Care of Clients with Genito-Urinary Disorders

Diagnostic Assessments
1. Urine examination or analysis
a. Routine- midstream first voided urine
b. Sterile or catheterized
c. 24 hours- collection starts at second voided urine
d. Residual

2. Blood examination or chemistry
a. CBC
b. BUN (10-20 mg/dL)
c. Creatinine (0.4 1.2 mg/dL)
d. Uric acid (2.5 8 mg/dL)
e. Electrolytes

3. Radiologic
a. KUB (Kidneys, Ureters, Bladder)- identifies number and size of kidney, ureters, bladder, tumors,
malformation,. Calculi
b. IVP (Intravenous Pyelography)- fluoroscopic visualization of kidney after dye injection via IV
c. Cystography or cystoscopy
Prep- NPO 6-8 hrs with premedications like nubain, valium
d. PSP (phenolsuphthalein)- checks the secretory ability of the kidneys; urine expected to be red
e. Renal angiography
f. Percutaneous renal biopsy

Urinary Tract Infection (UTI)

Classifications:
1. Upper UTIs are known as Pylonephritis.
2. lower UTIs:
a. ______________________
b. Cystitis.
c. ______________________
Women develop UTI more than men because their shorter urethras.

Predisposing Factors:
1. Sexual intercourse.
2. _________________________
3. _________________________
4. Urinary tract instrumentation.
5. Metabolic disorders.

Clinical Manifestations:
1. Upper UTIs:
a. Chills, fever.
b. Malaise.
2. Lower UTIs:
a. Back pain .
b. Blood in the urine (hematuria).
c. Cloudy urine.
d. Inability to urinate despite the urge.

Prevention:
1. Avoid products that may irritate the urethra (e.g., bubble bath, scented feminine products).
2. ________________________________________________________________________
3. Change soiled diapers in infants and toddlers promptly.
4. Drink plenty of water to remove bacteria from the urinary tract.
5. ________________________________________________________________________
6. Take showers instead of baths.
7. __________________________________________
8. Women and girls should wipe from front to back after voiding to prevent contaminating the
urethra with bacteria from the anal area.

Urolithiasis

Urolithiasis: The process of forming stones in the kidney, bladder, and/or urethra (urinary tract).
Etiology:
1. Immobility.
2. Hypercalcemia.
3. UTIs.

Clinical Manifestations:
1. Renal colic.
2. Nausea and vomiting accompanying severe pain.
3. Fever and chills.

Diagnostic tests:
1. _________________reveals visible calculi.
2. _________________ determines size and location of calculi.
3. Renal Ultrasonography reveals obstructive changes.

Nursing Management:
a. ________________________________
b. Crush all clots
c. Force fluids ______________day
d. Encourage ambulation to prevent stasis
e. Relieve pain by analgesics or moist heat
f. I and O

Classification of Stones:
a. Acid stones- uric acid, Xanthine
b. Alkaline stones- phosphate, oxalate

Nursing Management:
1. Modified diet
a. Alkaline ash- vegetables, fruits, except prunes, plums and cranberries
b. Acid ash- cranberries, prunes and plums, meat fish, eggs, whole grain; limit milk

2. Allopurinol or zyloprim- decrease uric acid production; enhance excretion of uric acid
3. Lithotripsy- crushing of stone
a. ESWL- Extracorporeal Shock Wave Lithotripsy
4. Surgery
a. Pyelithotomy,
b. Nephrolithotomy,
c. Utero-lithotomy,
d. Cystolithotomy

Benign Prostatic Hypertrophy
The hyperplasia and overgrowth of smooth muscles and connective tissues of the prostate gland; most common
problem of male reproductive system

Incidence: 50% men over 50; 75% men over 75

Cause: hormonal mechanism
Signs and Symptoms- nocturia, frequency, decrease force and amount of urinary system, hesitancy, hematuria,
increased alkaline phophatase
Nursing mgt:
a. Antibiotics
b. Proscar

Surgical Intervetions:

