Introduction to Medical-Surgical Nursing, 6th ed.
42
Lesson Plans for
Urologic Disorders
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 42.1:
2. Describe the diagnostic tests and procedures for patients with urologic disorders.
3. Explain the nursing responsibilities for patients having tests and procedures to diagnose urologic
disorders.
Lesson 42.2:
5. Explain the pathophysiology, signs and symptoms, complications, and treatment of disorders of the
kidneys, ureters, bladder, and urethra.
6. Assist in developing a nursing care plan for patients with urologic disorders.
CHAPTER TEACHING FOCUS
• In this chapter, students have the opportunity to learn about the various urologic disorders and their
diagnosis and treatment.
• Guidelines for patient assessment are presented along with diagnostic techniques commonly used.
• Students will also be presented with information on the nurse’s responsibility related to these
procedures.
• Various therapies commonly used to treat urologic disorders are also presented.
• Special attention is given to various cancers of the urologic system, renal failure, and renal
transplantation.
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
Concepts for nursing practice. St. Louis: Elsevier. The specific exemplars chosen and listed below for
each concept have been tailored specifically to correspond to the Linton textbook.
THEME: Protection and Movement
• Concept: Infection
2 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) The nephron is the functional unit of the kidney. It would be correct to say that __________.
a) urinary incontinence is caused by nephron dysfunction
b) the nephron is located primarily in the medulla
c) there is a single nephron in each kidney
d) there are more than 1 million nephrons in each kidney
2) The kidneys play a significant role in the regulation of blood pressure. One mechanism involved in
this renal function is release of __________.
a) the enzyme trypsin
b) the hormone renin
c) potassium ions
d) bicarbonate and ammonia
3) Normal age-related changes in the urinary system include __________.
a) decreased frequency and urgency
b) increased aldosterone levels
c) decreased creatinine clearance
d) increased bladder capacity
4) A routine urinalysis will not provide any information about __________.
a) osmolality
b) pH
c) blood urea nitrogen (BUN)
d) ketones
5) A urodynamic study is used to evaluate the __________.
a) flow of urine or voiding disorders
b) interior of the urethra and bladder
c) renal blood vessels
d) size and shape of the kidneys
6) A common nursing diagnosis for the patient with pyelonephritis is __________.
a) Decreased cardiac output
b) Alteration in integument
c) Fluid and electrolyte imbalance
d) Acute pain and discomfort
7) A urinary diversion procedure is typically performed on people who have __________.
a) bladder cancer
b) urinary stress incontinence
c. acute renal failure d. renal calculi
8) During the procedure of peritoneal dialysis, __________.
a) pyelonephritis is a common complication
b) strict aseptic technique must be maintained
c) an AV shunt is used instead of venipuncture
d) the patient must remain in bed for more than 4 hours
9) The formation of renal calculi can be linked to __________.
a) genetic predisposition
b) bladder cancer
c) vigorous physical exercise
d) anxiety
10) To be an eligible kidney donor, a person must be __________.
a) older than 60 years
b) declared brain dead
c) at least 18 years old
d) related to the recipient
______________________________________________________________ Chapter 42Urologic Disorders 3
Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: The kidneys are organs vital for life. What functions do the kidneys perform?
Question: What are the possible long-term effects of chronic infections of the urologic system?
Answer: Infections of the urologic system can be localized in the urethra, bladder, ureters, or kidneys. If
4 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.1
Instructor Preparation
Textbook Objectives Covered
2. Describe the diagnostic tests and procedures for patients with urologic disorders.
3. Explain the nursing responsibilities for patients having tests and procedures to diagnose
urologic disorders.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying urologic disorders, including:
• The anatomy and physiology of the urinary system
• Diagnosis and treatment of various urinary disorders
• Nursing interventions for the care of various urinary disorders
• Renal failure
• Renal transplantation
• Assemble materials and supplies needed for each lesson as indicated below.
