Monitoring water balance

The purposes: reveal obscure edemas,determine quantity of daily urine, assessment of therapy adequacy, first of all, diuretic therapy.

Equipment: medical balance, clean dry 2-3 l container, two graduated basins, blank of water balance data, temperature datasheet.

◦The day before warn the patient about forthcoming procedure and rules of urine gathering.

◦At 6 a.m. wake the patient so that he urinates by himself in a toilet, or to let out urine with a catheter; this portion of urine is not counted.

◦All next portions of urine till 6 a.m. next day the patient should collect into the container.

◦During the day the patient or the nurse calculate the fluid introduced into organism in milliliters, including drunk liquids (first meals - 75% of fluid) and introduced parenterally.

◦By means of graduated basin calculate the quantity of the daily urine.

◦Thedata is written into a special column in temperature datasheet.

Syncope (Greek synkope; syncopal state) - short-term loss of consciousness caused by acutely arisen insufficiency of brain blood supply. Usually syncope results from strong neuropsychologicalaffects (fright, severe pain, seeing blood), in a stuffy room, in strong overfatigue. The loss of consciousness is often preceded by vertigo, tinnitus, blackout, sensation of nausea, etc. Skin and visible mucosas are pale, extremities are cold, colliquative sweat, sharp BP decraese, small threadlike sphygmus. Unlike epileptic fit, in syncope spontaneous urination is seldom, apnoea and tongue biting does not happen. Usually syncope happens when patient is in erect position; as soon as he liesthe blood inflow to brain increases, and the consciousness is quickly restored. The syncope lasts, as a rule, 20-30 sec, after that the patient comes to senses.

The aid in syncope involvesplacing the person in horizontal position with raised feet (provide inflow of blood to the head), removingrestraining clothes, providing access of fresh air. We may rub temples and chest of the person, sprinkle some cold water on the face, give the person to smell liquid ammonia (respiratory centre activation).

Collapse (Latin collapsus) – manifestations of acute vascular insufficiency with decrease of vascular tonus, depression of heart contractile function, decreaseof circulating blood volume and BP fall. It can happen in acute bloodloss, myocardial infarction, infectious diseases (because of dehydration caused by repeated vomiting, diarrhea), poisonings, overdose of antihypertensive drugs. Clinical manifestations are similar to those of syncope, but the collapse is not always accompanied by loss of consciousness, patient can be deferred, indifferent, the pupils are dilated.

The help in collapse includes lyingin horizontal position with lowered head, treating the cause of collapse, for example elimination of bleeding, warming of the person etc. If necessary according to doctor's orders parenterally restore circulating blood volume by means of infusionof blood preparations or blood substitutes, introduction of drugs that improve vascular tonus.

MONITORING AND CARE OF PATIENTS WITH RENAL AND URINARY TRACTS DISORDERS

Symptoms of urological diseases can be of 3 groups:

1) Pains;

Renal colic - syndrome characterised by spontaneouscramp-like pains in lumbar regionthat descend downwards along the ureterintogroin, externalia, hip (inner surface). Pains can be accompanied by nausea, vomiting, increase of arterial pressure, vegetative disorders. Remember! First aid in renal colic includes heat application (hot-water bottle on lumbar region, hot bath), spasmolytics and anaesthetics.

Inurinary bladder diseases (acute and chronic cystitis, stones, bladder tumours, acuteretention of urine) pains are localised in the bottom of abdomen, behind pubis and in region of sacrum. Quite often painful sensations can irradiate to the area of urethra and externalia, sharpen during urination and after it.

Urethralgia is frequent in urethra inflammation (urethritis), causing cutting painthat increases during urination, these pains are less frequent in cases of stones, urethra tumours.

