Exam 3 (Mod 5&6) Flashcards
Uncomplicated or Complicated UTI?
No anatomical or functional abnormality that increases risk for infection
Uncomplicated UTI
Uncomplicated or Complicated UTI?
Contributory factors of UTI include Pregnancy, male gender, obstruction, diabetes, neurogenic bladder, chronic kidney disease, decreased immunity.
Complicated UTI
Inflammatory condition of the bladder usually from infection
Cystitis
What type of cystitis?
Usually from E.coli, travels from the external urethra to the bladder. Infection can also occur in any area of the urinary tract and kidney.
Infectious cystitis
What type of cystitis?
Caused by some irritants such as drugs, chemicals, and local radiation therapy. Can also occur as a complication of other disorders such as: gynecologic cancers, pelvic inflammatory disorders, endometriosis, impaired immunity (systemic lupus erythematosus) and Crohn’s disease are examples.
Noninfectious cystitis
What type of cystitis?
Not related to infection. Rare, chronic inflammation of the entire lower urinary tract (bladder, urethra, adjacent pelvic muscle). Pain associated with bladder filling and voiding; frequency, urgency, and nocturia.
Interstitial cystitis
Etiology of Complicated UTIs/Cystitis
More than 80% of UTIs are caused by E. coli.
Candida is another infecting microbe (can occur during long-term antibiotic therapy).
Other microbial sources are mycobacteria, yeast, and parasites.
Catheters are the most common factor associated with new onset UTI and in long-term care settings.
Guidelines to prevent UTIs?
Sterile technique when inserting catheters. Clean technique when using intermittent catheters at home. Single-use catheter recommended for home settings.
Liberal fluid intake to flush out toxins.
Cystitis itself is not life-threatening; however, its associated complications are:
Pyelonephritis and severe kidney damage (rare, most at risk population includes anatomical abnormalities/complications).
Sepsis, bacteria from the urinary tract enters the bloodstream> bacteremia/urosepsis> potential septic shock.
Cystitis Laboratory & Diagnostic assessment
*Clean catch urine specimen (urinalysis, culture, and sensitivity) - usually need at least 10 mLs. UTI may be indicated with presence WBCs, RBCs, or casts (clumps of cells), combination of leukocyte esterase and nitrates.
*Serum WBC with differential: May be elevated. Left shift? # of immature WBCs (bands) is increasing and number of mature WBCs is decreasing.
*Why is it more common in urosepsis, as compared to cystitis? Local vs. systemic infection response.
What are some s/sx of UTI/Cystitis?
back pain, flank pain, frequency, dysuria, urgency, distention of abd, tenderness
What are some s/sx a UTI is getting worse?
fever, increased WBC/left shift, pain would radiate upward from urethra (systemic infections signs)
Cystoscopy is performed when pt has recurrent UTIs. Identifies structural abnormalities (calculi, diverticula, strictures, foreign bodies, etc). Needed to specifically identify interstitial cystitis. Why obtain culture first?
Because it could put the patient at risk for developing sepsis from a urinary source.
If a patient is suspected of developing SEPSIS (SIRS criteria), blood culture is required.
Two major goals of Cystitis drug therapy
Alleviate pain/discomfort & treat bacteriuria
What antibiotics are used to treat UNCOMPLICATED UTI?
-Nitrofurantoin
-Trimethoprim/sulfamethoxazole (Bactrim-watch for sulfa allergy)
-Fosfomycin is first line for patients with low resistance
-Cephalexin, ciprofloxacin, levofloxacin, and amoxicillin are also used.
What antibiotics are used to treat COMPLICATED UTI?
Fluconazole drug of choice for fungal infections (Candida).
May require longer therapy (7-21 days).
Other nonsurgical management of UTI/Cystitis
*Fluid intake: Maintain dilute urine (2–3 L of water)
*Comfort measures: Warm sitz baths, Analgesics: Phenazopyridine, Antispasmodics: Oxybutynin common.
*Avoid spices and acidic foods > can lead to bladder irritation
*Conflicting evidence related to cranberry juice
Conflicting evidence related to cranberry juice
*Benefits = may help decrease bacterial adhesion to epithelial cells
*Negative = may be an irritant and should be avoided in interstitial cystitis
If UTI/Cystitis is left untreated it can lead to
Pyelonephritis and severe kidney disease
What condition?
