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MedSurg Chapter 66 Outline
MedSurg Chapter 66 Outline
MedSurg Chapter 66 Outline
Priority concepts applied in this chapter are ELIMINATION, PAIN, INFECTION, and INFLAMMATION.
The components of the urinary system are the ureters, bladder, and urethra.
With problems in the urinary system, homeostasis of fluids, electrolytes, nitrogenous wastes, storage
or ELIMINATION of urine, and blood pressure is disrupted.
Although life-threatening complications are rare, patients may have significant functional, physical,
and psychosocial changes that reduce quality of life.
Nursing interventions are directed toward prevention, detection, and management.
Bladder
Internal urinary Sphincter: Involuntary
External Urinary Sphincter: Voluntary
Rugae: When the bladder is empty there is a lot of folds. As the bladder fills rugae
disappear.
Urinary Incontinence
Continence is a learned behavior to control the time and place of urination and is
unique to humans and some domestic animals.
Efficient bladder emptying from coordination between bladder contraction and
urethral relaxation is needed for continence.
Not a normal part of aging
The SNS and PNS work together to help with bladder control and storage.
Incontinence occurs any time there is a disconnect between the brain, spinal cord and
sphincters.
Related to: Surgery, Brain or spinal cord injury, diseases, drugs
Functional Incontinence caused by factors other than disease of the lower Urinary T.
common in PT’s with Dementia
Causes of functional or chronic intractable incontinence vary greatly, so
the focus of intervention is treatment of reversible causes.
Other interventions
o MEDS: Generally used for incontinence: TCA’s, Alpha Adrenergic Blockers,
Beta 3 Blockers,
o Training:
Bladder Training: PT who are alert, teaching them to void at certain
intervals
Habit training: PT’s who are confused, you can’t teach them, so you help
them instead Scheduled toileting times.
o Strengthening Pelvic Muscles
Kegel Exercises: Tighten pelvic muscles for a count and then relax takes
weeks to notice improvement
Pessary: Small divice helps to reposition the pelvic organs something that
is worn inside
Cone Therapy: Weighted cones you wear for 15 min 2x day then move to
heavier cone
Surgery as a last resort
The Goal with incontinence is to prevent or stop that leakage, stop skin breakdown, odder
control.
Assess the abdomen to estimate bladder fullness, to rule out palpable hard stool, and to
evaluate bowel sounds.
With a physician’s order, determine the amount of residual urine by portable ultrasound
or catheterizing the patient immediately after voiding.
In women, inspect external genitalia to determine whether there is apparent urethral or
uterine prolapse, cystocele, or rectocele with pelvic floor muscle weakness.
Imaging is rarely needed unless surgery is being considered.
Infections of the lower urinary tract and kidneys are common, especially among women
(50% of Women in her life time)
Urinary tract INFECTION (UTI) is the most common health care–associated INFECTION.
UTIs are described by their location in the tract.
Acute infections in the lower urinary tract include urethritis, cystitis, and prostatitis,
while acute pyelonephritis is an upper urinary tract infection.
The site of INFECTION and type of bacteria or other organism determines treatment.
Care with catheters
Women: age lose estrogen decreases moisture leads to dryness cracks and tears that
cause infection
Elderly &UTI: Affects mental status (delirium) more prone to falls and confusion.
Meds:
o Trimethoprim Bactrim ( sulfa drug): ask about allergies, Drink 3 L/day because it
can form crystals
o Ciprofloxin Antibiotics, Amoxicillin
o Phenazopyridine Prodium (Analgesic): orange urine
o Antispasmodics to control bladder spasms
Urethritis
Urolithiasis
Urolithiasis is the presence of calculi or stones in the urinary tract.
Stones often do not cause symptoms until they pass into the lower urinary tract, where
they can cause excruciating PAIN.
Commonly found in the Kidneys. Nephrolithiasis is stones in the kidney and
ureterolithiasis is stones in the ureter.
Composed of calcium mostly caused by Calcification.
Symptoms: Pain,
Nutrition
patients are encouraged to drink lots of fluids and eat lots of fruits and
vegetables, a low amount of protein, and a balanced intake of calcium, fats,
and carbohydrates. Foods high in oxalate stay away: Spinach, Okra, Beats
Types of stones:
Calcium Oxalate
Struvite
Uric Acid: Develop more in PT with GOUT
Cystine
Staghorn
Assessment
The major manifestation of stones is severe PAIN commonly called renal colic, most
intense when the stone is moving or when the ureter is obstructed.
Oliguria or anuria suggests obstruction, possibly at the bladder neck or urethra.
Urinary tract obstruction is an emergency and must be treated immediately to preserve
kidney function.
Stones are easily seen on x-rays of the kidneys, ureters, and bladder; IV urograms; or CT
Nursing interventions:
Causes
The higher the stone the harder to pass, causes permanent damage you need to
intervene,
PT might have Hematuria because of trauma
WBC elevated because of urinary stasis
Check for what causes the narrowing of the tube
Urinary Diversion
Tumors confined to the bladder mucosa are treated by simple excision, whereas those that
are deeper but not into the muscle layer are treated with excision plus intravesical
chemotherapy.
Complete bladder removal with additional removal of surrounding muscle and tissue
offers the best chance of a cure for large, invasive bladder cancers.
Chemotherapy and radiation therapy are used in addition to surgery.
Assess the patient’s coping methods and available support from family members. Social
support may provide motivation and improve coping during recovery from treatment.
Bladder Trauma