2) Urination disorders;

(Dysuria) can be of two principal types: frequenturination (pollakiuria) can sometimes have physiological origin (increased intake of liquids, cooling, emotional tension) or be the result of nonurological disease (insular or other type of diabetes) and urinary difficulty (strangury), theextreme degree of it is delay of urination (ischuria), urinary incontinence. Urinary incontinence is spontaneous urine excretion without micturate urge, the cases are more frequent in women with colpoptosis and weakening of tonus of sphincter of urinary bladder and urethra

3) changes in quantity and quality of excreted urine. Urine quantitative changes includeincrease of its quantity (polyuria - diuresis more than 2lper day), its decrease (oliguria - diuresis less than 500 ml per day) and completearrest of urine entering intourinary bladder (anuria).Besides, both symptoms can be the result of anextrarenal disease; polyuria manifests in diabetes, oliguria - vomiting and diarrhea, cardiovascular insufficiency, fever. Polyuria and oliguria serve in urological practice more often as signs of renal insufficiency.There are three basic types of anuria: prerenal, renaland postrenal. First two types are secretory anurias (urinary passage is absent, i.e. kidneys do not secrete urine), and the third one - excretory anuria (uropoiesis is broken, i.e. urine does not go from kidneys to bladder). Principal causes of prerenalanuria are circulatory disorders - general (cardiac insufficiencey, shock, collapse, when arterial pressure falls below the level that is necessary for filtration of blood in renal glomerules, i.e. below 80/50 mm mercury) or local (thrombosis, vascular embolism of both kidneys or one kidney). The causes of renal anuria are various: poisonings that damage renal parenchyma, acute necrosis in septic states, hemolysis due incompatible blood transfusion, etc. Most frequent is postrenal anuria (obturative), caused by lesion of upper urinary tracts, most often – occlusion with stones of ureters on both ends, more rare - bilateral hydronephrosis or compression of ureters in case of tumours of pelvic organs (bladder, prostate, rectum, uterus and its appendages), or in case of metastasiseslocated in retroperitoneal lymph nodes.

Urine qualitative changes are rather various. They involve different qualities of urine: its density (specific weight), reaction, transparency, colour, amount of protein.These changes are also connectedwithpresence in urine of pathological admixturesthat can be detectedin microscopic examination of urocheras. The change of urine colour - special attention should be paid to hematuria (blood in urine), whenurine becomes red of various intensity that depends on degree admixture of blood in urine: from hardly noticeable pinkish colour to bright red colour.

First aid in acute ischuria: should start with introduction of rubber catheter into urinary bladder, most suitable catheter would be with narrowed and beak-shaped end (Thiemann catheter).

— In case of sharp overfill of bladder (accumulation of 1 l of urine and more!) its release should happen gradually in order to avoid fast change of pressure in its cavity that can lead to quickblood filling of dilated and scleroticbladder veins, their damage and bleeding. Emptying of urinary bladder in such cases should be done in separate portions of 300-400 ml, pressing the catheter for 2-3 minutes during the intervals.

— If it is difficult to introduce rubber catheter into the bladder, then after the discharge of bladder it is better not to remove it, but to leave it in as permanent, because attempts of further catheterization may fail.

— If anamnesis (acute retention of urination after a fit of renal colic) indicates the occlusion of urethra with a stone, then hot bath can be applied, anaesthetics or antispasmodics in order to relax urethrisms surrounding the stone. If these measures have no result the patient is sentto urology department. Bladder catheterization in such cases is strictly contraindicated, as it is fraught with threat of additional injury, intensifying of bleeding, infectioning of the wound and is practically always unsuccessful.

Remember! The most dangerous symptoms of uropoiesis organs diseases are: renal colic, acute retention of urination, anuria, hematuria.

TAKING URINE FOR LABORATORY TESTS

For the majority of tests urine is taken in the morning, right after a sleep.Recently urine in women is not takenthrough catheterization (it is dangerous with bringing bacterial flora inside bladder). Women give urine for analysis from “middle portion». Containers for urine which is send for diagnostics should be washed carefully and dried.Nowadays in clinical practice we apply quantitative means of detection of leukocyturia, erythrocyturia, cylindruria.

Kakovsky-Addis method, the number of elements in diurnal urine (norm is up to 2*10⁶/daily leucocytes, up to 1*10⁶/daily erythrocytes and 100000 hyaline cylinders). For analysis urine is collectedduring 12 h.

Hamburger method -after discharge of urinary bladder a three-hour portion of urine is collected; also detection of“minute leukocyturia” is conducted, i.e. the numbers of leucocytes in urine excretedin 1 minute; for that purpose laboratory takes a portion of urine which has been excreted during certain number of minutes.

