Glogowski- AH Test 2 Review Nursing implications with administration of the following medications (pyridium, kayexalate, Depo provera) Pyridium

Urinary analgesic Relief of pain, burning, frequency in UTI

Soothing effect on urinary tract mucosa **Stains urine reddish orange Can often be mistaken as blood if patient not taught about this side effect. Skin may also turn orange d/c if skin/sclera become yellow take w/ meals to decrease GI disturbances Never give to pt w/ ileus bc of bowel necrosis May cause diarrhea Monitor F&E Increased appetite Weight gain Irritability Depression Spotting Breast tenderness ** Drug alert** Report immediately sudden loss of vision, severe headache, chest pain, hemoptysis, pain with swelling and tenderness, numbness in arm/leg, and abdominal pain/tenderness

Kayexalate Removes potassium associated w/ AKI from body Depo provera (medrooxyprogesterone) Post menopause Endometriosis

Endometriosis: drug will suppress ovulation

Diagnostic tests mentioned in class- urinalysis, urine spec grav., PH, GFR, BUN, creatinine etc Nursing interventions with radiological studies Urinalysis Color Odor Protein General exam of urine to est. baseline info Try to obtain first morning specimen Examine specimen w/in 1 hr of collection Wash perineal area if soiled w/ blood or feces before collection Amber yellow Aromatic Odor = UTI / infection Want 0 to trace

Glogowski- AH Test 2 Review Glucose Ketones Abn: = acute or chronic renal disease involving glomeruli; heart failure Want none If have= DM Want none If present= DM, altered CHO and fat metabolism, starvation, dehydration, vomiting, diarrhea Want none If present= liver disorder Want: 1.003-1.030 If low= dilute urine, excessive diuresis, DI If high= dehydration, albuminuria, glycosuria Fixed at 1.010= renal inability to concentrate urine; ESRD

Bilirubin Specific gravity

pH

Want : 4.0-8.0 >8= UTI

GFR

BUN Range: 6-20

Urine formation begins at glomerulus where blood is filtered Normal range: 125 ml/min Used to identify presence of renal problems Concentration of urea in blood is regulated by rate at which kidney excretes urea More reliable than BUN End product of protein and muscle metabolism Detects protein (albumin) in urine Dip end of stick in urine and read result Grading is 0-4 Positive result may not indicate significant proteinuria Some meds can give false results

Creatinine Range: 0.6-1.3 Protein dipstick

Glogowski- AH Test 2 Review Radiological studies/ nursing interventions: KUB

Xray exam of abdomen and pelvis Shows size, shape, and position of kidneys Stones and FB can be seen Nursing intervention: prepare bowel prep if needed Intravenous pyelogram Visualized urinary tract after IV injection of contrast media Shows cysts, tumors, lesions, and obstructions ** do not perform on pt with decreased renal function because contrast media is nephrotoxic and worsens rental functioning Nursing intervention: Night before: give enema to empty colon and gas Before procedure: assess pt for iodine allergy and avoid anaphylactic shock Inform that procedure involves lying on table and having serial X-rays taken Warmth flushed face and salty taste during contrast injection may occur After procedure: increase fluids to flush contrast from body

IVP

Cystogram

Cystoscopy: Inspect interior of bladder. Can be sued to insert ureteral catheters, remove calculi, obtain biopsy, and treat bleeding lesions. Lithotomy position May be done using local or GA Complications= urinary retention, UT hemorrhage, bladder infection, and perforation of bladder

Visualizes BLADDER Eval for neurogenic bladder Contrast media instilled in bladder Nursing intervention: Force fluids or give IV Consent form signed Pre op meds prn After procedure: may feel burning on urination or pink tinged urine, and urinary frequency. These are NORMAL Observe for bright red bleeding which is not normal Do not let patient walk alone immediately after procedure because of orthostatic hypotension Offer warm sitz baths, head, and mild

Glogowski- AH Test 2 Review analgesics to relieve discomfort. VCUG

Voiding cystourethrogram Voiding study of bladder opening Bladder filled w/ contrast media Films taken to visualize the bladder and urethra After urination, another sets of films taken to assess for residual urine

