0133427269 Module05 Elimination LectureOutline

Module 5 Elimination The Concept of Elimination Elimination processes ( indirect gauge of general health See CONCEPTS RELATED TO ELIMINATION, p. 258 Urinary elimination Normal urinary elimination Physiology review Urination ( the process of emptying the bladder Factors affecting urinary elimination Fluid and food intake Muscle tone Psychosocial factors Pathological factors Surgical and diagnostic procedures Medications See Figure 51 FEMALE AND MALE URINARY , p. 260 Kidneys Genetic and lifespan considerations Developmental factors (see LIFESPAN CONSIDERATIONS Changes In Urinary Elimination Through the Life Span, p. 262) Infants Output Frequency Control Preschoolers Independent toileting Modeling, reminders Instruction for wiping School-age children Patterns Enuresis Nocturnal enuresis Older adults Patterns Muscle weakness Nocturnal frequency Pregnant women First trimester (enlarging uterus presses on bladder Second trimester ( uterus becomes an abdominal organ, and pressure on bladder decreases Third trimester ( pressure increases as uterus descends into pelvis Glycosuria sometimes arises during pregnancy Postpartum ( woman at risk for overdistention, incomplete emptying, residual urin Alterations in urination Altered urine production Polyuria Anuria Oliguria Inadequate kidney function ( dialysis Hemodialysis Peritoneal dialysis Altered urinary elimination Frequency Nocturia Urgency Dysuria Urinary hesitancy Neurogenic bladder See Table 52 SELECTED FACTORS ASSOCIATED WITH ALTERED URINARY ELIMINATION, p. 264 See ALTERATIONS AND THERAPIES Urinary Elimination Problems, p. 266 Prevalence Common in the U.S. Urinary incontinence is more prevalent than urinary retention Urinary retention appears in older men, especially those with PBH Genetic considerations and nonmodifiable risk factors Women at risk for incontinence Men at risk for retention Older age is a risk factor for both incontinence and retention Disability and family history are additional risks Prevention Modifiable risk factors Obesity Pregnancy Bowel problems Chronic conditions ( diabetes, BPH, arthritis Surgery and anesthesia Screening No standard screenings for urinary problems Basic verbal screenings, especially for older adults, should be included at each regular checkup Assessment See ASSESSMENT INTERVIEW Urinary Elimination, p. 267 See URINARY ASSESSMENT, p. 268 See Table 53 NORMAL AND ABNORMAL FINDINGS Urinalysis, p. 270 Lifespan and cultural considerations Privacy ( major concern during urinary assessment When assessing children, use language they will understand Diagnostic tests Characteristics, components Ultrasound, uroflowmetry, cystometerography Radiologic examinations Cystoscopy Noninvasive tests Interventions and therapies Independent therapies Aseptic technique is essential Care of clients depends on severity and cause of problems Urinary catheterization and teaching Collaborative therapies Pharmacologic therapy Diuretics Anticholinergics Cholinergics See MEDICATIONS Urinary Elimination, p. 272 Dialysis For clients with severely reduced or absent renal function, renal dialysis may be required Hemodialysis ( clients blood flows through vascular catheters, passes by the dialysis solution in an external machine, and then returns to the client Peritoneal dialysis ( dialysis solution is instilled into the abdominal cavity through a catheter to rest there while the fluid and molecules exchange, and then removed through the catheter Case Study Part 1 ( Dennis Wellborn, 52-year-old Caucasian man, complains of severe pain in his back and abdomen, and painful urination with blood in it Bowel elimination Normal bowel elimination Terms ( feces, stool, defecation Frequency is highly individual Physiology review ( factors affecting bowel elimination Diet Fluid Activity Defecation habits Medications Diagnostic procedures Anesthesia and surgical procedures Pathological conditions Pain Psychological factors Genetic and lifespan considerations Newborns and infants Meconium Consistency Frequency Toddlers Bowel control School-age children and adolescents Patterns vary Older adults Constipation Management Gastrocolic reflex Laxative use Pregnant women Elevated protesterone levels cause smooth muscle relaxation Causes bloating and constipation Bowels can be sluggish following delivery Cesarean delivery may cause flatulence Alterations in bowel elimination Alterations and manifestations Diarrhea Rapid movement of fecal contents through large intestine