Infection Flashcards
Role of the RN (4)
- collaborate for healing of infection
- prevent complications
- promote function
- promote prevention of future infection
What is urinary elimination?
excretion of body wastes
What part of the urinary system is sterile?
the part above the urethra
examples of lower UTIs (3)
cystitis, prostatitis, urethritis
examples of upper UTIs (3)
pyelonephritis, renal abscess, nephritis
What is an uncomplicated urinary infection?
community acquired infection, usually non-recurrent
Ex of complicated urinary infection? Diseases that can cause it to be complicated and is it recurrent or nonrecurrent?
HAI, CAUTI, pregnancy, diabetes, obstruction, recurrent
UTI risk factors (6)
- increased urine stasis: obstruction
- foreign bodies: calculi
- anatomy: shorter urethra in women
- Immunocompromised, aging, DM, HIV
- constipation, catheterization
- pregnancy, personal hygiene, delay of urination (nurses bladder)
Causes of Lower UTIs (LUTI)
- ineffective defense mechanisms of defense (normal flora, urinary IgA)
- uretrovescial reflux (dysfunction, menopause)
What can cause lower UTIs from the transurethral route?
fecal contamination and sexual intercourse
Clinical manifestations of uncomplicated LUTIs (6)
- burning during urination
- urinary frequency
- urgency
- suprapubic/pelvic pain
- hematuria
- nocturia
Clinical manifestations of complicated LUTIs and evaluate for what?
- from asymptomatic to sepsis with shock
- evaluate for urosepsis
How do LUTIs occur?
bacteria colonization of epithelium of urethra and/or bladder
Positive urine culture for LUTIs
> 100,000 CFU/ml from clean catch midstream or catheter sample
1000-100,000 CFU/ml may still indicate UTI, especially for a specimen taken at cystoscopy or other invasive procedure
LUTIs gerontological considerations
- cognitive impairment
- frequent use of antimicrobials, immunocompromised, infected pressure ulcers
- multiple chronic medical conditions, indwelling catheter
- urine stasis (older women incomplete bladder emptying), immobility
- decreased bladder tone, neurogenic bladder (stroke), diabetic autonomic neuropathy
Gerontological considerations: Frequent ___ are common
reinfections
Gero considerations: subjective clinical manifestation
fatigue
Gero considerations: objective clinical manifestations
change in cognitive function
Gero considerations: s/s urosepsis (6)
- ALOC
- lethargy
- anorexia
- new incontinence
- hyperventilation
- low-grade fever
UTI assessment and diagnosis
- pain, urine color and characteristics
- past medical hx
- medications
- fluid intake
- elimination patterns
- paralyzed or chronically ill patient: ask about usual bladder pattern
Anuria
no urine output or less than 50 mL in 24 hours
Oliguria
urine output < 0.5 ml/kg/hr
hematuria
blood in urine
dysuria
pain upon urination
pyuria
pus (WBC) in urine
Normal UA (protein, glucose, ketones, pH, specific gravity, hematuria, WBC, casts)
- no protein
- no glucose
- no ketones
- pH: 4.0-8.0
- specific gravity: 1.010-1.025
- WBC: 0-5
- no casts
What does a clean catch for urine C&S differentiate?
true bacteriuria from contamination
clean catch urine steps (9)
- wash hands with soap and water
- remove lid of urine container; do not touch inside of container
- clean urethral area with antiseptic wipes (no Betadine)
- urinate small amount into toilet, then stop
- place empty sterile container in the path of the urine stream
- restart voiding into the container; stop when container is half full
- finish urinating into the toilet
- tightly screw the lid onto the urine container; do not touch the inside of the container
- turn in sample as instructed
How will a female clean her genitalia before doing a clean catch urine specimen?
separate genital folds and gently wipe inside folds with antiseptic wipes from front to back (2 or 3 times)
How will a male clean his genitalia before doing a clean catch urine specimen?
if not circumcised pull foreskin back before cleaning; keep holding skin back until sample is collected- gently wipe the tip of the penis with antiseptic wipes (2 or 3 times)
UTI diagnosis (3)
- symptomatic UTI even if culture < 100,000 CFU/mL
- urine culture if bacteriuria
- pyuria, hematuria (50% of cases)
situations when bacteriuria is present and a urine culture will be done (9)
men, diabetic patients, recent urinary tract procedure, recent admission or long-term care, recurrent UTIs, pregnancy, sexually active women, postmenopausal, immunocompromised
LUTI Diagnostic Studies (5)
- normal multiple test dipstick: no WBCs, no nitrates
- test for STIs (similar symptoms)
- CT scan: obstruction, abscesses
- transrectal US: visualize prostate and bladder in men with recurrent, complicated UTIs
- cytourethroscopy: Visualize ureters
LUTI Medical management (5)
- pharm therapy and patient education
- short (3 d) or longer (7 day) course regimens
- If anatomical abnormalities: self-test and antimicrobial standing order
- long-term therapy for recurrent up to 6-7 months, after midstream clean catch for C&S
- cranberry juice: daily intake to help prevent and control UTI symptoms
LUTI nursing management: assessment (9), diagnosis (1), planning (1)
- hx of pain
- urgency
- frequency
- hesitancy
- color
- odor
- risk factors
- knowledge about prescribed therapy
- prevention
- collaborative dx
- planning and goals
LUTI nursing management: interventions (4)
- relief of pain
- fluid intake
- use analgesics (phenazopyridine/pyridium-pt teaching)
- prevent complications
LUTI nursing management: adequate fluid intake
