Disorders of the GenitoUrinary Tract

Urinary Tract Infection (UTI)

1. General information
1. Bacterial invasion of the kidneys or bladder
2. More common in girls, preschool, and school-age children
3. Usually caused by E. coli; predisposing factors include poor hygiene, irritation from bubble baths, urinary reflux
4. The invading organism ascends the urinary tract, irritating the mucosa and causing characteristic symptoms.
2. Assessment findings
1. Low-grade fever
2. Abdominal pain
3. Enuresis, pain/burning on urination, frequency, hematuria
3. Nursing interventions
1. Administer antibiotics as ordered; prevention of kidney infection/glomerulonephritis important. (Note: obtain cultures
before starting antibiotics.)
2. Provide warm baths and allow child to void in water to alleviate painful voiding.
3. Force fluids.
4. Encourage measures to acidify urine (cranberry juice, acid-ash diet).
5. Provide client teaching and discharge planning concerning
1. Avoidance of tub baths (contamination from dirty water may allow microorganisms to travel up urethra)
2. Avoidance of bubble baths that might irritate urethra
3. Importance for girls to wipe perineum from front to back
4. Increase in foods/fluids that acidify urine.

Vesicoureteral Reflux
1. General information
1. Regurgitation of urine from the bladder into the ureters due to faulty valve mechanism at the vesicoureteral junction
2. Predisposes child to
1. UTIs from urine stasis
2. Pyelonephritis from chronic UTIs
3. Hydronephrosis from increased pressure on renal pelvis
2. Assessment findings: same as for urinary tract infections
3. Nursing interventions for surgical reimplantation of ureters
1. Assist with preoperative studies as needed (IVP, voiding cystourethrogram, cystoscopy).
2. Provide postoperative care.
1. Monitor drains; may have one from bladder and one from each ureter (ureteral stents).
2. Check output from all drains (expect bloody drainage initially) and record carefully.
3. Observe drainage from abdominal dressing; note color, amount, frequency.
4. Administer medication for bladder spasms as ordered.

Exstrophy of the Bladder

1. General information
1. Congenital malformation in which nonfusion of abdominal and anterior walls of the bladder during embryologic
development causes anterior surface of bladder to lie open on abdominal wall
2. Varying degrees of defect
2. Assessment findings
1. Associated structural changes
1. Prolapsed rectum
2. Inguinal hernia
3. Widely split symphysis
4. Rotated hips
2. Associated anomalies
1. Epispadias
2. Cleft scrotum or clitoris
3. Undescended testicles
4. Chordee (downward deflection of the penis)
3. Medical management: two-stage reconstructive surgery, possibly with urinary diversion; usually delayed until age 3-6 months
4. Nursing interventions: preoperative
1. Provide bladder care; prevent infection.
1. Keep area as clean as possible; urine on skin will cause irritation and ulceration.
2. Change diaper frequently; keep diaper loose fitting.
3. Wash with mild soap and water.
4. Cover exposed bladder with Vaseline gauze.
5. Nursing interventions: postoperative
1. Design play activities to foster toddler's need for autonomy (e.g., Play- Doh, talking toys, books); child will be immobilized
for extended period of time.
2. Prevent trauma; as child gets older and more mobile, trauma more likely; teach parents to avoid areas such as sandboxes.

Undescended Testicles (Cryptorchidism)

1. General information
1. Unilateral or bilateral absence of testes in scrotal sac
2. Testes normally descend at 8 months of gestation, will therefore be absent in premature infants
3. Incidence increased in children having genetically transmitted diseases
 4. Unilateral cryptorchidism most common
5. 75% will descend spontaneously by age 1 year
2. Medical management
1. Whether or not to treat is still controversial; if testes remain in abdomen, damage to the testes (sterility) is possible because
of increased body temperature.
2. If not descended by age 8 or 9, chorionic gonadotropin can be given.
3. Orchipexy: surgical procedure to retrieve and secure testes placement; performed between ages 1-3 years.
3. Assessment findings: unable to palpate testes in scrotal sac (when palpating testes be careful not to elicit cremasteric reflex, which
pulls testes higher in pelvic cavity)
4. Nursing interventions
1. Advise parents of absence of testes and provide information about treatment options.
2. Support parents if surgery is to be performed.
3. Post-op, avoid disturbing the tension mechanism (will be in place for about 1 week).
4. Avoid contamination of incision.

Hypospadias
1. General information
1. Urethral opening located anywhere along the ventral surface of penis
2. Chordee (ventral curvature of the penis) often associated, causing constriction
3. In extreme cases, child's sex may be uncertain
2. Medical management
1. Minimal defects need no intervention
2. Neonatal circumcision delayed, tissue may be needed for corrective repair
3. Surgery performed at age 3-9 months; 2 years of age for complex repairs.
3. Assessment findings
1. Urinary meatus misplaced
2. Inability to make straight stream of urine
4. Nursing interventions
1. Diaper normally.
2. Provide support for parents.
3. Provide support for child at time of surgery.
4. Post-operatively check pressure dressing, monitor catheter drainage, assess pain.