Urinary system assessment- (auscultation, palpation (CVA), and percussion techniques) Inspection Auscultation Assess for skin changes ( pallor, yellowgray cast, excoriations, changes in turgor, bruises, texture) Mouth: stomatitis, ammonia breath odor Face/extremities: generalized edema, peripheral edema, bladder distention, masses, enlarged kidneys Abdomen: skin changes, stiae, abd. Contour for midline mass in lower abdomen, Weight: weight gain secondary to edema; weight loss and muscle wasting in renal failure General state of health: fatigue, lethargy, diminished alertness Assess over both CVA and upper abdominal quadrants Listen for bruit- abnormal /impaired blood flow to kidneys Tenderness in flank area may be found on fist percussion Normally no pain felt If pain= infection or polycystic kidney disease Bladder not perusable until contains 150 ml fluid If bladder is full will hear dullness CVA, normal sized left kidney not palpable because spleen is on top of it Can sometimes feel lower pole of right kidney Bladder not normally palpable unless full

Percussion

Palpation

Glogowski- AH Test 2 Review Will be felt as smooth, round, firm, and sensitive to palpation

Renal and urologic problems- Collaborative care for patients with the following: Lower and upper UTI (pyelonephritis) - assessment findings (be able to differentiate assessment finding in Lower UTI from Upper UTI), risk factors, nursing interventions, patient teaching Lower UTI S/S: Upper UTI (pyelonephritis) Treatment: Vancomycin, adequate fluids, NSAIDS Severe cases: - Hospitalization - IV abx - May need abx for 14-21 days S/S: Flank pain Fever Chills Pregnancy induced changes Can happen from reflux from lower to upper urinary tract Stricture Stone Dysuria Frequent urination Urgency Suprapubic discomfort Hematuria or sediment Cloudy appearance

Often starts in renal medulla and spreads to adjacent cortex. Fatigue Experience same symptoms from LUTI Urinalysis shows: pyuria (pus in urine); bacteriuria, hematuria, WBC

Risk factors for UTI

Increase in urinary stasis - BPH, stone, stricture - Urinary retention - Renal impairment - Neurogenic bladder Foreign Bodies - Urinary tract calculi - Catheters - Instrumentation (cystoscopy, ect). Anatomic factors:

Glogowski- AH Test 2 Review - Congenial defects - Fistula - Shorter female urethra - Obesity Compromised Immunity - Aging - HIV - DM Function disorders - Constipation - Voiding dysfunction Other factors - Pregnancy - Hypo estrogen state - Multiple sex partners - Use of spermicide - Poor hygiene Mid-stream urine collection Abx treated with Bactrim (TMP/SMX) or Macrodantin Increase fluid intake Empty bladder frequently Evacuate bowel regularly Wipe perineal area from to back after urination and defecation 15 ml per pound / water fluid intake Monitory elimination Pain management Teach medication effects Complete ABX entirely Avoid vaginal douches, harsh soaps, bubble baths, powders, sprays in perineal area Drink unsweetened cranberry juice for prevention Macrodantin: avoid sunlight; use sunscreen, wear protective clothing - Also notify MD if fever , chills, chest pain, dyspnea, rash, or paresthesias develop in fingers or toes

Nursing Intervention and patient teaching

Glogowski- AH Test 2 Review Glomerulonephritis- Etiology/Patho, assessment findings, collaborative care, evaluation Glomerulonephritis

Chronic glomerulonephritis

Inflammation of glomeruli Autoimmune: body attacks Acute post streptococcal glomulonephriits - occurs from untreated step infections typically 5-21 days after infection - Edema- anascaria (generalized body) - Increased BUN and creatinine - Protein urea - Hematuria - Can lead to heart failure and kidney failure Dx testing includes: - Urinalysis - CBC w/ WBC - BUN, Creatinine, Albumin Treatment of APSG: - Rest : lying down promotes diuresis - Sodium and fluid restriction for edema - Diuretics - Antihypertensive meds - Adjust protein intake - Corticosteroids - Abx only given if strep infection still present End stage of glomerular inflammatory disease Leads to ESRD Patient has hx of several acute glomerulonephritis incidents

S/S: Proteinuria Hematuria, slow development of uremia (syndrome where kidney fx declines to pint that symptoms develop in multiple body systems and GFR is <10) Dx studies: U/S Renal bx CT Treatment: Treat HTN and UTI vigorously

