Nursing Management of Patients with Renal & Urologic Problems

Question 1

Urinary Tract Infection (UTI)

Answer 1

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

Question 2

Classification of UTI

Answer 2

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

Question 3

Etiology & Pathophysiology UTI

Answer 3

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

Question 4

Clinical Manifestations of Urinary Tract Disorders
Lower Urinary Tract Symptoms

Answer 4

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

Question 5

Clinical Manifestations of Urinary Tract Disorders
Upper UTI

Answer 5

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

Question 6

Diagnostic Studies UTI

Answer 6

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

Question 7

UTIs: Interprofessional Care

Answer 7

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

Question 8

UTIs: Medications

Answer 8

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)

Question 9

Nursing Assessment UTI

Answer 9

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

Question 10

Health Promotion & Ambulatory Care UTI

Answer 10

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

Question 11

Acute Care & Prevention of CAUTI

Answer 11

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

Question 12

Acute Pyelonephritis

Answer 12

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

Question 13

Pyelonephritis

Answer 13

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

Question 14

Chronic Pyelonephritis

Answer 14

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!

Question 15

Clinical Manifestations of Pyelonephritis

Answer 15

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)

Question 16

Interprofessional Care
Pyelonephritis

Answer 16

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

Question 17

Sites & Causes of Upper & Lower Urinary Tract Obstruction

Answer 17

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

Question 18

Obstructive Uropathies

Answer 18

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

Question 19

Nephrolithiasis: Urinary Tract Calculi (Kidney Stones)

Answer 19

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

Question 20

Nephrolithiasis: Urinary Tract Calculi (Kidney Stones)
-Etiology and patio
-Risk factors

Answer 20

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

Question 21

Examples of Kidney Stones

Answer 21

Five categories of stones
Calcium oxalate
Calcium phosphate
Cystine
Struvite
Uric acid

Calcium stones; Most common
May be mixed & in various locations

Question 22

Kidney stones
- clinical manifestations

Answer 22

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

Question 23

Kidney stones
-diagnostic studies

Answer 23

Noncontrast helical (spiral) CT scan
Ultrasound
Urinalysis
24-hour urine

Retrieval & analysis of stones; Important to determine problem contributing to stone formation

Question 24

Interprofessional Care for Kidney Stones

Answer 24

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

Question 25

Endo-Urologic Procedures

Answer 25

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

Question 26

Surgical Therapy

Answer 26

Primary indications: Pain, infection, & obstruction
Procedure type depends on location of stone:
Nephrolithotomy - Kidney
Pyelolithotomy - Renal pelvis
Ureterolithotomy - Ureter
Cystotomy - Bladder
Postop complication: Hemorrhage

Question 27

Nutritional Therapy

Answer 27

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

Question 28

Kidney Cancer

Answer 28

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

Question 29

Kidney Cancer
- Prevention
- Interprofessional Care

Answer 29

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

Question 30

Nephrectomy
- Open
- Laparoscopic

Answer 30

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

Question 31

Urinary Retention

Answer 31

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

Question 32

Urinary Retention: Etiology & Pathophysiology

Answer 32

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

Question 33

Nursing Interventions to Stimulate Voiding

Answer 33

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

Question 34

Interventions for Chronic Urinary Retention

Answer 34

Behavioral methods
Scheduled toileting; every 3 to 4 hours
Catheterization
Surgery
Medications

Question 35

Alpha-adrenergic Blockers

Answer 35

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

Question 36

Nursing Management of Acute Urinary RetentionMedical Emergency

Answer 36

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

Question 37

Indications for Urethral Catheterization

Answer 37

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

Question 38

Preventing CAUTI

Answer 38

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

Question 39

Suprapubic Catheters

Answer 39

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

Question 40

Female Genital Cutting/Mutilation (FGC/FGM)

Answer 40

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

Question 41

Infibulation “Pharonic Circumcision”

Answer 41

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

Question 42

Surgical Interventions for Obstruction

Answer 42

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

Question 43

Urinary Incontinence

Answer 43

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

Question 44

Etiology & Pathophysiology
Urinary incontinence

Answer 44

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

Question 45

Urinary incontinence
Diagnostic studies

Answer 45

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

Question 46

Interprofessional Care of Incontinence

Answer 46

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

Question 47

Medications for OAB(Urge & Reflex incontinence)

Answer 47

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)

Question 48

Nursing Management: Urinary Incontinence

Answer 48

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

Question 49

Nursing Interventions for Incontinence

Answer 49

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

Question 50

External Urinary Collection Systems

Answer 50

Texas Condom Catheter
Purewick