Nechiporenkomethod -count leukocytes and erythrocytes in 1 ml of urine (norm is 2000 and 1000accordingly). For this method of diagnostics any portion of urine, at any time and of any volume, starting from 2-3 ml can be used.

Zimnitskyassay -at 6 a.m. the patient urinates and after that till 6 a.m. next day collects urine in 8 containers. Thus from 6 till 9 the patient urinates into the first container, from 9 till 12 - into the second, etc. If in case of polyuria the volume of a container is not sufficient, the patient takes additional container for urine on which the number of urine portion and surname of the patient is written. It is necessary to control that the patient fills all containers. In the absence of urine within 3 hoursthe empty container isnevertheless sentto the laboratory. Zimnitsky assay is considered good if total daily urine is sufficient (1-2 l), in separate 3-hour portions volume of urine is different (from 100 to 300 ml), and relative density of urine varies from 1,010 to 1,025.

Dilution and concentration test of urine (Volhard’s test). Each test is made within 12 h. Forurine dilution test the patient drinks on an empty stomach 1,5 l of water, then within 4 h the volume and urine density is determined every 30 minutes, and throughout following 8 h - every 2 h. If renal functionsare good most part of the previously drunk liquid is excreted within the first 4 h and its density in the end of the test becomes normal. For urine concentration test the patient is not allowed to drinkduring 12 h and every 2 h the volume of discharged urine and its density is determined. In case of normal concentration ability of kidneysin the last portions of urine the volume is considerably low (up to 100 ml and even lower), but its density increases (up to 1,030).

PROCESS OF URINARY CATHETERIZATION

— Catheterization of urinary bladder in men for the first time is done with rubber catheter. In case it is not possible to introduce it through urethra, elastic catheter is used and last resort is a metal catheter. Introduction of a rubber catheter into bladder for men:The patient lies on his back. Foreskinis moved and the balanus is open. With the III and IV fingers of left handfixate sexual organ below balanus, and with I and II fingers extendthe outside end of urethra. With the right arm the balanus in the area of foramen is smeared with disinfectant solution (0,02% furacilin solution, 0,1% solution of rivanol, 2% solution of boric acid, etc.). Then take sterile forcepsinto the right handand with it take the catheter, whichis lying on a sterile table or in a sterile tray, near its end in 5-6 cm from the opening. It is most convenient to hold the external part of the catheter between the IV and V fingers of the same hand. Before introduction of the catheter it is lubricated with sterile vaseline oil, glycerol, or synthomycin emulsion. Thecatheter end is introduced into the foramen of urethra and, gradually moving it, advance into urethra, and the sexual organby the left hand is pulled up, as though putting the organ onto the catheter. When catheter reaches external sphincter, there can be an obstacle, which is usually easy to overcome. Only occasionally strong spastic stricture of sphincter becomes impermeablefor catheter. For spastic stricture elimination an injection with anaesthetics and antispasmodics is done. It is possible to check the proper introduction of a catheter into bladder by the starting outflow of urine.

The catheter is removed by simple pulling out.

During catheterization of urinary bladder the following complications are possible:

a) infectioning;

b) damage of mucosa of urethra and bladder;

c) urethral fever.

PREPARATION OF PATIENTS FOR THE X-RAY DIAGNOSTICSON ORGANS OF UROPOIESIS

Перед обзорной и выделительной урографией, всеми видами ангиографии накануне вечером и утром до исследования рекомендуется ставить очистительную клизму, но при абсолютно нормальной самостоятельной функции кишечника необходимости в этом нет. Ввиду возможности побочных реакций на введение в кровь рентгеноконтрастного вещества, вплоть до шока и коллапса в рентгеновском кабинете всегда должны находиться средства реанимации.

Before plain and selective urography, all types of angiography the night before and in the morning before diagnostics it is recommended to apply cleansing enema, but in absolutely normal independent functioning of intestine it is not necessary. Because of possibility of side effectsto introduction of radiopaque substances, including shock and collapse, in the X-ray room always there should always be available equipment for resuscitation.