Elimination Flashcards
Lower Urinary Tract
- Cystitis (Bladder)
- Urethritis (Urethra)
Upper Urinary Tract
Pyelonephritis (Kidney)
Occur in an otherwise healthy urinary tract; usually only involve the bladder
Uncomplicated
- Include infections w/ coexisting obstruction, stones, or catheters
- Includes UTIs in patients w/ coexisting DM or neurologic diseases; pregnancy-induced changes; recurrent infections
Complicated
What are the body’s defenses against a UTI?
- Complete bladder emptying
- Uretrerovesicle Junction Competence
- Urine propelled towards bladder
- Antibacterial characteristics
What are predisposing factors for a UTI?
- Urinary stasis
- Foreign bodies
- Anatomic factors
- Compromised immune response
- Functional disorders
What are clinical manifestations of a UTI
Emptying Symptoms:
- Hesitancy
- Intermittence
- Postvoid Dribbling
- Urinary retention/ incomplete emptying
- Dysuria (painful urination)
Storage Symptoms:
- Frequency
- Urgency
- Incontinence
- Nocturia
- Nocturnal enuresis
How do you diagnose a UTI?
-Urinalysis
Nitrites, WBCs, Leukocyte esterase
Indicated for complicated or heath care associated, persistent bacteriuria, and recurring UTIs
Culture and Sensitivity (UTI)
Treatment of an uncomplicated UTI
- antibiotics, patient teaching, adequate fluid intake (6 8-oz glasses a day)
1. Trimethoprim-sulfamethoxazole (Bactrim, Septra); it patient has sulfa allergy, trimethoprim alone can be used
2. Nitrofurantoin (Macrodantin, Macrobid)
Treatment of a complicated UTI
- Repeat urinalysis
- Urine culture and sensitive testing
- Antibiotics (above)
- Sensitive guided antibiotic therapy – ampicillin, amoxicillin, cephalosporins, fluoroquinolones
- **Phenazopyridine (Pyridium) – urinary analgesic used for dysuria
What is a urinary analgesic used for dysuria?
Phenazopyridine (Pyridium)
- A bacterial infection of the kidney pelvis which usually results from an ascending UTI
- Results from inflammation in the renal parenchyma and collecting system
- Acute or chronic
Pyelonephritis
Clinical manifestations for pyelonephritis
- Variable
- Lower UTI symptoms
- Also: fever, chills, flank pain, CVA tenderness, malaise
How do you diagnose pyelonephritis?
a. Urinalysis – pyuria, bacteruria, varying degrees of hematuria, WBC casts
b. Urine and blood cultures
c. CBC (complete blood count) – leukocytosis, left shift
d. Ultrasound – identify anatomic abnormalities, hydronephrosis, renal abscess, or stone
e. Later stages
i. Intravenous pyelogram
ii. CT scan with IV contrast
Treatment of mild pyelonephritis
- May be treated as outpatient or inpatient
- Antibiotics
- Fluids
- NSAIDS/antipyretics
- F/U urine culture and imaging
Treatment of severe pyelonephritis
- Requires hospitalization
- IV antibiotics
- IV fluids
- NSAIDS/antipyretics
- F/U urine culture and imaging
- Kidneys become small, shrunken
- Loss of renal function due to scarring and fibrosis
- leads to renal failure
Chronic pyelonephritis
- Bacteruria and Bacteremia
- Requires close observation and vital sign monitoring
Urosepsis
Goals for a UTI:
- relief from symptoms
- no urinary tract involvement
- no recurrence
Goals for Pyelonephritis:
- normal renal function
- normal body temp
- no complications
- relief of pain
- no recurrent symptoms
Interventions for UTI
- Adequate fluid intake if not contraindicated
- Local heat to supra-pubic area or lower back
- Warm shower
- Antibiotic teaching
When to all HCP during UTI
- Persistent, bothersome symptoms after antibiotic course completed
- Onset of flank pain
- Fever
involuntary loss of urine during activities that increase abdominal and detrusor (bladder muscle) pressure
Stress Incontinence
involuntary loss of urine associated with a strong urge to urinate
Urge Incontinence
involuntary loss of urine associated with over-distention of the bladder when bladder capacity has reached its maximum due to urethral obstruction/spasm
Overflow Incontinence
involuntary loss of urine that occurs without warning; associated with CNS disorders
Reflex Incontinence
loss of urine resulting from cognitive, functional, or environmental factors
Functional Incontinence
Treatments for urinary incontinence
- Lifestyle modifications
- Scheduled voiding mechanisms
- Anti-incontinence devices
- Containment devices
- Drug therapy
Drug Therapy for UTI
- Muscarinic Receptor antagonists and anti-cholinergics
- Reduce overactive bladder contractions
- Used for urge incontinence and overactive bladder
- Ex: oxybutynin (Ditropan), Tolterodine (Detrol), Solifenacin (Vesicare), Dicyclomine (Bentyl)
Used when incontinence is related to BPH
