1. OBSTRUCTION

2. PROBLEMS WITH OBSTUCTION CAUSE.....

1. ANY ANATOMICAL OR FUNCTIONAL CONDITION THAT BLOCKS OR OBSTRUCTS THE FLOW OF URINE.

2. URINE BACKUP CREATES ENLARGEMENT OF THE KIDNEYS & INFECTION

 (3) CAUSES OF INTRINSIC OBSTRUCTION ____

 * __: presence of calculi in urinary tract. Stones are norm asymptomatic until they reach ____, causing excruciating pain.

*___: term used for stones that form in kidney & ___ used for stones forming in the ureter.  

1.ANOMALIES (ENLARGED PROSTATE)

2. GROWTHS

3. TUMORS

*UROLITHIASIS

*NEPHROLITHIASIS -- URETEROLITHIASIS

FOUR EXTRINSIC CAUSES

OF OBSTRUCTION:

1. PROLAPSED UTERUS

2. ABDOMINAL TUMOR

3. ADHESIONS (fibrous bands that form b/t tissue & organ, often as a result of injury during surgery... internal scar tissue)

4. FUNCTIONAL: SPINAL CORD INJURY

SEVERITY OF URINARY OBSTRUCTION

DEPENDS ON WHAT 4 THINGS?

1. LOCATION

2. DURATION

3.AMOUNT OF PRESSURE

4. PRESENCE OF URINARY STASIS

URINARY STASIS

*OBSTRUCTION CREATES WHAT 4 COMPLICATIONS

FROM BAD --->WORSE?

1. HYDROURETER

2. HYDRONEPHROSIS

3. PYELONEPHRITIS & RENAL ATROPHY

4. KIDNEY FAILURE

WHEN A CALCULUS BLOCKS URETER & BLOCKS THE FLOW OF URINE, THE URETER DILATES & ENLARGES. THIS IS __1__.  THE PAIN ASSOCIATED W/ URETERAL SPASM SO BAD, PT. MAY GO INTO __2__. ALSO, __3__ (BLOODY URINE) MAY OCCUR FROM DAMAGE OF URTHELIAL WALL. IF OBSTUCTION IS NOT REMOVED URINARY STASIS RESULTS IN INFECTION & IMPAIR THE KIDNEY ON THE SIDE OF OBSTRUCTION. AS THE BLOCKAGE PERSIST __4__(ENLARGEMENT OF KIDNEY CAUSED BY BLOCK OF URINE IN LOWER TRACT & FILLING OF KIDNEY W/ URINE) & IRREVERSIBLE KIDNEY DAMAGE MAY OCCUR.

1. HYDROURETER

2. SHOCK

3. HEMATURIA

4. HYRONEPHROSIS

*Occurs in 2-3% of population, men are more effected then women. Recurrance is 50% with in ten years after perveious episode. Occurs more in warm, humid climate and w/ family hx.

*Nephrolithiasis

(Kidney stones)

Types of stones: (Calculi)

1.__: may be drug induced, increased circulating calcium.

2.__: most common type. Thought that high levels of calcium intake cause this.

3.__: Seen in gout, hereditary. A diet low in animal proteins are reccomended.

4.__: a genetic disorder of the transport of a amino acid causes excess in urine.

5.__:caused by bacteria-mostly in females.

1. Calcium Phosphate

2. Calcium oxalate

3. Uric Acid

4. Cystine

5. Struvite

The 3 Marjor parts of assessment of pt. with posible stones:

1. History: family hx, immobility, diet, medications, fluid intake.

2.Urinalysis: Common findins- Hematuria (urine may be smokey/rust color), RBC(trauma), WBC & Bacteria, increases in serum calcium, phosphate, or uric acid levels.

3. Imaging is needed to confirm/rule out diagnosis.

1. Name 3 Diagnostic Test used to locate & diagnose Stones without potential damage to kidneys.

2. What would be a more invasive way that should be avoided if possible to avoid damaging kidneys?

3. The only way to see cystine or uric acid stones?

1. Abdominal Ultrasound

2. Abdominal X-Ray (KUB)

3. Non-contrast CT scan

2. Intravenous Pyelogram (IVP)- contrast injected could cause acute renal failure b/c of contrast dye.

3. CT or MRI- both of these cannot be seen on an x-ray

The most Important part of collaborative managment of kidney stones is.... and ....

