can occur in 50% of men between 40-70 for numerous causes see Table 55- o Dx: self report , IIEF, and through history and physical exam o Labs: Glucose, lipids, BMP, PSA, and CBC to rule out or determine other underlying problems o Function: Erectogenic drugs taken 30-60 min before intended sexual activity; monitor for hypotension
• Andropause o Gradual decline in male hormone with aging o Can begin as early as age 40 o S/S: loss of libido, fatigue, ED, depressions, mood swings, sleep disturbances o Labs: Testosterone; normal 280-1000 ng/dL; replacement at 200 o Replacement: gel (Testim, Androderm), injections (cypoinate); oral can cause liver damage; underarm (Axiron), and buccal (Striant) o Avoid contact with pregnant, childbearing age women and children o Handwashing with soap and water after gel or cream application
• Infertility o Inability to conceive after 1 year of frequent, unprotected sex. o Most common cause of male infertility is varicocele o First test: semen analysis for concentration, motility, and morphology o Other labs: plasma testosterone, LH and FSH o Nursing and collaborative management: concern and tactful; lifestyle changes, in vitro, and counseling Acute Renal injury and Chronic Kidney Disease Acute Kidney Injury

• The rapid loss of kidney function from renal cell damage
• Can be reversible but has a high mortality rate
• Can develop over hours or days
• Increases in blood urea nitrogen (BUN), creatinine, and potassium
• Mortality rate hospitalized- 1 in 5; Critical Care 70-80%
• Azotemia: accumulation of waste products in blood
• Renal function stops when blood flow to the kidneys is comprimised
• Inability to excrete metabolic waste products and water.
• Acute Kidney injury is the rapid onset of injury, whereas chronic kidney disease comes on over time and is linked to CV disease
• In acute kidney injury, there can be a decrease in urine output
• Can include the development of azotemia, an accumulation nitrogenous waste products in the blood (urea, creatinine)
• AKI is potentially reversible
• Can be due to prolonged hypotension, hypovolemia, or nephrotoxins
• Causes o Prerenal – issue with systemic circulation and decreased renal blood flow; nephrons are not getting oxygen ▪ Hypovolemia ▪ Decreased cardiac output ▪ Decreased peripheral vascular resistance ▪ Decreased renovascular blood flow ▪ Shock ▪ Liver failure ▪ Artery stenosis, thrombus o Intrarenal – direct damage to kidney tissue resulting in impaired nephron function, which could be due to ischemia or drugs ▪ Nephrotoxic injury ▪ Interstitial nephritis ▪ Other causes ▪ Trauma to the kidney, venous stenosis or thrombosis, nephrotoxic drugs, contrast dye, blood transfusion reaction, infection, vasculitis, acute glomerulonephritis ▪ ATN: is the most common type of intrarenal problem where drugs or ischemia cause destruction of the epithelium (sepsis, blood tx reaction). In these causes, damage to kidney is caused by lack of oxygen and acute tubular necrosis o Postrenal – mechanical obstruction in the outflow of urine. If untreated, could have hydronephorsis, tubular atrophy and irreversible kidney fibrosis; THIS IS AN OUTFLOW PROBLEM ▪ BPH ▪ Bladder CA ▪ Prostate CA ▪ Calculi – kidney stones

▪ Neuromuscular disorders – neurogenic bladder ▪ Spinal cord disease/SCI ▪ Strictures ▪ Trauma

• Patient Teaching for AKI/AKD o Drink plenty of fluids (up to 2 L per day). If needed, talk with provider regarding any needed restriction (CKD, HF) o Smoking Cessation o Healthy BMI o Use NSAIDs with caution o Major complicating co-morbid conditions include HTN and DM o Antibiotic usage-complete course, report s/s of UTI/Pyelonephritis
• Clinical Manifestations o Pre and postrenal AKI are often resolved by treating the cause o If intrarenal is damaged, AKI has a longer recovery period o Patients with AKI progress through phases: oliguric, diuretic, and recovery. o If recovery phase does not occur, CKD may develop
• Phases of Acute Kidney Injury
• o Onset: starts with event and end when patient becomes oliguric, and this can last for hours to days o Oliguria: Urine Output is 100-400 mL/day-this can last up to 1-3 weeks o Diuretic phase: This is when the kidneys are starting to recover. Diuretic: 1-3 L and up to 5 L per day of output from osmotic diuresis, where the tubules can’t concentrate urine. This can cause hypovolemia and hypotension! This can last 2- 6 weeks

o Recovery: This phase continues until the kidney is fully recovered and could take up to a year.

