Chapter 50: Renal & Urologic Problems

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Alright, let's unpack this.

Imagine you're a nursing student about to step onto a busy floor.

You could face a patient with maybe a simple infection or someone with life -threatening kidney failure, all tied to their urinary system.

It's a vast and frankly often overwhelming area, right?

How do you quickly get up to speed on the really critical info without drowning in details?

That's exactly what we're aiming for in this deep dive.

The kidneys and urinary tract are just fundamental.

They maintain the body's delicate balance, fluids, electrolytes, acid base.

When things go wrong, the impact, well, it cascades through the entire system.

It affects everything from a patient's basic comfort right up to their critical bodily functions.

So, we're going to guide you through the essentials of renal and urologic problems and we're drawing directly from a core text, Lewis's Medical Surgical Nursing, the 12th edition.

Think of this as your shortcut, maybe your curated guide to understanding the most important bits of knowledge.

We're going to break down that dense med -surg content, give you a clear, structured, and hopefully engaging overview.

We'll dive into the why behind the diseases,

the pathophysiology, and crucially, the what to do.

That means the nursing management, the interventions that really make a difference.

We want to connect this to real -world stuff, specific examples, essential terms, preparing you not just for exams, but for actual patient care.

Exactly.

And we'll keep emphasizing the nursing process, how you assess, how you prioritize, collaborating with the team, and of course, patient education.

And where the textbook might show a chart or a care plan, we'll actually describe that critical information verbally so you don't miss anything.

By the end, you should have a really robust foundation.

You'll feel more ready for those NCLEX -style questions and, maybe more importantly, ready to walk into a clinical setting feeling prepared.

Okay, great.

So let's kick things off with what's probably the most common outpatient infection around.

Urinary tract infections, UTIs, we've all heard of them, maybe many of us have even had one, but what's really going on beneath the surface and what do we as nurses need to know?

Yeah, it's fascinating just how common they are, especially for women.

UTIs are, well, they're infections anywhere in the urinary tract, the main culprit.

Usually escherichia coli or E.

coli.

That accounts for about 75 % of the straightforward cases and maybe 65 % of the more complicated ones.

But it's not just E.

coli.

You also see fungal and parasitic infections causing UTIs, particularly in vulnerable patients, maybe immunocompromised, those with diabetes or existing kidney issues.

Okay, so it's an infection of the urinary tract.

How do we classify them?

Does the location actually matter?

Oh, location absolutely matters.

It's key for understanding severity and how we treat it.

We broadly classify them into upper and lower UTIs.

Upper UTIs involve the kidney itself, the renal parenchyma, the collecting system, think pylonophritis, which we'll definitely talk about.

Lower UTIs affect the bladder that's cystitis and the urethra, which is urethritis, and then there's the really severe one, urosepsis, that's life -threatening, where the infection goes systemic, needs emergency treatment stat.

That upper versus lower distinction sounds pretty critical for a nurse to grasp quickly.

What about differentiating between uncomplicated and complicated UTIs?

Great.

Another crucial distinction for your assessment.

An uncomplicated UTI typically happens in a normal urinary tract, usually just involves the bladder, like a healthy young woman with classic cystitis.

A complicated UTI, though, involves underlying conditions, maybe an obstruction, stones, a catheter, diabetes, even pregnancy.

These patients, they're at a much higher risk for serious stuff, pylonophritis, urosepsis, potential renal damage.

So our approach has to be different, more vigilant.

Okay, that makes sense.

Now the mechanics,

how do these infections actually start?

What are the pathways for the bacteria?

Good question.

You see, the urinary tract above the urethra, it's normally sterile.

Our bodies have these amazing defenses, complete bladder emptying, competent ureterovesical junctions.

They stop urine backflow, and the urine itself is slightly acidic, which is antibacterial.

But most infections, they start from bacteria in the perineum, often those gram -negative ones from the GI tract, and they just, well, ascend from the urethra.

It's like a pathway upwards.

Urologic procedures, especially catheterization, that's a prime way to introduce bacteria.

Ah, okay.

Yeah, and even sexual intercourse can kind of milk bacteria up into the bladder.

Less commonly, you might see hematogenous spread blood -borne bacteria invading the kidneys, but that usually needs a prior injury there.

And here's a really key point for you as nursing students.

