20 Chapter 42Urologic Disorders _______________________________________________________________
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LESSON 42.2
5
Slide 35
Renal Calculi
• Urinary tract obstruction
• Pathophysiology
• Precipitations of calcium salts (calcium phosphate or calcium oxalate), uric acid,
magnesium ammonium phosphate, or cystine
• All are normally found in the urine
• Factors for development of calculi
Slide 36
Renal Calculi (cont.)
• Signs and symptoms
• Pain
• Dull flank pain: a calculus in the renal pelvis or stretching of the renal capsule
from urine retention (hydronephrosis)
• If calculus lodges in a ureter, excruciating pain in the abdomen that radiates to the
groin or the perineum
TALKING POINTS:
• Where do most calculi originate?
• Some substances tend to precipitate in acid urine, causing calculus formation; others
precipitate in alkaline urine.
Slide 37
Renal Calculi (cont.)
• Medical treatment
• Most calculi are passed spontaneously
• Ambulation and adequate hydration facilitate passage
• Opioid analgesics/antispasmodics relieve pain
• Lithotripsy
______________________________________________________________ Chapter 42Urologic Disorders 21
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
5
&
6
Slide 38
Renal Calculi (cont.)
• Prevention
• High fluid intake to keep urine dilute, dietary restrictions for specific elements (i.e.,
calcium and purines), regular exercise, medications to alter urine pH
• Assessment
TALKING POINTS:
• The fluid needs to be consumed over the 24-hour period so that urine does not become
concentrated at night.
• How much fluid should be consumed by the patient with renal calculi?
6
Renal Calculi (cont.)
• Interventions
• Acute pain
Slide 40
Renal Calculi (cont.)
• Postoperative interventions
• Risk for infection
• Decreased cardiac output
• Ineffective breathing pattern
5
Slide 41
Urologic Trauma
• Penetrating injuries most often from knives or guns
• Blunt trauma: a force is applied to the abdominal wall and the energy is diffused into the
abdominal cavity
TALKING POINTS:
• What is the most common indication of urologic trauma?
• If the injury is not severe, if there is little bleeding, and if there are no signs of shock,
monitor the patient closely.
• More severe injuries most likely require surgery to repair damage.
Slide 42
Urologic Trauma (cont.)
• Grey-Turner’s sign
• Bruising over the flank and lower back; occurs with retroperitoneal bleeding
22 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Slide 43
Renal Cancer
• 80% of malignancies are adenocarcinomas; primarily affect men 55 to 70 years of age
• Less common squamous cell carcinomas of the renal pelvis affect men and women
equally
TALKING POINTS:
• How many new cases of renal cancer occur each year in the United States?
• What are the age and racial risk factors?
• Direct extension of the tumor may be found in the ureter.
Slide 44
Renal Cancer (cont.)
• Medical diagnosis
• Palpable mass in the flank, excretory urography, IVP, retrograde pyelography,
ultrasound, arteriography, computed tomography, magnetic resonance imaging, and
renal biopsy
Renal Cancer (cont.)
• Medical treatment
• Radical nephrectomy
6
Slide 46
Renal Cancer (cont.)
• Assessment
• Weakness, fatigue, and changes in the urine
• Patient’s emotional state, usual coping strategies, and support systems
Slide 47
Renal Cancer (cont.)
• Preoperative care
• Ineffective coping related to potentially fatal disease
• Deficient knowledge of tests, procedures, and effects of nephrectomy
• Postoperative care
• Monitor vital signs; record intake and output
• Routinely check drains and tubes
• Monitor dressings for drainage
• Auscultate breath sounds and bowel sounds
TALKING POINTS:
• What are the goals of nursing care for the preoperative patient with renal cancer?
• Once the dressings have been removed, inspect the wound for intactness and signs of
______________________________________________________________ Chapter 42Urologic Disorders 23
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Slide 48
Renal Cancer (cont.)
• Interventions
• Acute pain
• Risk for deficient fluid volume
• Deficient knowledge
Bladder Cancer
• Most common malignancy of urinary tract
• Ureteral orifices and bladder neck are the most common sites
TALKING POINTS:
• In what population does bladder cancer occur most frequently?
Slide 50
Bladder Cancer (cont.)
• Signs and symptoms
• Painless, intermittent hematuria
• Other signs and symptoms: bladder irritability; infection, with dysuria, frequency, and
urgency; and decreased stream of urine
• Medical diagnosis
• Urinalysis, IVP, CT scan, and cystoscopy
Slide 51
• What does the type of surgery for bladder cancer depend on?
Bladder Cancer (cont.)
