Nursing Management of Patients with Renal & Urologic Problems Flashcards
Urinary Tract Infection (UTI)
Most common infection
2nd most common bacterial disease in women
Causes:
Most common: Escherichia coli (E. coli)
2nd most common: Candida albicans; indwelling catheter or asymptomatic colonization
Fungal & parasitic
Risk Factors
Obstruction
Retention
Renal impairment
Foreign bodies
Anatomic factors
Compromised immune response
Functional disorders
Classification of UTI
Upper UTI (Pyelonephritis):
Renal parenchyma
Renal pelvis
Ureters
Lower UTI:
Bladder (Cystitis)
Urethra (Urethritis)
Uncomplicated: Bladder only
Complicated: Occurs with structural or functional problem in urinary tract
Urosepsis: Systemic spread, life-threatening
Etiology & Pathophysiology UTI
Urinary tract above urethra normally sterile
Defense mechanisms:
Complete emptying with void
Uretero-vesical junction competence
Ureteral peristalsis propels urine towards bladder
Acidic pH (below 6.0)
High urea
Glycoproteins; inhibit bacterial growth
Organisms from perineum ascend urethra
GI tract: Gram-negative bacilli
Contributing factors:
Urologic instrumentation
Sexual intercourse
Hematogenous transmission
UTI: Most common health-care associated infection (HAI)
Catheter-associated urinary tract infections (CAUTI); E.coli or Pseudomonas
Increased length of stay, costs, morbidity, mortality
Clinical Manifestations of Urinary Tract Disorders
Lower Urinary Tract Symptoms
Emptying symptoms
Hesitancy, intermittency, post void dribbling, urinary retention or incomplete emptying, dysuria
Storage symptoms
Urinary frequency, urgency, incontinence, nocturia, nocturnal enuresis
Hematuria and/or cloudy appearance
Many problems can produce these symptoms, be confused with UTI
Clinical Manifestations of Urinary Tract Disorders
Upper UTI
Flank pain, chills, fever
Other: fatigue, anorexia, or asymptomatic
Older adults: Classic manifestations may be absent
Non-localized abdominal discomfort
Cognitive impairment, or generalized deterioration
Often afebrile
Asymptomatic bacteriuria: Colonization of bacteria in bladder
Screen & treat with pregnancy
Diagnostic Studies UTI
Initial: Urine dipstick for nitrates, WBCs, & leukocyte esterase
Urine culture/sensitivity
History
Recurring UTIs (More than 2 – 3 per year)
Complicated UTIs
CAUTIs or HAI UTIs
UTI unresponsive to empiric therapy
Imaging: Ultrasound or CT scan
UTIs: Interprofessional Care
Diagnosis: H & P, UA, C & S, Imaging
Management (Uncomplicated)
Patient teaching, adequate fluids
Medications:
Phenazopyridine (Pyridium, Azo); Urinary analgesic
Antibiotics (empiric) for approximately 3-days
Recurrent UTI
Addition of susceptibility testing & possibly suppressive or prophylactic antibiotics
Antibiotics 7 to 14 days or longer
UTIs: Medications
Uncomplicated or initial UTIs
Trimethoprim/sulfamethoxazole (TMP-SMX) (Bactrim)
Nitrofurantoin
Cephalexin
Fosfomycin
Others:
Ampicillin
Amoxicillin
Cephalosporin’s
Complicated
Fluoroquinolones
Ciprofloxacin (Cipro)
Levofloxacin (Levaquin)
Fungal: Fluconazole (Diflucan)
Nursing Assessment UTI
Subjective
Past health history
Medications
Surgery or other treatments
Functional health patterns
Health perception; health management
Nutritional; metabolic
Elimination
Cognitive; perceptual
Sexuality; reproductive
Objective
General
Urinary
Possible diagnostic findings
Health Promotion & Ambulatory Care UTI
Health promotion
Recognize at-risk patients
Patient teaching
Empty bladder regularly & completely
Evacuate bowel regularly
Wipe front to back
Adequate fluid intake
Hospitalized patients routine & thorough perineal hygiene
Ambulatory care
Patient & caregiver teaching
Take antimicrobials as ordered
Adequate fluid intake
Void regularly
Void before & after intercourse
Stop using diaphragm (temporarily)
Follow-up care
Acute Care & Prevention of CAUTI
Adequate fluid to dilute urine & reduce irritation