UTIs are the most common healthcare -associated infection, or HAI, mostly due to indwelling catheter.

Yeah, CaUTIs.

Exactly.

CaUTIs, catheter -associated UTIs, they lead to longer hospital stays, higher costs.

Preventing CaUTIs is a massive nursing priority.

That's a powerful reminder about CaUTIs.

Beyond that, what are some other key risk factors nurses should keep in mind?

There's quite a list, actually.

Anatomic things like congenital defects or just the shorter female urethra make women more susceptible.

Anything compromising the immune system, aging, diabetes, HIV, that's a factor.

Increased urinary stasis, you know, when urine just sits there.

That can be from obstructions, renal impairment, neurogenic bladder issues, that plays a big role.

Foreign bodies like catheters and stones are significant.

Functional issues like constipation or just poor voiding habits, too.

Even things like habitually delaying urination, that nurse's bladder phenomenon, or pregnancy, menopause, certain sexual activities, poor hygiene.

They can all increase the risk.

So when a patient actually has a UTI, what are we looking for?

What symptoms show up?

Symptoms can really vary.

For those uncomplicated lower UTIs, it's often painful urination dysuria.

They might also report frequency, urgency, that super -puvic discomfort.

The urine might look cloudy, maybe even have visible blood, but, and this is vital, older adults often present very differently.

Yeah, they might not have those classic LUTs, the lower urinary tract symptoms.

Instead, maybe they report general abdominal discomfort, or you might notice cognitive changes, confusion, more falls, and fever.

It's often an unreliable sign in this group, so you can't just rely on that.

That's a really great clinical pearl about older adults.

Okay, so how do we actually confirm a UTI?

What are the diagnostics?

Typically, we start with a dipstick urinalysis, often right at the bedside.

It's quick, checks for nitrites, those bacterial byproducts, white blood cells, and leukocyte esterase, which points to white cells.

A microscopic urinalysis confirms those findings.

Generally, bacterial counts of 100 ,000 CFUs per ml, or higher, usually mean a significant UTI.

Though sometimes even lower counts with strong symptoms can be clinically significant.

A urine culture with sensitivity testing, that's crucial for persistent or recurrent UTIs, complicated cases, or if that initial antibiotic isn't working.

We prefer a clean catch midstream sample, but catheterization, while invasive, does give the most accurate result.

And if you suspect an obstruction or it keeps coming back, imaging like an ultrasound or CT might be needed.

Got it.

So once it's diagnosed, what's the usual interprofessional and nursing management plan?

The interprofessional care really focuses on antimicrobial therapy.

For uncomplicated UTIs, it's all for a short course, maybe three days, of antibiotics like TMPSMX or nitrofren -twin.

Complicated UTIs, well, they need longer treatment, like seven to 14 days, maybe more.

Often with broader spectrum antibiotics like fluoroquinolones, if it happens to be a fungal UTI, fluconazole is the go -to.

And for symptom relief, that urinary analgesic finessopyridine can be a lifesaver for dysuria, but you have to teach patients it turns urine orange or red.

It can be quite alarming otherwise.

You definitely need to warn them about that one.

Right.

And for recurrent UTIs, sometimes prophylactic antibiotics are considered, but carefully, because of resistance concerns.

And what about the specific nursing responsibilities here?

What are our key actions?

Nursing management really starts with a solid assessment, getting the patient's history, their pain details, looking at the urine objectively.

Our goals are pretty clear.

Relieve symptoms, stop the infection from moving up to the kidneys, and prevent it from coming back.

Health promotion is huge.

Teaching patients to empty their bladder regularly and completely, manage bowels to avoid constipation, wipe print to back, and drink enough fluids.

For hospitalized patients, routine perineal care, answering call lights promptly, and that CIU -TI prevention we talked about.

Yes, super important.

Absolutely.

Avoiding unnecessary catheters, getting them out ASFP when not needed, strict aseptic technique, hand washing, gloves, all fundamental.

It sounds like fluids are a really big deal, even if the patient feels like more fluid equals more pain initially.

Absolutely.

Unless there's a medical reason not to, adequate fluid intake is vital.

It literally helps flush the bacteria out.

Patients should also try to avoid bladder irritants, caffeine, alcohol, citrus, chocolate, spicy foods.

Applying some heat, like a heating pad, to the suprapubic area or lower back can really help with discomfort.

