Chapter 49 Management of Patients w/ Urinary Disorders

Question 1

Urinary Tract Infections (UTIs)

Answer 1

Occurs when a pathogen enters the urinary tract, remember this system is sterile above the urethra

Question 2

How are UTIs classified?

Answer 2

Classified by location: Upper or Lower

Question 3

Lower UTIs

Answer 3

Involves the bladder & structures below the bladder

Includes: Cystitis (bladder), prostatitis (prostate), & urtheritis

Question 4

Cystitis

Answer 4

Inflammation of the urinary bladder

Question 5

Prostatitis

Answer 5

Inflammation of the prostate gland

Question 6

Urethritis

Answer 6

Inflammation of the urethra

Question 7

Lower UTI Pathophysiology

Answer 7

Bacteria migrates to the bladder and causes an infection
-Most commonly, fecal organisms (such as E. coli) migrate via
the transurethral route

Reflux of urine from the urethra into the bladder (urethrovesical)
-Commonly happens with:
-> Coughing, sneezing, or straining
due to an increase of bladder pressure that pushes urine into the urethra, as pressure decreases, the urine flows
back to the bladder and can carry bacteria with it

Question 8

Urethrovesical Reflux

Answer 8

Backflow of urine from the urethra to the urinary bladder

Question 9

Ureterovesical/ Vesicoureteral Reflux

Answer 9

Backward flow of urine from the bladder into 1 or both ureters

Question 10

Nursing Considerations for Lower UTIs

Answer 10

Assessment variations
- Elderly: incontinence, delirium,
decreased sensation leading to no
report of symptoms
- Post-menopausal women: Malaise, nocturia, incontinence, foul-smelling urine

Treatment typically involves a
pharmacologic agent
- Anti-infectives/antibiotics and
urinary analgesics; 3-5 days
- Be sure to administer them timely
and check for nursing implications

Use external catheters, not
indwelling

Patient education related to treatment and prevention
- Promote adherence to antibiotics regimen for when they go home
- Promote increased water intake and avoid fluids that dehydrate: must flush urinary tract
- Monitor I/O and notify MD of abnormal changes to urine appearance
- Encourage/promote frequent voiding (go when you feel the need, and every 3-4 hours)
- Maintain good perineal hygiene, especially important for dependent/incontinent patients
- Urinate before and after intercourse
- Preventive measures for any modifiable risks

Question 11

Upper UTIs

Answer 11

Involves the kidney & ureters

Includes: Pylonephritis, interstitial nephritis, & abscess (renal or perineal)

Question 12

Upper UTI Pathophysiology

Answer 12

Typically caused by bacteria traveling upward from the bladder or from a blood stream infection that reaches the kidneys
- Pyelonephritis: bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys
- Other causes can be interstitial inflammation, abscess, kidney damage, tubular cell necrosis, a bladder infection, urinary stasis, or obstructions
(tumors/strictures/BPH) that cause reflux from the bladder into either of the ureters (ureterovesical or
vesicoureteral reflux)

Question 13

Pyelonephritis

Answer 13

Bacterial infection of the renal pelvis, tubules, & interstitial tissue of one or both kidneys

Question 14

What type of UTIs are more common: upper or lower?

Answer 14

Lower UTIs (usually diagnosis & treatment takes care of the infection before it reaches the upper urinary tract)

Question 15

Nursing Considerations for Upper UTI/ Pyelonephritis

Answer 15

Assessment variations
- Acute: Physical assessment may
show chills, fever, low back/flank
pain, N/V, headache, malaise
- Chronic: no symptoms unless the
patient is experiencing an acute
exacerbation; they may show poor
appetite, excessive thirst, and
weight loss (plus the regular acute
symptoms)

CT imaging or a pyelogram may
also be ordered

Complications of chronic pyelonephritis can cause ESKD, HTN, and renal calculi

Treatment typically involves a pharmacologic agent
- Anti-infectives/antibiotics
and urinary analgesics for 2 weeks

Patient education related to
treatment
- Promote adherence to antibiotics
regimen for when they go home
- Monitor for watery stool
- Take with food and lots of water
- If not contraindicated, promote
increased water intake (3-4L/day)
and avoid fluids that dehydrate –
must flush urinary tract

Question 16

General UTI Risk Factors

Answer 16

Bacteria in the urinary tract

Female gender: Shorter urethral length, pregnancy, & intercourse

Immunosuppression

Urinary stasis &/or backflow

Instrumentation of the urinary tract: Catheters/procedures

Question 17

Age-Related UTI Contributing Factors

Answer 17

Cognitive impairment

Frequent use of antimicrobials

Multiple chronic medical conditions

Immunocompromise

Immobility

Incomplete emptying of the bladder

Low fluid intake, dehydration

Poor hygeine

Stool incontinence

Question 18

“Hard to Avoid” UTI Risk Factors

Answer 18

Hormone changes (pregnancy, menopause)

Antibiotics (changes the normal flora)

Renal stones (obstructs flow of urine)

Diabetes (high glucose levels and poor immunity)

Toiletries (powders, perfumes, bubble baths)

Obstruction – BPH (enlarged prostate), masses/tumors

Vesicoureteral reflux (urine returns to the ureters-usually congenital)

Overextended bladder (immobility, spinal cord injury, etc.)