• Assessment and Labs o History and physical to determine cause o Decline in urine output (see RIFLE) o Hypovolemia o Edema o Hypertension o Urine proteinuria if damage to glomerulus (intra) o CBC (monitor for signs of infection) o Serum increases creatinine (best indicator) and BUN ▪ Basic metabolic panel: Hyperkalemia or hypokalemia, hyponatremia, hypocalcemia, hyperphosphatemia o About 50% of patients will not experience the oliguric phase, making diagnosis more difficult. o Diuretic phase—1-5 L/day o Can obtain a 24 hour urine, creatinine clearance, to assess GFR. This patient could have tachypnea due to acidosis, kidneys not producing bicarb
• More Assessment Findings o Fluid and Electrolyte Imbalance ▪ Fluid overload or fluid deficit ▪ Hyperkalemia or hypokalemia – ALWAYS PUT PT ON TELE ▪ Hyponatremia ▪ Hypocalcemia ▪ Hyperphosphatemia o Metabolic acidosis o Inability to excrete waste ▪ Uremia o Neuro---fatigue and difficulty concentrating all the way to seizures, stupor, and coma
• AKI RIFLE Classification Staging (used to describe the phases of AKI) STAGE GFR CRITERIA URINE OUTPUT CRITERIA Risk Serum Creatinine increases x 1. GFR ¯ 25% < 0.5 mL/kg/hr for 6 hr Injury Serum Creatinine increases x 2 GFR ¯ 50% < 0.5 mL/kg/hr for 12 hr Failure Serum Creatinine increases x 3 GFR ¯ 75% < 0.3 mL/kg/hr for 24 hr or anuria for > 12 hr

Loss Persistent AKI Complete loss of kidney function

4 wk ESKD Complete loss of kidney function 3 months

• Collaborative Care o Remove and treat precipitating cause o Possible fluid challenge with diuretics o Fluid restriction o Restrict excess sodium, phosphate, and potassium o Monitor electrolytes (especially K+) ▪ Treat hyperkalemia as needed ▪ Calcium supplements or phosphate-binding agents ▪ PUT PT ON TELE o Nutritional therapy: parenteral, enteral to maintain caloric and protein intake o Dialysis initiation if indicated o Diet: adequate calories to prevent catabolism; energy should be from high carb and fat sources; protein based upon clinical condition—could be restricted, normal; potassium and sodium usually restricted o Acute I/O-STRICT o Daily wt with same scale, same time each day o If on abx, monitor renal funcation o Diet will be low sodium, low potassium, low protein. Acute Kidney Injury: Nephrotoxic Injury
• SBAR o 70 year old Caucasian female o Hx: T2DM, HTN, HLD, Asthma, GERD, allergic rhinitis, OA o s/p total hip replacement o DC’d to rehab post-surgery o RN noted erythema at incision o Patient re-admitted to acute care for drainage of infected surgical site o PICC line placed o Patient placed on vancomycin and cefepime at home o Vanc: Which class? Cefepime: Which class? o Home health nurse notes a creatine of 6.2 o Patient is readmitted to hospital, for workup and ultimately discharged back to SNF for IV antibiotics. o Continued Vanc and Cefepime. o Patient is given IV abx at SNF for days without lab work o Which monitoring would you expect? o Patient becomes edematous and lethargic

o 21 lb weight gain o VS: 36.3 C HR 98 BP 162/65 RR 28 O2 93% o Patient sent to hospital and labs ordered, including urine. o Results show: Phosphorus 6.7, K 6.4, Creatinine 9.4, BUN 6, proteinuria, hematuria, elevated vancomycin level (60) o Diagnosis: metabolic acidosis, hyperkalemia, acute tubular necrosis and acute kidney injury due to antibiotic therapy o TELE ORDERED TO MONITOR CARDIAC STATUS WITH HYPERKALEMIA