And critically, emphasize taking the entire course of antibiotics, even if they feel better after a day or two.

This is key for preventing recurrence and fighting resistance.

Patient teaching should cover monitoring for improvement, but also knowing when to report persistent symptoms or, importantly, any new flank pain or fever, which could signal it's moving upward.

That makes perfect sense.

Okay, let's move a bit deeper into the system now and talk about pyelonephritis.

This sounds quite a bit more serious than a standard UTI.

It definitely is.

Pyelonephritis is inflammation right in the kidney,

the renal parenchyma, and the collecting system.

It's almost always bacterial, often starting as a lower UTI that ascends.

Common culprits are still E.

coli, but also Proteus, Klebsiella, and Terebacter.

Certain pre -existing factors really increase the risk, like vesicoretorol reflux, that's when urine flows backward from the bladder up the ureters, or any lower urinary tract obstruction, maybe from an enlarged prostate, strictures, or stones.

Pregnancy changes can also be a risk factor.

So if a patient has pyelonephritis, what are the classic signs and symptoms we'd see, and how do we diagnose it?

The classic picture is more systemic, more severe than cystitis.

Think high fever, chills, nausea, vomiting, just feeling generally unwell malaise and significant flank pain.

You might still see some of those lower urinary tract symptoms, LUTS, like dysuria or urgency A key physical finding is cospovertebral angle tenderness, CVA tenderness, that sharp pain when you gently tap over the kidney area on the affected side.

Your analysis will show pyuria pus in the urine, bacteria area, and hematuria.

Crucially, you'll often see white blood cell casts, that's a strong sign that kidney tissue itself is involved.

We'll also get urine and blood cultures to pinpoint the bug and guide antibiotics.

And imaging, usually ultrasound or CT, helps spot any underlying kidney abnormalities or complications.

Given how serious this is, what's the management approach for acute pyelonephritis?

It really depends on severity.

Mild cases might maybe be managed outpatient with oral antibiotics for about 5 to 14 days, but severe cases.

They almost always need hospitalization, often starting with IV antibiotics to get high drug levels quickly.

Then, once the acute symptoms calm down and the patient can take pills, they'll transition to oral antibiotics.

Key nursing interventions include pushing fluids, giving NSAIDs or antipyretics for pain and fever, and making sure follow -up urine cultures are done to confirm the infection's gone.

And if you're a sepsis is even a remote possibility, it's all about close observation, frequent vital signs, and being ready to act fast if septic shock develops.

So the nursing management still involves health promotion, but there's this added layer of urgency because the kidneys are directly involved.

Exactly.

Health promotion is similar to cystitis prevention, but with a really strong emphasis on treating lower UTIs early and effectively to stop that upward spread.

For patients with known structural issues, regular medical care is vital.

Teaching covers taking the full antibiotic course, the importance of follow -up cultures, and knowing the signs of recurrence.

We push fluids at least 8 glasses a day, even after they're better, and encourage rest.

Okay, let's shift gears now from infection to another incredibly common and frankly infamous problem, kidney stones or nephrolithiasis.

People say the pain is just .legendary.

That's certainly the reputation, and often deservedly so.

Kidney stone disease hits a lot of people, about 11 % of men, 7 % of women in their lifetime.

For many, it is truly excruciating.

There isn't one single theory explaining why stones form, but the common factor is crystals forming out of supersaturated urine.

Things like urine pH, how concentrated the solutes are, and natural inhibitors in the urine all play a role.

For instance, a high pH makes calcium and phosphate less soluble, easier to form stones.

Low pH does the same for uric acid and cysteine.

I've heard UTIs can actually play a role in forming certain stones, is that right?

It is, yeah.

Obstruction leading to urinary stasis, combined with UTIs from specific bacteria, the urea -splitting kind like Proteus or Klepthella can make the urine alkaline.

This environment favors the formation of what we call streuvite stones, these are sometimes called infected stones.

They can get really big, sometimes filling the whole renal peltus in a staghorn shape.

This can cause chronic infection, hydronephrosis, and serious kidney damage.

There are five main types.

Calcium oxalate, by far the most common, then calcium phosphate, cysteine, streuvite, and uric acid stones.

So what are the classic symptoms when someone's actively passing a kidney stone, that legendary pain?