Glogowski- AH Test 2 Review Protein and phosphorus restrictions

Nephrotic syndrome- assessment findings/clinical manifestations, nursing intervention and collaborative care, dietary modifications Nephrotic syndrome Causes: Primary glomerulus disease SLE (lupus) DM Amyloidosis Infections (strep, syphilis, viral, protozoa) Neoplasm (Hodgkins, solid tumors of lungs, colon, stomach, breast) Leukemia Allergens (bees and pollen) Drugs: ( penicillamine, NSAIDs, Captopril, heroin) S/S: Proteinuria HTN Hyperlipidemia Hypoalbuminemia Hypocalcemia Hyperparathyroidism Osteomalacia Hypercoagulability= increase risk for thromboembolism or PE Treatment: Relieve edema and cure or control primary disease Caution with use of ACE and NSAIDS Low to sodium Low to moderate protein Dietary salt restrictions Loop diuretics or thiazides Treat hyperlipidemia Corticosteroids Daily weights for edema/fluid check I/O intake Measure abd girth Serve small frequent meals Avoid infections Protein leaks from glomerulus which leads to low plasma albumin and tissue edema Ascites

Glogowski- AH Test 2 Review Renal calculi- Types, risk factors, assessment findings, priority nursing interventions, health promotion/pt teaching, and dietary modifications for calcium, oxalate and uric acid calculi (see tables 46-11, 46-12, 46-13) Renal Calculi S/S: Guarding, back pain, fever, dehydration Warm, flushed skin, cool, moist skin with mild shock Abdominal distention Absence of bowel sounds Oliguria Hematuria Tenderness upon palpation Passage of stones Possible Increase in BUN and creatinine Pyruria, increase RBC and WBC, increase in uric acid, calcium, phosphors, oxalate on 24 hr urine collection Risk factors: Metabolic - Abnormalities that result in increased urine levels of calcium, oxaluric acid, uric acid, or citric acid Climate - Warm climates that cause increased fluid loss, low urine volume, and increased solute concentration of urine Diet - Large intake of dietary proteins that increase uric acid excretion - Excessive amnts of tea or fruit juices that elevate urinary oxalate level - Large intake of calcium and oxalate - Low fluid intake that increases urine concentration Genetic factors - Family hx of stone formation, cystinuria, gout, or renal acidosis Lifestyle - Sedentary occupation, immobility Calcium oxalate - Small - Often trapped in ureter - Men>W - Treatment includes: * reduce dietary oxalate * give thiazide diuretics * give potassium citrate to maintain alkaline urine * reduce daily sodium intake Calcium Phosphate - Mixed stones - Occur from alkaline urine or hyperparathyroidism Struvite W>M Occur from UTIs Treat with antimicrobial agents and

Types of stones Foods that are high in: (if stones are present in any of these, then want to teach decrease of foods) Purine: sardines, herring, mussels, liver, kidney, goose, venison, meat, soups, sweetbreads, chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham Calcium: milk, cheese, ice cream, yogurt, sauces containing milk, all beans but green beans, lentils, fish with fine bones, dried fruits, nuts, ovaltine, chocolate, cocoa Oxalate: Dar roughage, spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery, parsley, runner beans, chocolate, cocoa, instant coffee, ovaltine, tea, Worcestershire sauce

Glogowski- AH Test 2 Review acidify urine Uric Acid M>W Predisposed from gout, uric acid, inherited Treat: : decrease uric acid concentration : allopurinol :reduce purines

10

Cystine Autosomal recessive defect Acid urine Treat: increase hydration, maintain alkaline urine by giving potassium citrate

Treatment of stones

Lithotripsy - Hematuria common afterwards Surgical removal Increase fluids Low sodium diet for certain stones Maintain hydration Pain management Impaired urinary elimination Acute pain Deficient knowledge

Nursing diagnosis includes

Nursing diagnosis- renal and urologic problems Bladder cancer- risk factors Bladder cancer risk factors Common b/w 60-70 yrs old M>W Cigarette smoking Exposure to dies used in rubber and cable industries Chronic abuse of phenacetin contain analgesics Women treated w/ radiation for cervical cancer Patients receiving cyclophosphamide (Cytoxan) Chronic and recurrent renal calculi

Glogowski- AH Test 2 Review Chronic LUTIs Indwelling catheters for long periods of time

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Incontinence- clinical manifestations, nursing interventions, patient teaching Incontinence Uncontrolled leakage of urine Common manifestation on BPH and prostate enlargement in men Men= overflow due to urinary retention W>M Women= stress and urge most common Sudden increase in intra-abdominal pressure Occurs from cough, sneeze, laugh, physical activity Common in women w/ relaxed pelvic floor muscles