Followed by what 4 other things?

*Finding cause of stones & pain management

*Hydration

*Strain Urine

*Diet

* Flank pain suggest that the stones are in the __1__ or the __2__. Flank pain that radiates abdominally or into the scrotum & testes or vulva suggest the stones are in the __3__ or the __4__. 

*Pain is most intense when stone is __5__ or when the ureter is __6__.

1. KIDNEY

2. UPPER URETER

3. URETERS

4. BLADDER

5. MOVING

6. OBSTRUCTED

1. Kidney stone pain is most severe in what time frame?

2. Drugs:oxybutyinin (Ditropan) & propantheline bromide (Pro-Banthine) are important for control of pain, they are classified as... and are used for...

1. In the first 24-36 hrs.

2. Antispasmodics- used to relieve symptoms associated w/ bladder spasms.

1. Avoiding over/ under ___ in the acute phase help make spontaneous passage of a stone less painful.

2. How would one monitor for passage of the stone?

3. Why is it important to send the stone to the Lab?

1. HYDRATION

2. STRAINING

3. KNOWING THE COMPOSITION OF THE STONE CAN HELP PREVENT OCCURANCE OF FUTRUE STONES.

1. __:TREATS STONES IN ALL LOCATIONS, OUT PT. PROCEDURE. SHOCK WAVES BREAK UP STONES BY DELIVERING 500-1500 SHOCKS MAKING STONES EASIER TO PASS. PT. IS NORM BURIED AFTERWARD IN PLACE WHERE THEY ARE SHOCKED. PT. IS MONITORED FOR _2_ W/  _3_.  STONE IS LOCATED W/ A __4__. ANESTHESIA IS USED ALONG WITH AN ANESTHETIC CREAM ON SKIN. OCCATIONALLY _5_ IS PLACED IN URETER B4 TO EASE PASSAGE OF STONE. __6__ STONES ARE OFTEN RESISTANT

1.EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL)

2. DSYRHYTHMIAS

3. ECG

4. FLUOROSCOPE

5. STENT

6.CYSTINE STONES

1.___: A SMALL TUBE PLACED IN THE URETER THAT DILATES THE URETER & CREATES A PASSAGEWAY FOR THESTONE OR STONE FRAGMENTS. 

2. ENDOSCOPE PROCEDURE CALLED ____ OR ____.

3. DURING______ , THE URETEROSCOPE IS PASSED THRU THE URETHRA & BLADDER. ONCE THE STONE IS SEEN, THEY CAN BE REMOVED W/ FORCEPTS.

1. STENT

2. URETEROSCOPY OR URETERORENOSCOPY

3. RETROGRADE URETEROSCOPY

WHEN A STONE IS REMOVED, PT. IS AT RISK FOR ___ B/C IF THE STONE IS SHARP, AS IT MOVES, OR IS PULLED THRU URETHRA IT CAN CAUSE MAJOR DAMAGE TO THE LINING. USING A ____ PREVENTS THE STONE FROM COMMING IN CONTACT WITH URETHRAL MUCOSA.

1. BLEEDING

2. STENT.

1. PERCUTANEOUS NEPHROLITHOTOMY

~NEPHROSTOMY TUBE~

1. BLEEDING @SITE OR THRU TUBE (MAJOR COMP)

2. PNEUMOTHORAX

3. INFECTION

NURSING CARE AFTER STONE REMOVAL:

*PAIN RELIEF- WORKS BEST WITH....

*PREVENTION OF ____ W/ GENTAMICIN (GARAMYCINE) & CEPHALOSPORINS (KEFLEX)

*ENCOURAGE ____

*PREVENT____

*OBSERVE FOR _____

*PT. EDUCATION ON......

*MEDS GIVEN AT A REGULAR SCHEDULE INTERVALS INSTEAD OF PRN, PRN MEDS CAN BE GIVEN FOR BREAK THRU PAIN MANAGMENT.

*INFECTION

*FLUIDS- CHECK HYDRATION STATUS (URINE COLOR)

*OBSTRUCTION (FLUIDS, I&O, MEDS FOR DIF KINDS OF STONES

*POST OP COMPLICATIONS

*PREVENTING FUTURE STONES

1.PREVENTING CALCIUM PHOSPHATE STONES?