Cramps, increased bowel sounds Fluid, electrolyte losses Risk for skin breakdown See Table 54 MAJOR CAUSES OF DIARRHEA, p. 276 Flatulence Eructation Distention Causes Constipation Passage of fewer than three bowel movements per week May be primary problem or reflect underlying disorder Bowel incontinence Inability to voluntarily control passage of fecal contents and intestinal gas through the anal sphincter Usually a manifestation of another disorder See ALTERATIONS AND THERAPIES Bowel Elimination, p. 277 Prevalence Varies based on etiology Diarrhea ( most adults once/year children twice/year Constipation ( less in children more prevalent in older adults Prevention Modifiable risk factors Practice good hygiene Cook all food thoroughly Stay active Eat a balanced diet Screening Specific screening tests unusual Verbal screening during checkups is recommended Assessment Nursing assessment Usual patterns Recent changes See ASSESSMENT INTERVIEW Bowel Elimination, p. 279 Physical examination Inspection Auscultation Percussion Palpation See BOWEL ASSESSMENT, p. 280 Inspecting the feces Observation Lifespan and cultural considerations Privacy and modesty issues must be considered Use age-appropriate language Diagnostic tests Direct visualization techniques Indirect visualization techniques Interventions and therapies Independent therapies Diet ( encourage increased intake of fluid and fiber Bowel training Kegel exercises and biofeedback Teach clients not to strain Collaborative therapies See MEDICATIONS Bowel Elimination, p. 283 Surgery ( resection of the bowel with or without ostomy Promote absorption of excess fluid Coalesce gas Case Study Part 2 ( Mr. Welborns physician consults with a urologis. Review The Concept of Elimination Relate Link the Concepts Ready Go to Compantion Skills Manual Refer Go to Student Nursing Resourcs Reflect Case Study Part 3 ( Mr. Welborn is discharged to home Exemplar 5.1 Benign Prostatic Hyperplasia Overview Prostatitis ( inflammatory disorders of the prostate gland Prostatodynia ( client experiences symptoms of prostatitis, but shows no evidence of inflammation of infection Benign prostatic hyperplasia (BPH) ( nonmalignant enlargement of the prostate gland Most common benign neoplasm in men Pathophysiology and etiology BPH begins as small nodules in the periurethral glands, which are the inner layers of the prostate Nodules are formed from hyperplasia ( increase in the number of cells Occurs over a long period of time, making PBH more common in older men See Figure 54 BENIGN PROSTATIC HYPERPLASIA, p. 285 Etiology Growth of prostate is influenced by androgens ( dihydrotestosterone (DHT) Estrogen appears to sensitize prostate gland to effects of DHT Risk factors Age Presence of testes Race ( black and Hispanic men develop symptoms earlier than white men Asian men develop symptoms later than white men Clinical manifestations Expanding prostate tissue compresses urethra Partial or complete obstruction of outflow of urine Increased resistance to urinary flow Irritation Retention Bladder distention Diverticula Obstruction of ureters Hydroureter Hydronephrosis See CLINICAL MANIFESTATIONS AND THERAPIES Benign Prostatic Hyperplasia, p. 287 Collaboration Diagnostic tests Digital rectal examination (DRE) Prostate-specific antigen (PSA) Cystoscopy Surgery Minimally invasive surgery Transurethral microwave thermotherapy Transurethral needle ablation Transurethral surgery Transurethral resection of the prostate (TURP) Transurethral incision of the prostate (TUIP) Open surgery Laser surgery New treatments Pharmacologic therapy Treatment with medication based on two considerations Hyperplastic tissue is androgen dependent Antiandrogen agents Cause enlarged prostate to shrink Side effects Excessive smooth muscle contraction Alpha-adrenergic antagonists Relieved obstruction Increase flow of urine Defense See Table 55 AGENTS FOR BENIGN PROSTATIC HYPERPLASIA, p. 287 Nonpharmacologic therapy Urinating a first urge Avoiding alcohol and caffeine Drinking small amounts of fluid throughout the day Avoiding OTC cold and sinus medications Exercising regularly, including Kegel exercises Reducing stress Nursing process Assessment Digital rectal examination (DRE) Health history Laboratory tests, procedures International Prostate Symptom Score (IPSS) Subjective questionnaire Diagnosis Impaired Urinary Retention Risk for Infection Acute Pain Overflow Urinary Incontinence Deficient Knowledge Planning Regain urinary continence after catheter removal Verbalize rationale