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• anuria (p. 895)
• azotemia (p. 926)
• calculus (pl. calculi) (p. 913)
• nephrotoxic (p. 895)
• nocturia (p. 894)
• oliguria (p. 895)
______________________________________________________________ Chapter 42Urologic Disorders 5
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.1
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 890-895)
REVIEW
• Figure 42-1: The kidneys and related structures (p. 891)
• Figure 42-2: Location of the kidneys (p. 891)
• Figure 42-3: Interior kidney structures (p. 891)
ANSWER – Text
• Review Questions for the NCLEX Examination: 1, 2 (p. 938)
ANSWER – Study Guide
• Part IB: A-I and 1-4 (p. 268)
• Part IF: 1-2 (p. 269)
• Part IIH: 1-5, 7-10, 12-16, 19 (pp. 270-271)
• Part III I: 2-4 (p. 274)
• Part III J: 1 (p. 275)
2
READ – Textbook (pp. 896-902)
REVIEW
• Table 42-1: Diagnostic Tests and Procedures: Urinary Disorders (pp. 897-900)
• Table 42-2: Urinalysis Data (p. 901)
ANSWER – Study Guide
• Part IC: 1-11 (pp. 268-269)
• Part IG: 1-7 (p. 270)
• Part IIH: 6, 20, 26, 53 (pp. 270-274)
3
READ – Textbook (pp. 896-902)
ANSWER – Study Guide
• Part IIH: 21-25, 52, 55 (pp. 271-274)
• Part III I: 1 (p. 274)
6 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.1
50-Minute Lesson Plan
Lecture Outline 20 minutes
Slide 1
Chapter 42
Urologic Disorders
1
Slide 2
Components
• The urinary system consists of
• Two kidneys
• Two ureters
Slide 3
Kidneys and Ureters
• Kidneys are bean-shaped organs located just under and below the 12th rib near the flank
• The hilus, or entry, to the kidney is located on the concave surface of the kidney near the
spine
TALKING POINTS:
• What is the functional unit of the kidney?
• The entire blood supply circulates through the kidneys every 4 to 5 minutes.
Slide 4
Kidneys and Ureters (cont.)
• Cortex: outer layer; medulla: inner layer
• Cortex receives a large blood supply; very sensitive to changes in blood pressure and
blood volume
Slide 5
Kidneys and Ureters (cont.)
• The nephron is the functional unit of the kidney
• 1 to 1.25 million nephrons in each kidney
• Vascular tubular system: glomerulus, Bowman capsule, and tubule
• Glomerulus: mass of blood vessels tucked into the cuplike Bowman capsule
______________________________________________________________ Chapter 42Urologic Disorders 7
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.1
Slide 6
Bladder and Urethra
• Bladder: muscular sac; stretches to store urine
• On floor of pelvic cavity behind the peritoneum
• In front of the rectum in men; in front of the vagina and uterus in women
• Trigone: triangular-shaped area on posterior wall
• Control possible by sensory and motor nerves
• Urethra: muscular tube lined with mucous membranes; carries urine from bladder out of
the body
TALKING POINTS:
• How much urine can the bladder hold before it has the sensation to empty?
• The urethra functions as a sphincter, meaning that it contracts to hold urine in the bladder
and relaxes to allow urine to flow from the bladder.
Slide 7
Physiology of the Urinary System
• Regulation and excretion
• Urine production
• Glomerular filtration, tubular reabsorption, and tubular secretion
• Urine elimination
Slide 8
Age-Related Changes in the Urinary System
• Loss of nephrons, thickening of membranes in nephrons, and sclerosis of renal blood
vessels
• Creatinine clearance decreases with age
• Nocturia: awaken from sleep to void
• Bladder muscles weaken; connective tissue increases
• Incontinence not normal consequence of age, but it is common
• In men, urethral obstruction often a problem
TALKING POINTS:
• Fortunately, the kidneys have enough reserve that normal function is usually maintained.
• Why do older people often have nocturia?
Slide 9
Health History
• Chief complaint
• Changes in urine quality or quantity, pain
• History of present illness
• Patient’s normal or usual pattern of urination
• Pain or discomfort
• Problem initiating or controlling urination
• Document circumstances under which these problems occur
TALKING POINTS:
• What do the terms polyuria, oliguria, and anuria mean?
8 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.1
Slide 10
Health History (cont.)
• Medical history
• A history of streptococcal infections, recurrent urinary tract infections (UTIs), renal
calculi (“stones”), gout, or hypercalcemia
• A history of urologic surgery, trauma, urinary diversion, exposure to nephrotoxins.
• Family history
• Congenital kidney problems, such as polycystic kidneys or urinary tract
malformations, diabetes mellitus, and hypertension
Slide 11
Health History (cont.)
• Review of systems
• Changes in skin color, respiratory distress, edema, fatigue, nausea, vomiting, chills,
and fever
• Functional assessment
Slide 12
Physical Examination
• Skin color (ashen, yellow); crystals on skin (uremic frost)
• Tissue turgor: to detect dehydration or edema
• Periorbital edema: suggests fluid retention. Inspect the mouth for moisture and odor
• Observe respiratory rate, pattern, and effort
• Auscultate the lungs for crackles or rhonchi
TALKING POINTS:
• What are Kussmaul respirations a symptom of?
