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Zoya Minasyan RN MSN-Edu Bladder and its contents are free of bacteria in most healthy patients. Escherichia coli most common pathogen Fungal and parasitic infections can cause UTIs. Patients at risk ◦ ◦ ◦ ◦ Are immunosuppressed Have diabetes Have undergone multiple antibiotic courses Have traveled to certain Third World countries Upper versus lower Upper tract Renal parenchyma, pelvis, and ureters Typically causes fever, chills, flank pain Example Pyelonephritis: inflammation of renal parenchyma and collecting system Lower urinary tract Usually no systemic manifestations Example Cystitis—Inflammation of bladder wall Complicated versus uncomplicated ◦ Uncomplicated Occurs in otherwise normal urinary tract Usually involves only the bladder ◦ Complicated Those with coexisting presence of Obstruction Stones Catheters Existing diabetes/neurologic disease Pregnancy-induced changes Recurrent infection Bacterial persistence ◦ Occurs when Bacteria develop resistance to antibiotic agent. Foreign body in urinary system allows bacteria to survive Unresolved bacteriuria ◦ Occurs when Bacteria are resistant to antibiotic Drug is discontinued before bacteriuria is completely eradicated Antibiotic agent fails to achieve adequate concentrations in bloodstream or urine to kill bacteria Urinary tract above urethra normally sterile Defense mechanisms exist to maintain sterility/prevent UTIs. ◦ Complete emptying of bladder Defense mechanisms ◦ Acidic pH ◦ High urea concentration Alteration in defense mechanisms increases risk of contracting UTI. Predisposing factors ◦ Factors increasing urinary stasis Examples: BPH, tumor, neurogenic bladder,stones ◦ Foreign bodies Examples: Catheters, instrumentation ◦ Anatomic factors Examples: Obesity, congenital defects, fistula ◦ Compromising immune response factors Examples: Age, HIV, diabetes ◦ Functional disorders Example: Constipation ◦ Other factors Examples: Pregnancy, multiple sex partners (women) Organisms are introduced via the ascending route from the urethra. Less common routes ◦ Bloodstream Lymphatic system Hospital-acquired UTI accounts for 31% of all nosocomial infections. ◦ Causes Often: E. coli Seldom: Pseudomonas ◦ Catheter-acquired UTIs Bacterial biofilms develop on inner surface of catheter. Symptoms related to bladder storage or bladder emptying ◦ Bladder storage Urinary frequency Abnormally frequent (> every 2 hours) Sudden strong desire to void immediately Waking up ≥2 times at night to void Complaint of loss of urine during sleep Urgency Incontinence Loss or leakage of urine Nocturia Nocturnal enuresis ◦ Bladder emptying Weak stream Hesitancy Difficulty starting the urine stream Intermittency Interruption of urinary stream while voiding Urine loss after completion of voiding Difficulty voiding Postvoid dribbling Urinary retention Inability to empty urine from bladder Dysuria ◦ Pain on urination Flank pain, chills, and fever indicate infection of upper tract. Pyelonephritis Older adults ◦ Symptoms are often absent. ◦ Experience nonlocalized abdominal discomfort rather than dysuria ◦ May have cognitive impairment ◦ Are less likely to have a fever Patients over age 80 years may experience a slight decline in temperature. History and physical examination Dipstick urinalysis ◦ Identify presence of nitrates, WBCs, and leukocyte esterase. Urine for culture and sensitivity (if indicated) ◦ Clean-catch sample preferred ◦ Specimen by catheterization or suprapubic needle aspiration more accurate Determine susceptibility of bacteria to antibiotics Imaging studies ◦ ◦ ◦ ◦ ◦ IVP(IV pyelogram) Antegrade pyelogram Retrograde pyelogram Abdominal CT when obstruction suspected Renal ultrasound for recurrent UTIs ◦ IVP(IV pyelogram) Visualizes urinary tract after IV injection of contrast media. Size, shape, position of kidneys, ureters, bladder, tumor, cysts, lesions, obstructions Nursing ◦ Check for iodine sensitivity Warmth, a flushed face and salty taste during injection of contrast media Force fluid after procedure to flush out contrast media. Antegrade pyelogram If pt has allergy to contrast media or decreased renal fx or no passage to ureteral catheter -contrast media inserted into renal pelvis or via nephrostomy tube ◦ Retrograde pyelogram-X ray If pt has allergy to contrast, cyctoscope is inserted and ureteral catheter are inserted through it into renal pelvis and contrast is inserted through catheter ◦ Abdominal CT when obstruction suspected Visualization of kidneys Masses, tumor Iv contrast to differentiate masses ◦ KUB- Kidneys, ureters, bladder Bowel prep if needed X-ray of