DIET FOR MANAGEMENT OF STONES:

 1. CALCIUM OXALATE STONES--PH?

2. URIC ACID--PH?-- DRUG USED?

1. LOW OXALATE DIET- BEETS,SPINACH, COCOA, BLACK TEA. TREAT W/ VIT. C AND DIURETICS. URINARY PH IS NOT A FACTOR 

2. LOW PURINE DIET- ORGAN MEATS, POULTRYM FISH, GRAVIES, RED WINES, & SARDINES.

WANT TO MAKE URINE PT ALKALINE

ALLPURINOL (INCREASES URINE PH)

MANAGEMENT OF STONES BASED ON TYPE:

1. CYSTINE: DIET? DRUG USED?  

2. STRUVITE: DIET? PH?

1. INCREASE VEGGIES (ALKALINE/ASH)-LIMIT ANIMAL PROTEIN, ENCOURAGE FLUIDS (500ML Q4H)

-PENICILLLAMINE

2. ACID/ASH DIETS- LIMIT HIGH-PHOSPHATE FOOD (DAIRY PRODUCTS, RED/ORGAN MEETS, & WHOLE GRAINS). - WANT ACID PH

*___: PART OF NORM AGING PROCESS, AFFECTS 1/2 MEN OVER 50. AFRO AMERICANS DEVEL. AT YOUNGE AGE WHILE ASIAN AM. ARE LESS LIKEY TO HAVE IT.

*NOTHING IS PROVEN TO REDUCE RISK!!

BPH

BENIGN PROATIC HYPERTROPHY

1. DECREASED FORCE OF URINARY STREAM

2. NOCURIA 

3.DIFFICULTY STARTING URINATION

4.URGENCY

5. FREQUANCY

6. INCOMPLETE BLADDER EMPYING

7.TERMINAL DIBBLING

8. URINARY RETENTION

During a assessment of BPH a ____ may be done to look for infection or hematuria

*____ &____ : evidence of infection

*___ &___ are checked to evaluate renal function.

(Levels are ____ if renal disease is present)

*URINALYSIS

*WBC & RBC

*BUN & SERUM CREATININE

(ELEVATED)

ALL MEN OVER AGE 50 SHOULD HAVE THIS TEST DONE:___

-EXPLAIN THAT HE MAY FEEL THE URGE TO URINATE WHEN PALPATION OCCURS.

-HELP PT TO BEND OVER THE EXAM TABLE OR INTO ____ POSTION. THE HEALTH CARE PROVIDER FEELS FOR ___ & ___.

~DIGITAL RECTAL EXAM

~SIDE LYING FETAL POSITON.

~SIZE & CONSISTENCY.

1. BLOOD STUDY DONE TO DETECT PROSTATE CANCER?

2. ASSESSMENT FOR RECURRING INFECTIONS. A SERIS OF X-RAYS W/ CONTRAST DYE. PT. SHOULD BE NPO FOR 8HRS B4 TEST AND AFTERWARD DRINK ALOT OF FLUIDS TO FLUSH OUT CONTRAST DYE.

1. PSA- PROSTATE-SPECIFIC ANTIGEN

2. IVP- IV PYELOGRAPHY

*OPERATIVE PROCEDURE THAT CAN BE USED FOR DIAGNOSIS OR TREATMENT OF BPH. IT CAN BE USED TO EXAMINE THE BLADDER & ID CAUSES OF OBSTRUCTION. CAN ALSO BE USED TO REMOVE TUMORS OR AN ENLARGED PROSTATE. GENERAL/ LOCAL W/ SEDATION MAY BE USED. PT. SOULD BE NPO AFTER MIDNIGHT & A BOWEL PREP (LAXATIVES/ENEMAS) IS DONE NIGHT BEFORE.

CYSTOSCOPY

1. WHAT WOULD YOU INSTRUCT A PT. W/ BPH ABOUT OTC MEDS?

2. ALCOHOL INTAKE & CAFFINE?  

1. NOT TO TAKE OTC COLD & SINUMS MEDS W/ DECONGESTANTS AS THEY CAN MAKE CONDITION WORSE (URINARY RETENTION).

2. DECREASE INTAKE B/C IT MAKES YOU HAVE TO PEE.

BPH MEDICATION:

1.___: ANTI- ANDROGENS, BLOCK MAKING OF TESTOSTERONE. SHRINKS PROSTATE & IMPROVES URINARY FLOW. PREGNANT WOMEN SHOULD NOT HANDLE THESE PILLS!!!