Alpha-adrenergic antagonists and 5a-reductase inhibitors
Inability to empty bladder despite micturition or accumulation of urine in the bladder because of inability to urinate
Urinary Retention
Causes of urinary retention:
a. Bladder outlet obstruction (BPH)
b. Deficient detrusor (bladder muscle) contraction strength – from neurologic diseases, DM, alcoholism, anti-cholinergic drugs
Collaborative care for urinary retention:
-Behavioral therapies:
Scheduled toileting
Double voiding
-Intermittent catheterization
-Drug therapy
α-blockers for BPH
-Surgical therapy
For obstruction
Pelvic reconstruction
Indications for indwelling catheter:
i. Relief of urinary retention caused by urinary tract obstruction, paralysis, inability to void
ii. Bladder decompression pre-op and operatively for lower abdominal surgery
iii. Facilitation of surgical repair of urethra and surrounding structures
iv. Splinting of ureters/urethra to facilitate healing after surgery/trauma
v. Accurate measurements of urinary output in critically ill vi. Measurement of residual urine after urination (referred to as postvoid residual) if portable ultrasound is not available
vii. Contamination of stage III or IV pressure ulcers with urine that has impeded healing, despite appropriate personal care
viii. Terminal illness or severe impairment which makes positioning or clothing changes uncomfortable
Indications for a straight catheter
i. Study of anatomic structures of urinary system
ii. Urodynamic testing
iii. Collection of sterile urine sample
iv. Instillation of medications into bladder
- As men age, the glandular units in the prostate begin to undergo hyperplasia (abnormal increase in the number of cells), resulting in prostate enlargement (hypertrophy)
- The enlargement causes narrowing of the urethra and results in partial or complete obstruction
Benign Prostatic Hyperplasia (BPH)
Clinical Manifestations of BPH
Clinical Manifestations
Obstructive (due to urinary retention)
- Difficulty initiating voiding
- Changes in size and force of urinary stream
- Dribbling at end of urination
Irritative (associated w/ inflammation and infection)
- Urgency, frequency
- Nocturia
- Dysuria
- Incontinence
Diagnostic tests for BPH
-Digital Rectal Exam (DRE)
To estimate size, symmetry, consistency of prostate gland
Additional tests depending on symptom severity
- Urine culture
- Prostate-specific antigen blood test
- Serum creatinine
- Transrectal Ultrasound (TRUS)
What are goals for BPH?
restore bladder drainage, relieve symptoms, prevent and treat complications
Conservative goals for BPH:
- Decrease caffeine and artificial sweeteners
- Avoid spicy and acidic foods
- Avoiding decongestants and anticholinergics
- Restricting PM fluid intake
- Timed voiding schedule
Medications for BPH:
i. 5a-reductase inhibitors
1. Finasteride (Proscar)
a. Reduces size of prostate gland to improve urine flow
b. Blocks 5a-reductase isoenzyme (type 2), which is needed to convert testosterone to dihydroxy-testosterone
c. Takes 6 months to be effective
- Dutasteride (Avodart)
a. Same effect as above
b. Dual inhibitor or 5a-reductase isoenzyme type 1 and 2 - Side effects: decreased libido, decreased volume of ejaculate, erectile dysfunction
ii. Alpha blockers
1. Work on alpha adrenergic receptors in prostate smooth muscle to constrict prostate gland
2. May cause orthostatic hypotension
3. Ex: Sildosin/Rapafo, Alfuzosin/Uroxatral, Terazosin/Hytrin, Doxazosin/Cardura, Tamsulosin/Flomax, Prazosin/Minipress
Minimally invasive therapy for BPH
Transurethral Microwave Thermotherapy (TUMT)
Transurethral Needle Ablation (TUNA)
Laser Prostatectomy
Transurethral Electrovaporization of Prostate (TUVP)
Intraprostatic Urethral Stents
Surgical Intervention for BPH
Transurethral Resection of the Prostate (TURP)
- The portion of the prostate that is blocking the urethra is removed
- Procedure: A resectoscope is inserted into the urethra via the penis and into the bladder
- The portion of the prostate that has become enlarged is then removed
What are complications of TURP?
- Bleeding is common following the TURP procedure
- A continuous bladder irrigation (CBI) will be prescribed postoperatively with a LARGE indwelling foley
- To decrease bleeding and keep the bladder free of clots
3-way lumen catheter
a. Lumen for inflating balloon (30 mL)
b. Lumen for outflow
c. Lumen for instillation (inflow)
Home care for BPH
- Managing urinary continence
- Adequate fluid intake
- Monitoring for UTI and wound infection
- Managing sexual dysfunction
a. Retrograde ejaculation
b. Erectile dysfunction