Inflammation of urethra
Urethritis
*Infectious: Highest incidence is adults aged 20-24. Most common cause is STI—treat with antibiotics
*Noninfectious: Postmenopausal women – uretero-genital tissue changes from low estrogen
Common STIs that cause infectious urethritis
Gonorrhea, chlamydia, trichomonas
Signs/sx of urethritis
- Symptoms similar to cystitis, vaginitis, or heaviness in the genitals
- Mucopurulent or purulent discharge, dysuria, and/or urethral pruritus.
- Possible fever. Urgency and frequency. Urinalysis may show pyuria (WBCs in urine)
If urethritis is left untreated or patient does not complete abx therapy, the patient is at risk for
developing pelvic inflammatory disease
Interventions for Urethritis
-Test for STIs (both genders), pregnancy in women
-Pelvic exam: May reveal hormone-related tissue changes
-Antibiotic therapy for STI-related cases
-Noninfectious urethritis may resolve spontaneously; postmenopausal women may use local/topical estrogen cream.
What condition?
Presence of calculi (stones) in urinary tract. Commonly associated with dehydration.
Urolithiasis
Involves two conditions:
1. Supersaturation of the urine – element (e.g., calcium, uric acid) becomes crystallized.
2. Formation of a nidus (crystal deposit that becomes infectious) along the tract. High urine acidity or alkalinity, and drugs (corticosteroids), contribute to stone formation. Metabolic conditions that increase calcium absorption in the intestine (hyperparathyroidism, vitamin D intoxication)
Urolithiasis etiology
Metabolic risk factors (dehydration), hyperparathyroidism, urinary tract obstruction, inflammatory bowel diseases, and GI problems.
Patients who are obese, have diabetes or gout are at higher risk.
Certain vitamin supplementation may be connected with stone formation: Calcium, vitamin D, and vitamin C.
What is the pain described as w/ kidney stones?
EXCRUCIATING pain in the kidney region
Urolithiasis Assessment
*Major symptom is renal colic (sudden, unbearable pain in the kidney region). Often associated with: NV (usually 1st sign of kidney stone), pallor, & diaphoresis.
*Flank pain? Stone may be in the kidney or upper ureter. -Murphy’s punch-
*CVA(costovertebral angle) tenderness indicates implications of renal calculi. Radiating to lower abdomen/pelvic region = suggests stone is in ureters or bladder
*When is the pain most intense? When stone is moving OR the ureter is obstructed
When is the pain re: kidney stone most intense?
when stone is moving OR the ureter is obstructed
Kidney stones- What does frequency and dysuria indicate?
Stone has reached the bladder
Urinary tract obstruction is an emergency and must be treated to
preserve kidney function
Urolithiasis Interventions
*Promote hydration and natural passing of stones (<5mm). Strain urine.
*Opioid analgesics for severe pain.
*NSAIDs (ketorolac) in the acute phase (Nephrotoxic if used long term)
*Spasmolytic drugs (oxybutynin)
*Thiazide diuretic and allopurinol to aid in stone expulsion.
*Alpha-adrenergic blockers and calcium channel blockers to aid in relaxing smooth muscle.
*Lithotripsy: Temporary stent may also be placed for stone(s) >5mm
*Minimally invasive surgical procedures: Ureteroscopy with stenting, Percutaneous ureterolithotomy or nephrolithotomy.
*Open surgical procedures: Open ureterolithotomy (ureter), pyelolithotomy (kidney pelvis) or nephrolithotomy (kidney). Nephrostomy tube often left in place
Drug therapies to prevent obstruction depends on the type of stone.
Hypercalciuria?
Hyperuricemia?
Hypercalciuria- thiazide diuretics (promotes calcium reabsorption)
Hyperuricemia- fluid promotion, diet modifications to restrict purines and drugs to alkinize urine (potassium citrate, sodium citrate, and sodium bicarbonate)
Which stones require antibiotic therapy?
Struvite stones form as a result of UTI with urease-producing pathogens. As such, they are often referred to as infection stones.
Quinolones (risk for Achilles tendon rupture), ampicillin, or other broad-spectrums.
Why aren’t NSAIDS used in the long term?
Nephrotoxic if used long term
Approximately 60%-85% of bladder injuries result from blunt trauma, while 15%-40% are from penetrating injury. The most common mechanisms of blunt trauma are motor vehicle collision (87%), fall (7%), and assault (6%). In penetrating trauma, the most frequent culprit is gunshot wound (85%), followed by stabbing (15%).
Bladder trauma requires surgical repair.
Often patients will present w/
anuria or hematuria
What condition?