Invasive (intercourse, indwelling catheters, procedures)

Disease states (remember the disease related complications)

Question 19

Clinical Manifestations of UTIs

Answer 19

Uncomplicated Lower UTI:
- Burning on urination
- Urinary frequency
- Urgency
- Nocturia
- Incontinence & suprapubic/pelvic pain
- Hematuria & back pain may also be present

Patients w/ Complicated UTIs:
- May be asymptomatic
- Can become septic w/shock
- Have lower response range to treatment & may recur

Question 20

Urosepsis

Answer 20

Spread of infection from the urinary tract to the bloodstream & results is systemic infection

Question 21

Supporting Diagnostic Data Associated w/ UTIs

Answer 21

Urinary symptoms: May be asymptomatic (common w/indwelling catheter)
- Nurse should inquire about association of symptoms w/ personal activity
Ex) Intercourse, hygeine

Urinary Characteristics: Appearance, urinalysis, culture

Kidney/bladder ultrasound

Abnormal Abdominal Assessment Findings: Back, suprapubic, pelvic pain

Question 22

Nursing Interventions for UTIs

Answer 22

Pain Relief: Heat therapy for pain and spasm relief (if indicated)

Admin of meds per MD order: Antibiotics, analgesics,
and antispasmodic

Increase fluid intake, but avoiding
irritants (coffee, tea, citrus, etc…)

Patient education

Question 23

What is the most common route of infection in UTIs?

Answer 23

The transurethral route (ascending infection) is the most common route
- Bacteria (often found in fecal matter) colonize the periurethral area & enter the bladder via urethra

Question 24

Incontinence

Answer 24

Involuntary loss of urine

Question 25

Stress Incontinence

Answer 25

Occurs with sneezing, laughing, coughing, exertion w/out structural damage
- Male: After prostatectomy
- Female: After pregnancy

Question 26

Urge Incontinence

Answer 26

Aware of need to void but can’t reach a toilet quickly enough

Question 27

Functional Incontinence

Answer 27

Results from either physical/ cognitive impairment
Ex) Stroke, spinal injury

Question 28

Iatrogenic Incontinence

Answer 28

Extrenal medical factors
Ex) Excessive diuretic use, procedure where urthra is dilated

Question 29

Mixed Incontinence

Answer 29

Combination of factors

Question 30

Overflow Incontinence

Answer 30

Overdistended bladder due to bladder muscle dysfunction or obstructed outflow

Question 31

Retention

Answer 31

Incomplete emptying

Question 32

Nuerogenic Bladder

Answer 32

Nervous system disorder that impacts voiding
- Typically caused by spinal
cord injury, spinal tumor or herniation, congenital disorders, and any
neuro- impacted disease process

Can cause either incontinence or retention

Complications include infection, impaired skin integrity, and renal calculi

Question 33

Nursing Considerations for Urinary Incontinence

Answer 33

Assessment should include discussion of symptoms

Skin care!!

Patient education (chart 49-8)
 Non-pharmacologic interventions are the first choice of treatment: Fluid
management, voiding schedule/retraining, pelvic floor “Kegel” exercises
 Pharmacologic can be used in conjunction w/ behavioral changes: first-line meds are anticholinergics (for inhibiting bladder
contraction)
 Surgery may be indicated when no
medications or behavioral methods work
 Discuss financial impact/support/
resources

Affects 9-12% of all adults
 More common in women (nearly 2x the rate of men)
 Nearly 50% of elderly
patients in institutions

Often goes undiagnosed
 Pts are embarrassed to seek
help and may not want to
discuss symptoms

Question 34

Nursing Considerations for Urinary Retention

Answer 34

Changes w/ elderly: Older adults may retain 50-100 mL due to changes in bladder tonicity

Assessment/diagnosis can be
challenging since symptoms can
be vague
 Ask the patient lots of questions
to understand their voiding
patterns
 Palpate for bladder distention and
lower abdominal pain

