Unit 15 - Urinary Flashcards
Lower UTIs
Cystitis, prostatitis, urethritis
Upper UTIs
Acute pyelonephritis, chronic pyelonephritis, renal abscess, interstitial nephritis, perirenal abscess
Uncomplicated Lower UTI
Community-acquired infection; common in young women and not usually recurrent
Compliated Lower or Upper UTI
Often nosocomial (acquired in the hospital) and related to catheterization; occur in patients with urologic abnormalities, pregnancy, immunosuppression, diabetes mellitus, and obstructions and are often recurrent
Pyelonephritis
Inflammation of kidney and renal pelvis
Interstitial nephritis
inflammation of spaces between kidney tubules
renal abscesses
pus filled cavity of kidney
Urethrovesical reflux
reflux of urine from urethra into bladder (coughing, sneezing, straining causes pressure forcing urine from bladder to urethra and then back when pressure recedes)
Ureterovesical reflux
reflux of urine from bladder to ureters, can cause bacteria to reach kidneys
UTI Risk factors
Inability or failure to empty the bladder completely Obstructed urinary flow: Congenital abnormalities Urethral strictures
Contracture of the bladder neck
Bladder tumors
Calculi (stones) in the ureters or kidneys Compression of the ureters
Neurologic abnormalities Decreased natural host defenses or immunosuppression Instrumentation of the urinary tract (e.g., catheterization, cystoscopic procedures) Inflammation or abrasion of the urethral mucosa Contributing conditions: Diabetes mellitus (increased urinary glucose levels create an infection-prone environment in the urinary tract)
Pregnancy
Neurologic disorders
Gout
Altered states caused by incomplete emptying of the bladder and urinary stasis
S+S of UTI
Dysuria • Urgency • Frequency • Nocturia • Suprapubic or pelvic pain • Hematuria • Back pain • Incontinence • Dullness on percussion
Gerontologic Considerations
Lack typical symptoms • Altered mental status • Lethargy • Anorexia • New incontinence • Low grade fever • May still have frequency, urgency and dysuria
Urosepsis
Sepsis resulting from infected urine, usually a UTI. Indwelling catheter. Can cause signs of septic shock
Septicemia from UTI
Kidneys receive 25% cardiac output, with pyelonephritis can lead to bacteremia. Septicemia syndrome (vasodilatation, microvascular permeability, massive inflammatory response)
S+S of urosepsis
hypo/hyperthermia tachycardia tachypnea leukocytosis/leukopenia >10% immature band forms``
Urine dipstick:
bacteriuria
Leukocyte markers for leukocyte esterase and nitrites (Greiss test) (WB + Nitrites = infection). Elevated SG.
Urinalysis (UA)
> WBC , bacteria >10^5
Urine C&S
Clean catch + catheterization
Culture - determines infectious agents
Sensitivity - determines susceptibility of bacteria to Abx
Also differential dx: test for STDs
Groups needing cultures when bacteriuria is present
All men (because of the likelihood of structural or functional abnormalities)
Women with a history of compromised immune function or renal problems
Patients with diabetes mellitus
Patients who have undergone recent instrumentation (including catheterization) of the urinary tract
Patients who have been recently hospitalized or who live in long-term care facilities
Patients with prolonged or persistent symptoms
Patients with three or more UTIs in the past year
Pregnant women
Postmenopausal women
Pt Education for UTI
Shower rather than bath
After BM clean front to back
Pt Education for UTI (Fluid intake)
Drink liberal fluids to flush
Avoid coffee tea colas alcohol and other irritants
Pt education for UTI (Voiding habits)
Void q2/3 hr during day and completely empty bladder to prevent overdistention and compromised blood supply to bladder wall which can predispose to UTI.
Void after sex.
Pt education for UTI (Therapy)
Take meds exactly as prescribed (short term 3-4 d, 7-10 d)
Long term Abx may be required (4-12 mo)
Special timing of admin may be required (bedtime)
Acidification of urine (OJ or cranberry juice)
Notify HCP if fever occurs or s+s persist
Consult PCP for follow up
Tx for UTI
Uncomplicated 1-3 day resolution
Suppressive/prophylactic tx
Culture first if Sx persist
Floroquinolones
ciprofloxacin (Cipro)
levofloxacin (Levaquin)
Tx of choice for uncomplicated (3 days)
SE: Tendonitis/rupture, Rash, GI discomfort, *C-diff diarrhea, seizures
Take 1 hr before or 2 hr after meals
Sulfonamides for UTI
nitrofurantoin (Macrodantin)
Ineffective with pts GFR < 50
Can cause periph. neuropathy
Penicillins
Amoxicillin (Amoxil, Augmentin)
PCN Allergies
Highly resistant
Urinary Analgesics
phenazopyridine (Pyridium)
Turns urine dark orange, might be confused with blood.