A bacterial infection that starts in the bladder and moves upward to infect the kidneys.
Pyelonephritis
Bacterial infection in kidney and renal pelvis (upper urinary tract).
Most common in women 20-30 years old.
Usually normal intestinal and fecal flora. Common causative bacteria is E.coli or enterococcus faecalis. Also common in the second trimester and beginning of the third trimester of pregnancy.
Acute or chronic Pyelonephritis?
Acute
Rarely characterized by infection alone. Structural deformities, urinary stasis, obstruction and or reflux. Incidence related to underlying condition that leads to inflammatory damage (congenital structural abnormalities, neurogenic bladder dysfunction).
Acute or chronic Pyelonephritis?
Chronic
Patients with Pyelonephritis are prone to
bacteriuria
Pyelonephritis Assessment
Recurrent UTIs, Diabetes, stone disease, GU defects, reduced immunity, kidney function.
Sx may be similar between acute and chronic presentation.
Presence of bacteriuria= changes in urine color/odor. Inspect flank, CVA tenderness.
Psychosocial assessment: acute confusion in elderly, anxiety, embarrassment, guilt.
BUN, Creatinine, and GFR trend indicate kidney function and/or deterioration. What does each mean?
BUN= influenced by dehydration
Creatinine= best for kidney function
GFR= best for nephron function
How to manage pain associated with Pyelonephritis?
Non-surgical: Antibiotics (usually IV), increased fluids (at least 2L/Day), pain management (Tylenol), catheter replacement for long-term indwelling catheters.
Surgical: Goal is to correct structural problems leading to reflux and remove source of infection: pyelolithotomy (kidney stone removal), urethroplasty (reconstruction of the ureter), nephrectomy (last resort).
Pyelonephritis- How to prevent CKD?
antibiotic compliance, BP control, encouraging fluid intake, dietary management: protein may be restricted.
What condition?
Condition of increased glomerular permeability. Allows larger molecules to pass through the membrane into urine and be excreted. Massive loss of protein into urine, edema formation, and decreased plasma albumin levels. Most common cause is altered immunity with inflammation.
Nephrotic Syndrome
What is the most common cause of Nephrotic syndrome?
Altered immunity with inflammation
What must be assessed frequently w/ Nephrotic syndrome?
assess for dehydration
What is the hallmark condition associated with nephrotic syndrome?
proteinuria
Which lab value findings are altered in pts with Nephrotic Syndrome?
- Severe proteinuria (more than 3.5 g in a 24-hour urine sample) (Protein in urine think Nephrotic syndrome or glomerulonephritis!)
- Serum albumin less that 3 g/Dl
- Elevated serum lipid levels
- Lipids in the urine
What medications are used to treat Nephrotic syndrome?
-ACE inhibitors decrease protein loss
-lipid lowering agents
-heparin decreases vascular defects and improves kidney function
Nephrotic Syndrome Sx
impaired kidney function with increased proteinuria, decreased serum albumin, hyperlipidemia, lipids present in the urine, hypertension, and facial edema
Problems of urine elimination with outflow obstruction: may begin with urethral strictures, may lead to permanent kidney damage if left untreated.
Name the two conditions.
Hydronephrosis and Hydroureter
What condition?
Enlargement in the renal pelvis and kidney tissue that leads to kidney enlargement.
Hydronephrosis
What condition?
Enlargement in the ureter and kidney tissue that leads to dilation above the obstruction. Causes kidney enlargement. GFR decreases or ceases due to pressure applied to the nephrons.
Hydroureter
S/sx of Hydronephrosis and Hydroureter
Pt may experience flank or abdominal pain, chills, fever, malaise.
Inspect flanks/abd, can complete bladder scanner
Nephrostomy drain for strictures:
- Assess for bleeding or signs of infection at insertion site
- Sterile technique with dressing changes
- Never clamp the tube
- Assess patency frequently
- Never irrigate the tube
Kidney trauma may be caused by penetrating wounds, blunt injuries to the back/flank/abdomen, or certain urologic procedures.
How is is classified?
Classified into five grades depending on severity
One (low-grade= bruising) to five (most severe= shattering of kidney and tearing of blood supply)
When assessing kidney trauma it is important to
document the mechanism of injury to help determine severity
If the kidney trauma is a penetrating injury and graded 5, what is going to happen? Lots of bleeding. Important to restore circulating blood volume w/ crystalloid fluid, packed RBCs, & plasma. Why?
