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Hesi med surg 1 & 2 study materials
Med Surg (Fortis College)
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Renal
Nursing Interventions
⧫ Assess for and document patient's normal voiding pattern.
⧫ Monitor quality and color of urine. Optimally, urine is straw colored and
clear and has a characteristic urine odor. Dark urine is often indicative of
dehydration, and blood-tinged urine can result from rupture of ureteral capillaries as
the calculus passes through the ureter.
⧫ Encourage fluid intake of at least 2-3 L/day (in patients for whom fluids
are not restricted) to help flush calculus through the ureter, into the bladder, and
out through the urinary meatus.
⧫ Record accurate I&O; teach patient how to record I&O to verify
adequacy of urine output.
⧫ Strain all urine for evidence of solid matter; teach patient the
procedure. Send any solid matter to the laboratory for analysis.
⧫ Monitor output from ureteral catheter. If patient has more than one
catheter, label one right and the other left, as appropriate; keep all drainage records
separate. Amount will vary with each patient and depend on catheter dimension. If
drainage is scant or absent, milk catheter and tubing gently to try to dislodge the
obstruction. If this fails, notify health care provider. Never irrigate catheter without
specific health care provider instructions to do so. If irrigation is prescribed, use
gentle pressure and sterile technique. Always aspirate with sterile syringe before
instillation to prevent ureteral damage from overdistention. Use another sterile
syringe to instill irrigant amounts of 3 mL or less.
⧫ Explain to patient that bed rest is required when ureteral catheter is
indwelling. Semi-Fowler's and side-lying positions are acceptable. Fowler's position
should be avoided, however, because sutures are seldom used and gravity can
cause catheter to move into the bladder. Urinary bladder (ureteral) catheters are
often attached to the urethral catheter after placement in the ureters. Carefully
monitor urethral catheter for movement to ensure that it is securely attached to
patient.
⧫ Monitor for indicators of ureteral obstruction, including flank pain, CVA
tenderness, nausea, and vomiting after ureteral catheters have been removed.
Ureteral catheters are usually removed simultaneously with the urethral catheter.
Renal
Clinical Manifestations
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The first symptom is usually sudden, severe pain. Typically, a person feels sharp
pain in the flank area, back, or lower abdomen. People describe the pain as
excruciating.
▪ Renal colic is the term used for the sharp, severe pain, which results
from the stretching, dilation, and spasm of the ureter in response to the obstructing
stone. Nausea and vomiting may also occur.
▪ Urinary stones cause manifestations when they obstruct urinary flow.
The type of pain is determined by the location of the stone. If the stone is
nonobstructing, pain may be absent. If it produces obstruction in a calyx or at the
ureteropelvic junction (UPJ), the patient may experience dull costovertebral flank
pain or even colic. Pain resulting from the passage of a calculus down the ureter is
intense and colicky. The patient may be in mild shock, with cool, moist skin. As a
stone nears the ureterovesical junction (UVJ), pain will be felt in the lateral flank and
sometimes down into the testicles or labia or groin.
▪ Manifestations may also include those of a UTI, with dysuria, fever, and
chills.
Assessment
Physical Assessment/Clinical Manifestations.
Frequency, urgency, and dysuria are the common manifestations of a urinary tract
infection (UTI), but other manifestations may be present (Chart 66-3). Urine may be
cloudy, foul smelling, or blood tinged. Ask the patient about risk factors for UTI
during the assessment (see Table 66-1). For noninfectious cystitis, the Pelvic Pain
and Urgency/Frequency (PUF) patient symptom scale can identify patients with
interstitial cystitis ( Richmond, 2010).
Chart 66-3
Key Features
Urinary Tract Infection
Common Clinical Manifestations
• Frequency
• Urgency
• Dysuria
• Hesitancy or difÏculty in initiating urine stream
• Low back pain
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• Nocturia
• Incontinence
• Hematuria
• Pyuria
• Bacteriuria
• Retention
• Suprapubic tenderness or fullness
• Feeling of incomplete bladder emptying
Rare Clinical Manifestations
• Fever
• Chills
• Nausea or vomiting
• Malaise
• Flank pain
Clinical Manifestations that May Occur in the Older Adult
• The only manifestation may be something as vague as increasing
mental confusion or frequent, unexplained falls.
• A sudden onset of incontinence or a worsening of incontinence may be
the only manifestation of an early urinary tract infection (UTI).
• Fever, tachycardia, tachypnea, and hypotension, even without any
urinary manifestations, may be signs of urosepsis.
• Loss of appetite, nocturia, and dysuria are common manifestations.
Before performing the physical assessment, ask the patient to void so that the urine
can be examined and the bladder emptied before palpation. Assess vital signs to
help identify the presence of infection (e.g., fever, tachycardia, and tachypnea).
Inspect the lower abdomen, and palpate the bladder. Distention after voiding
indicates incomplete bladder emptying.
Using Standard Precautions, record any lesions around the urethral meatus and
vaginal opening. To help differentiate between a vaginal and a urinary tract
infection, note whether there is any vaginal discharge. Vaginal discharge and
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