• Renal bruits indicate renal artery stenosis (narrowing).
2
&
3
Slide 13
Diagnostic Tests and Procedures
• Urine tests
• Urinalysis
• Urine culture and sensitivity
• Creatinine clearance
• Blood tests
• Blood urea nitrogen
• Serum creatinine
• Serum electrolytes
Slide 14
Diagnostic Tests and Procedures (cont.)
• Radiographic tests and procedures
• Kidneys, ureters, bladder (KUB)
• Intravenous pyelogram
______________________________________________________________ Chapter 42Urologic Disorders 9
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.1
Slide 15
Diagnostic Tests and Procedures (cont.)
• Ultrasonography
• Invasive procedures
• Renal biopsy
• Cystoscopy
• Urodynamic studies
Slide 16
Question 1
• Which of the following does not occur in urine production?
A. Glomerular filtration
B. Red blood cell production
C. Tubular reabsorption
D. Tubular secretion
TALKING POINTS:
Slide 17
Question 2
• During tubular secretion, _______ and hydrogen ions are secreted into the tubules from
the blood.
A. oxygen
B. magnesium
C. potassium
D. sodium
TALKING POINTS:
10 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.1
Activities
Classroom Choose from below to make 30 minutes
Online
1
ASSESS BASELINE
• Have the class complete the Pretest. Collect
their work and use the results to guide how
you teach the class.
DISCUSS
• Discuss the location of the organs that
comprise the urinary system.
• Discuss how control of the bladder is
maintained by sensory and motor nerves.
• Discuss how the functions of the kidneys
PRACTICE
• Refer to Box 42-1. Lead a class discussion
by having students provide rationales for
each item listed under Health History and
Physical Examination.
ASSESS BASELINE
• Post the Pretest and the Background
Assessment online and have your class
complete them. Use the results to guide how
you teach the class.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss the
effects of aging on the urologic system. How
would these changes affect everyday living?
2
DISCUSS
• Discuss the components of a urinalysis.
• Discuss the relationship between serum
creatinine and urine creatinine levels and
what information this provides the health
care provider and nurse.
• Discuss why a flat plate radiograph should
be done before studies that require contrast
media.
PRACTICE
• Refer to the list of invasive procedures in
your text. Lead a class discussion asking
students to identify rationales for each
nursing intervention listed under
postprocedure care for a patient undergoing
a renal biopsy and a patient undergoing a
cystoscopy.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss the
similarities and differences among KUB x-
ray, intravenous pyelogram, arteriogram,
and cystogram. Ask students to provide
constructive comments on each other’s
posts.
______________________________________________________________ Chapter 42Urologic Disorders 11
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.1
3
DISCUSS
• Discuss patient preparation for obtaining a
urine sample for culture. Explain how you
would instruct the patient to collect the
sample.
• Discuss what patient instructions are
particularly important before a serum
creatinine test.
• Discuss what postprocedure care is
necessary for the patient undergoing an
intravenous pyelogram (IVP).
• Discuss what postprocedure care is
necessary for the patient undergoing a renal
angiogram.
PRACTICE
• Before class, divide the class into small
groups and assign each group a different
radiologic, imaging, biopsy, or other
diagnostic procedure used to study
disorders of the urologic system. Have each
group explore the nurse’s role in each
procedure and do a 3– to 5-minute
presentation to the class.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to prepare and post a video of a nurse
explaining the procedure for collection of a
urine sample for culture. The nurse should
use appropriate terminology to explain the
procedure to a patient of the opposite
gender as the student. Ask students to
provide constructive comments on each
other’s videos.
Critical Thinking Question
An older patient complains to the nurse that he has difficulty starting to urinate and then
once he starts, he says that he has difficulty maintaining a steady stream of urine. He tells
the nurse that for 2 days now he has had severe pain in the lower abdomen, left mid–back
region, and left flank. What might be the cause of this patient’s symptoms?
Discussion Guidelines: The patient likely has an obstruction of his urinary tract, most likely due to
an enlargement of his prostate gland. The enlargement may be obstructing the flow of urine and
12 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.1
Instructor Notes/Student Feedback
______________________________________________________________ Chapter 42Urologic Disorders 13
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Textbook Objectives Covered
5. Explain the pathophysiology, signs and symptoms, complications, and treatment of disorders of
the kidneys, ureters, bladder, and urethra.