When untreated, this can lead to a UTI
and calculi formation

Question 35

Nursing Interventions for Urinary Retention

Answer 35

Promote good body position for
elimination

Apply warmth to perineum

Reduce caffeine

Request MD order for bladder ultrasound to check for retention/distention or post-void residual

Straight cath if indicated, try to avoid
indwelling catheters

Question 36

Catheter-Associated Urinary Tract Infections (CAUTI)

Answer 36

A UTI associated w/indwelling urinary catheters

Question 37

Indications for Indwelling Catheters

Answer 37

Retention/nuerogenic bladder

Post-op following urological procedures

Stage 3-4 skin injuries of the perineum

Urinary tract obstruction

End-of-life Care/ critical illness care

Question 38

Nursing Considerations for Catheter Use

Answer 38

CAUTI Prevention!!!

Catheter Care Bundle: Below the bladder, not on the floor, perineal care 2X/day, secured to leg, no kinks in tubing

Identify true patient need

Advocate for external device & removal as soon as possible

Skin care (stat-lock & moisture)

Asepsis of catheter bag/ports, do not disconnect tubing for samples

Question 39

A client admitted for pyelonephritis secondary to nephrolithiasis and is about to start antibiotic therapy. Which statement would the nurse expect this client to make?

A) “ I’ve been drinking a lot of caffeine-free soft drinks recently”

B) “ I’ve been jogging more than usual”

C) “ I’ve had more stress since adopting a child last year”

D) “ I’m a vegetarian & eat cheese 2-3 times a day”

Answer 39

D) “ I’m a vegetarian & eat cheese 2-3 times per day”

Renal calculi (nephrolithiasis) are commonly composed of Ca+2; diets high in calcium predispose a client to calculi (milk/dairy & many veggies are high in calcium)

Caffeine free soft drinks do not directly increase the risk of calculi; exercise and/or stress are not considered risk factors for this condition.

Question 40

The nurse is completing a health history & physical assessment on a client. Which client statement indicates a possible renal calculi?

A) HTN

B) Flank pain

C) Bradycardia

D) Inability to walk

Answer 40

B) Flank Pain

The patient would exhibit flank pain because the kidney is enlarged, & there may possibly be an abscess/infection due to blockage caused from a stone.

HTN is associated w/chronic pyelonephritis or w/pain, but is not a direct correlation to a renal calculi; HR would not be decreased by this condition; although the patient may have pain when walking, it should not take away the ability to walk altogether

Question 41

The nurse is completing a physical assessment & finds the client’s urinary drainage bag lying on the bed. Based on this, the nurse identified which nursing diagnosis as the priority?

A) Risk for infection

B) Reflex urinary incontinence

C) Risk for pain

D) Potential for ruptured bladder

Answer 41

A) Risk for infection

Urine can flow upward from the bag back into the bladder & carry bacteria w/it which could lead to an infection.

The bag being in this position does not create a risk for incontinence, pain, or ruptured bladder.

Question 42

A client w/ AKI has a serum potassium level of 7 mEq/L. What is the nurse’s priority (most important) assessment for this client?

A) Urine specific gravity

B) ECG results

C) Mental

D) BP

Answer 42

B) ECG Results

Hyperkalemia can lead to ECG changes (interval changes/irregular beats). This could become life threatening.

Urine specific gravity, mental status, & BP do not need to be evaluated as urgently as the ECG results.

Question 43

A client had a TURP procedure for BPH & is being treated w/continuous bladder irrigation ( via 3-way catheter system). The client reports an increase in severity of bladder spasms. Which intervention is most important for the nurse to implement?

A) Admin an oral analgesic

B) Stop the irrigation & call the provider

C) Admin anti-spasmodic suppository

D) Check for blood clots & make sure the catheter is draining properly

Answer 43

D) Check for blood clots & make sure the catheter is draining properly

If there are clots in the urinary drainage system it will block the flow of the irrigation & cause bladder spasms.

The irrigation should not be stopped as long as the system is draining properly. The patient can receive the anti-spasmodic medication as long as the drainage system has been assessed 1st & is confirmed to be properly working. The analgesic should be given last if the suppository does not help.

Question 44

The nurse is preparing discharge instructions for a client w/chronic pyelonephritis following treatment for an acute exacerbation. What is the most important information for the nurse to include?

A) Avoid dairy products

B) Return to follow-up urine cultures

C) Stop taking the antibiotics when the symptoms have resolved

D) Recurrence is unlikely once you have taken antibiotics

Answer 44

B) Return to follow-up urine cultures

This is necessary because bacteriuria may be present but asymptomatic.

Dairy intake does not lead to pyelonephritis, abx should always be taken for the full duration of the prescription, pyelonephritis may recur w/in 2 weeks of treatment as a relapse or new infection