patient may think condition will worsen because of discomfort, but it dilutes urine, making bladder less irritable. flushes out bacteria before they colonize
LUTI nursing management: frequent voiding
-decreases risk for reflux, contamination from urethra, q 2-3 hr with complete bladder emptying
LUTI nursing management: hygiene and catheter management
-proper hygiene; EBP catheter management
LUTI nursing management (what to avoid, what to instruct pt about, monitor)
- avoid caffeine, alcohol, citrus juices, chocolate and highly spicy foods- potential bladder irritants
- Instruct pt about drug therapy and side effects
- monitor VS, LOC for pyelonephritis, sepsis
LUTI nursing management: Ambulatory and home therapy (5)
- emphasize importance of compliance with drug regimen
- take medication as ordered
- maintain adequate fluids
- regular voiding (q 3-4h)
- void after intercourse (NEVER ASSSUME PT ISNT SEXUALLY ACTIVE)
LUTI nursing management: Pt teaching (5)
- empty bladder regularly and completely
- regular bowel evacuation
- wipe front to back
- adequate fluid intake
- drink cranberry juice or tablets: urine acidification for recurrent infection
LUTI Potential complications (5)
- pyelonephritis
- renal failure
- sepsis
- strictures and obstructions
- CAUTI
Quick risk assessment for sepsis: 10 s/s
- increased RR
- Increased HR
- decreased BP
- decreased UO
- either increased or decreased BS
- Increased or decreased temp
- Increased neutrophils
- Increased or decreased WBC
- decreased O2 sat
- ALOC
qSOFA score (what is measured, scores, serum lactate level)
- SBP at or less than 100 mmHg
- RR at or above 22 bpm
- any change in mental status
score of 2 or 3: increased risk for mortality or extended ICU stay
serum lactate level > 2 suggests hypoperfusion
LUTI potential complications
CAUTI
how to avoid CAUTI
- frequent assessment of urine
- meticulous daily perineal care
CAUTI Core prevention strategies (CDC) (7)
- insert catheters only for appropriate indications
- leave catheters in place only as long as needed
- ensure only properly trained personnel insert and maintain catheters
- Insert catheters using aseptic technique and sterile equipment (Acute care setting)
- following aseptic insertion, maintain a closed drainage system
- maintain unobstructed urine flow
- hand hygiene and standard precautions
Upper Urinary Tract Infections (UUTI): pyelonephritis, how it can happen (2)
contamination from bladder: vesicoureteral reflux, obstruction, BPH
from blood stream: systemic infections
Acute pyelonephritis
inflammation with enlargement of kidneys and possible renal dysfunction
chronic pyelonephritis
scarring, contraction, dysfunction, leading to CKD
Acute pyelonephritis clinical manifestations (3)
- chills, fever, leukocytosis, bacteriuria, pyuria, n/v
- possible LUTI symptoms, positive urinalysis
- low back pain, flank pain, costovertebral angle tenderness
Pyelonephritis Diagnosis (5)
- urinalysis
- US, CT scan: locate obstruction, abscess
- IVP pyelogram: renal abnormalities suspected
- urine C&S
- CBC: leukocytosis, shift to the left (bands?)
Pyelonephritis management (5) (if uncomplicated, how long antibiotic course, follow up, risk for, what needs to be done if adequate kidney fxn)
- uncomplicated: outpatient treatment (no sepsis, dehydration, n/v)
- 2-week antibiotic tx
- must have follow-up culture 2 weeks after therapy completion
- risk for chronic asymptomatic infection: antibiotic therapy up to 6 months if relapse
- oral/IV hydration if adequate fxn: flush urinary system
Pyelonephritis complication: urosepsis (what is it, what needs to be done promptly, can lead to, monitor what?)
- systemic infection from urologic source
- prompt dx/tx critical (IV antibiotics and fluids)
- can lead to septic shock and death
- monitor VS (hypotension, tachycardia, etc)
Pyelonephritis complication: CKD (what it occurs from, what it is, monitor what?)
- from chronic pyelonephritis
- progressive loss of nephrons from chronic inflammation and scarring
- monitor renal fxn tests (creatinine, BUN)
- monitor CBC
Anatomy of Urinary system (3)
- urinary tract is sterile above the urethra
- normal flora of vagina and urethra interferes with bacterial adherence
- urinary immunoglobulin in urethra provide a barrier to bacteria
Host defenses for UTI (5)
- physical barrier of urethra
- urine flow
- ureterovesical junction competence
- antibacterial enzymes/bacteria
- anti-adherent effects of bladder mucosa
patho of UTI
bacteria gain access to bladder –> attach and colonize to epithelium of urinary tract to avoid being washed out with voiding –> evade host defense mechanisms –> initiate inflammation
Urethrovesical reflux (what it is, that causes it)
- backward flow of urine from urethra to bladder
- coughing, sneezing
ureteovesical reflux (what it is, that causes it)
backward flow of urine from bladder to ureters
-valve impairment due to congenital or ureteral abnormalities
UTIs in older adults
- most common infection of OA
- bacteriuria increases with age
- gap between genders narrow later in life
Risk factors for older women
-estrogen levels decrease or are absent causing an increase of adherence of bacteria to vagina and urethra
risk factors for older men
lack antibacterial activity of prostatic secretions
most common bacteria causing UTI
E.coli
common bacterias for patient with indwelling catheter causing UTI
-proteus, Klebsiella, Pseudomonas, Staph
S/S chronic pyelonephritis
- fatigue
- HA
- poor appetite
- polyuria
- excess thirst
- weight loss