TURP Suprapubic
Prostatectomy

Retropubic
Prostatectomy

Perineal
Prostatectomy

Incision LOWER
ABDOMINAL
LOWER
ABDOMINAL
Perineal
Bladder
involvement
NONE NONE NONE

Sterility YES YES YES YES
Impotence,
Incontinence

NO NO NO
REMARKS



Nursing Care in Cystolysis (CBI- Continuous Bladder Irrigation):
a. Maintain patency of the catheter system
b. Monitor appearance of urine; _____________(24hrs) to ______________________(3days)
c. Monitor for signs of water intoxication; prevent water intoxication by using saline solution
d. Avoid enemas and rectal temperature

a. Use prescribed medications like analgesics and antispasmodics
b. After catheter removal, monitor output for signs of urinary retention; monitor for continence; perineal
exercise (Kegels) if with dribbling; encourage frequent voiding and increased fluid intake

Renal Failure
- state of total or nearly total loss of kidney function

Acute Renal Failure- sudden inability of the kidneys to regulate fluid and electrolyte balance and remove toxic
products from the body

Causes:
a. Pre-renal- factors interfering with perfusion and resulting in decreased blood flow
b. Intra-renal- conditions that cause damage to nephrons
c. Postrenal- mechanical obstruction from tubules to urethra

Phases:
1. Onset- period precipitating event to development of oliguria
2. Oliguria ( to anuria)- urinary output less 400ml
3. Diuretic- gradual return of GFR and BUN level
4. Convalescent- renal function stabilizes with gradual improvement in 3-12 months

Signs and Symptoms:
a. oliguria to anuria
b. edema
c. anorexia
d. nausea or vomiting
e. Leukocytosis

Nursing Management
a. Fluid and nutrition
b. Low protein diet
d. Precautions: side rails up
e. Mouth or skin care
g. Dialysis

Chronic Renal Failure- progressive irreversible destruction of kidneys that continues until nephrons are replaced
with scar tissues
Predisposing Factors: recurrent infections, exacerbations of nephritis, urinary tract obstructions, diabetes,
hypertension

Stages of Chronic Renal Failure

Stage 1: Reduced Renal Reserve

Stage 2: Renal Insufficiency

Stage 3: End-Stage Renal Disease

Signs and Symptoms:
a. Electrolyte imbalance
b. Cardiovascular
c. Hematologic- anemia, decreased ______________, increased hematocrit and bleeding tendencies
d. Gastro-intestinal- ______________________________________
e. Respiratory- fluid overload, pulmonary edema: ___________________
f. Orthopedic- increased Ca elimination, decreased serum Ca, _____________________________
g. Dermatological- excoriation or dry skin, ___________________
h. Neurologic- ____________________, burning feet; CNS nystagmus, twitching, seizure
i.Reproductive-menstrual irregularities;_____________, testicular atrophy and decreased sperm count
j. Psychological- behavioral and personality changes
k. impaired immunologic system

Nursing Management:
1. Conservative- assess uremia, mental function and supportive; avoid undue fatigue
2. Advanced renal failure- oliguric or uremic phase
a. peritoneal dialysis
b. hemodialysis
c. kidney transplant
3. Dietary- early- no restriction
- advanced- low protein

Dialysis- removal by artificial means of metabolic wastes, excess electrolytes and excess fluids
Principles:
-Diffusion, Osmosis, Ultrafiltration
Purposes:
1. To remove excessive amounts of drugs or toxins in poisoning
2. To check serious electrolyte or acid base imbalance
3. To maintain kidney function when renal shutdown occurs
4. To temporarily replace kidney function in patients with acute renal failure and permanently replace in chronic
renal failure

Hemodialysis- shunting of blood from clients vascular system through an artificial dialyzing system and return
of dialyzed blood to clients circulation
___________________- acts as a semipermeable membrane
Access Routes:
AV shunt or cannula
AV fistula
Femoral or subclavian cannulation

Nursing Interventions:
1. Auscultate for bruit and palpate thrill- check patency
2. Check bleeding
3. Observe arm precaution
4. Avoid restrictive clothing or dressings over site