• Medical treatment
• Surgery is the treatment of choice
• Cystoscopic resection and fulguration or laser photocoagulation
• Segmental bladder resection and radical cystectomy
• Urinary diversion
• Chemotherapeutic drugs or immune-stimulating agents instilled directly into the
bladder (intravesical therapy)
TALKING POINTS:
• Bladder malignancies respond more favorably to chemotherapy than do kidney tumors,
Slide 52
Bladder Cancer (cont.)
• Assessment
• Description of urinary signs and symptoms
• Fatigue and weight loss
• Health history may reveal use of tobacco or exposure to carcinogenic chemicals
• Patient’s emotional state, coping strategies, and sources of support
24 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Bladder Cancer (cont.)
• Interventions
• Acute pain
5
Slide 54
Acute Renal Injury
• Causes
• Prerenal failure: decreased blood flow to glomeruli
• Intrarenal failure: nephrotoxic agents, kidney infections, occlusion of intrarenal
arteries, hypertension, diabetes mellitus, or direct trauma to the kidney
• Postrenal failure: obstructions beyond the kidneys that cause urine to back up
TALKING POINTS:
Slide 55
Acute Renal Failure: Stages
• Onset stage
• Short (1 to 3 days); increasing BUN and serum creatinine with normal to decreased
urine output
• Oliguric stage
• The urine output decreases to 400 mL/day or less
TALKING POINTS:
• What is the urine specific gravity in the oliguric stage?
• The patient becomes hypervolemic, meaning that the blood volume is greater than
normal.
• Urine osmolality decreases and serum osmolality increases as waste products are
retained.
Acute Renal Failure: Stages (cont.)
• Diuretic stage
• Urine output exceeds 400 mL/day; may rise above 4 L/day
TALKING POINTS:
• Despite the production of large quantities of urine, few waste products are excreted, and
wastes accumulate in the blood during the diuretic stage.
• What happens if complete recovery does not occur in the recovery stage?
______________________________________________________________ Chapter 42Urologic Disorders 25
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Slide 57
Acute Renal Failure
• Medical treatment
• Fluid and dietary restrictions, restoration of electrolyte balance, and dialysis
• Nephrotoxic drugs and drugs that reduce renal blood flow to be avoided
TALKING POINTS:
• What is the primary goal of medical treatment?
• Nephrotoxic drugs and drugs that reduce renal blood flow must be avoided.
• Daily fluid needs usually are calculated by adding 600 mL to the previous day’s fluid
output.
6
Slide 58
Acute Renal Failure (cont.)
• Assessment
• Monitoring fluid status is critical
• Signs and symptoms of electrolyte imbalances
Slide 59
Acute Renal Failure (cont.)
• Interventions
• Excess fluid volume OR Deficient fluid volume
• Decreased cardiac output
• Anxiety
• Risk for disuse syndrome
• Deficient knowledge
5
Chronic Kidney Disease
• Progressive nephron destruction of both kidneys
• Creatinine clearance: important measure of renal function
TALKING POINTS:
• Chronic kidney disease is characterized by what?
Slide 61
Chronic Kidney Disease: Signs and Symptoms
• Azotemia
• Hyperkalemia
• Hypocalcemia
• Metabolic acidosis
26 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Slide 62
Chronic Kidney Disease: Signs and Symptoms (cont.)
• Neurologic system (mental status changes)
• Integumentary system (uremic frost, accumulation of waste products)
• GI system (irritation, nausea, vomiting, a metallic taste in the mouth, and bleeding)
Slide 63
Chronic Kidney Disease: Medical Treatment
• IV glucose and insulin, calcium carbonate, calcium acetate, or sodium polystyrene
sulfonate to treat hyperkalemia
• Statins to decrease risk of cardiovascular complications
• Calcium, active vitamin D, and phosphate binders to treat hypocalcemia
TALKING POINTS:
• What is the goal of treatment for chronic kidney disease?
• When kidney failure can no longer be managed conservatively, dialysis is required to
sustain life.
Slide 64
Chronic Kidney Disease: Dialysis
• Passage of molecules through semipermeable membrane into special solution called
dialysate solution
• Dialysis operates like the kidney
• Small molecules (urea, creatinine, and electrolytes) pass out of the blood, across a
membrane, and into a solution
• The goals of dialysis
• Remove end products of protein metabolism from the blood
• Maintain safe concentrations of serum electrolytes
• Correct acidosis and replenish the body’s bicarbonate buffer system
• Remove excess fluid from the blood
______________________________________________________________ Chapter 42Urologic Disorders 27
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Slide 65
Chronic Kidney Disease: Dialysis (cont.)
