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NR 325 Urinary and Renal System Exam Review.
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NR 325 Urinary and Renal System Exam Review1. Chronic kidney & metabolic acidosis
2. Ileal conduit – patient teaching
How to apply one….how often you should empty it. When do you need to empty it
The patient with a continent reservoir needs to self-catheterize every 4 to 6 hours but does not
need to wear external attachments. Patients may wear a small bandage on the stoma to collect
any mucous drainage or excess drainage. Examples of continent diversions are the Kock (Fig. 45-
13), Mainz, Indiana, and Florida pouches. The main difference among the various diversions is
the segment of bowel used. For example, the Indiana pouch uses the right colon as a reservoir
and has become a popular form of continent urinary diversion.
Patients with a neobladder may have postoperative urinary retention and require
catheterization. It may take up to 6 months for them to regain bladder control. Patients empty
their neobladders by relaxing their outlet sphincter muscles and bearing down with their
abdominal muscles. Since there is no longer neurologic feedback between the reservoir and the
brain, the patient should not expect a normal desire to void. To avoid bladder overdistention,
patients should void at least every 2 to 4 hours, sit during voiding, and practice pelvic floor
muscle relaxation to aid voiding. Follow-up x-ray studies include a “pouchogram” 3 to 4 weeks
after surgery to assess for healing.
Discharge teaching after an ileal conduit includes instructing the patient about
symptoms of obstruction or infection and care of the ostomy. The patient with an ileal conduit is
fitted for a permanent appliance 7 to 10 days after surgery. It may have to be refitted at a later
time, depending on the degree of stoma healing and shrinkage.
Nursing Management: Urinary Diversion
Preoperative Management
Teaching is important for the patient awaiting cystectomy and urinary diversion surgery. Assess
the patient's ability and readiness to learn before initiating a teaching program. If the patient is
not ready to learn, modify the teaching plan. The patient's anxiety and fear may be decreased
by providing more information. However, the anxiety and fear may also interfere with learning.
Involve the patient's caregiver and family in the teaching process.
Discuss the psychosocial aspects of living with a stoma (including clothing,
changes in body image and sexuality, exercise, and odor). This may allay some
fears. Teach the patient with a continent diversion (e.g., Indiana pouch) to catheterize at least
every 6 hours and irrigate the pouch daily. The patient with an orthotopic neobladder may have
problems with incontinence. Discuss patient's' concerns about sexual activities and let them
know that counseling is available. A wound, ostomy, and continence nurse (WOCN) should be
involved in the preoperative phase of the patient's care. A visit from an ostomate can be helpful.
Additional interventions are presented in eNursing Care Plan 45-3 for the patient with an ileal
conduit (on the website for this chapter).
Postoperative Management
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, Plan the nursing interventions during the postoperative period to prevent surgical complications
such as postoperative atelectasis and shock (see Chapter 19). After pelvic surgery, there is an
increased incidence of thrombophlebitis, small bowel obstruction, and UTI. With removal of
part of the bowel, the incidence of paralytic ileus and small bowel obstruction is increased, the
patient is kept on NPO status, and a nasogastric tube may be needed for a few days. Prevent
injury to the stoma and maintain urine output. Advise the patient that mucus in the urine is a
normal occurrence. The mucus is secreted by the mucosa of the intestine (which is used to
create the ileal conduit) in response to the irritating effect of urine. Encourage a high fluid
intake to “flush” the ileal conduit or continent diversion. When an ileal conduit is created,
provide meticulous care for the skin around the stoma. Alkaline encrustations with dermatitis
may occur when alkaline urine comes in contact with exposed skin (Fig. 45-14). The urine is kept
acidic to prevent alkaline
encrustations. Other common peristomal skin problems include yeast infections, product
allergies, and shearing-effect excoriations. Changing appliances (pouches) is described in Table
45-23. A properly fitting appliance is essential to prevent skin problems. The appliance should
be about 0.1 in (0.2 cm) larger than the stoma. It is normal for the stoma to shrink within the
first few weeks after surgery.
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