Complications:
1. Hypovolemic Shock
2. Dialysis disequilibrium syndrome

Peritoneal Dialysis- introduction of specially prepared dialysate solution into the abdominal cavity where the
peritonem acts as a semipermeable membrane between the dialysate and blood in the abdominal vessels

Nursing Interventions:
a. weight, VS every 15 mins then every hour
b. Patient voids
c. Warm dialysate solution to body temperature
d. Assist in trocar insertion
e. Inflow time, Dwell time and Drain time
f. Observe character of dialysate flow

Types of Peritoneal Dialysis
CAPD- Continuous Ambulatory Peritoneal Dialysis
CCPD- Continuous Cycle Peritoneal Dialysis
IPD- Intermittent Peritoneal Dialysis


Acute Glomerulonephritis

Types:
1. Postinfectious:
2. Rapidly progressive glomerulonephritis:
3. Membranous glomerulonephritis

Preceded (10 days) by an infection
Assess for:
Lesions
Signs of circulatory overload
Interventions:
Treat cause: antibiotics, corticosteroids, immunosuppressants
Restrict sodium, water, potassium, protein

Chronic Glomerulonephritis

20-30+ years to develop
Diagnostics:
Urine with fixed specific gravity, casts, and proteinuria
Electrolyte imbalances
Causes:
______________________________________________________________________
Manifestations:
Mild proteinuria and hematuria, hypertension, and occasional edema

Nephrotic Syndrome
Increased glomerular permeability
Severe loss of protein into urine
Treatment:
Immunosuppresive agents
ACE Inhibitors
Heparin

CARE OF CLIENTS WITH SHOCK

SHOCK - a condition of profound hemodynamic and metabolic disturbance due to inadequate blood flow and
oxygen delivery to the capillaries and tissues of the body

Must know in understanding SHOCK well:
Cardiac Output : _______________________________________________________________
_____________________: There should be adequate amount of blood for the heart to pump around the body
_____________________________________: Blood vessels must have good tone with the ability to constrict
or dilate depending on the demands of the body
________________________: the amount of blood that the ventricle contains after diastolic filling
___________________: The amount of resistance needed to be overcome to promote ventricular ejection
Mechanisms on Maintaing Circlatory Homeostasis:
a.) Autonomic Response of the Body (Interplay of catecholamines : Epinephrine and Norepinephrine)
b.) Renin-Angiotensin-Aldosterone Mechanism
c.) Interplay of the Anti-diuretic hormone

CLASSIFICATIONS OF SHOCK
1. Hypovolemic =This results from excessive blood loss, loss of body fluids or third spacing of fluids leading to a
sudden decrease of circulating blood volume.
Cause: Blood loss
2. Cardiogenic Shock =This results from severely decreased cardiac output
Cause: Decreased cardiac output
3. Distributive shock=This results from profound and massive vasodilatation that leads to the disproportion
between the size of vascular space and the amount of blood contained in it.
4. Neurogenic shock=results from loss of vasomotor tone that includes generalized arteriolar and venous
dilatation; Affects the medulla of the Adrenal Gland and the Sympathetic Nervous System
Cause:____________________________________________________________________________________
5.Septic shock=results from a severe and profound condition of generalized vascular collapse secondary to a
systemic infection
6. Anaphylactic shock=There is a profound peripheral vascular collapse induced by severe allergic reactions,
mediated by Inflammatory mediators (e.g. Histamines, Bradykinins, Leukotrienes and Prostaglandins). ; Large
quantities of fluid may leak out of the capillaries due to increased capillary permeability and vasodilatation that
occurs with the inflammatory process, thus leading to Hypovolemia

