Hydronephrosis is the distension of the pelvis and calyces of one or both kidneys, resulting in thinning of the renal tubules because of obstructed urinary flow. When the obstruction is a stone or kink in one of the ureters, only one kidney is damaged. The obstruction causes backup, resulting in increased pressure in the kidneys. If the pressure is low to moderate, the kidney may dilate with no obvious loss of function.
Over time, intermittent or continuous high pressure causes irreversible nephron destruction. If the patient has a chronic partial obstruction, the kidneys lose their ability to concentrate urine. The kidneys may lose renal mass and atrophy and have a lowered resistance to infection and pyelonephritis because of urinary stasis. If hydronephrosis is caused by an acute obstructive uropathy (any disease of the urinary tract), the patient may develop a paralytic ileus. If bilateral hydronephrosis is left untreated, renal failure can result. At the time of death, approximately 3% of the U.S. population has hydronephrosis.
Any type of urinary obstruction can lead to hydronephrosis. The most common types of obstruction are caused by prostate hypertrophy (enlargement), renal calculi that form in the renal pelvis or drop into the ureter, or urethral strictures. Causes that are more unusual include structure of the ureter or bladder outlet, tumors pressing on the ureter, congenital abnormalities, blood clots, and a neurogenic bladder.
Nursing care plan assessment and physical examination
Elicit a careful history about urinary patterns to determine a history of burning sensations or abnormal color. The patient may be completely anuric (no urine flow) or experience polyuria (large urine output) or nocturia (excessive urination at night) because of a partial urinary obstruction. Determine any recent history of mild or severe renal or flank pain that radiates to the groin. Ask about vomiting, nausea, or abdominal fullness. Ask a male patient if he has had prostate difficulties. Establish any history of blood clots, bladder problems, or prior urinary difficulties. Some patients will report very mild or even no symptoms.
Inspect the flank area for asymmetry, which indicates the presence of a renal mass. Inspect the male urethra for stenosis, injury, or phimosis (narrowing so that the foreskin cannot be pushed back over the glans penis). A genitourinary (GU) exam is performed in the female patient to inspect and palpate for vaginal, uterine, and rectal lesions. When the flank area is palpated, you may feel a large fluctuating soft mass in the kidney area that represents the collection of urine in the renal pelvis. Palpate the abdomen to help identify tender areas. If the hydronephrosis is the result of bladder obstruction, markedly distended urinary bladder may be felt. Gentle pressure on the urinary bladder may result in leaking urine from the urethra because of bladder overflow. Rectal examination may reveal enlargement of the prostate or renal or pelvic masses.
Although hydronephrosis is a treatable condition, the patient is likely to be upset and anxious. Many find GU examinations embarrassing. Urinary catheterization can also be a stressful event, particularly if it is performed by someone of the opposite gender. If the patient’s renal condition has been permanently affected, determine the patient’s ability to cope with a serious chronic condition.
Nursing care plan primary nursing diagnosis: Risk for infection related to urinary stasis and instrumentation.
Nursing care plan intervention and treatment plan
Temporary urinary drainage may be achieved by a nephrostomy or ureterostomy. Other options are ureteral, urethral, or suprapubic catheterization. When no infection is present, immediate surgery is not necessary even if there is complete obstruction and anuria. Urologists often place a ureteral stent, which is performed along with a cystoscopy and retrograde pyelography. Stents can bypass an obstruction and dilate the ureter for further evaluation and treatment such as a percutaneous nephrostomy tube, which may be placed when a retrograde stent cannot be passed because of an obstruction in the ureter. Advances in endoscopic and percutaneous instrumentation have reduced the surgical role, although some cases of hydronephrosis still require treatment with open surgery. Many surgeons will wait until acid-base, fluid, and electrolyte balances are restored before operating. Surgery includes options such as prostatectomy for benign prostatic hypertrophy, tumor removal, and dilation of urethral strictures.
When bilateral complete urinary obstruction is relieved, the patient usually has massive polyuria and excessive natriuresis (sodium loss in the urine). In general, the physician will prescribe the replacement of two-thirds of the loss of urinary volume per day to be replaced by saltcontaining intravenous solutions. Further expansion of the extracellular volume may sustain the diuresis. With impaired renal function, a diet low in sodium, potassium, and protein is often prescribed. Preoperative diet restrictions are sometimes used to limit the progression of renal failure before surgical removal of the obstruction.
The urinary drainage system requires close monitoring. Check the color, consistency, odor, and amount of urine hourly and as needed. Inspect the tube insertion site for signs of infection (purulent drainage, swelling, redness) and bleeding. If the tube is obstructed, follow the appropriate protocol for either irrigation or physician notification. Clamp the drainage tube only after specific discussion with the physician.
The patient requires careful fluid balance. Weigh the patient at the same time of day on the same scale with the same clothing. Elicit the patient’s and family’s support in maintaining an accurate record of fluid intake and output. Pay particular attention to the patient’s response to the illness. Respect the patient’s privacy by isolating him or her from others during urinary drainage system insertion and insertion site care. Provide an honest appraisal of the patient’s condition, and answer all questions. Note that both men and women link urinary functioning to sexual functioning. Be open to and supportive of the patient’s fears of sexual dysfunction and provide accurate information. Provide meticulous skin care. Request a consultation from the enterostomal nurse for unusual problems.
Nursing care plan discharge and home health care guidelines
Teach the importance of adequate fluids. Explain the importance of notifying the physician at the first signs of inability to void or of urinary infection, such as burning or painful urination, cloudy urine, rusty or smoky urine, blood-tinged urine, foul odor, flank pain, or fever. Be sure the patient, family, or other caregiver understands all medications, including the dosage, route, action, and adverse effects. Encourage the patient to take the entire course of antibiotics as prescribed. Teach the patient, family, or other caregiver how to drain a Foley catheter or nephrostomy tube and to examine the insertion site for infection. Encourage older male patients with a family history of benign prostatic hypertrophy or prostatitis to have annual medical checkups.