Avoid irritating fluids & foods
Heating pad to suprapubic or lower back; warm shower or bath
Patient teaching:
Drugs & side effects
Complete entire prescription
What improvement looks like
What to report to HCP
Prevention of CAUTI
Avoid unnecessary catheterization
Prompt removal of indwelling catheters
Hand hygiene
Gloves for catheter care
Sterile technique
Evidence-based clinical tool from ANA
Acute Pyelonephritis
Etiology
Most common - Bacteria from intestinal tract: E.coli, Proteus, Klebisella, or Enterobacter Other: fungi, protozoa, or viruses
Other factors: Vesicoureteral reflux, obstruction, stricture, or stones
Pathophysiology
Initial colonization & infection of lower urinary tract from urethra
Inflammation of renal parenchyma & collecting system
Urosepsis: Systemic infection from urologic source
Risk Factors
CAUTI: LTC residents
Pregnancy-induced changes
Starts in renal medulla, spreads to cortex
Pyelonephritis
Clinical Manifestations
Mild fatigue
Sudden onset of
Chills
Fever
N/V
Malaise
Flank pain
Costo-vertebral (CVA) tenderness
Dysuria
Urgency / Frequency
Treatment
Outpatient: 14 – 21 days of PO antibiotics
Inpatient: IV antibiotics then
14 – 21 days of PO antibiotics
Teaching
Take meds as prescribed
Complete antibiotic course
Adequate fluid intake (8 glasses/day)
UTI prevention measures
Follow-up care; Signs & symptoms of relapse or recurrence
Chronic Pyelonephritis
Kidney inflammation causes scarring leading to loss of renal function
Result from anatomic abnormalities or recurrent upper UTI infections
Diagnosis: Radiologic imaging & biopsy
Treatment: Treat infection & underlying contributing factors
Prevent progression to end-stage renal disease (ESRD)
More about nursing & interprofessional management of chronic kidney disease (CKD) to come!
Clinical Manifestations of Pyelonephritis
Classic:
Fever/chills
Nausea/vomiting
Malaise
Flank pain
Other: Dysuria, urgency, frequency
Costovertebral angle (CVA) tenderness
Diagnostic Studies:
Urinalysis:
Pyuria
Bacteriuria
Hematuria
WBC casts
Urine culture & sensitivity
Blood cultures
Tests for decreased kidney function
Ultrasound
CT scan (Preferred imaging study)
Interprofessional Care
Pyelonephritis
Mild symptoms (Outpatient or short inpatient)
Fluids, NSAIDs, follow-up cultures & imaging
PO Antibiotics: 7 - 14 days
IV to PO Antibiotics: 14 - 21 days
Sensitivity guided
Severe symptoms
IV fluids until PO tolerated
Combination parenteral antibiotics
Relapses: 6-weeks of antibiotics
Recurrent: Prophylactic antibiotics
Urosepsis: Monitor for & treat for septic shock to prevent irreversible damage or death
Sites & Causes of Upper & Lower Urinary Tract Obstruction
Anatomic or functional condition that blocks or impedes the flow of urine
Congenital or acquired
Damage occurs above level of obstruction
Severity depends on:
Location
Duration
Amount of pressure or dilation
Presence of urinary stasis or infection
May affect only one kidney & other kidney may compensate
Obstructive Uropathies
Bladder neck or prostate
Detrusor muscle hypertrophy
Eventual large, residual urine
Bladder outlet
Increased pressure with filling or storage
Vesicoureteral reflux, hydroureter, & hydronephrosis
Chronic pyelonephritis & renal atrophy
Partial obstruction of ureter or ureteropelvic junction (UPJ)
Low to moderate pressure; kidney dilates without noticeable loss of function
Urinary stasis & reflux; Increases risk of pyelonephritis
Both kidneys or only one functioning kidney involved; Changes in renal function occur & BUN / Cr increase
Progressive obstruction can lead to renal failure
Treatment: Find & relieve blockage
Insertion of tube, surgery, or urinary diversion
Nephrolithiasis: Urinary Tract Calculi (Kidney Stones)
United States: 13% men, 7% women
Middle-aged; Risk increases with age
More frequent in:
White than Black, Hispanic, & Asian populations
Family history
Southeast U.S.; followed by Southwest, & Midwest