for performing postoperative exercise Verbalize need for continued follow-up care Verbalize warning signs of urinary tract infection Verbalize proper administration of prescribed medications, adverse effects Report pain of 3 or less and obtain adequate pain relief to allow for comfort Implementation Preoperative care Education Support Informed consent Preoperative activities Postoperative conditions Postoperative care Maintain usual postoperative assessments Monitor vital signs closely for 24 hours Risk for hemorrhage, infection Maintain accurate intake and output records Assess patency of catheters, drains Monitor color, character of urine Assess, manage clients pain Maintain antiembolic stockings, pneumatic compression devices Indwelling catheter Client education Continuous bladder urination TURP syndrome Catheter care, postremoval instructions Retropubic prostatectomy Suprapubic prostatectomy Perineal prostatectomy See Box 52 DISCHARGE INSTRUCTIONS AFTER PROSTATE SURGERY, p. 290 See CLIENT TEACHING Caring for Catheters and Drainage Bags, p. 290 Evaluation Client is continent Client retains adequate pain control to allow for comfort, performance of ADLs Client is asymptomatic, or symptoms are less severe Client describes symptoms to report to the provider upon occurrence Client list over-the-counter medications to be avoided Review Benign Prostatic Hyperplasia Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study  Exemplar 5.2 Bladder Incontinence and Retention Overview Psychosocial issues may interfere with clients willingness to seek help Urinary incontinence Incidence and prevalence Approximately 10 - 13million people in U.S. have some degree of urinary incontinence Not normal consequence of aging Pathophysiology and etiology Urinary continence requires A bladder that can expand and contract A sphincter that can maintain a urethral pressure higher than that of the bladder Incontinence occurs when pressure in the bladder exceeds urethral resistance, allowing urine to escape Etiology May be acute or chronic Congenital disorders Epispadias Meningomyelocele Acquired disorders Central nervous system, spinal cord trauma Stroke Chronic disorder Multiple sclerosis (MS) Parkinson disease Reversible Medications Prostatic enlargement Vaginal, urethral atrophy Urinary tract infection (UTI) Fecal impaction Acute confusion See Table 56 TYPES OF URINARY INCONTINENCE, p. 294 Risk factors Women more than men Smokers Older adults housebound, living in nursing homes Other factors Medications Prevention Lifestyle modifications Maintaining healthy weight Eating balanced diet Avoiding bladder irritants Clinical manifestations Symptoms Inability to avoid urinating Inability to urinate Increased rated of urinations Leakage Uncontrollable wetting Frequent bladder infections Lifespan and cultural considerations Children ( age at which children attain urinary continence differs Nocturnal enuresis more common in boys than girls Pregnant women ( experience stress incontinence due to hormonal changes and pressure on the bladder Collaboration Diagnostic tests Bladder diary Urinalysis Blood tests Surgery Cystocele Urethrocele Enlarged prostate ( prostatectomy Suspension of bladder neck Pharmacologic therapy Contract smooth muscles of bladder neck ( mild stress incontinence Postmenopausal atrophic vaginitis ( estrogen therapy Urge incontinence ( drugs to inhibit detrusor muscle contractions, increase bladder capacity Nonpharmacologic therapy Kegel exercises Behavior modification Scheduled toileting Habit training Bladder training See Box 53 PELVIC FLOOR MUSCLE (KEGEL) EXERCISES, p. 295 Urinary retention Urinary retention ( inability to empty the bladder Etiology and pathophysiology When bladder emptying is impaired ( urine accumulates and bladder becomes overdistended Causes poor contractility of the detrusor muscle If problem persists, may cause Hydronephrosis ( accumulation of urine in renal pelvis Vesicoureteral reflux ( backflow of urine from the bladder to the kidney Etiology Mechanical obstruction of the bladder outlet Functional problem BPH is a common cause Acute inflammation associated with infection or trauma Scarring from UTIs Anesthesia Risk factors Advanced age Male gender History of prostate, bladder, or voiding problems Urinary incontinence UTIs or prostatitis Cognitive impairment Diabetes Alcoholic neuropathy TIA, stroke, or neurologic disease Abdominal pain Immobility Chronic pain Emotional distress Medications Clinical manifestations Discomfort due to inability