• Medications Ordered o Admission medication orders ▪ HCTZ 10 mg PO daily ▪ Iron sulfate PO ▪ Insulin detemir 20 units SQ daily ▪ Flonase ▪ Amlodipine 5 mg PO daily ▪ Furosemide 20 mg daily IV ▪ Kayexalate ▪ 60 mg PO prednisone daily for possible acute interstitial nephritis- BG now running high 300’s ▪ SSI ordered in addition to NPH to be given with steroid ▪ Nephrology and ID consult ordered Aranesp (Darbepoetin alfa) SQ
• Nephrology Orders o Kidney biopsy ▪ Consistent with ATN ▪ Daily weight/Strict I&O ▪ HD catheter placed in IJ ▪ Dialysis performed 3x/week ▪ After two weeks, K levels start to ▪ normalize, BUN trends down, ▪ acidosis corrected o After 2 weeks, patient is able to stop HD and catheter is pulled for discharge. Treating Hyperkalemia
• Regular Insulin IV - Helps to move K+ into cells
• Sodium bicarb IV- corrects acidosis and moves K+ into cells
• Calcium gluconate IV- raises the threshold for excitation from K+
• Hemodialysis - Most effective way to remove K+
• Sodium Polystyrene Sulfonate (Kayexalate )- Exchange of Na for K+; oral or retention enema creates diarrhea and removes K+
• Dietary restriction- limit intake to 40 mEq day of potassium rich foods and drink

•

CRRT

• Acute Renal Therapy includes multiple therapy types, including the two most common; continuous renal replacement therapy (CRRT) and Therapeutic Plasma Exchange (TPE).
• CRRT is a dialysis modality used to treat critically ill, hospitalized patients in the intensive care unit who develop acute kidney injury (AKI). Unlike chronic kidney disease, which occurs slowly over time, AKI often occurs in hospitalized patients treated in an intensive care environment, and it typically occurs over a few hours to a few days.
• TPE is a procedure that separates plasma, with may contain disease mediators, from your blood. During TPE, the patient's blood is filtered through a filter membrane, thereby separating the plasma from other blood components thought to be the contributing factor to patient's compromised health. Healthy components are then put back into the patient's blood by administering a prescribed replacement fluid eventually restoring any imbalance.”
• Continuous renal replacement therapies (CRRTs) involve either dialysis (diffusion- based solute removal) or filtration (convection-based solute and water removal) treatments that operate in a continuous mode [1-4]. Variations of CRRT might run 12 to 14 hours, especially during daytime periods of full staffing. This regimen has become more prevalent in Europe and has been called "go slow dialysis." Other variations of this technique are discussed below and probably should be called hybrid therapies because they are a merging of intermittent and continuous duration. The longer duration of CRRT makes it quite different from conventional intermittent hemodialysis, in which each treatment lasts four to six hours or less.
• The major advantage of continuous therapy is the slower rate of solute or fluid removal per unit of time. Thus, CRRT is generally better tolerated than conventional therapy since many of the complications of intermittent hemodialysis are related to the rapid rate of solute and fluid loss.” Geriatric Considerations
• More susceptible to AKI
• Dehydration more frequent
• Hypotension

• Need for diuretic therapy
• Urinary obstructive problems (BPH, strictures, etc.)
• More difficult to recover form AKI
• Decrease in renal function as the patient ages=changes in GFR=possible changes in drug dosing
• At risk for build up for drug metabolites, insulin/opiods/etc Chronic Kidney Disease
• Progressive, irreversible loss of kidney function
• Diabetes and hypertension are the leading causes with vascular and cardiac implications
• Prognosis depends on etiology, condition, age, and follow-up
• Increased risk with African Americans and American Indians
• Most common cause of death is cardiac related

• There is an increase risk in AA 4:1 to Caucasian
• Native American 2:1
• ESRD is GFR less than 15 ml/min and this patient needs dialysis
• Clinical Manifestations o o Anemia o Dysrhthmias o HTN o Kussmaul breathing o Dyspnea o Ulcerations in the GI tract; possible GI bleed o Lethargy o Malnutrition o Constipation o Peripheral neuopathy o Leg cramps o Osteomalacia – activated vitamin D needed to absorb calcium from the GI tract ▪ Hypocalcemia then stimulates the parathyroid gland to secrete PTH, which stimulates bone demineralization, releasing calcium from the bones and hyperphosphatemia ▪ This can lead to vascular calcification and calcyphylaxis (a rare and severe skin condition occurring mainly in end stage renal disease (ESRD) patients. This high mortality rate disorder presents a multifactorial etiology but is frequently associated with elevated calcium and phosphorus levels seen in secondary hyperparathyroidism (HPT) of ESRD patients.) o Calcium deposits in the eye o Pruritus o Infertility and decreased libido o Fatigue o Depression