1. FINASTERIDE (PROSCRE, PROPECIA)

BPH MEDS:

1. ____, OR ____: ALPHA-ANDRENERGIC BLOCKER. RELAXES SMOOTH MUSCLE OF THE BLDDER & PROSTATE.(RISK OF HYPOTENSION). BEGIN DOSE AT NIGHT TO MINIMIZE SIED EFFECS

~TERAZOSIN (HYTRIN)

OR

TAMSULOSIN (FLOMAX)

AN HERBAL REMEDIE- THERE IS NO ASSURANCE OF STRENGHT OR PURITY, BUT THERE IS SCIENTIFIC EVIDENCE THAT IT DECREASES SYMPTOMS OF BPH.

~ SAW PALMETTO & PYGEUM AFRICANUM (HAS ANTI-INFLAMMATORY EFFECTS).

1. ___: A OUT PT. PROCEDURE, DOES NOT CURE BPH.  A CATHETER IS INSERTED & HEATED TO BURN AWAY PROSTATE TISSUE. DOES NOT CURE!

2. __: THE GOLD  STANDARD. REQUIRES ANETSHSIA. ACCOUNTS FOR 90% OF PROSTATE SURGERIES. PROSTATE IS RESECTIONED IN SMALL PIECES. (CLOSED PROCEDURE)

1. MICROWAVE (THERMOTHEARAPY)

2. TURP- TRANSURETHRAL REMOVAL OF PROSTATE

1.___: PERFORMED WHEN PROSTATE IS LARGER TAN CAN BE REMOVED TNSURETHRLLY & PT.HAS ANY OTHER BLADDER PROBLEMS THAT CAN BE TREATED AT THE SAME TIME.

2. ___: WHEN PROSTATE IS TO LARE TO BE RESECTIONED BUT NO COEXISTING BLADDER PROBLESM IDENTIFIED.

1. SUPRAPUBIC PROSTATECTOMY

2. RETROPUBIC PROSTATECTOMY

NURSIN CARE AFTER A TURP:

1. THE CATHETER IS PULLED IN THE PROSTETIC FOSSA TO HELP PREVENT____.

2. ____: RATE ADJUSTED SO FLUID RETURN IS COLORLESS OR LIGHT-PINK.(PREVENT CLOT)

3. PLENTY OF __ ON CATH REMOVAL, MON. URINE OUTPUT FOR BLEEDING & H&H VALUES FOR BLOOD LOSS.

4.__- BLADDER SPASM MEDS

1.BLEEDING

2.CONTINUOUS BLADDER IRRIGATION (CBI)

3. FLUIDS

4. DICYCLOMINE HYDROCHLORIDE

CBI MANAGMENT:

*CHECK DRAINAGE BAG FOR ___, ___,  ___, & _____.

*ADJUST CLAMPS FOR CONTINUOUS FLOW RATE OF ____ IRRIGATION.

*BLEEDING: CHECK __ OF DRAINAGE. __ RATE OF SALINE FLOW, NOTIFY MD.

*CLOTS: ASSESS __ FREQUENTLY (SUBTRACT AMOUNT OF IRRIGATION FLUID), CHECK FOR IRRIGANT ___, ASCERTAIN __, CHECK DRAINAGE BAG FOR __, TURN OFF IRRIGANT, __ DRAINAGE TUBE, PALPATE THE ___. IF THERE IS A CLOT IRRIGATE W/ ___ ML OF SALINE

*AMOUNT, COLOR, CONSISTENCY, & POSITION

*SALINE

*COLOR OF DRAINAGE. INCREASE RATE

* I&O

*RETENTION

*PAIN

*POSITION

*MILK

*BLADDER

*30-50ML

NAME 4 NURSING DX R/T POST TURP?

1. KNOWLEDGE DEFICIT R/T INDWELLING URINARY CATHETER

2. FLUID VOL. IMBALANCE R/T BLEEDIN AT OPERATIVE SITE OR ABSORPITON OF IRRIGATION FLUID

3. RISK FOR INFECTION

4. RISK FOR CONSTIPATION

1. ____: REMOVAL OF THE WHOLE BLADDER & SURROUNDING TISSUE. THREE MAIN RASONS FOR THIS PROCEDURE?