Stress incontinence Treatment: Kegel exercises Weight loss for obese Cessation of smoking Condom caths for men Bladder sling Urge incontinence Treatment: Treat underlying cause Bladder retraining Kegel exercises Anticholinergic agents Containment devices Absorbent products Overflow Treatment: Cath to decompress bladder Flomax or procar to decrease outlet resistance Bethanechol to enhance bladder contractions Reflex Treatment: Intermittent self cath Diazepam or baclofen to relax external sphincter Treatment of underlying issue

Involuntary urination is preceded by urinary urgency Leakage is periodic but frequent and in large amounts Nocturnal frequency and incontinence are common Caused by uncontrolled contraction or over activity of detrusor muscle

Occurs when pressure of urine in overfull bladder overcomes sphincter control Leakage of small amounts of urine is frequent throughout the day and night Occur from neurogenic factors like herniated disc, diabetic neuropathy, neurogenic bladder

No warning or stress precedes periodic involuntary urination Urination is frequent Moderate in volume Occurs equally during day and night

Glogowski- AH Test 2 Review Happens from spinal cord injury

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AKI and CKD AKI- prerenal, intrarenal and post renal failure ARF Pre renal: -interference with renal perfusion - blood cannot get to kidneys - causes: hypotension, hypovolemia, dysthymias, dehydration Intra-renal: (Nephrotoxins, infections, renal injury, prolonged prerenal state, vascular lesions, acute pyelonephritis) - Kidney damage from HTN, DM, acute tubular necrosis, medications Post renal: (calculi, BPH, tumors) - Urine cannot get out of kidneys Ex: BPH, stones, obstructions Abrupt deterioration of the renal system Is reversible

HESI hint: Normally, kidneys excrete approx. 1ml of urine for kg of weight per hour Total daily output averages 1500-2000 ml depending on type of fluid intake, amount, perspiration, environmental temp, and presence of vomiting/diarrhea Occurs when metabolites accumulate in body and urinary output changes 3 phases Oliguric: Diuretic recovery

Glogowski- AH Test 2 Review

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AKI- oliguric and diuretic phase- assessment and lab findings, nursing intervention, calculation for fluid restriction Oliguric phase **minimize protein breakdown and prevent rise in BUN by limiting protein intake. When the BUN and creatinine stabilize, ARF is determined to be resolved** oliguria (decrease urine output) less than 400 ml/day occurs w/in 1-7 days of injury duration of this phase is b/w 10-14 days

Diuretic phase

Recovery phase

Will find: hypovolemia fluid retention from decrease urine output JVD Bounding pulses Edema HTN Fluid overload leading to HF, pulmonary edema, pericardial and pleural effusions Metabolic acidosis Kussmaul respirations (rapid, deep) b/c body trying to rid carbon dioxide Hyponatremia due to fluid retention Hyperkalemia (watch for dizziness, weakness, cardiac dysthymias, muscle cramps, diarrhea, vomiting) Elevated BUN and creatinine Asterixis bc of elevated nitrogenous waste and buildup of ammonia Gradual increase of urine output 1 to 3 L/ day Kidneys have recovered ability to excrete wastes but not able to concentrate urine Hypovolemia and hypotension can occur from massive fluid loss from increase diuresis Watch for Hyponatremia, hypokalemia, and dehydration Phase can last from 1-3 weeks GFR increases BUN and creatinine level out Kidney fx can take up to 12 months to stabilize

Glogowski- AH Test 2 Review Nursing management of AKI ** Renal failure retains sodium. With water retention, sodium becomes diluted and serum levels appear near normal. With excessive water retention, sodium levels appear decreased. It is important to limit fluid and sodium intake in ARF patients**

14 Monitor I/O Give enough fluids in oliguric phase to replaces losses (usually 400-500 mL) Document and report any fluid volume status Monitor labs for electrolyte status, hyperkalemia Watch for ECG changes Daily weights Assess level of consciousness Prevent infection Kayexalate for high potassium (may cause diarrhea) Limit diet with potassium restrictions ( dont give potassium rich foods like bananas, orange juice, cantaloupe, strawberries, avocados, spinach, fish, or salt substitutes (they are high in K))

CKD- nephrotoxic agents CKD S/S: Retention of urea, creatinine, phenols, hormones, electrolytes, water Uremia common: where kidney function declines to the point where other symptoms develop in other body systems and GFR is <10 Early stages: no change in urine output, polyuria can be seen (in pts who have DM) As CKD progresses: fluid retention occurs and need diuretic therapy Early detection is key Hx of medication (nephrotoxic agents) Fx hx of renal disease Increased BP / chronic HTN Edema Pulmonary edema Progressive, irreversible damage to the nephrons and glomeruli ; resulting in uremia GFR < 60 x 3 months or more Leading causes are: DM, HTN, Frequently asymptomatic