Summer (Hot climate & dehydration)
Uric acid stones in Jewish men
Nephrolithiasis: Urinary Tract Calculi (Kidney Stones)
-Etiology and patio
-Risk factors
Risk factors for kidney stones
Metabolic
Climate
Dietary
Genetic
Lifestyle
Concentration of supersaturated crystals precipitate & form stone
Reduce risk by keeping urine dilute & free flowing
Stone formation; Influencing factors
Higher urinary pH: Calcium & phosphate less soluble
Lower urinary pH: Uric acid & cysteine less soluble
Solute load
Inhibitors in urine
Obstruction with urinary stasis
Infection with urea-splitting bacteria (Struvite stones)
Infected stones (Staghorn)
Renal infection, hydronephrosis, loss of kidney function
Examples of Kidney Stones
Five categories of stones
Calcium oxalate
Calcium phosphate
Cystine
Struvite
Uric acid
Calcium stones; Most common
May be mixed & in various locations
Kidney stones
- clinical manifestations
First symptom; Sudden, severe pain (Renal colic)
Flank area, back, or lower abdomen
Ureter stretches, dilates, & spasms
May see: nausea and vomiting; “kidney stone dance;” dysuria, fever, chills; moist, cool skin
Common sites of obstruction
Ureteropelvic junction (UPJ); Dull costovertebral flank pain or renal colic
Ureterovesical junction (UVJ); Lower abdominal pain; testicular or labial pain
Kidney stones
-diagnostic studies
Noncontrast helical (spiral) CT scan
Ultrasound
Urinalysis
24-hour urine
Retrieval & analysis of stones; Important to determine problem contributing to stone formation
Interprofessional Care for Kidney Stones
Manage acute attack
Pain, infection, and/or obstruction
Opioids, NSAIDS, -adrenergic blockers
Evaluate cause of stone formation & prevent further development
Family history; geographic residence
Nutritional assessment; fluid intake; vitamins A, C, & D
Activity pattern
History of: prolonged illness, GI or GU disease or surgery, previous stones, prescribed & OTC meds, dietary supplements
Treatment & Patient Teaching:
Adequate hydration, Sodium restriction, Dietary changes
Drugs; Alter pH of urine, prevent excess urinary secretion of a substance, or correct primary disease
Struvite stones: Antibiotics & acetohydroxamic acid; surgery
Stones 4 mm or less may pass spontaneously (May take weeks)
Endo-urologic, lithotripsy, or open surgical stone removal if stones:
Are too large (> 7 mm) to pass spontaneously
Are associated with bacteriuria or symptomatic infection
Impair renal function
Cause persistent pain, nausea, or paralytic ileus
Patient can’t be treated medically or only has one kidney
Endo-Urologic Procedures
Cystoscopy: Remove stone in bladder
Cystolitholapaxy: Large stones broken up with lithotrite (stone crusher)
Cystoscopic lithotripsy: Ultrasonic waves break stones
Complications:
Hemorrhage
Retained stone fragments
Infection
Lithotripsy (Ultrasonic, laser or electrohydraulic)
Flexible ureteroscopy: Remove stones from renal pelvis & upper urinary tract
Percutaneous nephrolithotomy: Nephroscope inserted through skin into renal pelvis; stone fragmented & removed, followed by irrigation
May place nephrostomy tube
Complications: Bleeding, Injury to adjacent structures, Infection
Surgical Therapy
Primary indications: Pain, infection, & obstruction
Procedure type depends on location of stone:
Nephrolithotomy - Kidney
Pyelolithotomy - Renal pelvis
Ureterolithotomy - Ureter
Cystotomy - Bladder
Postop complication: Hemorrhage
Nutritional Therapy
Obstructing stone: Adequate fluids to avoid dehydration
Forcing fluids not recommended d/t potential for increased pain
After urolithiasis: High intake (Approximately 3 L/day), Goal: 2.5 Liter urine/day
Water is best! (Prevents super-saturation of minerals)
Reduce risk of dehydration
Limit colas, coffee, & tea: Increased stone formation
Low-sodium diet
Dietary restrictions according to type of stone; Purine, calcium, oxalate
Kidney Cancer