Acute Pyelonephritis
Lower UTI S+S: Fever, chills, leukocytosis, lower back pain , flank pain, NV, HA, malaise, CVA tenderness
Englarged kidneys, abcesses on renal capsule.
Complication - could relapse and become asymptomatic and chronic
Chronic Pyelonephritis
Asymptomatic unless acute exacerbation
S+S: HA, fatigue, poor appetite, polyuria, excessive thirst, wt loss
Complication: ESRD (kidneys scar and contract and nonfunctional)
Dx Complicated UTI
IV urogram and degree of renal dysfunction via measurements of BUN, creatnine, creatnine clearance. CT scan for obstruction. Urine C+S.
Voiding cystouretherography
Tx for Pyelo
Outpatient if no dehydration, n/v, or sepsis sx. 2 week abx .
Parenteral admin in hosp. to rapidly est. drug levels
trimethoprim-sulfamethoxazole (Bactrim,
TMP/SMX)
Cipro
gentamicin
3rd gen cephalosporin.
**Use with caution of pt has renal or liver dysfunction.
NSAID and Tylenol for fever and discomfort
Fluids 3-4 L /day
BPH Sx
Obstructive sx, similar to UTI
Frequency, nocturia, urgency, hesitancy, straining, decrease in volume and force of stream, dribbling, sensation of incomplete emptying, acute retention, recurrent UTI.
Dx Studies for BPH
H+P w/ digital rectal exam UA Labs: PSA + Creatinine Transrectal Ultrasound TRUS Uroflowmetry Post Void Residual PVR Cystourethroscopy
Risk factors for BPH
AA younger, smoking, ETOH, HTN, heart disease, DM, diet.
BPH Pharma
5-alpha reductase inhibitors
finasteride (Proscar), dutasteride
Interfere with conversion of testosterone to DHT to decrease size
SE: decreased libido and ejaculate volume, ED
Alpha Blockers
amsulosin (Flomax)
doxazosin (Cardura)
terazosin (Hytrin)
prazosin (Minipress)
Relax smooth muscle, does not decrease hyperplasia, sx relief
SE: Ortho hypo, dizzy, retrograde ejaculation, nasal congestion
Herbal:
Saw palmetto
Sx relief, reverses hyperplasia
SE: GI, bleeding risk (stop before dental/surgical)
Better tolerated and cheaper, may be as effective
BPH Minimally Invasive Therapy
Coude (curved) catheter for uroretention Transurethral microwave thermotherapy TUMT Transurethral needle Ablation TUNA Laser prostatectomy Intraprostate urethral stents
Invasive therapy BPH
Transurethral Resection of Prostate TURP
Transurethral incision of prostate TUIP
Suprapubic/ Perineal/ Retropubic/ Robotic/ Laparoscopic prostatectomy
Prostatectomy Preop care
: Reduce anxiety, relieve discomfort (bedrest, analgesics). Watch void pattenrs, bladder distention, assist w/ catheterization.
Prostatectomy Postop care
Maintenance of fluid volume balance,- irrigation causes excess fluid retention. Observe for JVD, S3 gallop, crackles. Monitor UO record. Electrolyte imbalances (Na), increased BP, confusion, resp. distress. Hemorrhage monitor for tachy, hematuria, restlessness, pallor, dec. hct and hgb. UO should be 0.5ml/kg/hr
pain relief - determine cause (incisional or bladder spasm - severe cramping suprabpubic). Feeling of pressure and fullness in bladder. Secure drainage to leg to decrease tension. Dont sit for prolonged time, will increase intrabdominal pressure (bleeding and discomfort)
Prostatectomy Postop complications
Hemorrhage: clots can obstruct flow. Bright red blood is aterial (surgical intervention), dark red is venous (can be stopped by PCP inflation). HOB slightly elevated to avoid incr. pressure. Monitor VS, admin meds, fluids, and blood. Accurate IO, monitor drainage system patency.
Infection - avoid rectal thermos and tubes. sitz baths. Monitor for sx of infection.
DVT - LMWH, assess for DVT, stockings.
Cath obstruction - admin diuretic to keep patent. observe for abd distention which could indicate blockage. Suprapubic dullness. Monitor urine color, VS, restlessness, pallor, diaphoresis. Fluid in drainage bag must = fluid infused.
