Care of Patients with Urinary Problems Flashcards
UTI’s are the most common health care-acquired infection
Acute infections in the lower urinary tract include:
Acute infection in the upper urinary tract (kidney) include:
Infectious disorders of the urinary system
Cystitis (bladder) - can lead to pyelonephritis is concern
Urethritis (urethra)
Prostatitis (prostate gland)
Acute infections in the lower urinary tract include:
Acute pyelonephritis - kidney infection
Acute infection in the upper urinary tract (kidney) include:
Obstruction
Stones (calculi) - obstruct flow and cause retention
Vesicoureteral reflux
Diabetes mellitus
Characteristics of urine
Gender
Age
Sexual activity
Recent use of antibiotics
Factors contributing to UTI’s
Bacteria laden urine is forced backward from the bladder up into the ureters and kidneys
Vesicoureteral reflux
Excess glucose in urine provides a rich medium for bacterial growth
Diabetes mellitus
Alkaline urine and concentrated urine promotes bacterial growth
Characteristics of urine
Increased incidence in female - shortened urethrae
Gender
Increased incidence in older patients
Age
Antibiotics change normal protective flora
Recent use of antibiotics
Maintain good hand hygiene
Insert for appropriate use only
Assess daily for need, assess appropriate alternatives
Use sterile technique when inserting
When emptying the urine bag, do not allow the tip of the outflow tube to touch the urine collection container
Select a small-size catheter, and do not overfill the balloon
Maintain a closed system
Keep tubing patent and collection bags below the level of the bladder at all times, elevation of bag causes reflux
Monitor and report CAUTI rates
Secure the catheter
Perform daily catheter care
Consider the use of coated catheters for patients requiring indwelling catheters for more than 3 to 5 days
Minimizing catheter-related infections
Avoid dependent loops in catheter tubing
Keep tubing patent and collection bags below the level of the bladder at all times, elevation of bag causes reflux
Increasing mental confusion or frequent, unexplained falls
Sudden onset of incontinence or worsening incontinence
Loss of appetite
Nocturia
Dysuria
CM that may occur in the older adult: Manifestations can be vague
Fever
Tachycardia
Tachypnea
Hypotension
May not have any urinary manifestations
CM that may occur in the older adult: Urosepsis manifestations
Inflammatory condition of the bladder
Infectious cystitis
Noninfectious cystitis
Interstitial cystitis
Urosepsis
Cystitis
Caused by pathogens from the bowel or in some cases, the vagina
90% are caused by Escherichia coli
Can lead to life-threatening complications including pyelonephritis and sepsis
Infectious cystitis
Results from chemical exposure (drugs), radiation therapy, and from immunologic responses (SLE)
Noninfectious cystitis
Rare, chronic inflammation of the entire lower urinary tract (bladder, urethra, and adjacent pelvic muscles) that is not a result of infection
Interstitial cystitis
Spread of the infection from the urinary tract to the bloodstream
Urinary tract is the infection source of severe sepsis or shock in about 10% to 30% of the cases
Urosepsis
Drink 2-3 L daily
Get enough sleep, rest, and nutrition daily
If spermicides are used, consider changing to another method of contraception
Women
Do not routinely delay urination
Notify provider if signs/symptoms of UTI develop
Nutritional supplements to reduce the risk for developing UTI
Prevention (inpatient care)
Cystitis - prevention
Cleanse perineum area from front to back
Avoid using or wearing irritating substances
Empty bladder before and after intercourse
Gently wash the perineal area before and after intercourse
Women
Cranberry substances
Ingest apple cider vinegar
Apply topical estrogen to the perineal area
Ingest D-mannose
Nutritional supplements to reduce the risk for developing UTI
Reduce the use of indwelling catheters
About 50% of inpatient clients become infected within 1 week of catheter insertion
Prevention (inpatient care)
Most common - frequency, urgency, dysuria
Hesitancy or difficulty in initiating stream
Low back pain
Nocturia
Incontinence
Hematuria
Pyuria
Bacteriuria
Retention
Suprapubic tenderness or fullness
Feeling of incomplete bladder emptying
Common clinical manifestations - Cystitis - assessment
Urinalysis