6. Assist in developing a nursing care plan for patients with urologic disorders.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speakers: infection control nurse, local ostomy club member
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying urologic disorders, including:
• The anatomy and physiology of the urinary system
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• anuria (p. 895)
• azotemia (p. 926)
• calculus (pl. calculi) (pp. 895,
• nephrotoxic (p. 895)
• nocturia (p. 894)
• oliguria (p. 895)
Assignments 2 hours
4
READ – Textbook (pp. 902-907)
REVIEW
• Table 42-3: Medications for Urinary Disorders (pp. 904–906)
• Table 42-4: Medications for Suppressing Immunity (p. 907)
ANSWER – Text
• Review Questions for the NCLEX Examination: 4, 6, 7, 10 (p. 938)
ANSWER – Study Guide
• Part IE: Drug Therapy (p. 269)
14 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
5
READ – Textbook (pp. 906-937)
REVIEW
• Box 42-2: Risk Factors for Urinary Tract Infections (p. 908)
• Figure 42-7: Polycystic kidney (p. 911)
• Figure 42-8: Extracorporeal shock wave lithotripsy (p. 914)
• Figure 42-9: Surgical procedures for renal calculi (p. 915)
• Figure 42-10: Hydronephrosis (p. 917)
• Figure 42-11: Types of urinary diversion procedures (p. 921)
ANSWER – Study Guide
• Part IA: 1-7 (p. 267)
• Part ID: 1-6 (p. 269)
• Part IIH: 11, 17, 18, 28-34, 36, 37, 39-43, 45-47, 50, 51, 54 (pp. 271-274)
• Part III I: 7, 9 (p. 275)
• Part IIIJ: 2, 3 (p. 276)
6
READ – Textbook (pp. 906-937)
REVIEW
• Nursing Care Plan 42–1: Patient with Renal Calculi (p. 916)
ANSWER – Study Guide
• Part IIH: 35, 44, 49 (pp. 272-273)
• Part III I: 8, 11, 12 (p. 275)
• Part IIIJ: 4-6 (p. 276)
______________________________________________________________ Chapter 42Urologic Disorders 15
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Lecture Outline 20 minutes
4
Slide 18
Therapeutic Measures
• Catheterization
• Ureteral catheter
• Nephrostomy tube
• Urinary stent
• Drug therapy
• Urologic surgery
• Nephrectomy
• Removal of calculi
• Lithotripsy
5
Slide 19
Urethritis
• Inflammation of the urethra
• By microorganisms, trauma, or hypersensitivity to chemicals in products such as vaginal
deodorants, spermicidal jellies, or bubble baths
• Signs and symptoms
• Dysuria, frequency, urgency, and bladder spasms
• Urethral discharge may be noted
• Medical diagnosis
• Based on patient signs and symptoms, urinalysis, and urethral smear
Slide 20
Urethritis (cont.)
• Medical treatment
• Antimicrobials
6
Slide 21
Urethritis (cont.)
• Assessment
• Comfort, possible causative factors, and understanding of treatment and prevention
• Interventions
• Acute pain
• Ineffective self-health management
TALKING POINTS:
• To prevent urethritis, what activities are discouraged?
16 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
5
Slide 22
Cystitis
• Inflammation of the urinary bladder
• Common cause is bacterial contamination
• Other factors: prolonged immobility, renal calculi, urinary diversion, and indwelling
catheters
• Signs and symptoms
• Urgency, frequency, dysuria, hematuria, nocturia, bladder spasms, incontinence, and
low-grade fever
TALKING POINTS:
• Why are women more susceptible than men to cystitis?
• Bladder spasms may be manifested by pain behind the symphysis pubis.
Slide 23
Cystitis (cont.)
• Medical diagnosis
• Urinalysis, culture, and sensitivity
• White blood cells (WBCs)
• Medical treatment
• Antibiotics
TALKING POINTS:
• The presence of bacteria does not mean the patient has an infection, unless the patient
also has white blood cells (WBCs) in the urine.
• What are the uses of phenazopyridine (Pyridium)?
6
Slide 24
• How much fluid should the patient be advised to consume?
Cystitis (cont.)