Sexual dysfunction
Self care . Perform Kegel exercises, as they may help with regaining urinary control:
Tense the perineal muscles by pressing the buttocks together; hold this position; relax. This exercise can be performed 10 to 20 times each hour while sitting or standing.
Try to interrupt the urinary stream after starting to void; wait a few seconds and then continue to void.
While the prostatic fossa heals (6 to 8 weeks), avoid activities that produce Valsalva effects (straining, heavy lifting), as this may increase venous pressure and produce hematuria.
Avoid long motor trips and strenuous exercise, which increase the tendency to bleed.
Note that spicy foods, alcohol, and coffee may cause bladder discomfort.
Maintain fluid intake to avoid dehydration, which increases the tendency for a blood clot to form and obstruct the flow of urine.
Report signs of complications, such as bleeding, passage of blood clots, a decrease in the urinary stream, urinary retention, or symptoms of UTI, to the urologist.
Nephro/urolithiasis
Stones in kidney/urinary tract
FOrmed with high concentrations of calcium oxalate, calcium phosphate, and uric acid.
S+S depend on location, obstruction, infection. Similar regardless of cause
Calcium calculi
Majority of stones Hypercalcemia Hyperparathyroidism Renal tubular acidosis Tumors that increase Vit D prod Dehydration
Uric acid stones
Gout
Alteration in purine metabolism
Increaed uric acid prod
Struvite
Recurrent UTIs
Neurogenic bladder
Foreign bodies
Increased urine alkalinity
Cysteine stones
Rare inherited defect in renal absorption of cysteine
Renal pelvis stone pain
Intense deep aching in CVA
Hematuria and pyuria
Radiating downward
Ureter obstruction from stone
Ureteral colic - acute excruciating colicky wavelike pain radiating down to thigh
Bladder stone pain
Bladder irritation and uti
Hematuria
Renal colic
Sudden acute pain
CVA tenderness
NV diarrhea and discomfort
Pallor and cold clammy skin
Stones Dx
H+P: Diet, meds, and history KUB Xrays Ultrasound IV Urography Retrograde pyelography VCUG 24h urine test for Ca, uric acid, urine creatnine, Na, pH, total volume Stone chemical analysis Blood: WBC BUN creatnine
Stones nursing mgmt
Pain mgmt - opiods and NSAIDs Hydration to increase prssure to drive stone down , mainstay of therapy, >2L UO recommended. Dietary changes per type of stone. Conrol infection Strain urine for stones I/O, VS Cessation of stone generating meds. Limit Na to 3-4g/day Possible uric acid meds
Stones surgeries
Ureteroscopy
Extracorporeal shock wave lithotripsy (ESWL) SE: possible obstruction from fragments
Percutaneous stone removal
Nephrolithotomy, cystotomy SE: hemorrhage
Stones Pt teaching
Avoid stone causing meds: Antacids, Vit D, Laxatives, high dose aspirin
Limit Na intake
Avoid oxalate foods: spinach, rhubarb, tea, panuts, wheat bran
Drink 2 glasses H20 at night to prevent urine concentration
Avoid dehydration
Notify HCP of S+S of infection
Acute glomerulonephritis
Inflammatory disease of glomeruli
Antigen-antibody response to infection: Group A Beta-hemolytic strep, impetigo,shingles, EBV, hep, HIV
Result is inflamation of glomerular capillaries and GFR
Mild to severe Azotemia and uremia Proteinuria Hematuria HTN Periorbital and peripheral edema Increased BUN and cretnine Oliguria Fluid Overload Neurologic sx Elderly - circulatory overload
CHronic glomerulonephritis
Glomerular destruction from repeated injury HTN, DM, Hyperlipidemia, SLE Major complications: Renal failure or ESRD Hyperkalemic Metabolic acidosis Anemia Hypoalbuminemia Increased phosphorous level Decreaed Vit D and Ca Decreased GFR Mental status changes Impaired Nerve conduction Cardiac enlargement and pulmonary edema
Glomerulonephritis Mgmt
Assess for previous infections (sore throat, skin lesions)
Physiologic assessments: fluid and electrolyte , cardiac and neuro status
Strict IO and daily weight
Monitor VS
Diet restrict Protein Na and fluid
Meds as indicated: antiHTN, diuretics, biologics,
Teach importance of followup care.
TUR Syndrome
absorption of irrigation fluid interoperatively, can lead to bradycardia, hyponatremia, confusion