Nursing assessment

Glogowski- AH Test 2 Review

15 Neurological impairments Decrease urinary fx - Hematuria - Proteinuria - Cloudy urine - Oliguric < 400 mL/day - Anuric < 100 mL/day - Jaundice - GI upset - Metallic tastes in mouth - Ammonia breath - Dialysis - Prior kidney transplant - Azotemia, increase BUN/creatinine - Decrease in calcium - Increase in phosphorus and Mg Avoid antacids that contain mg and aluminum since pats are no longer able to rid body of these substances NSAIDs can contribute to development of AKI and progression of CKD Decongestants and antihistamines contained pseudoephedrine that may worsen HTN Phenylephrine and pseudoephedrine cause vasoconstriction and lead to increase in BP Watch for s/s of F and E imbalance Suck on ice cubes, lemon, candy to help reduce thirst if on fluid restriction Take iron supplements between meals Report increase in weight, BP, SOB, edema, increase fatigue, confusion. Monitor respiratory pattern and difficulty Daily weights I/O Diet control Labs Vitals Monitor electrolytes Provide intake of Vit D to facilitate GI absorption of calcium Give appropriate calcium supplement Provide oral care to prevent stomatitis, remove bad taste, increase pt appetite Monitor wt.

Hypervolemia management for CKD Nursing dx: excess fluid volume

Risk for injury : Nursing dx: electrolyte management for Hypocalcemia Nutrition imbalance

Glogowski- AH Test 2 Review

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Care

Focus on prevention and early identification of DM, HTN, ect. Drug therapy: Acute hyperkalemia may require IV glucose and insulin or IV 10% calcium gluconate Kayexalate common used ** never give to person w/ ileus or obstruction (hypoactive bowel sounds) bc fluid shifts could lead to bowel necrosis HTN treated to have BP <130/<80 Weight loss, therapeutic lifestyle changes, diet (DASH), HTN meds: CCB, ARBS (sartans), ACE Limit phosphorus Supplement with Vit D Control hyperparathyroidism Caltrate and Phoslo are phosphate binders to be given- cause phosphate to be excreted in stool Give phosphate binders w/ each meal b/c most is absorbed within one hr after eating Vit D to control Hypocalcemia Decrease Vit D and calcium if hypercalcemia occurs Exogenous EPO used to treat anemia Iron supplementation Treat hyperlipidemia

Nutritional therapy: Protein restriction Dialysis: protein not normally restricted Avoid high protein diets and protein supplements Low sodium and potassium Pre ENRD: no fluid restriction HD patients have more restricted diet than PD. 600 ml (insensible loss) plus an amount equal to previous days urine output is allowed for patient n HD. Space fluid throughout the day so patient

Glogowski- AH Test 2 Review does not become thirsty.

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Sodium/Potassium restriction Stages 2-5 restrict sodium to 2-4 g day Avoid cured meats, pickled foods, canned soups, hotdogs, cold cuts, soy sauce, salad dressing Potassium restriction depends on ability of kidneys to excrete potassium. Salt substitutes have high potassium b/c they contain potassium chloride

CKD- Nursing assessment and plan of care for patients with dialysis access (Fistula, Graft) Hemodialysis Very rapid blood flow is needed

Arteriovenous fistula: - Most common - Created in forearm with anastomosis b/w artery and vein - Provides for arterial blood flow thru vein - Arterial blood flow important to provide the rapid blood flow required - Increased pressure of arterial blood flow through the vein makes the vein dilate and become tough, making it amenable to repeated VP. - Recommended that AVF be placed 3 months before starting HD - Best overall patency - Least number of complications (thrombosis, infections) - Are more difficult to create in pts w/ PVD, IV drug use, and obese women Arteriovenous graft (AVG) - Placed under skin - 2-4 weeks for graph to heal - Graft assessed using 2 large bore needles - One needle is placed to pull blood from circulation and the other is used

Glogowski- AH Test 2 Review

18 to return dialyzed blood A thrill felt by palpating area of anastomosis Bruit can be heard w/ a stethoscope These are created by arterial blood rushing into vein NEVER do BP, VP, insert of IV on extremity w/ this graft Thrombosis is common Can develop distal ischemia Increase pain Numbness of fingers that worse during dialysis Poor capillary refill Aneurysms can also develop