The first symptom is usually sudden, severe pain.

Often starts in the flank, back, or lower abdomen.

Patients describe it as excruciating renal colic, this sharp, cramping pain from the ureter stretching, dilating, and spasming as the stone moves.

Nausea and vomiting are really common because the pain is just so intense.

These patients often can't get comfortable, they're restless, pacing, literally doing what some call the kidney stone dance.

As the stone moves down towards the bladder junction, the pain can radiate lower abdomen, testicles in men, labia in women, the groin.

You might even see signs of mild shock, like cool, clammy skin.

And yes, UTIs can definitely tag along, bringing dysuria, fever, and shills.

How do we actually confirm it's a kidney stone, especially when the patient's in so much distress?

Diagnosis usually relies on a non -contrast CT scan, it's very good at spotting stones.

Ultrasound is another option, especially for pregnant patients, to avoid radiation.

A urinalysis helps confirm by looking for hematuria blood and crystalluria crystals.

Urine pH can also give clues about the stone type, and crucially, if the stone passes, we need to retrieve it.

Analyzing the stone is vital to figure out what it's made of, which guides long -term prevention.

Right, strain the urine.

Exactly, strain all the urine.

Blood tests check calcium, phosphorus, uric acid, BUN, creatinine -assessing kidney function and potential metabolic causes.

For recurrent stone formers, a 24 -hour urine collection might be ordered to measure various substances.

Okay, so beyond managing that acute, intense pain, what's the overall game plan for kidney stones, especially preventing them from coming back?

It's really a two -pronged approach.

First, manage the acute attack.

Pain, infection, any obstruction.

Opioids, NSAIDs are key for that renal colic.

Most small stones, say 4mm or less, often pass on their own.

We might use alpha blockers like Tamzolosan to help relax the ureter muscle, easing passage.

Second, and just as important, figure out the cause and prevent recurrence.

This means a thorough history asking about things like immobilization, dehydration, diet, fluid intake, family history, meds.

Then implement strategies.

Adequate hydration is paramount, aiming for maybe 2 .5 liters of urine output a day, unless there's a reason not to.

Sodium restriction is often helpful.

Specific diet changes depend on the stone type, like reducing perians for uric acid stones.

Sometimes specific meds are used to change urine pH or block substance excretion.

What happens if the stone is just too big to pass, or it's causing serious problems like blockage or infection?

Right, if conservative treatment isn't cutting it, we might need more intervention.

Endurology, lithotripsy, or sometimes even open surgery.

Endurologic procedures are minimally invasive.

A cystoscopy can remove small bladder stones.

For bigger ones, we might use ultrasound, laser, or a lithotrite to break them up transurethrally or percutaneously.

Ureter soaps let us go up and directly see and remove stones from the renal pelvis or ureter.

A percutaneous nephrolithotomy involves going directly into the kidney through the flank to break up and remove large stones.

Risks include bleeding, leftover fragments, infection.

And lithotripsy.

That's the non -invasive one where they use waves, right?

Exactly.

Lithotripsy uses energy waves to shatter stones into smaller pieces that can then be passed.

The most common is ESWL extracorporeal shockwave lithotripsy using high -energy sound waves from outside the body.

Other types use lasers, high -frequency ultrasound, or electrohydraulic shock waves.

Patients usually need anesthesia for these.

Complications are pretty rare, but hematuria is common for a while afterwards, and yeah, passing the fragments can still be painful.

Sometimes a temporary ureteral stent is placed.

Makes sense.

And as nurses, we really push fluids after the procedure to help flush everything out.

So after the acute phase, what's the long -term nursing focus for someone who's had kidney stones?

Our assessment gathers their history, pain details, hydration status, things like that.

The main goals are pain relief, ensuring no obstruction,

and really empowering the patient with knowledge for prevention.

We hammer home the importance of fluids maybe three, four liters a day if they're active.

Preventing immobility is key for bedridden patients.

Reducing metabolic risks through diet teaching and medication adherence is crucial.

Pain management remains vital.

And yes, straining all urine to catch any stones for analysis is a must.

Encouraging emulation helps stone movement.

And safety, too, if they're on pain meds.

Absolutely.

Safety during emulation if they're on opioids.

Finally we evaluate, are they pain -free?

Is their urine output normal?

Do they understand how to prevent future stones?