Enuresis
1. General information
1. Involuntary passage of urine after the age of control is expected (about 4 years)
2. Types
1. Primary: in children who have never achieved control
2. Secondary: in children who have developed complete control and lose it
3. May occur at any time of day but is most frequent at night
4. More common in boys
5. No organic cause can be identified; familial tendency
6. Etiologic possibilities
1. Sleep disturbances
2. Delayed neurologic development
3. Immature development of bladder leading to decreased capacity
4. Psychologic problems
2. Medical management

1. Bladder retention exercises

2. Behavior modification, e.g., bed alarm devices
3. Drug therapy: results are temporary; side effects may be unpleasant or even dangerous
1. Tricyclic antidepressants: imipramine HCI (Tofranil)
2. Anticholinergics
3. Assessment findings
1. Physical exam normal
2. History of repeated involuntary urination
4. Nursing interventions
1. Provide information/counseling to family as needed.
1. Confirm that this is not conscious behavior and that child is not purposely misbehaving.
2. Assure parents that they are not responsible and that this is a relatively common problem.
2. Involve child in care; give praise and support with small accomplishments.
1. Age 5-6 years; can strip bed of wet sheets.
2. Age 10-12 years: can do laundry and change bed.
3. Avoid scolding and belittling child.

Nephrosis (Nephrotic Syndrome)

1. General information
1. Autoimmune process leading to structural alteration of glomerular membrane that results in increased permeability to
plasma proteins, particularly albumin
2. Course of the disease consists of exacerbations and remissions over a period of months to years
3. Commonly affects preschoolers, boys more often than girls
4. Pathophysiology
1. Plasma proteins enter the renal tubule and are excreted in the urine, causing proteinuria.
 2. Protein shift causes altered oncotic pressure and lowered plasma volume.
3. Hypovolemia triggers release of renin and angiotensin, which stimulates increased secretion of aldosterone;
aldosterone increases reabsorption of water and sodium in distal tubule.
4. Lowered blood pressure also stimulates release of ADH, further increasing reabsorption of water; together with a
general shift of plasma into interstitial spaces, results in edema.
5. Prognosis is good unless edema does not respond to steroids.
2. Medical management
1. Drug therapy
1. Corticosteroids to resolve edema
2. Antibiotics for bacterial infections
3. Thiazide diuretics in edematous stage
2. Bed rest
3. Diet modification: high protein, low sodium
3. Assessment findings
1. Proteinuria, hypoproteinemia, hyperlipidemia
2. Dependent body edema
1. Puffiness around eyes in morning
2. Ascites
3. Scrotal edema
4. Ankle edema
3. Anorexia, vomiting, and diarrhea, malnutrition
4. Pallor, lethargy
5. Hepatomegaly
4. Nursing interventions
1. Provide bed rest.
1. Conserve energy.
2. Find activities for quiet play.
2. Provide high-protein, low-sodium diet during edema phase only.
3. Maintain skin integrity.
1. Do not use Band-Aids.
2. Avoid IM injections (medication is not absorbed into edematous tissue).
3. Turn frequently.
4. Obtain morning urine for protein studies.
5. Provide scrotal support.
6. Monitor I&O, vital signs and weigh daily.
7. Administer steroids to suppress autoimmune response as ordered.
8. Protect from known sources of infection.

Acute Glomerulonephritis
1. General information
1. Immune complex disease resulting from an antigen-antibody reaction
2. Secondary to a beta-hemolytic streptococcal infection occurring elsewhere
in the body
3. Occurs more frequently in boys, usually between ages 6-7 years
4. Usually resolves in about 14 days, self-limiting
2. Medical management
1. Antibiotics for streptococcal infection
2. Antihypertensives if blood pressure severely elevated
3. Digitalis if circulatory overload
4. Fluid restriction if renal insufficiency
5. Peritoneal dialysis if severe renal or cardiopulmonary problems develop
3. Assessment findings
1. History of a precipitating streptococcal infection, usually upper respiratory infection or impetigo
2. Edema, anorexia, lethargy
3. Hematuria or dark-colored urine, fever
4. Hypertension
5. Diagnostic tests
1. Urinalysis reveals RBCs, WBCs, protein, cellular casts
2. Urine specific gravity increased
3. BUN and serum creatinine increased
4. ESR elevated
5. Hgb and hct decreased
4. Nursing interventions
1. Monitor I&O, blood pressure, urine; weigh daily.
2. Provide diversional therapy.
3. Provide client teaching and discharge planning concerning
1. Medication administration
2. Prevention of infection
3. Signs of renal complications
4. Importance of long-term follow-up

Hydronephrosis
1. General information
1. Collection of urine in the renal pelvis due to obstruction to outflow
 2. Obstruction most common at ureteral-pelvic junction (see The
Genitourinary System - Vesicoureteral Reflux, in Unit 5) but may also be caused by adhesions, ureterocele, calculi, or
congenital malformation
3. Obstruction causes increased intrarenal pressure, decreased circulation, and atrophy of the kidney, leading to renal
insufficiency
4. May be unilateral or bilateral; occurs more often in left kidney
5. Prognosis good when treated early
2. Medical management: surgery to correct or remove obstruction
3. Assessment findings
1. Repeated UTIs
2. Failure to thrive
3. Abdominal pain, fever
4. Fluctuating mass in region of kidney
4. Nursing interventions: prepare child for multiple urologic studies (see The Genitourinary System - Vesicoureteral Reflux, in Unit

