NCLEX: Caring for the Client with Disorders of the Renal and Genitourinary System

Terms you’ll need to understand:
Anuria
Arteriovenous graft
Cutaneous ureterostomy
Cystectomy
Cystitis
Dialysis
Dysuria
End stage renal failure
Fistula
Glomerulonephritis
Hematuria
Ileal conduit
Ileal reservoir
Nephrectomy
Nephrotic syndrome
Oliguria
Polyarteritis nodosa
Scleroderma
Systemic lupus erythematosus

Nursing skills you’ll need to master:
Performing urinary catheterization
Administering medication
Performing bladder irrigation
Assessing and caring for AV shunt
Performing peritoneal dialysis
Performing stoma care
Collecting urine specimen (clean catch, sterile, 24 hour)
Assisting with renal biopsy
Caring for central lines

The renal system includes the kidneys and the urinary tract. Disorders of this system can be divided into conditions that affect the kidneys and conditions that affect the urinary tract, which includes the ureters and bladder. Renal disorders are of particular significance because the kidneys contribute to our health in a number of ways. The kidneys play a primary role in maintaining fluid volume and electrolyte balance, filtering waste for elimination, maintaining blood pressure, synthesizing red blood cells, and metabolizing vitamin D. Disorders of the ureters and bladder affect the storage and elimination of urine. Although these disorders are not as serious as renal disorders, those affected experience significant physical and emotional changes. In this chapter we review the most common conditions affecting urinary elimination.

Acute Glomerulonephritis
Acute glomerulonephritis is an antigen–antibody response occurring from one to two weeks following infection with Group A β-hemolytic Streptococcus.
Other causes include systemic lupus erythematosus, scleroderma, and polyarteritis nodosa.

Signs and symptoms include
- Dark, smoke-colored urine
- Hypertension
- Headache
- Nausea and vomiting
- Oliguria

Routine urinalysis typically reveals elevations in specific gravity, hematuria, and proteinuria. Blood studies reveal elevations in blood urea nitrogen (BUN), creatinine, and erythrocyte sedimentation rates. A positive antistreptolysin (ASO) titer indicates prior infection with Group A β-hemolytic Streptococcus. Two additional studies may be ordered to determine the extent of kidney damage. These studies are a 24-hour urine to check for creatinine clearance and a renal biopsy, which shows cellular changes in the glomerular tissue.
Know the normal ranges for urine specific gravity, BUN, and serum creatinine.

The management of the client with acute glomerulonephritis includes the use of
- Antibiotics
- Antihypertensives
- Steroids
- Bed rest
- Strict monitoring of fluid intake and output
- Limited intake of sodium and protein
- Assess for signs of edema and circulatory overload

Chronic Glomerulonephritis
Chronic glomerulonephritis refers to a long-term inflammation of the glomerular capillaries. The condition may follow an episode of acute glomerulonephritis or a milder antigen–antibody reaction.
Signs and symptoms include
- Proteinuria
- Pedal edema
- Weight loss
- Nocturia
- Gastrointestinal complaints
- Anemia
- Peripheral neuropathy
- Gout
- Hypertension
- Increased serum creatinine
- Increased BUN
- Normal or below normal urine specific gravity

Management of the client with chronic glomerulonephritis is largely symptomatic. Medications include diuretics, antihypertensives, and antianemics.
Hyperkalemia is treated with sodium polystyrene sulfonate (Kayexelate), which can be given alone or with sorbitol. Strict monitoring of fluid intake and output and restriction of dietary protein and sodium are essential in the prevention of fluid overload.

End Stage Renal Disease
End stage renal disease (ESRD) is a progressive, irreversible deterioration in renal function in which the kidneys are no longer able to maintain metabolic as well as fluid and electrolyte balance. Urea and other nitrogenous wastes are retained in the blood stream, necessitating management by peritoneal dialysis, hemodialysis, or renal transplant.

Peritoneal Dialysis
Peritoneal dialysis involves the instillation of dialysate via a flexible catheter implanted into the peritoneal cavity. Osmotic pressure allows waste products to be returned with the dialysate. Strict adherence to sterile technique is essential to prevent infection and peritonitis.
Symptoms of peritonitis include
- Fever
- Abdominal discomfort
- The return of cloudy dialysate

Hemodialysis
Hemodialysis is accomplished by using a dialyzer, which serves as a synthetic semipermeable membrane. Vascular access is obtained through the use of a subclavian, jugular, or femoral catheter as well as the placement of a fistula or arteriovenous graft. D. not check blood pressure or perform venous sticks in the extremity with a vascular access because damage can occur to the access site. The presence of a bruit indicates the access site is patent.
Do not administer rapid-acting antihypertensives prior to hemodialysis because some are not removed by dialysis and the client is more likely to experience shock.

Renal Transplants
Renal transplants can be obtained from a cadaver or living, compatible donor. The transplanted kidney is placed within the pelvis to provide greater protection against traumatic injury. Following transplantation, the client is placed on lifetime therapy with immunosuppressives, biologic response modifiers, and monoclonal antibodies. Commonly used medications administered after renal transplant include
- Azathioprine (Immuran)
- Corticosteroids (Prednisone)
- Cyclosporine (Sandimmune, Neoral)
- Tacrolimus (Prograf)

Mycophenolate (CellCept) has been approved by the FDA solely for the prevention of renal transplant rejection.