• Hemodialysis
• Blood is removed and circulated through an “artificial kidney” to remove excess fluid,
electrolytes, wastes
• Dialyzed blood then returned to the patient
TALKING POINTS:
• What are the advantages of hemodialysis? Disadvantages?
Slide 66
Chronic Kidney Disease: Dialysis (cont.)
• Peritoneal dialysis
• Uses the patient’s own peritoneum as a semipermeable dialyzing membrane
• Fluid instilled into peritoneal cavity
• Waste products drawn into the fluid, which is then drained from the peritoneal cavity
• May be temporary or permanent
• Temporary: catheter inserted into the peritoneal cavity through the abdominal wall
• Long-term: catheter is implanted into the peritoneal cavity
Slide 67
Chronic Kidney Disease: Dialysis (cont.)
• Peritoneal dialysis
• Advantages over hemodialysis: less anemia, reduced cost, fewer dietary and fluid
restrictions, independence, closer to normal kidney function
• Disadvantages: risk of peritonitis (the major complication) and catheter site infection,
hyperglycemia, elevated serum lipids, and body image disturbance
• Three phases: inflow, dwell, and drain
TALKING POINTS:
• What is continuous ambulatory peritoneal dialysis (CAPD)?
• Automated peritoneal dialysis uses a device called a cycler to perform the exchanges
during the night.
• Peritonitis, infection of the peritoneum, is the most serious complication of peritoneal
dialysis.
28 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
6
Slide 68
Chronic Kidney Disease
• Assessment
• Frequent monitoring for changes important
• Fluid balance evaluated closely
• Accurate intake and output records
• Signs and symptoms of fluid volume excess that can lead to cardiac failure:
increasing edema, dyspnea, tachycardia, bounding pulse, rising blood pressure
• Signs and symptoms of electrolyte imbalances
• Appetite, usual daily intake, weight gain or loss pattern, and prescribed diet
TALKING POINTS:
• Do not overlook mental and emotional status when assessing the patient with kidney
disease.
• What may cause increasing confusion or loss of consciousness?
• The long-term effects of chronic kidney disease and its treatment put the patient at risk for
many complications.
Chronic Kidney Disease
• Nutrition considerations
• Fluid intake may be restricted to 1000 to 1500 mL/day
Slide 70
Chronic Kidney Disease (cont.)
• Interventions
• Excess fluid volume
• Imbalanced nutrition: Less than body requirements
• Risk for acute confusion
• Ineffective coping
• Situational low self-esteem
______________________________________________________________ Chapter 42Urologic Disorders 29
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
5
Slide 71
Renal Transplantation
• Kidney donation
• Healthy kidney from live donor (a relative) or cadaver
• Tissues must match or recipient will reject new kidney
• Matching based on ABO blood groups and human leukocyte antigens
TALKING POINTS:
• When a kidney is obtained from a living related donor, the 1-year recipient survival rate is
97.6%.
• A national network maintains lists of people awaiting donor kidneys.
• When a cadaver kidney is available, the network tries to locate the best match for the
kidney to improve the chances of success.
• What disorders may make a person ineligible to be a kidney donor?
6
Slide 72
Renal Transplantation (cont.)
• Preoperative nursing care
• Patient must be prepared mentally and physically
• Recipient and live donor have complete diagnostic workups to rule out other medical
TALKING POINTS:
• The gift of a kidney can restore health, but the recipient may feel guilty about asking a
loved one to endure surgery and to give up an organ.
Slide 73
Renal Transplantation (cont.)
• Interventions
• Fear
• Deficient knowledge
• Encourage patient to discuss concerns
• Factual information helps the patient cope by reducing the fear of the unknown
• When patients are active participants in their care, they feel less helpless and
30 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
5
Slide 74
Renal Transplantation (cont.)
• Surgical procedure
• Donor kidney removed from live donor in operating room (OR); taken to adjacent
room where the recipient has been prepared
• Cadaver kidney removed under sterile conditions and transported to the hospital
where recipient is waiting
6
Slide 75
Renal Transplantation (cont.)
• Postoperative nursing care
• Assessment
• Fluid intake, urine output, weight changes, and vital signs
• Interventions
• Impaired urinary elimination
5
Slide 76
The Kidney Donor
• Physical care of the donor similar to that for a nephrectomy
• Nephrectomy may be conventional or laparoscopic
• Pain worse with conventional approach; provide good pain control
______________________________________________________________ Chapter 42Urologic Disorders 31
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Activities
Classroom Choose from below to make 30 minutes
4
DISCUSS
• Discuss the available sizes of urinary
catheters and the reasons for using different
sizes.
• Discuss medical reasons for urinary
catheterization.
• Discuss the procedure for performing urinary
catheterization.