to empty bladder Difficulty starting urination Overflow voiding, incontinence Distended bladder Collaboration Diagnostic tests Similar to those used for urinary incontinence Surgery Remove mechanical obstructions Resection of the prostate Bladder calculi removed Correct a cystocele or rectocele Pharmacologic therapy Cholinergic medications promote contraction of the detrusor muscle and emptying of the bladder A medication with no anticholinergic effect can be used when urinary retention is related to drug therapy Nonpharmacologic therapy (1) Complete decompression of the bladder via catheterization (2) Indwelling catheter or intermittent straight catheter to prevent future urinary retention Nursing Process Assessment Health history Voiding diary Use of exercises Physical examination Physical status, limitations Mental status, impaired cognition Inspection Palpation Percussion Inspection of perineal tissues for redness, irritation, tissue breakdown Observation for bulging of bladder into vagina when bearing down Hydration status Examination of urine Diagnosis Functional Urinary Incontinence Reflex Urinary Incontinence Stress Urinary Incontinence Total Urinary Incontinence Urge Urinary Incontinence Overflow Urinary Incontinence Urinary Retention Problems of urinary elimination may become etiology for other problems Urinary retention, invasive procedures can put client at risk for infection Incontinence is risk factor for low self-esteem, social isolation due to socially unacceptable effects Increases risk for impaired skin integrity due to prolonged skin dampness Risk for self-care deficits in toileting Associated with a disease process may put client at risk for deficient, excess fluid volume Client with urinary diversion ostomy may develop disturbed body image Clients who require new self-care skills may be at risk for deficient knowledge Incontinent client being cared for by family member may be at risk for caregiver role strain, deteriorating family relationships Planning Goals Maintain or restore a normal pattern Regain normal urine output Prevent associated risks Perform toileting activities independently, with or without assistive devices Contain urine with the appropriate device, catheter, ostomy appliance, or absorbent product Planning for home care See CLIENT TEACHING Urinary Elimination in the Home Setting, p. 303 Implementation Combination of strategies Education Bladder training Habit training Prompted voiding Pelvic muscle exercises Maintain skin integrity Wash perineal area, rinse, dry gently, thoroughly Provide clean, dry clothing, bed linen Apply barrier ointments, creams Pad bed as necessary Incontinent draw sheets Double layered Maintain normal voiding habits See Box 54 MAINTAINING NORMAL VOIDING HABITS, p. 301 Promoting effective urination Nursing measures Normal voiding positioning Provide for privacy Running water Place clients hand in warm water Pour warm water over perineum Warm sitz bath Acute retention Catheterization Coud-tipped catheter for man with enlarged prostate Observe client as distended bladder drains Home care Teach intermittent self-catheterization Medications to avoid Double voiding Scheduled voiding Indwelling catheter care Assist with toileting Assist to bathroom Urinary equipment close to bedside Prevent social isolation Assess for reasons, extent of social isolation Refer client for urologic examination, incontinence evaluation Explore alternative coping strategies with client, significant other, staff, other healthcare team members Community-based care Client, family teaching can contribute to client maintaining independence, residence in community Refer for urologic examination Discuss fluid intake management, perineal care, products for clothing protection Evaluation Determine whether outcomes were met Client perception of problem Client understanding of instructions Access to toileting Ability to manipulate clothing Schedule appropriate Lighting for nighttime toileting Review Bladder Incontinence and Retention Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study  Exemplar 5.3 Bowel Incontinence, Constipation, and Impaction Overview Bowel function can be affected by other functional health patterns Clients with disorders of bowel function often face extensive testing, surgery, and permanent changes in appearance and to their lifestyle Constipation Constipation ( fewer than three bowel movements per week or difficult passage of stool Pathophysiology Primary or manifestation of another disease, condition