Chapter 37 Nursing Care of Patients with Disorders of the Urinary System

Answers CHAPTER 37 NURSING CARE OF PATIENTS WITH DISORDERS OF THE URINARY SYSTEM AUDIO CASE STUDY Maleka and Kidney Disease 1. Hypertension and diabetes. 2. Diagnostic contrast media or nephrotoxins, including certain medications, such as aminoglycosides, NSAIDs, or even the wrong blood type. 3. Check glomerular filtration rate (GFR) and serum creatinine level, ensure patient is hydrated with fluids given intravenously, and encourage fluids. 4. Arteriovenous fistula. Palpated for a thrill (a tremor), which is produced by greater blood flow through the fistula, and listened for a bruit, which is a swishing sound, to make sure it’s patent and not clotted. VOCABULARY 1. Urethritis 2. Cystitis 3. Pyelonephritis 4. urethroplasty 5. urosepsis 6. nephrolithotomy 7. hydronephrosis 8. nephrostomy 9. nephrectomy 10. nephrosclerosis URINARY TRACT INFECTIONS 1. The usual cause of urinary tract infections (UTIs) in women is contamination due to the proximity of the rectum to the urinary meatus. Women who void infrequently are predisposed to UTIs. 2. The usual cause of UTIs in men is the presence of prostatic hypertrophy, leading to obstruction of urinary flow and predisposing to infection. 3. The patient should be advised to drink up to 3,000 mL of fluid (water preferred). Also, a glass of cranberry juice daily (or blueberry products) may help. 4. The single most important thing a patient with a history of UTIs should do is void frequently to prevent stasis of urine and then infection. 5. Fatigue, confusion, and delirium are often experienced by the older adult who has a UTI. 6. See the completed table below. Cystitis Pyelonephritis Symptoms Voiding urgency; frequency; burning; cloudy, foulsmelling urine; hematuria; pelvic pain or pressure Urinalysis Results Cloudy urine, white blood cells (WBCs), bacteria, sometimes red blood cells (RBCs), positive nitrites and leukocyte esterase Good with treatment; can become chronic with repeat infections Voiding urgency; frequency; burning; cloudy, foul-smelling urine; hematuria; also, flank pain, costovertebral tenderness, high fever, chills, nausea/vomiting Cloudy urine, bacteria, WBCs, positive nitrites and leukocyte esterase, casts Prognosis Acute pyelonephritis has a good prognosis; with repeat infections, the patient can develop chronic pyelonephritis with scarring and eventual destruction of the kidneys 1 2 Chapter 37 Answers URINARY TRACT OBSTRUCTIONS 1. The most common symptom of bladder cancer is hematuria because cancerous tissue readily bleeds. 2. The most common risk factor for bladder cancer is smoking because of continual exposure of the bladder mucosa to the carcinogenic by-products of smoking. 3. The most common symptom of kidney cancer is bleeding, again because cancerous tissue bleeds readily, just as in bladder cancer. 4. The urine of a patient with an ileal conduit is cloudy because of the presence of mucus; because a portion of the small intestine is used, it continues to secrete mucus. 5. To care for a patient with an ileal conduit, an appliance is kept on at all times that either holds urine or drains into a urinary catheter bag. When the appliance needs changing, it is necessary to use a wick to catch urine until the appliance can be applied. See Box 37-1 in the main textbook for how to apply an appliance to a patient with an ileal conduit. 6. The most important care of a patient with a kidney stone is to strain all urine to identify the stone. Pain relief measures are also important. 7. The patient with a calcium oxalate kidney stone should avoid foods high in calcium, such as large quantities of milk, and sources of oxalate, such as colas and beer. It can also be helpful to keep the urine acidic. The patient with a uric acid kidney stone should avoid foods that are high in purines, such as organ meats and sardines. CRITICAL THINKING 1. Mrs. Zins is having incidences of hypoglycemia because her kidney function is declining. The kidney helps degrade insulin and excrete it from the body. As the kidneys fail, smaller amounts of insulin are needed because it is not removed from the body. 2. It is important that Mrs. Zins not receive orange juice as would normally be given for a hypoglycemic patient because her potassium level is already high. Instead, cranberry juice or another low-potassium carbohydrate source should be given. 3. Diabetes causes atherosclerotic changes in the kidney vessels. In addition, diabetes causes an abnormal thickening of the glomerulus, which damages it. The patient with diabetes is predisposed to frequent pyelonephritis (kidney infections), which can damage the kidney. Also, the patient with diabetes can develop a neurogenic bladder, which predisposes the patient to both infection and obstruction of the urinary system. 4. Good control of diabetes—that is, keeping blood sugars within a defined range—can reduce the development of diabetic complications, including chronic kidney disease (CKD). 5. Nursing diagnoses that would be relevant for Mrs. Zins include Excess Fluid Volume (she has edema, weight gain, and jugular venous distention) and Fatigue (she states she feels exhausted and has a hemoglobin level of 7.2). 6. The serum creatinine level of 5.4 is most diagnostic of CKD. A 24-hour creatinine clearance is more diagnostic, but this laboratory test is not available in this case study. 7. Mrs. Zins is anemic because her kidneys have decreased or stopped production of a substance called erythropoietin, which stimulates the bone marrow to make red blood cells. It is also possible that she has slowly been bleeding through her gastrointestinal tract, a common occurrence in patients with CKD. 8. The three most important areas to monitor when caring for a patient with CKD are daily weight, intake and output (with fluid restriction if prescribed), and laboratory test results for dangerous levels of electrolytes. 