Let's switch gears now and talk about urinary incontinence, UI.

It's so common, but it's not just a normal part of getting older, right?

Absolutely not.

And that's such a critical message for nurses.

While it is more common in older adults, UI is not a natural part of aging.

It has a huge impact on quality of life, emotional distress, social isolation, other health issues.

Basically, it happens when bladder pressure overcomes urethral pressure due to anything messing with that sphincter control.

Risk factors are varied.

Obesity, enlarged prostate and men, smoking, recurrent UTIs, pelvic surgeries, vaginal delivery, poor mobility, certain meds, neuro problems, family history.

Patients often have more than one type, but stress and urge incontinence are really common, sometimes together as mixed incontinence.

Okay, so how do we figure out which type of UI a patient has?

The basic evaluation starts with a really focused history, physical assessment, and a urinalysis.

We ask detailed questions.

When did it start?

What triggers it?

Any other symptoms?

How much caffeine or alcohol?

What meds are they on?

Any temporary factors?

A bladder log or voiding diary, kept for maybe one to seven days, is super helpful.

Tracks voiding times, leaks, nighttime voids, a pelvic exam, checking pelvic floor muscle strength, a bladder stress test, and measuring post -void residual, PVR, are also key.

How do you measure PVR?

Usually with a quick bladder ultrasound right after they void, or sometimes with a catheterization, ideally within 10 -20 minutes.

Normal PVR is usually under 50 mL, maybe 100 mL in older adults.

Over 200 mL is definitely abnormal.

Some folks might need urodynamic testing or imaging too.

What's the overall management approach for UI?

Can it actually be cured?

Many cases can be significantly improved, sometimes even cured.

We always start least invasive first.

Correct any temporary issues.

Behavioral therapies are cornerstone.

Pelvics floor muscle training kegels to strengthen those support muscles.

Biofeedback can help patients learn to isolate and contract them correctly.

Bladder training is also vital, retraining the bladder to hold more.

For urgent reflex UI, medications are important.

Anticholinergics like oxybutynin relax the bladder muscle.

Botox injections are another option for severe cases.

Interestingly, there aren't specific drugs approved just for stress UI.

So for stress UI, surgical options aim to support the urethra, like placing a sub -urethral sling or injecting bulking agents.

An artificial sphincter is usually a last resort, mostly for men.

And from a nursing standpoint, how do we help patients manage UI while maintaining their dignity?

It's a two -step approach really.

First, containment using appropriate pads or devices.

Second, working on a plan to reduce or resolve the underlying causes.

Lifestyle changes are huge.

Adequate fluids but avoiding irritants like caffeine, alcohol, regular voiding schedule every three four hours.

Quitting smoking, managing constipation aggressively.

Behavioral treatments like scheduled voiding and kegels are key.

We assess their needs for absorbent products, making sure they use effective ones, not just household items.

In hospitals or long -term care, making sure they can easily get to the toilet and have privacy is crucial.

Okay, from the challenge of leakage, let's look at the flip side.

Urinary retention.

The inability to empty the bladder.

This can also cause major problems.

It absolutely can.

Urinary retention means you can't empty the bladder fully or maybe can't void at all.

Sometimes this leads to overflow incontinence where the bladder gets so full it just leaks.

Acute urinary retention, that's a medical emergency, needs prompt bladder drainage.

Chronic retention is incomplete emptying even when they do void.

Those PBRs over 200 mLL are abnormal and even 100 -200 mLL needs a closer look.

Causes include neuro issues, bladder outlet obstruction like that enlarged prostate in men, or a weak detrusor muscle, maybe from diabetes over distension, or drugs like anticholinergics.

How is urinary retention usually managed?

Diagnostics are similar to UI PVR checks, ultrasound, urodynamics.

For crawling retention with moderate PVRs, behavioral tricks like scheduled toileting and double voiding can help.

Double voiding.

Yeah, they void, wait a few minutes, then try to void again.

It helps empty more completely.

Often though, catheterization is needed either intermittent, in and out, or indwelling.

Intermittent is usually preferred to lower that CIUT risk.

Meds like alpha blockers can relax the bladder, neck, and prostate muscles, helpful for BPH.

Surgery might be needed to fix obstructions like prostate surgery, fixing strictures, or repairing severe pelvic organ prolapse in women.