Nephrotic Syndrome
Nephrotic syndrome can be caused by glomerulonephritis, systemic illness, or an acute allergic response. Diagnosis is based on the client’s symptoms, renal function tests, and 24-hour urine test for creatinine clearance.
Nephrotic syndrome involves a collection of symptoms that include
- Marked proteinuria
- Generalized edema
- Hypoalbuminemia
- Hypercholesterolemia
- Normal or below normal blood pressure

Management of the client with nephrotic syndrome includes
- Bed rest
- Prevention of skin breakdown
- Daily weights
- Strict intake and output
- Increased protein intake with sodium restrictions
- Medications, including steroids and immunosuppressives

Urinary Calculi
Urinary calculi (urolithiasis, kidney stones) can result from immobility, cancer, increased intake of vitamin D, or overactivity of the parathyroid. Urinary calculi are more common in men, particularly in those 30–50 years of age, and occur in all age groups with greater frequency in the spring and summer months. Kidney stones are more commonly made up of calcium, magnesium, phosphorus, or oxalate.
Symptoms associated with kidney stones include
- Flank pain
- Fever
- Nausea and vomiting
- Changes in urinary output

Diagnostic measures include x-ray with contrast, blood studies, and a 24-hour urine test.
Management of the client with kidney stones includes
- Use of IV fluids
- Pain management
- Lithotripsy
- Surgical management
- Dietary alterations for those with recurring calcium, uric acid, or oxalate stones
- Straining the urine to detect passage of the stone

Urinary Tract Infections
Urinary tract infections (UTIs) are caused by pathologic microorganisms of the urinary tract. UTIs represent 40% of hospital-acquired infections, with most of those being due to contamination during catheterization or instrumentation. Ascending infection with fecal material (E. coli) accounts for over one half of all UTIs. Symptoms of UTIs depend on whether the infection affects the bladder (cystitis) or the kidney (pyelonephritis). Symptoms of UTI include
- Pain and burning on urination
- Urinary frequency and urgency
- Flank pain
- Fever
- Nausea and vomiting

Management of the client with a UTI includes the use of specific antibiotics, urinary antispasmodics, and increased fluids.

Benign Prostatic Hyperplasia
One of the most common pathological conditions in men over age 50 is benign prostatic hyperplasia (BPH). Enlargement of the prostate can obstruct the vesicle neck or prostatic urethra, leading to incomplete emptying of the bladder and urinary retention. Retention of urine causes dilation of the ureters and kidneys and contributes to the development of urinary tract infections.
Signs and symptoms of BPH include
- Increased frequency of urination
- Nocturia
- Urinary urgency
- Hesitancy in starting urination
- Decrease in the volume and force of urinary stream
- Feeling of bladder fullness
- Recurrent urinary tract infections

Diagnostic tests include urinalysis, renal function tests, digital rectal exam, and complete blood studies.
Medical management of BPH includes the use of antiandrogens including finasteride (Proscar), as well as herbal therapy with saw palmetto. Alphaadrenergic receptors blockers such as terazosin (Hytrin) help reduce the obstructive symptoms.
Surgical management includes removal of the prostate. The most common surgical procedure for BPH is a transurethral prostatectomy (TURP). The most common complication following a TURP is hemorrhage; therefore, it is imperative that the urinary output is assessed for amount and color.

The presence of bright red urine with increased viscosity and clots indicates arterial bleeding and should be reported to the doctor immediately.
The presence of dark red urine with less viscosity and few clots indicates venous bleeding, which can be managed by applying traction to the urethral catheter.

Bladder Cancer
Malignancies of the bladder are the fourth leading cause of cancer in the United States. Risk factors in bladder cancer include
- Recurrent bacterial UTI
- High cholesterol intake
- Pelvic radiation
- Environmental carcinogens, including certain dyes
- Smoking

Symptoms of bladder cancer include visible painless hematuria, infection, dysuria, and frequency. Pelvic and back pain are common with metastasis.
Diagnostic tests include cystoscopy, CT scan, biopsy, and ultrasonography.
Management of the client with bladder cancer depends on the grade, degree of local invasion, and client’s age as well as physical and mental status.
Surgical management includes cystectomy with the creation of a urinary diversion.
Types of urinary diversions that may be performed following a cystectomy are ileal conduit, ileal reservoir, ureterostomy, and ureterosigmoidostomy. It is important for the nurse to review these because some require the client to wear an external appliance and some do not.

Chemotherapeutic management includes a combination of methotrexate, 5 florouracil, vinblastine, and doxorubicin. In cases where cystectomy is not performed, the client may be treated by intravesicle therapy with BCG.
Clients receiving intravesicle therapy can continue to eat and drink before therapy but should avoid urinating for at least two hours after instillation of the medication. This allows sufficient exposure time to the medication.
Afterward, the client is encouraged to drink additional fluids to remove drug residue.

Diagnostic Tests for Review
Routine diagnostic tests, including CBC and urinalysis, are ordered for the client with disorders of the renal and urinary system. Specific tests such as intravenous pyelogram and CT scan are ordered to detect structural abnormalities. The complete metabolic panel reflects changes in electrolytes that result from renal disease. The tests are as follows:
- CBC
- Complete metabolic panel
- Urinalysis
- Intravenous pyelogram
- CT scan

Pharmacology Categories for Review
Renal disorders affect many other organ systems including the cardiovascular system and hematopoietic system. Clients with renal disease will receive medication from a number of different categories depending on their condition. These medications include:
- Antibiotics
- Antihypertensives
- Antineoplastics
- Antispasmodics
- Diuretics
- Immunosuppressives