• Discuss how a ureteral catheter is different
PRACTICE
• Display a collection of catheters and tubes
used in the care of patients with urologic
disorders, and demonstrate to the class the
differences between them. Ask the class to
32 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
5
DISCUSS
• Discuss the risk factors for urinary tract
infections that are hospital-related.
• Discuss what information from the urinalysis
will indicate the presence of infection.
• Invite an infection control nurse to speak on
urosepsis, stressing the importance of UTI
prevention and management. Have the class
• Discuss cystitis and interstitial cystitis, listing
their signs and symptoms on the blackboard.
Ask the students to identify the
characteristics of each condition. Highlight
their similarities and differences on the list.
• Discuss the pathophysiology of polycystic
kidney disease.
• Discuss the pathophysiology of
glomerulonephritis.
• Lead a class discussion about the key
issues involved in caring for a patient with
polycystic kidney disease.
• Differentiate between uncomplicated cystitis
and recurring cystitis. Ask students to:
• Ask students to answer the following
questions and provide rationales:
• Why should a patient with acute
pyelonephritis be sure to follow up with
his or her provider?
• Why would a streptococcal antibody test
______________________________________________________________ Chapter 42Urologic Disorders 33
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
6
DISCUSS
• Discuss the most common causes of
urethritis and the most common causative
organisms involved.
• Discuss how to advise the patient to reduce
the risk of future infections.
• Discuss the nursing interventions for a
patient who has interstitial cystitis.
• Discuss why genetic counseling is advised
for patients with polycystic kidney disease.
• Discuss the hereditary causes of polycystic
• List key nursing diagnoses that may apply to
the patient with acute glomerular nephritis
(Excess fluid volume, Activity intolerance,
Self-care deficit, Anxiety). Ask the students
to list three interventions for each diagnosis.
Collect the answers, collate the results, and
share them with the class.
• Outline a nursing care plan on the board for
a patient with cystitis. Ask the class for input
• Write a nurse teaching plan on the board for
interstitial cystitis. Ask the class to contribute
to the plan as you write it. Summarize and
copy the information for distribution to the
entire class.
PRACTICE
• Ask a representative of the local ostomy club
to present information on how an ostomy
affects everyday living.
34 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 42.2
Critical Thinking Question
An 85-year-old male patient with a history of multiple strokes and requiring the use of an
indwelling urinary catheter is discharged from the hospital to a long–term care facility after
being treated for urosepsis. What are some interventions the nurse can implement to prevent
recurrence of the problem?
Discussion Guidelines: If the patient has an indwelling catheter, the nurse must maintain aseptic
technique when providing catheter care. The nurse should ensure that the drainage bag does not
urinary tract infection, the provider may prescribe medications.
Instructor Notes/Student Feedback
______________________________________________________________ Chapter 42Urologic Disorders 35
Introduction to Medical-Surgical Nursing, 6th ed.
42
Assessments for
Urologic Disorders
CHAPTER 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
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.
Assessments by Lesson & Objective
Lesson 42.1
1
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)
Evolve Instructor Resources
• Test Bank: 1, 2, 26, 27
• Open Book Quiz: 1, 2
Evolve Student Resources
• NCLEX Review: 4, 9
2
Study Guide
• Part IC: 1-11 (pp. 268-269)
• Part IG: 1-7 (p. 270)
• Part IIH: 6, 20, 26, 53 (pp. 270-274)
Evolve Instructor Resources
• Test Bank: 3, 4, 5
• Open Book Quiz: 3
Evolve Student Resources
• NCLEX Review: 2
36 Chapter 42Urologic Disorders _______________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
3
Study Guide
• Part IIH: 21-25, 52, 55 (pp. 271-274)
• Part III I: 1 (p. 274)
Evolve Instructor Resources
• Test Bank: 6
• Open Book Quiz: 4
Evolve Student Resources
• Prioritization: 4, 5
Lesson 42.2
4
Study Guide
• Part IE: Drug Therapy (p. 269)
Evolve Instructor Resources
• Test Bank: 7, 8, 11, 19, 20, 28
• Open Book Quiz: 5
Evolve Student Resources
• NCLEX Review: 3
• Prioritization: 1, 2, 3
5
Study Guide
• Part IA: 1-7 (p. 267)
6
• Part IIH: 35, 44, 49 (pp. 272-273)
• Part III I: 8, 11, 12 (p. 275)
• Part IIIJ: 4-6 (p. 276)
Evolve Instructor Resources
• Test Bank: 15-17, 25
Evolve Student Resources
• NCLEX Review: 1, 5, 7, 8
______________________________________________________________ Chapter 42Urologic Disorders 37
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
Instructor’s Notes/Student Feedback