Cystitis
1. General information
1. Inflammation of the bladder due to bacterial invasion
2. More common in women
3. Predisposing factors include stagnation of urine, obstruction, sexual intercourse, high estrogen levels
2. Assessment
1. Abdominal or flank pain/tenderness, frequency and urgency of urination, pain on voiding, nocturia
2. Fever
3. Diagnostic tests: urine culture and sensitivity reveals specific organism (80% E. coli)
3. Nursing interventions
1. Force fluids (3000 ml/day).
2. Provide warm sitz baths for comfort.
3. Assess urine for odor, hematuria, sediment.
4. Administer medications as ordered and monitor effects.
1. Systemic antibiotics: ampicillin, cephalosporins, aminoglycosides
2. Sulfonamides: sulfisoxazole (Gantrisin), sulfamethoxazole
(Gantanol), trimethoprim-sulfamethoxazole (Bactrim)
3. Antibacterials: nitrofurantoin (Macrodantin), methenamine
mandelate (Mandelamine), nalidixic acid (NegGram)
4. Urinary tract analgesic: pyridium
5. Provide client teaching and discharge planning concerning
1. Importance of adequate hydration
2. Frequent voiding to avoid stagnation
3. Proper personal hygiene; women to cleanse from front to back
4. Voiding after sexual intercourse
5. Acidification of the urine to decrease bacterial multiplication (acid- ash diet, vitamin C)
6. Need for follow-up urine cultures.

Bladder Cancer
1. General information
1. Most common site of cancer of the urinary tract
2. Occurs in men 3 times more often than women; peak age 50-70 years
3. Predisposing factors include exposure to chemicals (especially aniline dyes), cigarette smoking, chronic bladder infections
2. Medical management: dependent on the staging of cell type; includes
1. Radiation therapy, usually in combination with surgery
2. Chemotherapy: considerable research on both agents and methods of administration
1. Methods include direct bladder instillations, intra-arterial infusions, IV infusion, oral ingestion
2. Agents include 5-fluorouracil, methotrexate, bleomycin, mitomycin-C, hydroxyurea, doxorubicin, cyclophosphamide,
cisplatin; results variable
3. Surgery: see Bladder Surgery.
3. Assessment findings
1. Intermittent painless hematuria, dysuria, frequent urination
2. Diagnostic tests
1. Cytoscopy with biopsy reveals malignancy
2. Cytologic exam of the urine reveals malignant cells
4. Nursing interventions: provide care for the client receiving radiation therapy or chemotherapy, and for the client with bladder
surgery.

Bladder Surgery
1. General information
1. Cystectomy (removal of the urinary bladder) with one of the various types of urinary diversions is the surgical procedure
done for bladder cancer
2. Types of urinary diversions
1. Ureterosigmoidostomy: ureters are excised from the bladder and implanted into sigmoid colon; urine flows through the
colon and is excreted via the rectum
2. Ileal conduit: ureters are implanted into a segment of the ileum that has been resected from the intestinal tract with
formation of an abdominal stoma; most common type of urinary diversion
3. Cutaneous ureterostomy: ureters are excised from the bladder and brought through abdominal wall with creation of a
stoma
 4. Nephrostomy: insertion of a catheter into the renal pelvis via an incision into the flank or by percutaneous catheter
placement into the kidney
2. Nursing interventions: preoperative
1. Provide routine pre-op care.
2. Assess client's ability to learn prior to starting a teaching program.
3. Discuss social aspects of living with a stoma (sexuality, changes in body image).
4. Assess understanding and emotional response of client/significant others.
5. Perform pre-op bowel preparation for procedures involving the ileum or colon.
6. Inform client of post-op procedures.
3. Nursing interventions: postoperative
1. Provide routine post-op care.
2. Maintain integrity of the stoma.
1. Monitor for and report signs of impaired stomal healing (pale, dark red, or blue-black color; increased stomal height,
edema, bleeding).
2. Maintain stomal circulation by using properly fitted faceplate.
3. Monitor for signs and symptoms of stomal obstruction (sudden decrease in urine output, increased abdominal
tenderness and distension).
3. Prevent skin irritation and breakdown.
1. Inspect skin areas for signs of breakdown daily.
2. Patch test all adhesives, sprays, and skin barriers before use.
3. Change appliance only when necessary and when production of urine is slowest (early morning).
4. Place wick (rolled gauze pad) on stomal opening when appliance is off.
5. Cleanse peristomal skin with mild soap and water.
6. Remove alkaline encrustations by applying vinegar and water solution to peristomal area.
7. Implement measures to maintain urine acidity (acid-ash foods, vitamin C therapy, omission of milk/dairy products).
4. Provide care for the client with an NG tube (see Nasogastric (NG) Tubes); will be in place until bowel motility returns.
5. Assist client to identify strengths and qualities that have a positive effect on self-concept.
6. Provide client teaching and discharge planning concerning
1. Maintenance of stomal/peristomal skin integrity
2. Proper application of appliance
3. Recommended method of cleaning reusable ostomy equipment (manufacturer's recommendations)
4. Information regarding prevention of UTIs (adequate fluids; empty pouch when half full; change to bedside collection
bag at night)
5. Control of odor (adequate fluids; avoid foods with strong odor; place small amount of vinegar or deodorizer in
pouch)
6. Reporting signs and symptoms of UTIs (see Cystitis).

