Adult - Urinary

Clients receiving peritoneal dialysis should be monitored carefully for signs and symptoms of
respiratory compromise, including difficulty breathing, rapid respirations, and crackles. That can
result from instilling the dialysate too rapidly, overfilling of the abdomen, or fluid entering the
thoracic cavity.

Dialysis disequilibrium syndrome (DDS) is a complication of hemodialysis (HD) characterized by

cerebral edema that occurs during or immediately following a client's initial dialysis treatment.
Because the manifestations of DDS (eg, vomiting, headache, restlessness, confusion) and HD-
induced hypotension (eg, nausea, vomiting, chest pain) can be similar, the priority nursing action is
to check the client's blood pressure.

Creatinine clearance is a measure of the glomerular filtration rate. For a 24-hour urine collection,
the first urine specimen is discarded; then all other voided urine for the next 24 hours is collected in
a container.

The kidneys regulate fluid volume and blood pressure. Because renal damage often results in
elevated blood pressure, clients with chronic kidney disease are at risk for uncontrolled
hypertension and hypertensive emergencies. Nausea, vomiting, and headache could be signs of a
hypertensive crisis and require immediate further assessment.

A cystoscopy is a procedure that uses a flexible fiber-optic scope inserted through the urethra into
the urinary bladder with the client in the lithotomy position. Complications associated with
cystoscopy include urinary retention, hemorrhage, and infection.
Clients can expect pink-tinged urine, frequency, dysuria, and abdominal discomfort for up to 48
hours after cystoscopy. They are instructed to increase fluid intake, avoid alcohol and caffeine, take
a mild analgesic and tub/sitz bath to relieve discomfort, and notify the HCP immediately of inability
to void, gross hematuria, blood clots, fever, chills, or severe pain.

Acute pyelonephritis is an infection of the kidney usually caused by an extension of infection from
the lower urinary tract (bladder). Chills and fever, vomiting, flank pain, and costovertebral
tenderness are characteristic. The priority of care for acute pyelonephritis is to obtain blood and
urine cultures before initiating antibiotic therapy whenever possible.

When caring for a client with renal calculi, the nurse should provide adequate analgesia for pain,
encourage increased fluid intake, and assist with ambulation as tolerated to promote clearance of
calculi. All urine should be strained to retrieve any stones for analysis to determine preventive
measures.

The normal urine specific gravity value ranges from 1.003 to 1.030. Causes of increased specific
gravity include fluid deficit. The presence of a few (0-5 per high power field) WBCs on urinalysis is
normal.

Hyperkalemia alters the electrical signal that conducts the heart, causing tall, peaked T waves and
prolonged PR intervals (early signs). As hyperkalemia worsens, P waves become diminished or
absent and the QRS complex widens, leading to lethal ventricular dysrhythmias (eg, ventricular
fibrillation, ventricular tachycardia) and/or asystole.
Impaired kidney function increases the risk for hyperkalemia (>5 mEq/L [5 mmol/L]) because
potassium is normally excreted by the kidneys.

Pain in pyelonephritis is dull, constant, and maximal at the costovertebral angle area. Pain from
renal stones is excruciating, sharp, and often radiates toward the groin from the flank. Suprapubic
pain indicates bladder distension or cystitis. Spasms can be seen with infection (cystitis) or
manipulation of the bladder.

Urinary retention is common after surgical intervention, often caused by anesthesia, opioid
medications, edema from lower abdominal/pelvic surgeries, and outlet obstruction. Appropriate
interventions include performing a bladder scan, ambulating to the bathroom, encouraging oral fluid
intake, running the sink water, and performing intermittent urinary catherization as prescribed.
The flow of urine is dependent on gravity. The drainage bag should be hung below the level of the
bladder to maintain gravity flow.

Arteriovenous fistula (AVF) is a permanent hemodialysis access surgically created by connecting

an artery to a vein, typically in the forearm or upper arm. This anastomosis diverts arterial blood
into the vein, which increases intravenous blood flow and causes the vein to thicken and expand (ie,
"mature"). The matured AVF can then sustain frequent access by large-bore needles during
hemodialysis. Arterial steal syndrome is a complication of arteriovenous fistula (AVF) creation that
impairs distal extremity perfusion and may result in tissue ischemia and necrosis. Symptoms
include skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill distal to the
AVF.
Following placement of an arteriovenous fistula, it is imperative to monitor for signs of potential
clotting of the fistula such as absence of a bruit or thrill, decreased capillary refill, and numbness or
tingling of the extremity.

Nursing interventions related to stress incontinence include bladder training (eg, voiding every 2
hours (priority)), pelvic floor exercises (eg, Kegel exercises), lifestyle modifications (weight loss,
reduction of dietary bladder irritants, smoking cessation), and incontinence products.