STAGES OF SHOCK
I. INITIAL STAGE
This is also known as Compensated Stage of Shock
Body Compensatory Mechanisms are activated in order to maintain circulatory homeostasis:
Interplay of the Sympathetic Nervous System
Catecholamines :adrenaloine and epinephrine causing Increased heart rate, increased respiratory rate and
vasoconstriction to increase PVR leading to increased BP
Operational within seconds to minutes
o Renin-Angiotensin-Aldosterone Mechanism
RAAS causes sodium reabsorption in the juxtaglomerular site of the kidneys, leading to sodium retention in the
blood. Sodium in the blood attracts water causing a passive reabsorption of water ino the blood increasing the
blood volume
o Activation of the Anti-diuretic Hormone
ADH causes water reabsorption in the distal conculuted tubules of the kidneys increasing water in the blood,
thus increasing blood volume.
Assessment:
Restlessness, Confusion
Increased Pulse rate and Respiratory Rate
Diaphoresis
Normal or decreased Blood Pressure
Decreased Pulse Pressure

II. LATE SHOCK=a.k.a. Decompensated or Progressive Shock
In this condition, body compensatory mechanism fails and is unable to meet up demands of the body; Failure to
promote circulatory homeostasis; Leads to Multiple Organ Damage due to insufficient blood supply to major
organs of the body

KIDNEYS: This happens when the systolic blood pressure drops to 60 mmHgdecreased blood to
kidneysDecreased glomerular filtration _________ and retention of ________________________;
Acute Tubular Necrosis happens due to insufficient amount of blood to the kidneysComplication: RENAL
FAILURE

BRAIN=Decreased tissue Perfusion leads to decreased LOC;
HEART=Decreased tissue perfusion to the heart may lead to infarction and ____________

GI TRACT=decreased blood supply to the GI tract causes decrease in peristalsis that may progress to
______________________Lysis of Microorganisms may occur due to destruction of Kuppfer cells that may
have resulted from decreased blood supply to the liver. This leads to massive release of ____________causing
Septic Shock.

Assessment:
Shallow respirations
Increased Pulse Rate
Hyperkalemia
Edema
Decreased bowel sounds
Dilated pupils

PARAMETERS FOR ASSESSING STATUS OF CLIENT IN SHOCK
1. HEMODYNAMIC MONITORING
a. Blood Pressure
b. Pulse
c. Central Nervous System
2. RESPIRATORY MONITORING
a. Respiratory rate, depth, rhythm and effort
b. Blood gases (pH, pCO2, pO2)
3. FLUID-ELECTROLYTE MONITORING
a. Urine Specific Gravity
b. Serum Electrolytes
c. Blood Lactate levels
d. NEUROLOGIC MONITORING= Alertness, Orientation and Confusion
4. HEMATOLOGIC MONITORING
a. RBC
b. Hematocrit, hgb levels
c. WBC

MEDICAL MANAGEMENT
1. Administration of Fluids, Whole Blood and Blood products
a.) Whole Blood = Consists of blood cells (RBC), plasma, plasma proteinsand approximately _60__mL
anticoagulant/preservative solution in a total volume of approximately ______500___mL
Indication : ____________mL blood loss, when oxygen carrying capacity of the RBC and volume expanding
capacity of plasma is needed
b.) Packed RBC= Consists primarily of RBC and small amount of plasma and approximately 100 ml anti
coagulant in a total amount of _250-500 ml__________
Indications include restoration or maintenance of adequate organ oxygenation with
___increased_____expansion of blood volume

Nursing Considerations:
1. Infuse at prescribed rate.
2. Transfuse blood for 4 hours
c.) Platelet Concentrates
Consist of platelets suspended in plasma. Each unit platelet is consist of ___________platelets and the volume
of plasma is _______________
Indications include prevention or resolution of hemorrhage

d.) Plasma=Consist of water 91% ________, plasma proteins including _essential clotting
factors______________(7%) and ______carbohydrate________(2%), approximately ____200-250 ml_______;
May be stored in ___liquid state____________within ___24 hours______after collection
Indications include blood loss, loss of blood clotting factors , over anticoagulation with ________

e.) Cryoprecipitate=Consists of certain blood clotting factors suspended in frozen plasma. Each unit consists
of ___80-120 _______units of Blood Factor _ VII_____, 250 mg _fibrinogen_____and 20% to 30% of the
______factor VIII ___present in ____whole blood_________
Indications include deficiencies in Blood clotting factor VIII
Adult dosage is usually __10____units which is repeated every ____8-12___hours until deficiency is corrected
Infused within NSS
f.) Fractionated Plasma products=Composed of highly proteins that makes up a colloid solution to provide
blood volume expansion