2. 3 OPTIONS W/ CYSTECTOMY?

1. RADICAL CYSTECTOMY

 *BLADDER CANCER, NEUROGENIC BLADDER DYSFUNCTION, CHRONIC INFLAMMATORY DISEASE OF THE BLADDER.

2. DIVERSION, BLADDER RECONSTUCTION, REPLACEMENT OF THE BLADDER W/ VARIOUS INTESTINAL SEGMENTS.

NURSING CARE FOR URINARY DIVERSION

*MAJOR SURG- BOWEL MANIPULATED

-ASSESS ___ & ___

*URINARY OUTPUT MUST BE MAINTAINED

-___ & ___

-__ IS PLACED TO ALLOW FOR HEALING

-BOWEL SOUNDS & FLUIDS/ELECTROLYTE BALANCE

-ASESS & MEASURE

-STENTS

*IVP

*DYE

*MIDNIGHT THE EVENING B4

*IODINE ALLERGIES

*EDEMA, ITCHING, WHEEZING & DYSPNEA

*DRINK ALOT OF FLUIDS TO WASH DYE FROM SYSTEM

___: most common operation for invasive bladder Sug. for collecting urine. A small piece of the bowel (intesine) is cut & rejoined at the ends. Tubes (ilemum) is rejoined @ ends. Tubes (ureters) that carry urine from kidney is sewn into 1 end of the part of bowel removed. A small hole is then cut into the abdomen, the open end of the peice of bowel is put into the hole creating a stoma (usually to the R. of umbilicus). The pt. must then wear a pouch (urostomy bag).

*Condutis

(Urostomy)

1. Metabolic Defect

2. renal tubular defect

3. Urinary stasis

4. Urinary Retention

5. immobility

6. dehydration

7. Thiazides

8. Diuretics

*Pt. w/ urinary stones normally complain that the pain is wore when?

*Pain is of ___ onset un- r/t precipitating event, unrealived by _______ or ______ medications.

*B/C stone is blocking urine or damage to urter walls has happened, pain may be occupanied by what 3 urinary related symptoms?

*MOVING

*Sudden -- position changes -- non-narotic

*Frequency -- Dysuria -- Hematuria

the ureters which carry urine from the kidneys, are diverted into the sigmoid colon.

Problems: occasional bowel incontinence (in this case, a mixture of urine and feces similar to diarrhea) at night,procedure is an increased risk of kidney infections (nephritis) due to bacteria from faeces travelling back up the ureters (reflux)

URETEROSIGNMOIDOSTOMY

*After surgical placement, a stoma should be assessed Q8h. What should it look like?

*If it is pale or cyanotic, this indicates?

*Rose to brick red in color w/ minimal swelling.

*Altered blood supply.

*Broad spectrum antibiotic used to treat UTI

*Prescibed to decrease ca+ levels thru the urine?

These may cause ____, supplements to prevent this may be needed.

*__ makes it difficult for body to make uric acid. This decreases the amount of uric acid in the urine, reducing the chance that a uric acid stone will form.

*Graramycin (Keflex)

*Thiazide Diuretics: Hydrochlorothiazide (Hydrodiuril)

*Hypokalcemia

*Allopurinol (Zyloprim) - B6- Antigout med

*__: surgeon makes a small incision in your back to remove kidney stones. He or she then puts a hollow tube into your kidney and a probe through the tube. In nephrolithotomy, the surgeon removes the stone through the tube. General anesthesia is used. Used in treatment of larger stones.

Main Complication?

Pt. education?

Percutaneous nephrolithotamy

Bleeding

Preventing further stones

*Anti spasmatic drugs used in cotrol and pain relief of pain w/ stones

*Used w/ struvite stones....prevents bacteria from splitting urea-- UTI

*Drugs used for S&S of BPH- relaxes muscles and enables voiding. S.E: hypotension- begin dose at night to minimize side effects.

*Oxybutynin (Ditropan) & propantheline (Pro-Banthine)

*Acetohydroxamic Acid (Lithostat) or Hydroxurea (Hydrea)

*Antiadrenergics- Flomax (tamsulosin) & Hytrin