Acute constipation often caused by organic process Chronic constipation has functional causes Psychogenic factors Perceived constipation Overuse of laxatives, enemas Etiology Psychogenic factors are most common cause Overuse of laxatives and enemans See Table 57 SELECTED CAUSES OF CONSTIPATION, p. 306 Risk factors Age over 65 Insufficient fiber intake Insufficient fluid intake Insufficient activity or immobility Irregular defecation habits Change in daily routine Lack of privacy Chronic use of laxatives or enemas Irritable bowel syndrome Pelvic floor dysfunction or muscle damage Poor motility, slow transit Neurologic conditions Emotional disturbances Medications Prevention Eating foods high in fiber eliminating foods low in fiber Drinking plenty of fluids Exercising regularly Not ignoring urge to defecate Clinical manifestations Signs, symptoms Having bowel movement less often than usual pattern Frequent flatus Abdominal discomfort Diminished appetite Straining to have a bowel movement Passage of hard, dry stools Distended abdomen Reduced bowel sounds Fecal impaction ( mass or collection of hardened feces in the folds of the rectum Results from prolonged retention and accumulation of fecal matter May extend up into the sigmoid colon Foul-smelling liquid seeps out around the mass Enemas, stool softeners, and manual removal are used to remove the impaction Lifespan and cultural considerations Common in pediatric population Infants Bottle-fed infants more prone to hard stools Constipation in infancy is rare Toddlers, preschoolers Learning to control body functions May try to withhold stool School-age, adolescent Overflow fecal incontinence Recurrent UTIs, enuresis Limited toileting time Unfamiliar bathrooms Postsurgery See Table 58 INFLUENTIAL FACTORS IN CHILDHOOD CONSTIPATION, p. 308 Older adults Constipation affects older adults more than younger ones Related to impaired general health status, increased medication use, decreased physical activity Loss of teeth makes chewing and swallowing difficult Pregnant women Common complaint of pregnancy Mechanical compression from growing uterus contributes to displacement of intestines and reduces motility Hemorrhoids often develop late in pregnancy causing further discomfort Collaboration Diagnostic examinations Barium enema Sigmoidoscopy, colonoscopy Surgery Used to repair rectal abnormalities Pharmacologic therapy ( see MEDICATIONS CONSTIPATION, p. 309 Laxatives Short term Bulking agents Severe constipation Soften stool Evacuate stool Nonpharmacologic therapy Education Nutrition Vegetable fiber Fluids Behavior management and bowel training Encourage clients to exercise regularly Teach digital stimulation Provide rewards for children Biofeedback Use visual or auditory feedback to strengthen rectal sphincter and other rectal muscles Manual removal of stool Encopresis Cause Voluntary or involuntary retention of stool in lower bowel, rectum Too busy Leads to constipation ( stool leaks around hard feces Stress of environmental changes Birth of sibling Move to new house, new school History, physical, diagnostic studies Rule out organic causes Mental health, cognitive functions History about toilet training, parental attitudes Dietary history Treatment Behavior modification Dietary changes Lubricants Psychotherapy Nursing management Prevention is goal Partner with parents Toilet training techniques Encourage parents to praise successes High-fiber diets, regular times for elimination Explain treatment plan Reassure child of healthy body, normal functioning Fecal incontinence Fecal incontinence ( loss of voluntary control of fecal and gaseous discharges through the anal sphincter Pathophysiology and etiology Associated with impaired functioning of the anal sphincter or its nerve supply Partial ( inability to control flatus or to prevent minor soiling Major ( inability to control feces of normal consistency Etiology Multiple factors both psychological and physiological See Box 5-5 SELECTED CAUSES OF FECAL INCONTINENCE, p. 312 Risk factors Individuals with nerve damage, including those with MS, spinal cord injury, or long-term diabetes, are at most risk Older age and female gender Dementia and physical disability Prevention Controlling causes of incontinence Increasing physical activity, fiber consumption, and fluid intake Performing Kegel exercises Clinical manifestations Loss of voluntary bowel control Stool and mucus leak out of anus at unwanted time May be accompanied by constipation, diarrhea, gas, bloating, abdominal