• Assessment
• Patient symptoms, causative factors, and understanding of treatment and prevention
• Interventions
• Acute pain
TALKING POINTS:
• Patient teaching emphasizes the need for a high fluid intake, instructions about prescribed
______________________________________________________________ Chapter 42Urologic Disorders 17
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
5
&
6
Slide 25
Interstitial Cystitis
• Pathophysiology and diagnosis
• Inflammatory disease of the bladder, usually chronic
• Cause is unknown
• Bladder/pelvic pain; urinary frequency and urgency
• Diagnosed by cystoscopy
• Medical treatment
• Symptom management; attempts to treat causes
TALKING POINTS:
• Chronic inflammation can cause the bladder to become scarred and stiff, which reduces
its capacity.
• What are the goals of treatment for interstitial cystitis?
• Among the drugs that sometimes are helpful for interstitial cystitis are tricyclic
antidepressants, antispasmodics, bladder anesthetics, calcium channel blockers, urine
alkalinizers, and NSAIDs.
5
Slide 26
Pyelonephritis
• Inflammation of the renal pelvis
• Acute pyelonephritis most often caused by ascending bacterial infection, but it may be
TALKING POINTS:
• It most often is the result of reflux of urine from inadequate closure of the ureterovesical
junction during voiding.
• Chronic pyelonephritis, usually caused by long-standing urinary tract infections (UTIs) with
relapses and reinfections, may lead to chronic renal failure.
• What treatments are necessary if the patient progresses to renal atrophy and end-stage
renal disease?
Slide 27
Pyelonephritis (cont.)
• Signs and symptoms
• Acute pyelonephritis
• High fever, chills, nausea, vomiting, and dysuria; severe pain or a constant dull
ache occurs in the flank area
• Chronic pyelonephritis
• Bladder irritation, chronic fatigue, and slight aching over one or both kidneys
18 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Slide 28
Pyelonephritis (cont.)
• Medical treatment
• Antibiotics, urinary tract antiseptics, analgesics, and antispasmodics
• Drink at least eight 8-ounce glasses of fluids daily
TALKING POINTS:
• What is the goal of treatment for pyelonephritis?
6
Slide 29
Pyelonephritis (cont.)
• Assessment
• Related signs and symptoms, history of urinary tract disorders, predisposing factors,
and effects of the infection on daily activities
• Interventions
• Acute pain
• Activity intolerance
• Deficient fluid volume
• Imbalanced nutrition
• Ineffective management of therapeutic regimen
TALKING POINTS:
• What should be included in patient teaching?
5
Slide 30
Polycystic Kidney Disease
• Hereditary disorder
• Two types: childhood and adult
• In adults, usually manifested by age 40 years
• Grapelike cysts in place of normal kidney tissue
• Cysts enlarge, compress functional renal tissue, and result in renal failure
• Signs and symptoms
• Dull, aching abdominal, lower back or flank pain, or colicky pain that begins abruptly
Slide 31
Polycystic Kidney Disease (cont.)
• Medical treatment
• Supportive treatment is recommended to preserve kidney function, treat urinary tract
infections (UTIs), and control hypertension
TALKING POINTS:
• Why is genetic counseling advised for patients with polycystic kidney disease?
______________________________________________________________ Chapter 42Urologic Disorders 19
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Slide 32
Acute Glomerulonephritis
• Pathophysiology
• Immunologic disease: inflammation of the capillary loops in the glomeruli
• Signs and symptoms
• Urine becomes tea-colored as output decreases
• Peripheral and periorbital edema
• As glomerular filtration decreases, mild to severe hypertension occurs and
hypervolemia results
• Medical diagnosis
TALKING POINTS:
• A common type of glomerulonephritis follows an infection of the respiratory tract caused
by group A–negative hemolytic streptococci.
• Acute glomerulonephritis usually resolves completely, but some patients develop chronic
glomerulonephritis or progress to irreversible renal failure.
• Why do the blood urea nitrogen (BUN) and serum creatinine rise with acute
glomerulonephritis?
Slide 33
Acute Glomerulonephritis (cont.)
• Medical treatment
• Diuretics, antihypertensive medications, and antibiotics
• Bedrest; activity restriction
• Fluids, sodium, potassium, and protein may be restricted
• If renal failure develops, dialysis is necessary
TALKING POINTS:
• When are antibiotics indicated with acute glomerulonephritis?
• When fluid overload has been corrected, moderate activity is permitted, but the patient still
needs sufficient rest to allow the kidneys to heal.
6
Slide 34
Acute Glomerulonephritis (cont.)
• Assessment
• Signs and symptoms, recent infections, and changes in urine
• Interventions