Nephrolithiasis/Urolithiasis
1. General information
1. Presence of stones anywhere in the urinary tract; frequent composition of stones: calcium, oxalate, and uric acid
2. Most often occurs in men age 20-55; more common in the summer
3. Predisposing factors
1. Diet: large amounts of calcium, oxalate
2. Increased uric acid levels
3. Sedentary life-style, immobility
4. Family history of gout or calculi; hyperparathyroidism
2. Medical management
1. Surgery
1. Percutaneous nephrostomy: tube is inserted through skin and underlying tissues into renal pelvis to remove calculi.
2. Percutaneous nephrostolithotomy: delivers ultrasound waves through a probe placed on the calculus.
2. Extracorporeal shock-wave lithotripsy: delivers shock waves from outside the body to the stone, causing pulverization
3. Pain management and diet modification
3. Assessment findings
1. Abdominal or flank pain; renal colic; hematuria
2. Cool, moist skin
3. Diagnostic tests
1. KUB: pinpoints location, number, and size of stones
2. IVP: identifies site of obstruction and presence of nonradiopaque stones
3. Urinalysis: indicates presence of bacteria, increased protein, increased WBC and RBC
4. Nursing interventions
1. Strain all urine through gauze to detect stones and crush all clots.
2. Force fluids (3000-4000 ml/day).
3. Encourage ambulation to prevent stasis.
4. Relieve pain by administration of analgesics as ordered and application of moist heat to flank area.
5. Monitor I&O.
6. Provide modified diet, depending upon stone consistency.
1. Calcium stones: limit milk/dairy products; provide acid-ash diet to acidify urine (cranberry or prune juice, meat, eggs,
poultry, fish, grapes, whole grains); take vitamin C.
2. Oxalate stones: avoid excess intake of foods/fluids high in oxalate (tea, chocolate, rhubarb, spinach); maintain
alkaline-ash diet to alkalinize urine (milk; vegetables; fruits except prunes, cranberries, and plums).
3. Uric acid stones: reduce foods high in purine (liver, brains, kidneys, venison, shellfish, meat soups, gravies, legumes);
maintain alkaline urine.
7. Administer allopurinol (Zyloprim) as ordered, to decrease uric acid production; push fluids when giving allopurinol.
8. Provide client teaching and discharge planning concerning
 1. Prevention of urinary stasis by maintaining increased fluid intake especially in hot weather and during illness;
mobility; voiding whenever the urge is felt and at least twice during the night
2. Adherence to prescribed diet
3. Need for routine urinalysis (at least every 3-4 months)
4. Need to recognize and report signs/symptoms of recurrence
(hematuria, flank pain).

Pyelonephritis
1. General information
1. Inflammation of the renal pelvis; may be unilateral or bilateral, acute or chronic
2. Acute: infection usually ascends from lower urinary tract
3. Chronic: thought to be a combination of structural alterations along with infection, major cause is ureterovesical reflux,
with infected urine backing up into ureters and renal pelvises; result of recurrent infections is eventual renal parenchymal deterioration
and possible renal failure
2. Medical management
1. Acute: antibiotics, antispasmodics, surgical removal of any obstruction
2. Chronic: antibiotics and urinary antiseptics (sulfanomides, nitrofurantoin); surgical correction of structural abnormality if
possible
3. Assessment findings
1. Acute: fever, chills, nausea and vomiting; severe flank pain or dull ache
2. Chronic: client usually unaware of disease; may have bladder irritability, chronic fatigue, or slight dull ache over kidneys;
eventually develops hypertension, atrophy of kidneys.
4. Nursing interventions: acute pyelonephritis
1. Provide adequate comfort and rest.
2. Monitor I&O.
3. Administer antibiotics as ordered.
4. Provide client teaching and discharge planning concerning
1. Medication regimen
2. Follow-up cultures
3. Signs and symptoms of recurrence and need to report
5. Nursing interventions: chronic pyelonephritis

1. Administer medications as ordered.

2. Provide adequate fluid intake and nutrition.
3. Support client/significant others and explain possibility of dialysis, transplant options if significant renal deterioration.