cramps, and urinary incontinence Emotional distress is common Encopresis (abnormal elimination pattern characterized by recurrent soiling or passage of stool at inappropriate times by a child who should have achieved bowel continence Primary ( have never achieved bowel continence Secondary ( had achieved bowel continence for several months Usually associated with voluntary or involuntary retention of stool in the lower bowel and rectum Collaboration Diagnostic tests Anorectal manometry, rectal motility test Barium enema Surgery Repair of sphincter or rectal prolapse Permanent colostomy ( last-choice option Pharmacologic therapy Medications to relieve diarrhea or constipation Encopresis ( lubricants, bulk-forming laxatives, stool softeners Nonpharmacologic therapy High-fiber diet Fluids Exercise Kegel exercises Biofeedback Behavior modification techniques Nursing process Assessment Health history Physical examination Palpation Auscultation Observation Rectal exam Diagnosis Bowel Incontinence Constipation Perceived Constipation Diarrhea Etiology of other NANDA diagnoses Risk for Impaired Skin Integrity Low Self-Esteem Disturbed Body Image Deficient Knowledge Anxiety Planning Maintaining or restoring normal bowel elimination pattern Maintaining or regaining normal stool consistency Preventing associated risks Implementation Promote regular defecation Privacy Timing Nutrition and fluids Fluids and fiber Limiting carbonated beverages, gas-forming foods Exercise Supine abdominal tightening Supine thigh muscle contracting Positioning Squatting, leaning forward Elevated toilet seat Maintain skin integrity Clean skin thoroughly with mild soap and water before and after each bowel movement Apply a skin barrier cream Check incontinence pads or briefs frequently and change when feces are noted Facilitate bowel training programs Determine clients usual bowel habits Design a plan to increase fluid intake, fiber intake, and exercise Maintain daily routine of administering a cathartic suppository 30 minutes before clients defecation time, assist client to toilet, provide privacy and a time limit (30 40 minutes) Provide positive feedback Provide manualremoval of a fecal impaction as ordered Breaking up of fecal mass with finger in rectum, removing mass in portions See Box 5-6 MANUAL REMOVAL OR A FECAL IMPACTION . 315 Maintain a fecal incontinence pouch Used to collect, contain large volumes of liquid feces Secured around anal opening prior to perianal skin excoriation Nursing responsibilities Surgical repair, artificial sphincter Provide client education for home care Individualize care of pediatric clients with encopresis Evaluation Determine whether clients fluid intake, diet appropriate Determine whether clients activity level appropriate Determine whether prescribed medications, other factors affect gastrointestinal function Determine whether client and family understand instructions Determine whether sufficient physical, emotional support provided Review Bowel Incontinence, Constipation, and Impaction Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 5.4 Urinary Calculi Overview Urinary calculi (kidney stones, development of one or more crystals that lodge anywhere in the urinary tract Lithiasis ( stone formation Nephrolithiasis ( stones that form in the kidney Urolithiasis ( stones that form elsewhere in the urinary tract Pathophysiology and etiology Balance in kidneys between need to conserve water, need to eliminate poorly soluble materials Factors contributing to urolithiasis Supersaturation ( concentration of insoluble salt in urine is high Nucleation ( crystal formation Lack of inhibitory substances in urine ( bonds weak Fluid intake Composition of kidney stones Calcium oxalate and/or calcium phosphate Uric acid stones Struvite stones ( staghorn stones Etiology Most form in renal pelvis, composed of calcium salts Risk factors Most idiopathic Prior personal, family history Dehydration Excess dietary intake of calcium, oxalate, proteins Loss of calcium from bones See Table 59 RISK FACTORS AND INTERVENTIONS FOR RENAL CALCULI, p. 320 Clinical manifestations Symptoms due to size, location Kidney calyces, pelvis ( few symptoms Urinary flow gradually, partially obstructed ( dull, aching, flank pain Bladder calculi ( dull suprapubic pain with exercise, after voiding Renal colic Develops when stone obstructs the ureter ( ureteral spasm UTI Complications Obstruction Impede outflow of urine Gradual versus acute Hydronephrosis Kidneys produce urine behind obstructed