CKD- Nursing assessment, plan of care and teaching for patients undergoing peritoneal dialysis Peritoneal dialysis Access obtained by placing catheter through anterior abdominal wall Dialysis solution goes into peritoneal space 3 phases: inflow (fill), dwell (equilibration), and drain Inflow: about 2 L solution infused over 10 minutes Dwell: diffusion and osmosis occur b/w blood and peritoneal cavity. This part can last 30 min to 8 or more hours Drain: 15 to 30 mins; can gently massage abdomen or have pt change position. Cycle starts again Needs a period of 30-50 mins to complete exchange Dextrose most common used agent Need to watch for hypertriglycerides and hyperglycemia bc of dextrose

** watch for** - Exit site infection - Peritonitis (cloudy effluent from drain) and abd pain - Hernias - Lower back problems

Glogowski- AH Test 2 Review Bleeding Pulmonary complications Protein loss

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Renal Transplant- drug therapy Immunosuppressive therapy Prevents rejection of transplanted organ Corticosteroids Imuran Cyclosporine (dont give with grapefruit juice b/c of potential for toxicity) Hyperacute: occurs minutes to hours after transplant and requires immediate removal - Kidney most affected by this type Acute: common in first 6 months after transplant Chronic: occurs over months/years and is irreversible; no therapy for this type; treatment is supportive measures, put patient on transplant list

Type of organ rejections

Reproductive system Male reproductive system- Screening tests, patient teaching with use of erectogenic medications (Viagra, Cialis etc) Diagnostic testing for ED H&P Sexual hx Glucose and lipid panel Testosterone, prolactin, and thyroid levels Nocturnal penile tumescence and rigidity screen Vascular studies Digital rectal exam for checking size of prostate BP assessment Some test differentiated b/w physiological or psychogenic Doppler ultrasounds Drugs: Viagra, Levitra, Cialis

Patient education for ED

Glogowski- AH Test 2 Review Erectile dysfunction- collaborative care and nursing intervention

20 Causes smooth mx contraction and increase blood flow, promoting erection - Take 1 hr before sexual intercourse - Only take 1 x day - S/E include: h/a , dyspnea, flushing, nasal congestion - Report visual disturbances and blue green visual disturbance - Report sudden hearing loss - Dont take w/ NTG Vacuum assistive devices - Suction device applied to create erection by pulling blood to penis - Penile ring placed around penis to keep blood flow/erection Intraurethral device: - Vasoactive drugs, topical gels, injection to penis - Agents enhance blood flow to penis - Drugs: paparverine, alprostadil, caverject, phentolamine , vasomax Penile implants - Inflatable penile prosthesis - Used when other interventions dont work Reassurance and confidentiality Counseling therapy Conduct routine health assessments on men seeking treatment

Nursing intervention

BPH- Assessment findings and collaborative care BPH Enlargement or hypertrophy of prostate Tends to occur after age 40 Intervention when obstruction present Most common treatment is TURP (transurethral resection of prostate gland) - Prostate is removed by endoscopy allowing for shorter hospital stay Increased frequency of voiding w/ decrease in amount Nocturia

Nursing assessment

Glogowski- AH Test 2 Review TURP- care of patients post op

21 Hesitancy Terminal dribbling Decrease in size and force of urine stream Acute bladder retention Bladder distention Possible pain from bladder spasms that occur post op Maintain patent urinary drainage system ( large 3 way indwelling cath with 30 mL balloon) to decrease spasms Provide pain relief Avoid alcohol and caffeine b/c they increase prostate symptoms Minimize catheter manipulation by taping to inner leg or abdomen; will reduce pain Maintain gentle traction on cath Check cath for clots Irrigate bladder as ordered Keep foley bag empty to prevent retrograde pressure Sterile saline used only for bladder irrigation after TURP b/c the irrigation must be isotonic to prevent fluid and electrolyte imbalance Observe color, content of urine output Normal to see reddish/pink discharge, clearing to light pink after 24 hours Report bright red blood immediately Monitor Vitals frequently Watch Hgb and Hct for anemia/ possible bleeding After removing cath: - Monitor amount and number of patient voids - Encourage fluids - Use urine cups to provide a specimen w/ each void - Observe for hematuria; urine should progress to yellow by 4th day post op - Inform that burning on urination and frequency are common for 1 week post-surgery - Generally client is NOT impotent but sterility may occur - Report flank bleeding to MD immediately - Increase fluids to 3000 mL / day