Presence of 100,000 colonies/mL or three or more WBCs (pyuria) with RBCs (hematuria) indicates infection
Urine culture – confirms type of organism and number of colonies
Serum WBC count may be elevated
Laboratory assessment - Cystitis - assessment
Pelvic US or CT
Voiding cystourethrography
Cystoscopy
Diagnostic assessment
when urine reflux is suspected
Voiding cystourethrography
Performed when the patient has recurrent UTIs (more than three or four a year)
Identifies abnormalities that increase the risk for cystitis
Needed to accurately diagnose interstitial cystitis
Cystoscopy
Drug therapy
Maintain adequate fluid intake
Avoid fluids or food that can irritate bladder
Comfort measures
Cystitis - interventions
Antiseptics
Antibiotics
Analgesics
Antispasmodics
Drug therapy - Cystitis - interventions
used for relief of local symptoms, such as inflammation, hypermotility, and pain
Antiseptics
used for bacterial UTI’s
Antibiotics
reduce bladder pain and burning on urination by exerting a topical analgesic or local anesthetic effect on the mucosa of the urinary tract
Phenazypyridine (Pyridium) will turn urine red or orange
Analgesics
decrease bladder spasm and promote complete bladder emptying
Antispasmodics
Increase intake
Maintain adequate fluid intake - Cystitis - interventions
caffeine and carbonated beverages
tomato products
Avoid fluids or food that can irritate bladder - Cystitis - interventions
Warm sitz bath 2-3 times a day for 20 minutes
Comfort measures - Cystitis - interventions
Inflammation of the urethra
In men
In women
Assess
Lab:
Treatment – antibiotic therapy
Urethritis
Manifestations include burning or difficulty urinating and a discharge from the urethral meatus
Causes: STIs (gonorrhea, chlamydia, trichomonas)
In men - Urethritis
Manifestations similar to those of cystitis
Most common in postmenopausal women and caused by tissue changes related to low estrogen levels
In women - Urethritis
History of STI
Painful or difficult urination
Discharge from the penis or vagina
Discomfort in the lower abdomen
Assess - Urethritis
Urinalysis may show WBCs (pyuria) without a large number of bacteria
Lab: - Urethritis
Urethral Strictures
Urolithiasis
Urothelial cancer
Non-infectious disorders of the urinary system
Narrowing of the urethra
Narrowed areas of the urethra
Causes:
Occur more often in men
Symptom:
Complications:
Treatment: (surgical)
Urethral Strictures
Complications of a STD
Trauma during catheterization, urologic procedures, or childbirth
1/3 have no obvious cause
Causes: - Urethral Strictures
obstruction of urine flow
Symptom: - Urethral Strictures
At risk for developing a UTI
Overflow incontinence: involuntary loss of urine when the bladder is overdistended
Complications: - Urethral Strictures
Dilation of urethra (temporary)
Urethroplasty
Treatment: (surgical) - Urethral Strictures
Calculi or stones in the urinary tract
Presence of calculi (stones) in the urinary tract
Etiology:
Risk factors:
Stones usually do not cause symptoms until they pass into the lower urinary tract
Most patients can expel the stone without invasive procedures
Size, composition, and location of stone an important factor regarding whether it will pass on its own
Large stones higher up in the urinary tract, less likely to pass on their own
Urolithithiasis
Stones in the kidney: nephrolithasis
Stones in the ureter: ureterolithiasis
Presence of calculi (stones) in the urinary tract - Urolithithiasis
Unknown
90% have a metabolic risk factor
Calcium and vitamin D supplementation
High-dose ascorbic acid (Vitamin C)
Etiology: - Urolithithiasis
Family history
Overweight
Diet (animal proteins, decrease fluid intake)
History of urinary tract infections
Risk factors: - Urolithithiasis
History
Clinical manifestations
Lab
Diagnostic: KUB x-ray, CT, US
Urolithiasis - assessment
Severe pain (renal colic)
Hematuria
N/V, pallor, diaphoresis
Frequency and dysuria occur when a stone reaches the bladder
Flank pain suggests that the stone is in the kidney or upper ureter
Flank pain that extends toward abdomen or to the scrotum and testes or the vulva suggestions that stones are in the ureters or the bladder
Pain is most intense when the stone is moving or when the ureter is obstructed