Stoma care involves frequent nursing assessment for signs of potential complications such as
impaired perfusion, infection, and wound dehiscence. The stoma should be pink to brick-red and
moist. If the stoma is dusky or any shade of blue, the nurse should suspect impaired perfusion and
contact the HCP immediately.

Overflow urinary incontinence occurs due to compression of the urethra (eg, uterine prolapse,
prostate enlargement) or impairment of the bladder muscle (eg, spinal cord injury, diabetic
neuropathy, anticholinergic medications).

When caring for clients with overflow incontinence, the nurse should implement a fixed voiding
schedule, teach the client techniques that assist with bladder emptying (eg, Valsalva maneuver (ie,
"bearing down") and Credé maneuver (ie, gently applying pressure to the lower abdomen), double
voiding), monitor for perineal skin breakdown, and measure postvoid residual volumes as
prescribed.
Insufficient outflow from peritoneal dialysis commonly results from constipation; bowel movements
should be monitored and stool softeners administered as prescribed. Additional nursing measures
include checking the tubing for kinks or clots; maintaining the drainage bag below the abdomen;
and placing clients in a side-lying position or assisting with ambulation.

Acute nephrolithiasis (ie, kidney stones) is the presence of solid deposits composed of salts and
minerals that form in the kidney and travel through the genitourinary system, often causing an
obstruction in the ureters. Clinical manifestations include hematuria, tachycardia, nausea, vomiting,
and pain that radiates to the groin.

Poststreptococcal glomerulonephritis (PSGN) is a noninfectious kidney disease that occurs when

immune complexes are deposited in the glomeruli following infection with certain strains of group A
beta-hemolytic Streptococcus, resulting in decreased glomerular filtration. Clinical manifestations
of PSGN can occur up to 6 weeks after the initial infection and include hematuria, proteinuria,
tachycardia, nausea, and vomiting.

Clients with poststreptococcal glomerulonephritis (PSGN) are at risk for pulmonary edema. PSGN
causes decreased glomerular filtration, resulting in systemic sodium and fluid retention. Pulmonary
edema can occur as fluid backs up into the systemic circulation and the lungs.

Findings consistent with acute nephrolithiasis include the presence of stones in the genitourinary
tract and positive RBCs, pink-tinged urine, and sediment on urinalysis. Large stones (ie, >5 mm)
are difficult to pass in the urine and can cause obstruction, increasing risk for pyelonephritis.

Management of acute nephrolithiasis includes administering pain medication (eg, ketorolac,

opioids) and antiemetics (eg, ondansetron) to alleviate nausea and vomiting. The nurse should
strain the client's urine to monitor for the spontaneous passage of the kidney stone.
Kidney stones should be collected and evaluated to identify the stone and the cause of its
formation. Identifying the cause will help prevent future stone formation. The nurse should assess
the client's diet because dietary and supplement recommendations are specific to the type of
stone.

Discharge teaching for a client with a history of calcium oxalate kidney stones includes engaging in
regular physical activity, limiting intake of high-oxalate foods (eg, spinach, potatoes, tofu), and
drinking 2-3 L of water per day. Sodium, not calcium, should be restricted in diet.

Physical assessment of the renal system includes the techniques of inspection, auscultation,
percussion, and palpation, in that order. Allow the client to empty the bladder before beginning the
assessment and auscultate immediately after inspection as percussion or palpation may increase
bowel motility and interfere with sound transmission during auscultation. Always document the
findings.

Common causes of metabolic acidosis include:

● GI bicarbonate losses (eg, diarrhea)
● Ketoacidosis (eg, diabetes, alcoholism, starvation)
● Lactic acidosis (eg, sepsis, hypoperfusion)
● Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt)
● Salicylate toxicity

Hemodialysis (HD) removes excess fluid and electrolytes by filtering the client's heparinized blood
through a dialyzer. Hypotension is common, requiring frequent blood pressure measurements and
the withholding of blood pressure medications prior to HD. Blood pressure is measured on the arm
opposite the arteriovenous fistula or graft. Anticoagulants (eg, heparin) are used to prevent the
blood from clotting in the dialyzer. Dietary and fluid restrictions may be required to decrease risk for
fluid volume overload and electrolyte imbalances (eg, hyperkalemia, hypernatremia) between
treatments
Administration of IV 50% dextrose and regular insulin rapidly corrects an elevated serum potassium
level by shifting potassium intracellularly. If the client has ECG changes from hyperkalemia, calcium
gluconate should be given first to stabilize cardiac muscle.

The priority in treatment of hyperkalemia with ECG changes (eg, peaked T waves) is administration
of intravenous calcium gluconate to prevent life-threatening dysrhythmias. Once calcium gluconate
is administered, prescriptions to correct serum potassium (eg, intravenous regular insulin with
dextrose, sodium polystyrene sulfonate, hemodialysis) may be implemented.