Nursing interventions ** bladder spasms occur frequently after TURP procedure. Oversized balloon from cath will make patient feel like there is a continuous need to void. They should NOT try to void around the catheter bc this leads to increase spasms. Meds can be given to reduce the spasms are: belladonna and opium suppositories

TURP: use of excision and cauterization to remove prostate tissue cystoscopically. Considered most effective treatment for BPH. Advantages : - Best long term relief - ED unlikely Disadvantages: - Bleeding - Retrograde ejaculation Drugs used for BPH: - Proscar ** increase risk for orthostatic hypotension with use of ED drugs **women who are pregnant should not handle meds** Herbal drugs: Saw Palmetto ** does not reduce size of prostate ** S/E: N/V constipation (reduced w/

Glogowski- AH Test 2 Review taking w/ food) -

22 Continue to drink 12-14 glasses water daily Avoid constipation and straining Avoid strenuous activity , lifting, sexual intercourse, and sports for one month

Female reproductive system- screening tests (breast CA, cervical CA). Breast CA-clinical manifestations and diagnostic studies Clinical manifestations Lump (common in upper outer quadrant Hard, irregularly shape, poorly delineated, non- mobile, and non-tender Nipple discharge Peau dorange Dimpling Axillary lymph node BCRA 1 and 2 gene testing Lymphatic mapping TNM staging CBC with platelet counts Mammography Ultra sound Breast MRI Biopsy Calcium and phosphorus Liver fx Chest XRay Bone scan CT PET

Dx studies

Glogowski- AH Test 2 Review Ovarian CA-clinical manifestations, diagnostic studies, possible nursing diagnosis Clinical manifestations

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Dx studies for ovarian cancer

Care for ovarian cancer Etiology and Pathophysiology BRCA genes higher incidence Family history (one or more first degree relatives) Nulliparous Clinical Manifestations Abdominal Enlargement, bloating, feeling full or difficulty eating Vaginal bleeding rare Diagnostic Studies Ultrasound, tumor markers for high risk

Abdominal enlargement from fluid accumulation Symptoms that last more than 3 weeks: - Pelvic or abdominal pain - Bloating - Urinary urgency - Difficulty eating or feeling full quickly - Vaginal bleeding and pain are late symptoms - Later signs: increase abd girth, unexplained wt. loss or gain, menstrual irregularities No screening test exist H and P Pelvic exam Abd and transvaginal U/S Lapartomy Stage I: limited to ovaries Stage II: limited to true pelvis Stage III: limited to abd cavity Stage IV: distant metastatic disease

Treatment: Total hysterectomy Abd irradiation Chemo

Cervical cancer risk factors and collaborative care

Risk factors HPV causes 70% (now more) cases of cervical cancer

Care: Annual pap tests 3 years after first intercourse no later than 21yrs

Increase risk in low socioeconomic status Early sexual activity Multiple sex partners HPV infection Immunosuppressant Smoking HPV vaccine for boys and girls up to age 26 Pap test that also test for HPV Conization: excision of cone shaped section of cervix used for dx and tx.

Glogowski- AH Test 2 Review Complications of surgery: bleeding, cervical stenosis Irradiation and chemo

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Problems related to menstruation (dysmenorrhea, Amenorrhea etc) Dysmenorrhea Abd pain cramping and discomfort associated w/ menstrual flow Caused from endometriosis, PID, uterine fibroids

Clinical manifestations: Starts 12-24 hrs. before onset of menses Most severe first day Rarely last more than 2 days Abd pain, colicky in nature Radiating pain in lower back Nausea, diarrhea, loose stools, fatigue, headache, light headedness Care: Heat Exercise Analgesics NSAIDS started at first sign of menses BCP Acupuncture TENS Causes Emotional stress, anorexia, severe dieting, strenuous exercise, chronic or acute illness Tumors Autoimmune disease Polycystic ovary disease Congenital disorders Pregnancy Primary: ** menstruation failed before age 16 Secondary: ** started then stopped and has not happened in 3 months Cause unknown

Amenorrhea

Endometriosis

Glogowski- AH Test 2 Review

25 Endometrial tissue is located outside the uterus and implants on pelvic structures Tissue goes through cyclic process of menses Bleeding occurs at site of implantation Blood trapped Scarring and adhesions occur Treatment: Non-surgical Surgical NSAIDs Hormone therapy Nursing Management Reduce pain, Restore sexual function, Alleviate fear & anxiety, Educate the client Known as Uterine Fibroids May be r/t hormones grow during reproductive years and shrink after menopause Symptoms: May be asymptomatic Abnormal uterine bleeding, pain, pelvic pressure May enlarge lower abdomen - if large tumor

