Chapter 49 Management of Patients w/ Urinary Disorders Flashcards by Carrie Ortiz

Urinary Tract Infections (UTIs)

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

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How are UTIs classified?

Classified by location: Upper or Lower

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Lower UTIs

Involves the bladder & structures below the bladder

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

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Cystitis

Inflammation of the urinary bladder

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Prostatitis

Inflammation of the prostate gland

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Urethritis

Inflammation of the urethra

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Lower UTI Pathophysiology

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

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Urethrovesical Reflux

Backflow of urine from the urethra to the urinary bladder

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Ureterovesical/ Vesicoureteral Reflux

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

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Nursing Considerations for Lower UTIs

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

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Upper UTIs

Involves the kidney & ureters

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

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Upper UTI Pathophysiology

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)

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Pyelonephritis

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

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

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

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Nursing Considerations for Upper UTI/ Pyelonephritis

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

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General UTI Risk Factors

Bacteria in the urinary tract

Female gender: Shorter urethral length, pregnancy, & intercourse

Immunosuppression

Urinary stasis &/or backflow

Instrumentation of the urinary tract: Catheters/procedures

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Age-Related UTI Contributing Factors

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

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“Hard to Avoid” UTI Risk Factors

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)

Clinical Manifestations of UTIs

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

Urosepsis

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

Supporting Diagnostic Data Associated w/ UTIs

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

Nursing Interventions for UTIs

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

What is the most common route of infection in UTIs?

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

Incontinence

Involuntary loss of urine

Stress Incontinence

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

Urge Incontinence

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

Functional Incontinence

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

Iatrogenic Incontinence

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

Mixed Incontinence

Combination of factors

Overflow Incontinence

Overdistended bladder due to bladder muscle dysfunction or obstructed outflow

Retention

Incomplete emptying

Nuerogenic Bladder

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

Nursing Considerations for Urinary Incontinence

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

Nursing Considerations for Urinary Retention

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

Nursing Interventions for Urinary Retention

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

Catheter-Associated Urinary Tract Infections (CAUTI)

A UTI associated w/indwelling urinary catheters

Indications for Indwelling Catheters

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

Nursing Considerations for Catheter Use

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

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"

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.

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

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

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

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.

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

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.

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

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.

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

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