Nursing Considerations:
2. Observe closely for the most common acute complications associated with Blood Transfusion circulatory
overload, crackles, dyspnea, distended neck veins
3. Confirm ABO and Rh compatibility of recipient and blood. Compare the bag label, bag tag, transfusion form
and medical order
4. Obtain a record of vital signs
5. Obtain blood from blood bank, inspect for abnormal color, cloudiness, clots and excess air. Check expiration
date
6. Verify Patient identification
7. Start infusion slowly approximately 30 drops per minute
8. Remain at bedside for 30minutes and watch for side effects like difficulty in breathing and presence of rashes,
9. Monitor Vital signs every hour
10. Record the following on clients chart
a. Time and Names of Persons starting and ending the transfusion
b. Names of individuals verifying patient ID
c. Product and Volume infused
d. Immediate responses of the client

Note: This is only applicable in transfusing RBCs. If FWB is transfused, only specific blood types are
allowed to be used as donors. Example only Blood Type A is given for patients with Blood Type A

Plasma Expanders (e.g. Dextran, Hetastarch, Mannitol)

Crystalloid Solutions
Hypotonic Solutions: 45% NSS, 5% dextrose in Water
Isotonic Solutions : 90% NSS, Lactated Ringers Solution

2. MAST - medical antishock ___have been used to increase venous return to the heart until definitive care
could be given. This, combined with compression of blood vessels, is believed to cause the movement of blood
from the lower body to the brain, heart and lungs.

3. IABP intra aortic balloon pump is a mechanical device that is used to decrease myocardial oxygen demand
while at the same time increasing cardiac output.

PHARMACOLOGIC THERAPY
I. Vasoconstrictors =given to promote peripheral vasoconstriction increasing peripheral vascular resistance and
Blood Presure
a. Norepenephrine (Levarterenol)
b. Metaraminol (Amarine)

II. Vasodilators Given to promote vasodialtion on the microvasculature in major organs to promote blood flow
c. Nitroprusside (Nipride)
d. Nitroglycerine Isosorbide
e. Phentolamine (Regitine)

III. Sodium Bicarbonate=Given to counteract metabolic acidosis that occurs with shock and lactic acid
deposition
IV. Antibiotics=Given to treat underlying causes of Septic shock
5.________=Given to decrease the inflammatory reaction in the body leading to decreased vasodilaton, decreased
capillary permeability and leaking of intravascular fluid to the interstitial spaces
6. Albumin =Given to increase colloid oncotic pressure allowing ososis tooccur thus increasing blood volume

II. Anti-ulcer Medications
a. Cimetidine= decrease the possibility of ulcer formation associated with shock
b. Diphenhydramine (Benadryl)=Given to decrease anaphylaxis mediated by inflammatory mediators to
decrease inflammation and ots effects that may aggravate shock
III. Cardiotonic Medications
a. To treat dysrhythmias
1. Lidocaine
2. Bretylium
b. To treat Bradycardia
1. Isoproterenol
2. Atropine SO4

NURSING MANAGEMENT
PROMOTING FLUID BALANCE AND CARDIAC OUTPUT, RESPIRATORY, RENAL, GI SUPPORT and
PROMOTING SAFETY
1. Administer blood components and fluids as ordered
2. Position the client in REVERSE TRENDELENBURG POSITION
Supine, head supported with pillow, legs extended and elevated at 35 degree angle, pelvis slightly higher than
torso
3. Administer Oxygen therapy as ordered
4. Encourage client to perform deep breathing and coughing exercises
5. Suction client as necessary
6. Monitor hourly urine output, BUN and Creatinine
7. NGT to Suction
8. Antacids may be given to decrease gastric acidity
9. Soft restraints may be used if restless and attempts to remove life saving equipments
10. Prevent complications of immobility
11. protect client from chills, especially in septic shock, which causes sludging of blood in microcirculation