U.S. 63,340 cases/year (24% mortality)
Risk factors:
Cigarette smoking
Acute / Chronic kidney disease
Obesity
HTN
Exposure to asbestos, cadmium, & gasoline
1st degree relative
Early stage: Asymptomatic; often incidental finding for unrelated condition
25% have metastasis when diagnosed (Renal vein, vena cava, lungs, liver, & long bones)
Common manifestations: Hematuria, flank pain, palpable mass in flank or abdomen
Other: weight loss, fever, HTN, anemia
Diagnostic Studies: CT scan, ultrasound, angiography, biopsy, MRI; radionuclide isotope scan
Kidney Cancer
- Prevention
- Interprofessional Care
Smoking cessation
Healthy weight
Control BP
Avoid exposure to toxins
Identify high-risk groups
Patient teaching: Early manifestations
Staging I to IV; Early detection provides higher chance for cure
Treatments
Nephrectomy: Partial, simple total, or radical; open or laparoscopic
Cryoablation or radiofrequency ablation
Immunotherapy:
-interferon & interleukin-2
Nivolumab
Targeted therapy: Kinase inhibitors
Nephrectomy
- Open
- Laparoscopic
Open
Potential complications
Hemorrhage
Embolization of renal artery
Atelectasis
Pneumonia
Thrombo-embolism
Infection
Outcomes
Reduction of
Pain
Hematuria
LOS: 4 – 6 Day
RTW: 4 – 8 weeks
Laparascopic
Shorter procedure
2 hours vs 7-hours
Fewer analgesics
Resume PO sooner
Faster DC & RTW
Procedure used for organ donation
Urinary Retention
Inability to empty bladder with voiding or accumulation of urine because of inability to void
May be associated with leakage or post void dribbling (Overflow incontinence)
Acute urinary retention: Inability to pass urine (Medical emergency)
Chronic urinary retention: Incomplete emptying despite urination
Post void residual (PVR); 50 - 75 mL considered normal
> 100 mL - Repeat or further evaluation with UTIs
> 200 mL - Further evaluation
> 300 – 350 mL – Criteria for intermittent or indwelling catheterization in many agencies
Urinary Retention: Etiology & Pathophysiology
Bladder outlet obstruction: Bladder can’t empty due to severe blockage
Men - enlarged prostate
Deficient detrusor contraction: Muscle can’t contract with enough force or time to empty bladder
Neurologic diseases involving sacral 2, 3, & 4
Diabetes
Over-distention
Chronic alcohol use
Anticholinergic drugs
Diagnostic studies (Same as UI)
Urinalysis
Post void residual
Urodynamic studies
Ultrasound
Nursing Interventions to Stimulate Voiding
Privacy
Facilitate Normal standing / sitting position
Coffee or brewed tea to create maximum urgency (if allowed PO)
Running water / flushing toilet
Warm water over perineum using Peri-bottle
Immerse clients hands in water
Trigger micturition by applying ice or gently stroking inner thigh
Back Rub, and/or soothing music to induce relaxation
Interventions for Chronic Urinary Retention
Behavioral methods
Scheduled toileting; every 3 to 4 hours
Catheterization
Surgery
Medications
Alpha-adrenergic Blockers
Reduce urethral sphincter resistance to urinary outflow
Doxazosin (Cardura)
Tamsulosin (Flomax)
Indicated for:
BPH
Bladder neck incoordination
Detrusor muscle incoordination
Contraindicated/caution with:
Pregnancy/lactation
Hypotension
Hepatic / renal disease
Monitor for orthostatic hypotension
Report dizziness and/or palpitations
Monitor patients taking Warfarin
Nursing Management of Acute Urinary RetentionMedical Emergency
Insert urethral catheter; consider need for indwelling
Patient teaching to minimize risk:
Drink small amounts throughout the day
Be warm when trying to void
Avoid excess alcohol
Patient teaching if unable to void:
Drink caffeinated coffee or tea to increase urgency
Warm bath/shower
Seek medical care
Indications for Urethral Catheterization
Indications for Intermittent
Relief of urinary retention
Diagnostic study
Urodynamic testing
Sterile specimen
Medication instillation
Measure PVR
What other method is there to measure PVR that has less risk?