9. Mrs. Zins would probably be on a defined diabetic diet that is also low sodium, low potassium, decreased protein, and fluid restricted. If her phosphorus level was elevated, she would also be put on a low-phosphorus diet. This is one of the most restrictive diets possible and is very difficult to follow. Chapter 37 Answers 3 CHRONIC KIDNEY DISEASE Oral cavity Stomatitis Bad taste in mouth Cardiovascular system Hypertension Heart failure Arrhythmias Gastrointestinal system Anorexia Nausea Vomiting Gastrointestinal bleeding Ulcers Reproductive system Sexual dysfunction Infertility Neurological system Fatigue Depression Headache Confusion Seizures Coma Respiratory system Pulmonary edema Pulmonary effusion Dyspnea Renal system Anemia Oliguria/anuria Skin Pruritis Ecchymosis Uremic frost Dry skin Yellowish skin Musculoskeletal system Prone to fractures Fluid volume Edema REVIEW QUESTIONS—CONTENT REVIEW REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. The correct answers are in boldface. 1. (4) is correct. Hematuria is the most common symptom of cancer of the bladder. (1, 2, 3) are incorrect. Nocturia or dysuria may occur related to a resulting infection and retention may occur because of obstruction, but these are not the most common symptoms. 2. (2) is correct. A 24-hour creatinine clearance is most diagnostic of acute kidney injury; a result of 5 mL/min means that the patient has approximately 5% of normal kidney function. (1, 3, 4) would be elevated in the patient with acute kidney injury, but the creatinine clearance is most diagnostic. 3. (1) is correct. A damaged glomerulus allows protein that is not normally found in urine to leak into the urine. (2, 3, 4) are not correct. 4. (2) is correct. Beer is high in oxalate, which predisposes the patient to calcium oxalate kidney stones. (1, 3, 4) are not especially high in oxalate or calcium. 5. (4) is correct. Mucus is normally found in the urine of a patient with a urostomy (ileal conduit). This is because a portion of the small bowel is used to make the conduit, and the bowel continues to secrete mucus. (1, 2, 3) are not necessary since the finding is normal. 6. (3) is correct. The most obvious sign of acute kidney injury in those who develop oliguria is a decrease in urine output. (1) is incorrect. The blood pressure may elevate not decrease later as the patient continues into kidney disease. (2, 4) may occur in some patients, but they are not common or most significant. 4 Chapter 37 Answers 7. (4, 5) are correct because they are the only foods listed that do not contain significant potassium. (1, 2, 3) are all high in potassium. 8. (4) is correct because there is a sudden decrease in urine output, and the patient has symptoms of urinary retention, which are distention and pain in the suprapubic area. (1) is incorrect. Decreased renal perfusion would be an appropriate answer if the patient had not had symptoms of urinary retention. (2, 3) would not cause the symptoms of urinary retention. 9. (3) is correct. The patient should collect the specimen partway through urination. (1, 2, 4) are all relevant to other diagnostic tests of the urine but are not relevant to a midstream culture. 10. (2) is correct. The most serious complication of a high potassium level is cardiac arrhythmias. (1, 3, 4) may be present in chronic kidney disease but are not associated with high potassium levels. 11. (3) is correct. The daily weight is the single best determinant of fluid balance in the body. (1, 2, 4) are also important, but daily weight remains most significant. 12. (2) is correct. Orange juice is high in potassium, and the patient’s potassium level is already high. (1, 3) would still give the patient too much potassium. (4) is incorrect. It would be important to check the type of diet later, but the first priority is to protect the patient from more potassium intake. 13. (1, 5) are correct because a fistula provides greater blood flow, making dialysis more efficient and has less risk of infection since it is under the skin. (2) is incorrect. All blood access sites can clot. (3) is incorrect. It is harder to access a fistula than a two-tailed subclavian. (4) is incorrect. Either site can be damaged by trauma. 14. (2, 4, 5) are correct. The patient must be weighed following dialysis to determine fluid loss during dialysis, and vital signs are obtained to determine patient stability. After dialysis, the patient is very tired and usually needs to sleep. (1, 3, 6) are not relevant at this time. 15. (2) is correct because this is the mechanism by which peritoneal dialysis works. (1, 3, 4) do not describe how peritoneal dialysis works. 16. (3, 4, 5, 6) are correct because these are signs and symptoms that are seen with fluid retention and skin issues from urea buildup related to untreated kidney disease. (1, 2) are not symptoms of fluid excess and chronic kidney disease. 17. (4) is correct. Hematuria is the most common symptom of trauma to the kidney because the kidney has a very large blood supply. (1, 2, 3) are not symptoms of trauma to the kidneys. 18. (2) is correct because the patient has symptoms of too much fluid in the body, which is excess fluid volume. (1, 3, 4) are not relevant. 19. (4) is correct. The daily weight is the single best determinant of fluid balance in the body. (1, 2, 3) are not correct. 20. (1, 4, 6) are correct because they ensure patency and prevent damage to arteriovenous fistula. (2, 3) are not necessary, as the arteriovenous fistula is under the skin. (5) is incorrect. Lab draws are avoided on the arm with the arteriovenous fistula.