Glomerulonephritis
1. General information
1. Immune complex disease resulting from an antigen-antibody reaction
2. Secondary to a beta-hemolytic streptococcal infection occurring elsewhere
in the body
3. Occurs more frequently in boys, usually between ages 6-7 years
4. Usually resolves in about 14 days, self-limiting
2. Medical management
1. Antibiotics for streptococcal infection
2. Antihypertensives if blood pressure severely elevated
3. Digitalis if circulatory overload
4. Fluid restriction if renal insufficiency
5. Peritoneal dialysis if severe renal or cardiopulmonary problems develop
3. Assessment findings
1. History of a precipitating streptococcal infection, usually upper respiratory infection or impetigo
2. Edema, anorexia, lethargy
3. Hematuria or dark-colored urine, fever
4. Hypertension
5. Diagnostic tests
1. Urinalysis reveals RBCs, WBCs, protein, cellular casts
2. Urine specific gravity increased
3. BUN and serum creatinine increased
4. ESR elevated
5. Hgb and hct decreased
4. Nursing interventions
1. Monitor I&O, blood pressure, urine; weigh daily.
2. Provide diversional therapy.
3. Provide client teaching and discharge planning concerning
1. Medication administration
2. Prevention of infection
3. Signs of renal complications
4. Importance of long-term follow-up

Nephrosis
1. General information
1. Autoimmune process leading to structural alteration of glomerular membrane that results in increased permeability to
plasma proteins, particularly albumin
2. Course of the disease consists of exacerbations and remissions over a period of months to years
 3. Commonly affects preschoolers, boys more often than girls
4. Pathophysiology
1. Plasma proteins enter the renal tubule and are excreted in the urine, causing proteinuria.
2. Protein shift causes altered oncotic pressure and lowered plasma volume.
3. Hypovolemia triggers release of renin and angiotensin, which stimulates increased secretion of aldosterone;
aldosterone increases reabsorption of water and sodium in distal tubule.
4. Lowered blood pressure also stimulates release of ADH, further increasing reabsorption of water; together with a
general shift of plasma into interstitial spaces, results in edema.
5. Prognosis is good unless edema does not respond to steroids.
2. Medical management
1. Drug therapy
1. Corticosteroids to resolve edema
2. Antibiotics for bacterial infections
3. Thiazide diuretics in edematous stage
2. Bed rest
3. Diet modification: high protein, low sodium
3. Assessment findings
1. Proteinuria, hypoproteinemia, hyperlipidemia
2. Dependent body edema
1. Puffiness around eyes in morning
2. Ascites
3. Scrotal edema
4. Ankle edema
3. Anorexia, vomiting, and diarrhea, malnutrition
4. Pallor, lethargy
5. Hepatomegaly
4. Nursing interventions
1. Provide bed rest. 1. Conserve energy.
2. Find activities for quiet play.
2. Provide high-protein, low-sodium diet during edema phase only.
3. Maintain skin integrity.
1. Do not use Band-Aids.
2. Avoid IM injections (medication is not absorbed into edematous tissue).
3. Turn frequently.
4. Obtain morning urine for protein studies.
5. Provide scrotal support.
6. Monitor I&O, vital signs and weigh daily.
7. Administer steroids to suppress autoimmune response as ordered.
8. Protect from known sources of infection.

Acute Renal Failure

1. General information
1. Sudden inability of the kidneys to regulate fluid and electrolyte balance and remove toxic products from the body
2. Causes
1. Prerenal: factors interfering with perfusion and resulting in decreased blood flow and glomerular filtrate, ischemia,
and oliguria; include CHF, cardiogenic shock, acute vasoconstriction, hemorrhage, burns, septicemia, hypotension
2. Intrarenal: conditions that cause damage to the nephrons; include acute tubular necrosis (ATN), endocarditis, diabetes
mellitus, malignant hypertension, acute glomerulonephritis, tumors, blood transfusion reactions, hypercalcemia, nephrotoxins (certain
antibiotics, x-ray dyes, pesticides, anesthetics)
3. Postrenal: mechanical obstruction anywhere from the tubules to the urethra; include calculi, BPH, tumors, strictures,
blood clots, trauma, anatomic malformation
2. Assessment findings
1. Oliguric phase (caused by reduction in glomerular filtration rate)
1. urine output less than 400 ml/24 hours; duration 1-2 weeks
2. manifested by hypernatremia, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia, and metabolic
acidosis
3. diagnostic tests: BUN and creatinine elevated
2. Diuretic phase (slow, gradual increase in daily urine output)
1. diuresis may occur (output 3-5 liters/day) due to partially regenerated tubule's inability to concentrate urine
2. duration: 2-3 weeks; manifested by hyponatremia, hypokalemia, and hypovolemia
3. diagnostic tests: BUN and creatinine elevated
3. Recovery or convalescent phase: renal function stabilizes with gradual improvement over next 3-12 months
3. Nursing interventions
1. Monitor/maintain fluid and electrolyte balance.
1. Obtain baseline data on usual appearance and amount of client's urine.
2. Measure I&O every hour; note excessive losses.
3. Administer IV fluids and electrolyte supplements as ordered.
4. Weigh daily and report gains.
5. Monitor lab values; assess/treat fluid and electrolyte and acid-base imbalances as needed (see Tables 4.5 and 4.6).
2. Monitor alteration in fluid volume.
1. Monitor vital signs, PAP, PCWP, CVP as needed.
2. Weigh client daily.
3. Maintain strict I&O records.
4. Assess every hour for hypervolemia; provide nursing care as needed.
 1. maintain adequate ventilation.
2. decrease fluid intake as ordered.
3. administer diuretics, cardiac glycosides, and
antihypertensives as ordered; monitor effects.
5. Assess every hour for hypovolemia; replace fluids as ordered.
6. Monitor ECG and auscultate heart as needed.
7. Check urine, serum osmolality/ osmolarity, and urine specific gravity as ordered.
3. Promote optimal nutritional status.
1. Weigh daily.
2. Maintain strict I&O.
3. Administer TPN as ordered.
4. With enteral feedings, check for residual and notify physician if residual volume increases.
5. Restrict protein intake.
4. Prevent complications from impaired mobility (pulmonary embolism, skin breakdown, contractures, atelectasis; see Table
4.21).
5. Prevent fever/infection.
1. Take rectal temperature and obtain orders for cooling blanket/antipyretics as needed.
2. Assess for signs of infection.
3. Use strict aseptic technique for wound and catheter care.
6. Support client/significant others and reduce/relieve anxiety.
1. Explain pathophysiology and relationship to symptoms.
2. Explain all procedures and answer all questions in easy-to- understand terms.
3. Refer to counseling services as needed.
7. Provide care for the client receiving dialysis if used.
8. Provide client teaching and discharge planning concerning
1. Adherence to prescribed dietary regime
2. Signs and symptoms of recurrent renal disease
3. Importance of planned rest periods
4. Use of prescribed drugs only
5. Signs and symptoms of UTI or respiratory infection, need to report to physician immediately