Indications for Indwelling
Relief of urinary retention
Bladder decompression pre-op or post-op
Facilitate surgery
Facilitate healing
Accurate I & O in Critical Care
Stage III or IV pressure ulcer
Terminal illness; Comfort Care
Unacceptable reasons for catheterization
Routine urine specimen
Convenience for nurse or patient’s family
Complications of long-term use (more than 30 days)
CAUTI—most common HAI
Other: bladder spasms, periurethral abscess, chronic pyelonephritis, urosepsis, urethral trauma or erosion, fistula or stricture formation, and stones
Preventing CAUTI
Determine need for catheter; HCP must order
Chose appropriate size & type of catheter
Insert catheter in patient with urethral trauma, pain, or obstruction
Develop plan of care to decrease risk of infection
Teach catheter care to patient; especially if ambulatory
Use a sterile, closed drainage system
Do not disconnect system except for irrigation
Use sterile technique if need to open system
Consider triple-lumen catheter for continuous irrigations
Catheter change not necessary if less than 2 weeks
LTC: Determine necessity based on assessment, not routine
Use catheter sampling port for urine culture; prepare puncture site with antiseptic solution
Use leg bag for long-term catheter use; if reusing collection bag; clean thoroughly
Remove catheter as early as possible
Fewer cases of bacteriuria & CAUTI with intermittent catheterization & external catheters
RN Supervision of Tech to Ensure:
Maintains unobstructed downhill flow of urine
Empties collecting bag regularly; records output
Provides perineal care 1 to 2 x/day & PRN
Does not use lotion or powder near catheter
Uses securement device to prevent catheter movement & urethral tension
Suprapubic Catheters
Urinary diversion; may be temporary or long-term
Insertion through abdominal wall
General or local anesthesia
May be sutured; Tape to prevent dislodgement
Care similar to urethral catheter; Use skin barrier to protect skin at insertion site
Ensure patency: Prevent kinking, turn patient side to side, milk the tube, or irrigate (with order) using sterile technique
Antispasmotics for bladder spasms
Behavioral therapies
Scheduled toileting & double voiding
Catheterization: Intermittent or indwelling
Transurethral or open surgery for obstruction:
Prostate enlargement or cancer
Bladder neck contracture
Urethral strictures
Dyssynergia of bladder neck
Abdominal or transvaginal surgery for pelvic organ prolapse
Surgery for deficient detrusor contraction
Sacral neuro-modulation
Intra-urethral valve pump
Female Genital Cutting/Mutilation (FGC/FGM)
28 African nations including
Kenya
Sudan
Gambia
Somalia
Nigeria
Egypt - 50% school girls
Several Middle Eastern countries
Indonesian & Malaysian Muslims
Victoria era (1800’s): Britain & North America
One current U.S. cult believes the vulva more beautiful & erotic
Sunna Circumcision
Removal of prepuce (retractable hood) and/or tip of clitoris
Clitoridectomy
Removal of entire clitoris (prepuce & glands)
Removal of adjacent labia
Infibulation “Pharonic Circumcision” (15% of cultures)
Clitoridectomy
Removal of all or part of labia minora & labia majora
Suturing; small hole allows urine & menstrual blood to flow through
Infibulation “Pharonic Circumcision”
Girls 4 – 10 years old
80 – 110 million women worldwide
Difficult urination or avoidance of urination
When tightly infibulated