Leiomyomas ETIOLOGY

Care of patients with radical mastectomy with dissection of axillary lymph nodes and nursing intervention
for post op complication (e.g. lymphedema) Lymphedema Accumulation of lymph in soft tissue Fluid accumulates in arm, causing obstructive pressure on veins and venous return. Patient may experience heaviness, pain, impaired motor function of affected arm, numbness, paresthesias of fingers Cellulitis and progressive fibrosis can occur Can be controlled after surgery or radiation Restoring function on affected side after mastectomy and lymph node dissection is key Keep patient in semi fowler position with affected arm elevated on pillow Flexing and extending fingers should begin in recover room with progressive increases

Nursing care

Glogowski- AH Test 2 Review

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in activity encourages Pain management Coping of feelings and loss Support groups Support ROM exercises Monitor for lymphedema: can use compression bandage or massage like technique to mobilize accumulation of fluid. Can also wear compression sleeve Elevate arm Soft breast prosthetic Mammoplasty: reconstruction with tissue expander NO MRI if tissue expander b/c magnet for port Monitor for infection Dont take BP or blood on affected side with lymphedema or mastectomy

Glogowski- AH Test 2 Review Pelvic support problems (Rectocele, cystocele, uterine prolapse) - assessment findings, nursing intervention and patient teaching Uterine Prolapse

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Cystocele / rectocele

Downward displacement of uterus into vaginal canal. 1st through 3rd degree Treatment: depends on degree Kegel exercises may be all that is needed Pessary- placed in vagina to help support the uterus Give pt instructions for cleaning and follow up Can cause vaginal erosion and carcinoma if left in place too long Symptoms: Dysmenorrhea Pulling or dragging sensation in pelvis or back Dyspareunia Pressure/ protrusions Fatigue Lowe backache Worse after prolonged standing or deep penile penetration Cystocele: relaxation of the anterior vaginal wall with prolapse of the bladder - support between vagina and bladder weakened symptoms: - incontinence, stress incontinence - urinary retention - bladder infections Rectocele: relaxation of posterior vaginal wall with prolapse of rectum - Support between rectum and vagina weakened. - Symptoms: - Constipation, hemorrhoids - Sense of pressure to defecate Prevention: Kegel exercises Postpartum perineal exercise Spaced pregnancies Weight control Hysterectomy

Glogowski- AH Test 2 Review Anterior and posterior vaginal repair Knee chest position

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Nursing interventions

Pre op douche or enema Note vaginal discharge, post op should be less than 1 saturated pad per hour Avoid rectal thermometers or tubes Check for thrombophlebitis in extremities Pain management Encourage ambulation Monitor urinary output Observe for bleeding Note any abdominal distention Increase diet from liquid to general Stool softeners Limit tampon use Avoid douching No sex for 3-6 weeks No heavy lifting for 4-6 weeks Maintain 3L fluids daily Notify md for signs of infection

Patient teaching and collaborative care for patients on hormone replacement therapy Perimenopuase S/S: Post menopause S/S: Cessation of menses Vasomotor instability (hot flashes and night sweats) Atrophy of genitourinary symptoms Stress and urge incontinence Breast tenderness Estrogen for women w/out a uterus Estrogen/progesterone for women w/ uterus Increase risk for breast cancer, stroke, Irregular menses Occasional vasomotor symptoms Atrophy of genitourinary tissue with decreased support Stress and urge incontinence Osteoporosis Mood changes

HRT

Glogowski- AH Test 2 Review

29 heart disease, emboli Use lowest effective dose if choose to use HRT Depo Provera is used Report sudden loss of vision, severe h/a, chest pain, hemoptysis , pain, numbness, abd pain and tenderness ASAP

Non hormonal therapy options for perimenopausal women (also see complementary/alternative therapies pg 1356) Nonhormonal therapy Cool environment Limit caffeine and alcohol Relaxation technique Loose fitting clothes Cool clothes Vitamin E reduce hot flashes Good nutrition Adequate intake of Vit. D and calcium Post menopause takes 1500 mg Calcium Diet high in complex CHO and vit. B complex Foods containing phytoestrogens are good:

Herbs: Black cohosh: may lower BP Soy: consult MD if hx of cancer before taking soy Soy may interact w/ warfarin.