Chronic Renal Failure

1. General information
1. Progressive, irreversible destruction of the kidneys that continues until nephrons are replaced by scar tissue; loss of renal
function gradual
2. Predisposing factors: recurrent infections, exacerbations of nephritis, urinary tract obstructions, diabetes mellitus,
hypertension
2. Medical management
1. Diet restrictions
2. Multivitamins
3. Hematinics
4. Aluminum hydroxide gels
5. Antihypertensives
3. Assessment findings
1. Nausea, vomiting; diarrhea or constipation; decreased urinary output;
dyspnea
2. Stomatitis, hypotension (early), hypertension (later), lethargy, convulsions, memory impairment, pericardial friction rub,
CHF
3. Diagnostic tests: urinalysis
1. Protein, sodium, and WBC elevated
2. Specific gravity, platelets, and calcium decreased
4. Nursing interventions
1. Prevent neurologic complications.
1. Assess every hour for signs of uremia (fatigue, loss of appetite, decreased urine output, apathy, confusion, elevated
blood pressure, edema of face and feet, itchy skin, restlessness, seizures).
2. Assess for changes in mental functioning.
3. Orient confused client to time, place, date, and persons; institute safety measures to protect client from falling out of
bed.
4. Monitor serum electrolytes, BUN, and creatinine as ordered.
2. Promote optimal GI function.
1. Assess/provide care for stomatitis
2. Monitor nausea, vomiting, anorexia; administer antiemetics as
ordered.
3. Assess for signs of GI bleeding.
3. Monitor/prevent alteration in fluid and electrolyte balance.
4. Assess for hyperphosphatemia (paresthesias, muscle cramps, seizures, abnormal reflexes), and administer aluminum
hydroxide gels (Amphojel, AlternaGEL) as ordered.
5. Promote maintenance of skin integrity.
1. Assess/provide care for pruritus.
2. Assess for uremic frost (urea crystallization on the skin) and bathe in plain water.
6. Monitor for bleeding complications, prevent injury to client.
1. Monitor Hgb, hct, platelets, RBC.
2. Hematest all secretions.
3. Administer hematinics as ordered.
 4. Avoid IM injections.
7. Promote/maintain maximal cardiovascular function.
1. Monitor blood pressure and report significant changes.
2. Auscultate for pericardial friction rub.
3. Perform circulation checks routinely.
4. Administer diuretics as ordered and monitor output.
5. Modify digitalis dose as ordered (digitalis is excreted in kidneys).
8. Provide care for client receiving dialysis.