ureter Pressure builds up, can damage collecting and proximal tubules, glomeruli of kidney Colicky pain on affected side Hematuria, UTI may occur Infection See CLINICAL MANIFESTATIONS AND THERAPIES Urinary Calculi, p. 321 Lifespan and cultural considerations Most common in middle-age and older adults But can occur at any age and in all ethnicities Symptoms of urolithiasis common in pregnant women Collaboration Diagnostic testing Urinalysis Chemical analysis of any stones Urine strained Stones, sediment sent for analysis Urine calcium, uric acid, oxalate levels measured over 24-hour period Serum calcium, phosphorus, uric acid levels Kidney, ureter, bladder (KUB) Renal ultrasonography Computed tomography (CT) scan, with/without contrast Intravenous pyelogram (IVP) Cystoscopy Surgery Treatment depends on location, extent of obstruction, renal function, presence/absence of UTI, clients general state of health Lithotripsy Extracorporeal shock wave lithotripsy (ESWL) 30 minutes to 2 hours IV sedation See Figure 59 EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY, p. 322 Percutaneous ultrasonic lithotripsy See Figure 510 PERCUTANEOUS ULTRASONIC LITHOTRIPSY, p. 323 Laser lithotripsy Surgical intervention Ureterolithotomy Pyelolithotomy Nephrolithotomy Pharmacologic therapy Acute episode Analgesia Narcotic (morphine sulfate) IV Indomethacin (NSAID) suppository Hydration Oral IV Inhibit, prevent further lithiasis Thiazide diuretic ( calcium calculi ( reduce urinary calcium excretion Potassium citrate ( raises pH ( prevents stones that tend to form in acidic urine Nonpharmacologic therapy Increased hydration Dietary changes to prevent stone formation Nursing process Assessment Health history Pain assessment Other symptoms Contributing factors Physical examination General appearance Tenderness Amount, color, characteristics of urine See KIDNEY ASSESSMENT, pp. 324-329 Diagnosis Acute Pain Impaired Urinary Elimination Deficient Knowledge Anxiety Risk for Imbalanced Nutrition Risk for Infection Planning Client requests analgesics as needed at onset of pain Maintain urine output of 2,500 mL in each 24-hour period Verbalize understanding of disease process Demonstrate reduced anxiety Implementation Manage pain Assess pain using standard pain scale Administer analgesia as ordered Monitor effectiveness Encourage fluid intake, ambulation unless contraindicated Use nonpharmacologic measures as adjunctive therapy for pain relief Positioning Moist heat Relaxation techniques Guided imagery Diversion If surgery performed, monitor IO, catheters, incision, wound drainage Monitor urinary output Obstruction of the urinary tract is primary problem Report symptoms of hydronephrosis Dull flank pain, aching Changes in renal studies Monitor amount, character of urine output Strain all urine for stones Note hematuria, cloudy urine Maintain patency, integrity of all catheter systems Provide client teaching Multiple learning needs Assess understanding, previous learning Present material in manner appropriate to knowledge base, developmental, education levels, current needs Teach about all diagnostic, treatment procedures If client to be managed at home, in community teach to Collect, strain all urine, save stones Report stone passage to physician, bring in stone for analysis Report to physician any changes in amount, character of urine output Teach measures to prevent further urolithiasis Increase fluid intake to 2,5003,500 mL per day Follow recommended dietary guidelines Maintain activity level to prevent urinary stasis, bone resorption Take medication as prescribed Risk of recurrent lithiasis is approximately 50 Teach about relationship between urinary calculi and UTI Promote health and wellness Encourage hydration and physical activity Prepare client for discharge Prepare client, family for discharge Importance of maintaining fluid intake to produce 2.02.5 quarts of urine per day Prescribed medications, management, potential adverse effects Dietary recommendations Prevention, recognition, management of UTI Any further diagnostic, treatment measures planned See CLIENT TEACHING Discharge Instructions for Clients with Urinary Calculi, p. 75 Evaluation Client reports pain of 3 or less, comfortable enough to perform ADLs Client remains infection-free Client chooses appropriate diet to prevent recurrence of renal calculi Client demonstrates adequate fluid intake Review Urinary Calculi Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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