Drop-by-drop urination
Menstrual period can last up to 10 days & be very painful
Surgical Interventions for Obstruction
Bladder Neck Repair
Cystoplasty
Transurethral incision of bladder neck
Urethroplasty – removal of strictures
Meatotomy
Suprapubic Cystotomy (Suprapubic catheterization)
Bladder must be full during insertion
Lower rate of UTI
Increased comfort
Easier bladder training
Potential complications
Dislodgment
Hematuria
Bowel perforation
Urinary fistula (Failed closure
Urinary Incontinence
Involuntary leakage of urine
More prevalent in older adults (women > men)
Not a natural consequence of aging
Gender differences
Men: Common with BPH or prostate cancer; overflow incontinence from urinary retention
Women: Stress & urge incontinence
May have more than 1 type
Stress
Urge
Combined /Mixed Incontinence
Overflow
Reflex
Incontinence after trauma or surgery
Functional incontinence
Etiology & Pathophysiology
Urinary incontinence
Bladder pressure greater than urethral closure pressure
Interference with bladder or sphincter control
DRIP
D: Delirium, dehydration, depression
R: Restricted mobility, rectal impaction
I: Infection, inflammation, impaction
P: Polyuria, polypharmacy
Urinary incontinence
Diagnostic studies
Basic evaluation:
Bladder log or voiding record for 1 - 7 days
Onset, provoking factors & associated conditions
Physical exam:
General health & functional issues
Pelvic exam
Diagnostic studies: Urinalysis, post void residual, urodynamic studies, ultrasound
Interprofessional Care of Incontinence
Many can be cured or improved
Treat transient, reversible factors first
Interventions depend on type
Individualized to patient preference, type & severity, & anatomic defects
Lifestyle modifications
Scheduled voiding regimens
Pelvic floor muscle rehabilitation
Antiincontinence devices
Containment devices
Drug therapy
Surgical therapy; Depends of type of UI
Urinary structural support/repositioning
Increased urethral resistance of internal sphincter & intra-abdominal pressure
Retro-pubic colposuspension & pubo-vaginal sling
Sub-urethral sling
Bulking agent injection
Artificial sphincter surgery
Medications for OAB(Urge & Reflex incontinence)
Anticholinergics (Muscarinic blockade)
Oxybutinin (Ditropan)
Primarily M3 selective
Solifenancin (VESIcare)
Primarily M3 selective
Darifenacin (Enablex)
Highly M3 selective
Tolterodine (Detrol)
Nonselective
Trospium (Sanctura)
Nonselective
Side effects
Dry mouth
Constipation
Tachycardia
Urinary hesitancy / retention
Mydriasis/blurred vision
Dry eyes
Hallucination (Elderly)
Confusion (Elderly)
Sedation (Elderly)
Nursing Management: Urinary Incontinence
Identify physical & emotional concerns: Maintain dignity, privacy, self-worth
Two step approach:
Containment devices for urinary leakage
Plan to reduce or resolve UI factors
Tables 45-17 and 45-18
Lifestyle modifications
Behavioral treatments
Products to contain urine
Nursing Interventions for Incontinence
Pelvic muscle exercises (Kegel’s)
30% - 90% effective
Bio-feedback / pelvic floor rehab
54% - 77% effective
Electrical stimulation via vaginal / anal sensor
Inhibit micturition reflex
Contract pelvic floor muscles
Scheduled voiding: Clock vs Urge
Fluid intake & dietary modification
Weight reduction
Smoking cessation
Good bowel regimen
Avoid bladder irritants
Caffeine
Citrus
Aspartame
External Urinary Collection Systems
Texas Condom Catheter
Purewick