Oliguria (scant urine output) and anuria (absence of urine output) suggests obstruction; obstruction is an emergency and must be treated immediately to preserve kidney function – hydronephrosis which is enlargement of the kidney may occur
Clinical manifestations - Urolithiasis - assessment
Urinalysis (hematuria is common)
WBCs and bacteria may be present as a result of urinary stasis
Elevated serum WBC with infection
Lab - Urolithiasis - assessment
IV opioid analgesics
NSAIDs such as ketorolac (Toradol) or ketoprofen (Nexcede)
Give at regularly scheduled intervals or continuous delivery system for best control of pain
Spasmolytic drugs
Tamulosin (Flomax) and nifedipine (Procardia) to relax the urethra and aid in expulsion
Drug therapy - Urolithiasis - interventions; pain management
Strain the urine
If the stone does pass, send to lab for analysis
Other - Urolithiasis - interventions; pain management
Drug therapy
Assess for symptoms of infection
Urinalysis and C&S
Nutrition therapy
Urolithiasis - interventions; preventing infection
Broad spectrum antibiotics
Drug therapy - Urolithiasis - interventions; preventing infection
Chills
Fever
Altered mental status
Assess for symptoms of infection - Urolithiasis - interventions; preventing infection
Adequate calorie intake with a balance of all food groups
Encourage fluid intake of 2 to 3 L/day unless on a fluid restriction
Nutrition therapy - Urolithiasis - interventions; preventing infection
High intake of fluids of 3 L/day or more
Accurate measures of I/O
Drug therapy
Nutrition therapy
Other measures
Urolithiasis - interventions; preventing obstruction
Depends on the type of stone
Drug therapy - Urolithiasis - interventions; preventing obstruction
Depends on the type of stone
Nutrition therapy - Urolithiasis - interventions; preventing obstruction
Walk as often as possible
Check urine pH daily
Strain all urine
Other measures - Urolithiasis - interventions; preventing obstruction
SWL (shock wave lithotripsy)
Post procedure:
Minimally invasive surgical procedures are used if urinary obstruction occurs or if the stone is too large to be passed
Urolithiasis - interventions; lithotripsy
Use of sound, laser, or dry shock waves to break the stone into small fragments
Done under fluoroscopy with moderate sedation and local anesthesia
A stent can be placed in ureters if needed
SWL (shock wave lithotripsy) - Urolithiasis - interventions; lithotripsy
Strain urine to monitor the passage of stone fragments
Bruising may occur on the flank of the affected side after procedure (expected)
May have blood in urine after procedure
Monitor for increase pain, fever, chills, difficulty with urination
Post procedure: - Urolithiasis - interventions; lithotripsy
Ex. stenting, retrograde ureteroscopy, percutaneous ureterolithotomy or nephrolithotomy
Minimally invasive surgical procedures are used if urinary obstruction occurs or if the stone is too large to be passed - Urolithiasis - interventions; lithotripsy
Malignant tumors of the urothelium lining of the kidney, renal pelvis, ureters, urinary bladder and urethra
Most common in the bladder
Symptoms:
Diagnostic assessments:
Nonsurgical management:
Urothelial cancer
Hematuria often the first major sign
Dysuria, frequency, and urgency occur when infection or obstruction present
Symptoms: - Urothelial cancer
urinalysis, cystoscopy, biopsy, cystoureterography, CT, US, MRI
Diagnostic assessments: - Urothelial cancer
Prophylactic immunotherapy (BCG), a live virus compound, instilled in the bladder for 2 hours, live virus is excreted with the urine
Teach patients to prevent contact of the live virus with family members by not sharing a toilet with others for at least 24 hours after instillation
Chemotherapy
Radiation therapy
Nonsurgical management:- Urothelial cancer
Type of surgery depends on the type and stage of the cancer and the patient’s general health
Cystectomy
Four alternatives for urine elimination are used after cystectomy
Urothelial cancer - interventions: surgical management
Compete bladder removal
Additional removal of surrounding muscle and tissue offers the best change of a cure for large, invasive bladder cancers
Cystectomy - Urothelial cancer - interventions: surgical management
Ileal conduit
Continent pouch
Bladder reconstruction
Ureterosigmoidostomy
Four alternatives for urine elimination are used after cystectomy - Urothelial cancer - interventions: surgical management