Can lead to low BP and then shock
It is important to teach pt how to assess for infection and complications post kidney trauma. It is important to contact a health provider if the following sx arise?
-Delayed bleeding and urine leakage most common
-Development of abscess
-New-onset HTN
What condition?
Rapid reduction in kidney function resulting in failure to maintain fluid and electrolyte balance and acid/base balance.
Acute Kidney Injury)
AKA Acute Renal Failure (ARF)
It is important to know what defines an Acute Kidney Injury (AKI)
- Increase in serum creatinine by 0.3 mg/dL or more within 48 hours
- Increase in serum creatinine by 1.5 times more than baseline in previous 7 days
- Urine output less than 0.5 mL/kg/hr for at least 6 hours
What are the three types of AKI?
pre-renal, Intra-renal, and post-renal
AKI Reduced perfusion to kidneys
Pre-renal
AKI Damage to kidney tissue
Intra-renal
AKI Obstruction of urine outflow
Post-renal
AKI Health Promotion & Maintenance
-Avoid dehydration by drinking 2 to 3 L of water daily
-Be aware of urine characteristic changes
-**Be aware of patient’s fluid status!
-Avoid nephrotoxic substances such as NSAIDs and antibiotics (specific class to avoid is aminoglycosides (tobramycin & gentamycin)
How much water should someone with AKI drink?
2-3 L daily
It is important to monitor electrolyte values for AKI. Hyperkalemia is the most serious electrolyte disorder in kidney disease because it can cause fatal dysrhythmias.
What do you do 1st if patient has hyper or hypokalemia?
Place the pt on a cardiac monitor.
Hyperkalemia cocktail includes:
- Regular insulin IV (and glucose if needed)
- Sodium bicarbonate: Treats metabolic acidosis which shifts K+ out of cells
- Calcium gluconate IV: Treats muscle and cardiac effects
- Kayexalate (Na+ polystyrene)
- Dialysis (if hemodynamically unstable)
- Dietary restriction: Limit sodium, protein, potassium. Salt substitutes are high in potassium
Notifiable STIs
Notifiable means they have to be reported to the state (FL).
Chlamydia, Gonorrhea, Syphilis, Chancroid, HIV infection,
Others per local legal requirements, e.g., genital herpes
Safer Sex Practices to reduce STIs
-Using a latex or polyurethane condom for genital and anal intercourse
-Using a condom or latex barrier (dental dam) over the genitals or anus during oral-genital or oral-anal sexual contact
-Wearing gloves for finger or hand contact with the vagina or rectum
-Practicing abstinence
-Practicing mutual monogamy
-Decreasing the number of sexual partners
What STI?
An infection caused by bacteria. Most often, it spreads through sexual contact. The disease starts as a sore that’s often painless and typically appears on the genitals, rectum or mouth. Spreads from person to person through direct contact with these sores.
Syphilis
What is the first sign of primary syphilis?
chancre- looks like an ulcer, can be anywhere (genitals or mouth)
What should ALWAYS be worn when treating patients with syphilis?
GLOVES
Secondary syphilis develops in 25% of untreated individuals within a few months.
Sx of secondary syphilis
*Rash on palms, soles, trunk, and mucous membranes
*Flu-like symptoms: Malaise, Low-grade fever, Headache, Muscle aches, Sore throat, Adenopathy, Joint pain
Tertiary syphilis occur 4 to 20 years after initial infection. It is uncommon due to antibiotics.
S/sx include:
- Cardiovascular infection with T. pallidum.
- Neurosyphilis, including progressive dementia and locomotor ataxia.
- Gummatous syphilis lesions on the skin, bones, or internal organs.
What drug is used to treat syphilis?
Benzathine penicillin G
What STI?
*Chlamydia trachomatis- intracellular bacterium, causative agent of cervicitis, urethritis, proctitis
*Reportable to local health departments in all states
*Often asymptomatic
*High prevalence of rectal and pharyngeal infection in MSM
Chlamydia
What drug therapy is used to treat Chlamydia?
-1st-Line: Doxycycline (100mg, PO, BID, for 7 days)
-2nd-Line: azythromycin (1g orally, single dose), levofloxicin(500mg qd x 7days)
-Expedited Partner Therapy (EPT)
What is important to know about instructions for a patient taking doxycycline?
Photosensitivty –>Instruct pt to stay out of the sun, protect skin from the sun
Why was 1st line Chlamydia drug therapy switched from azithromycin to doxycycline?
due to antibiotic resistance