Kidney Transplantation
1. General information
1. Transplantation of a kidney from a donor to recipient to prolong the life of person with renal failure
2. Sources of donor selection
1. Living relative with compatible serum and tissue studies, free from systemic infection, and emotionally stable
2. Cadavers with good serum and tissue crossmatching; free from renal disease, neoplasms, and sepsis; absence of
ischemia/trauma.
2. Nursing interventions: preoperative
1. Provide routine pre-op care.
2. Discuss the possibility of post-op dialysis/ immunosuppressive drug therapy with client and significant others.
3. Nursing interventions: postoperative
1. Provide routine post-op care.
2. Monitor fluid and electrolyte balance carefully.
1. Monitor I&O hourly and adjust IV fluid administration accordingly.
2. Anticipate possible massive diuresis.
3. Encourage frequent and early ambulation.
4. Monitor vital signs, especially temperature; report significant changes.
5. Provide mouth care and nystatin (Mycostatin) mouthwashes for candidiasis.
6. Administer immunosuppressive agents as ordered.
1. Cyclosporine (Sandimmune): does not cause significant bone marrow depression. Assess for hypertension; blood
chemistry alterations (hypermagnesemia, hyperkalemia, decreased sodium bicarbonate); neurologic functioning.
2. Azathioprine (Imuran): assess for manifestations of anemia, leukopenia, thrombocytopenia, oral lesions.
3. Cyclophosphamide (Cytoxan): assess for alopecia, hypertension, kidney/liver toxicity, leukopenia.
4. Antilymphocytic globulin (ALG), antithymocytic globulin (ATG): assess for fever, chills, anaphylactic shock,
hypertension, rash, headache.
5. Corticosteroids (prednisone, methylprednisolone sodium succinate [Solu-Medrol]): assess for peptic ulcer and GI
bleeding, sodium/water retention, muscle weakness, delayed healing, mood alterations, hyperglycemia, acne.
7. Assess for signs of rejection. Include decreased urinary output, fever, pain/ tenderness over transplant site, edema, sudden
weight gain, increasing blood pressure, generalized malaise, rise in serum creatinine, and decrease in creatinine clearance.
8. Provide client teaching and discharge planning concerning
1. Medication regimen: names, dosages, frequency, and side effects
2. Signs and symptoms of rejection and the need to report immediately
3. Dietary restrictions: restricted sodium and calories, increased protein
4. Daily weights
5. Daily measurement of I&O
6. Resumption of activity and avoidance of contact sports in which the transplanted kidney may be injured.

Nephrectomy
1. General information
1. Surgical removal of an entire kidney
2. Indications include renal tumor, massive trauma, removal for a donor, polycystic kidneys
2. Nursing interventions: preoperative care
1. Provide routine pre-op care.
2. Ensure adequate fluid intake.
3. Assess electrolyte values and correct any imbalances before surgery.
4. Avoid nephrotoxic agents in any diagnostic tests.
5. Advise client to expect flank pain after surgery if retroperitoneal approach (flank incision) is used.
6. Explain that client will have chest tube if a thoracic approach is used.
3. Nursing interventions: postoperative
1. Provide routine post-op care.
2. Assess urine output every hour; should be 30-50 ml/hour.
3. Observe urinary drainage on dressing and estimate amount.
4. Weigh daily.
5. Maintain adequate functioning of chest drainage system; ensure adequate oxygenation and prevent pulmonary
complications.
6. Administer analgesics as ordered.
7. Encourage early ambulation.
8. Teach client to splint incision while turning, coughing, deep breathing.
9. Provide client teaching and discharge planning concerning
1. Prevention of urinary stasis
2. Maintenance of acidic urine
3. Avoidance of activities that might cause trauma to the remaining kidney (contact sports, horseback riding)
4. No lifting heavy objects for at least 6 months
5. Need to report unexplained weight gain, decreased urine output, flank pain on unoperative side, hematuria
6. Need to notify physician if cold or other infection present for more than 3 days
 7. Medication regimen and avoidance of OTC drugs that may be nephrotoxic (except with physician approval)

Disorders of the Male Reproductive System

Epididymitis
1. General information
1. Inflammation of epididymis, one of the most common intrascrotal infections
2. May be sexually transmitted, usually caused by N. gonorrhoeae, C. trachomatis; also caused by GU instrumentation, urinary
reflux
2. Assessment findings
1. Sudden scrotal pain, scrotal edema, tenderness over the spermatic cord
2. Diagnostic test: urine culture reveals specific organism
3. Nursing interventions
1. Administer antibiotics and analgesics as ordered.
2. Provide bed rest with elevation of the scrotum.
3. Apply ice packs to scrotal area to decrease edema.

Prostatitis
1. General information
1. Inflammatory condition that affects the prostate gland abacterial chronic prostatitis
3. Acute and chronic bacterial prostatitis usually caused by E. coli, N. gonorrhoeae, Enterobacter or Proteus species, and
group D streptococci
4. Most important predisposing factor: lower UTIs
2. Assessment findings
1. Acute: fever, chills, dysuria, urethral discharge, prostatic tenderness, copious purulent urethral discharge upon palpation
2. Chronic: backache; perineal pain; mild dysuria; frequency; enlarged, firm, and slightly tender prostate upon palpation
3. Diagnostic tests
1. WBC elevated
2. Bacteria in initial urinalysis specimens
3. Nursing interventions
1. Administer antibiotics, analgesics, and stool softeners as ordered.
2. Provide increased fluid intake.
3. Provide sitz baths/rest to relieve discomfort.
4. Provide client teaching and discharge planning concerning
1. Importance of maintaining adequate hydration
2. Antibiotic therapy regimen (may need to remain on medication for several months)
3. Activities that drain the prostate (masturbation, sexual intercourse, prostatic massage)

Benign Prostatic Hypertrophy (BPH)