Sacral neuromodulation might help if the muscle isn't contracting well.

What's the absolute nursing priority if a patient has acute urinary retention?

Acute retention is an emergency.

Recognize it quickly.

Get that catheter in to drain the bladder.

That's priority one.

For prevention, teach patients to void when they feel the urge, take their meds, drink fluids in small amounts throughout the day, not huge gulps at once, stay warm, avoid excess alcohol.

Warm showers or baths might help relax things.

If none of that works, seek immediate care.

For chronic retention, scheduled toileting every three, four hours, whether they feel the urge or not, and that double voiding technique are key behavioral strategies, especially for folks with nerve issues or poor bladder sensation.

Okay, finally, let's touch on urinary tract surgery.

This includes procedures like urinary diversion, where urine has to be rerouted from the bladder entirely.

Right.

Urinary diversion is done for things like bladder cancer, severe neurogenic bladder, trauma, strictures, chronic inflammation.

The most common type is probably an incontinent diversion, like the ileal conduit.

They use a piece of the small intestine ileum to create a channel, and urine drains continuously from a stoma on the abdomen into an external bag.

This requires wearing that pouch permanently, which is a big adjustment psychosocially and practically.

That sounds like a massive change for someone.

Are there alternatives that maybe avoid the external bag?

Yes, there are continent diversions, like the Indiana pouch.

Here, they create an internal reservoir from bowel segments.

The patient then inserts a catheter into a small abdominal stoma every four, six hours to drain the urine.

No external bag needed.

Another option is an orthotopic neobladder.

They construct a new bladder from intestine and place it where the original bladder was.

This allows for more natural voiding through the urethra.

But patients have to learn to empty it on schedule, usually by bearing down, as they don't get the normal urge to void.

And sometimes, intermittent self -catheterization is still needed initially or long term.

What's the crucial nursing role in helping patients manage these complex urinary diversions?

Preoperative teaching is absolutely vital for the patient and caregivers.

It covers the practical stuff, but also the huge psychosocial aspects.

Body image changes, sexuality, exercise, odor control.

Getting a wound, ostomy, and continence nurse, WCN, involved is key.

And often, having them meet someone who has successfully adapted to an ostomy can be incredibly helpful.

That makes sense.

Postoperatively, care focuses on preventing complications, monitoring urine output closely, and teaching them that mucus in the urine from the bowel segment is normal.

Pushing fluids is important to flush the system.

Meticulous skin care around the stoma is critical to prevent breakdown, yeast infections, or those alkaline crests.

A properly fitting pouch, changed regularly, is essential for continent diversions, teaching self -catheterization technique, for neobladders, teaching them how to void on schedule, usually every two, three hours, since they lack that natural urge.

Discharged teaching reinforces signs of infection or obstruction,

detailed care instructions, and really emphasizes support for accepting body image changes and the need for ongoing follow -up.

Wow, what a comprehensive journey through renal and urologic problems.

We've really covered the gamut from those super common UTIs to complex kidney stones and these life -altering urinary diversions.

It's so clear that understanding the why and the what -to -thought and the management is vital.

But the nursing role, wow, it really shines through at every single stage.

It really does.

And if you connect it all back, it's about so much more than just the specific disease.

It's recognizing how these issues affect the whole person fluid balance, electrolytes, sleep, skin, self -esteem.

Our discussion today really highlighted that huge range of nursing responsibilities, from prevention, like CIUTI protocols and hygiene teaching, to acute care for intense pain or infection, right through to long -term education and emotional support for adapting to chronic conditions or major surgeries like diversions.

So what does this all mean for you, the learner, the future nurse?

It means you are absolutely central to that patient's experience.

Whether you're teaching someone how to stop getting UTIs, helping manage that awful kidney stone pain, supporting a patient facing cancer, or empowering someone to live well with a urinary diversion.

Your assessment skills, your critical thinking, your compassion, your teaching, that's what makes the real difference.

Which leads to a really important question for you to think about.

How does applying that holistic nursing process, considering not just the physical but also the psychological and social pieces we talked about,

truly empower your patients?

How does it help them manage these complex conditions and maintain their quality of life long after they leave the hospital?

Think about how you'll take this knowledge and translate it into that kind of meaningful, patient -centered care.

Thank you for joining us for this deep dive into Lewis's Medical Surgical Nursing.