Clients with chronic kidney disease have high phosphorus levels as the kidney is unable to filter the
phosphate from the body; dialysis also does not filter it. Therefore, the client should still take
phosphate binders prior to dialysis. Phosphate binders (eg, calcium containing [calcium carbonate
and calcium acetate]) and non-calcium containing [sevelamer and lanthanum]) block absorption of
ingested phosphate from the intestine and excrete it through feces.

Unless otherwise indicated by the health care provider, antihypertensives and other blood pressure-
lowering medications (eg, furosemide), antibiotics, digoxin, and water-soluble vitamins (B, C, and
folic acid) should be held prior to dialysis.

NPO status preoperatively, dehydration, intraoperative fluid losses, antibiotic therapy, and advanced
age can negatively affect renal function. An elevated serum creatinine level preoperatively
increases the risk for postoperative kidney injury.

Prostatectomy uses either minimally invasive or open surgical techniques to remove all or part of
the prostate. Signs of complications (eg, reduced stream, persistent bleeding/blood clots,
retention, fever, dysuria) after discharge should be evaluated by the health care provider for further
treatment.

Painless hematuria is the most common presenting symptom of bladder cancer. Cigarette
smoking or other tobacco use is the primary risk factor.

A pessary is a vaginal support device recommended for pelvic organ prolapse. Pessaries are fitted
by an HCP; many clients can then remove, clean, and replace these themselves. Clients can remain
sexually active with a pessary in place.

Following extracorporeal shock wave lithotripsy, the client should increase fluid intake and ambulate
frequently to facilitate passage of the stone fragments. Expected side effects include hematuria as
well as bruising and pain of the back and/or flank. Urine color should progress from bright red to
pink-tinged during the first several hours.

Confusion is a common clinical manifestation of UTI in the elderly; however, it is still a cause for
concern and should be evaluated further by the nurse.

Some causes of confusion in the elderly include dehydration, lack of blood flow to the brain
(stroke), decreased ability to metabolize medications, and concurrent infections.

Benign prostatic hyperplasia (BPH) occurs with increasing age (usually in men age >50) and is often
undiagnosed until voiding difficulties and abnormalities are observed. Typical BPH symptoms
include acute urinary retention, voiding urgency, incomplete emptying, straining to void, weak
urinary stream, urinary frequency, and nocturia.

Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration (hypernatremia, elevated
BUN) can impair wound healing.

Peritonitis is a major complication of peritoneal dialysis. Signs of developing peritonitis are low-
grade fever, tachycardia, and cloudy outflow (effluent). Bloody effluent can indicate intestinal
perforation or that the client may be menstruating.

Peritoneal dialysis (PD) uses the peritoneum as a semipermeable membrane to dialyze clients with
decreased kidney function. Bacterial peritonitis is a potential complication of PD. Using sterile
technique when spiking or changing bags of dialysate is a priority to avoid contamination and
reduce the risk of peritonitis.

The diet for a client with chronic kidney disease may need to be restricted in fluids, sodium,
potassium, and phosphorus. Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas,
oranges, coconuts, watermelons, and avocados) contain high potassium levels. Dairy products are
also high in phosphorus.

The use of indwelling urinary catheters should be minimized during hospitalization. Appropriate
use includes urinary obstruction or retention, some perioperative circumstances, required
prolonged immobilization, end-of-life comfort, and facilitating healing of an open perineal or
sacral wound. Indwelling urinary catheters should not be used for convenience or as a substitute
for nursing care.

Residual urine volume of >100 mL on bladder scan may indicate urinary retention. Urine culture
showing values >10,000 organisms/mL can suggest UTI. Burning sensation is common after
cystoscopy. Renal arteriogram is performed with a contrast agent; excretion of the dye with oral
and intravenous hydration is recommended to prevent kidney injury.

Urge incontinence (ie, overactive bladder) occurs when the bladder contracts randomly, causing a
strong, sudden urge to urinate followed by urine leakage. Expected interventions include
administering antispasmodics, avoiding bladder irritants (eg, smoking, alcohol), performing pelvic
floor exercises, and using bladder training techniques (eg, timed voiding).

Benign prostatic hyperplasia is characterized by prostate enlargement that causes difficulties with
voiding. Treatment includes tamsulosin, urinary catheterization for severe retention, and behavioral
modifications (eg, urinating sitting down, relaxation techniques). Erectile dysfunction is an adverse
effect of tamsulosin.

A percutaneous nephrolithotripsy is a procedure to remove large kidney stones from the renal
pelvis. Post procedure, a nephrostomy tube may be placed to prevent obstruction by stone
fragments and to promote healing of injured tissue. Gentle irrigation of the nephrostomy tube with
sterile normal saline may be necessary to maintain tube patency.