1. General information
1. Mild to moderate glandular enlargement, hyperplasia, and overgrowth of the smooth muscles and connective tissue
2. As the gland enlarges, it compresses the urethra, resulting in urinary retention.
3. Most common problem of the male reproductive system; occurs in 50% of men over age 50; 75% of men over age 75
4. Cause unknown; may be related to hormonal mechanism
2. Assessment findings
1. Nocturia, frequency, decreased force and amount of urinary stream, hesitancy (more difficult to start voiding), hematuria
2. Enlargement of prostate gland upon palpation by digital rectal exam
3. Diagnostic tests
1. Urinalysis: alkalinity increased; specific gravity normal or elevated
2. BUN and creatinine elevated (if longstanding BPH)
3. Prostate-specific antigen (PSA) elevated. (Normal is <4>
4. Cystoscopy reveals enlargement of gland and obstruction of urine flow
3. Nursing interventions
1. Administer antibiotics as ordered.
2. Provide client teaching concerning medications
1. Terazosin (Hytrin) relaxes bladder sphincter and makes it easier to urinate. May cause hypotension and dizziness.
2. Finasteride (Proscar) shrinks enlarged prostate.
3. Force fluids.
4. Provide care for the catheterized client.
5. Provide care for the client with prostatic surgery.

Cancer of the Prostate

1. General information
1. Second most common cause of cancer deaths in American males over age 55
2. Usually an adenocarcinoma; growth related to the presence of androgens
3. Spreads from the prostate to the seminal vesicles, urethral mucosa, bladder wall, external sphincter, and lymphatic system
4. Highest incidence is in African American men age 60 or over
5. Cause is unknown
2. Medical management
1. Drug therapy: estrogens, chemotherapeutic agents
2. Radiation therapy
3. Surgery: radical prostatectomy
3. Assessment findings: same as for BPH above but diagnostic test results are
1. Elevated acid phosphatase (distant metastasis) and alkaline phosphatase (bone metastasis)
 2. Bone scan: abnormal in metastatic areas
4. Nursing interventions
1. Administer medications as ordered and provide care for the client receiving chemotherapy
2. Provide care for the client receiving radiation therapy.
3. Provide care for the client with a prostatectomy.

Prostatic Surgery

1. General information
1. Indicated for benign prostatic hypertrophy and prostatic cancer.
2. Types
1. Transurethral resection (TUR or TURP): insertion of a resectoscope into the urethra to excise prostatic tissue; good for
poor surgical risks, does not require an incision; most common type of surgery for BPH
2. Suprapubic prostatectomy: the prostate is approached by a low abdominal incision into the bladder to the anterior
aspect of the prostate; for large tumors obstructing the urethra
3. Retropubic prostatectomy: to remove a large mass high in the pelvic area; involves a low midline incision below the
bladder and into the prostatic capsule
4. Perineal prostatectomy: often used for prostatic cancer; the incision is made through the perineum, which facilitates
radical surgery if a malignancy is found
2. Nursing interventions: preoperative
1. Provide routine pre-op care.
2. Institute and maintain urinary drainage.
3. Force fluids; administer antibiotics, acid-ash diet to eradicate UTI.
4. Reinforce what surgeon has told client/significant others regarding effects of surgery on sexual function.
3. Nursing interventions: postoperative
1. Provide routine post-op care.
2. Ensure patency of 3-way Foley.
3. Monitor continuous bladder irrigations with sterile saline solution (removes clotted blood from bladder), and control rate to keep
urine light pink changing to clear.
4. Expect hematuria for 2-3 days.
5. Irrigate catheter with normal saline as ordered.
6. Control/treat bladder spasms; encourage short, frequent walks; decrease rate of continuous bladder irrigations (if urine is not red
and is without clots); administer anticholinergics (propantheline bromide [Pro-Banthine]) or antispasmodics (B&O suppositories) as
ordered.
7. Prevent hemorrhage: administer stool softeners to discourage straining at stool; avoid rectal temperatures and enemas; monitor Hgb
and hct.
8. Report bright red, thick blood in the catheter; persistent clots, persistent drainage on dressings.
9. Provide for bladder retraining after Foley removal.
1. Instruct client to perform perineal exercises (stopping and starting stream during voiding; pressing buttocks together then
relaxing muscles) to improve sphincter control.
2. Limit liquid intake in evening.
3. Restrict caffeine-containing beverages.
4. Withhold anticholinergics and antispasmodics (these drugs relax bladder and increase chance of incontinence) if permitted.
10. Provide client teaching and discharge planning concerning
1. Continued increased fluid intake
2. Signs of UTI and need to report them
3. Continued perineal exercises
4. Avoidance of heavy lifting, straining during defecation, and prolonged travel (at least 8-12 weeks)
5. Measures that promote urinary continence
6. Possible impotence (more common after perineal resection)
1. Discuss ways of expressing sexuality (massage, cuddling)
2. Suggest alternative methods of sexual gratification and use of assistive aids
3. Discuss possibility of penile prosthesis with physician
7. Need for annual and self-exams