abdomen for the size, shape and position of the kidneys Stones and foreign bodies can be seen ◦ Renal ultrasound for recurrent UTIs To detect mass •Teach women •To wipe the peri-urethral area from front to back using a moistened, clean gauze sponge (no antiseptic is used, as it could contaminate the specimen and cause false-positives) • tell them to collect the specimen 1 to 2 seconds after voiding starts. •Instruct men to wipe the penis around the urethra. The specimen is collected 1 to 2 seconds after voiding begins. •Refrigerate urine immediately on collection ◦ Trimethoprim/sulfamethoxazole (TMP/SMX) Used to treat uncomplicated or initial Inexpensive Taken twice a day ◦ E. coli resistance to TMP-SMX ◦ Nitrofurantoin (Macrodantin) Given 3 or 4 times a day Long-term use Pulmonary fibrosis Neuropathies ◦ Fluoroquinolones Treat complicated UTIs Example: Ciprofloxacin (Cipro) ◦ Pyridium Used in combination with antibiotics Provides soothing effect on urinary tract mucosa Stains urine reddish orange Can be mistaken for blood and may stain underclothing OTC Health history ◦ Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer ◦ Antibiotics, anticholinergics, antispasmodics ◦ Urinary hygiene ◦ N/V, anorexia, chills, nocturia, frequency, urgency ◦ Suprapubic/lower back pain, bladder spasms, dysuria, burning on urination Objective data ◦ Fever ◦ Hematuria, foul-smelling urine, tender, enlarged kidney ◦ Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP Impaired urinary elimination Ineffective self-health management Patient will have ◦ Relief from lower urinary tract symptoms ◦ Prevention of upper urinary tract involvement ◦ Prevention of recurrence Health promotion ◦ Recognize individuals at risk. Debilitated persons Older adults Underlying diseases (HIV, diabetes) ◦ ◦ ◦ ◦ ◦ Taking immunosuppressive drug or corticosteroids Emptying bladder regularly and completely Evacuating bowel regularly Wiping perineal area front to back Drinking adequate fluids Health promotion (cont’d) ◦ Cranberry juice may help decrease risk. ◦ Avoid unnecessary catheterization and early removal of indwelling catheters. ◦ Aseptic technique must be followed during instrumentation procedures. ◦ Wash hands before and after contact. ◦ Wear gloves for care of urinary system. ◦ Routine and thorough perineal care for all hospitalized patients ◦ Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals o Adequate fluid intake Dilutes urine, making bladder less irritable Flushes out bacteria before they can colonize ◦ Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods. Potential bladder irritants ◦ Emphasize taking full course of prescribed drugs despite disappearance of symptoms. Second or reduced drug may be ordered after initial course in susceptible patients. Instruct patient about drug therapy and side effects. Instruct patient to watch urine for changes in color and consistency and decrease in cessation of symptoms. ◦ Application of local heat to suprapubic or lower back may relieve discomfort. ◦ Counsel on persistence of lower tract symptoms beyond treatment; onset of flank pain or fever should be reported immediately Ambulatory and home care ◦ Emphasize compliance with drug regimen. Take as ordered. ◦ ◦ ◦ ◦ ◦ Maintain adequate fluids. Regular voiding (every 3 to 4 hours) Void after intercourse. Instruct on follow-up care. Recurrent symptoms typically occur 1 to 2 weeks after therapy. Use of nonanalgesic relief measures Appropriate use of analgesics Passage of urine without urgency Urine free of blood Adequate intake of fluids Inflammation of renal parenchyma(consisting of the nephrones) and collecting system Caused most commonly by ◦ ◦ ◦ ◦ bacteria Fungi protozoa viruses Cortical surface shows grayish white areas of inflammation and abscess formation (arrow). Urosepsis ◦ Systemic infection from urologic source Can lead to septic shock and death. Septic shock: Outcome of unresolved bacteremia involving gram-negative organism. Usually begins with colonization and infection of lower tract via ascending urethral route. Frequent causes ◦ ◦ ◦ ◦ Escherichia coli Proteus Klebsiella Enterobacter Hospitalization for patients with severe infections and complications ◦ Such as nausea and vomiting with dehydration •Signs/symptoms typically improve within 48 to 72 hours after therapy is started. •The patient with mild symptoms may be treated as an outpatient with antibiotics for 14 to 21 days. •When initial treatment resolves acute symptoms and the patient is able to tolerate oral fluids and drugs, the person may be discharged on a regimen of oral antibiotics for an additional 14 to 21 days. Health history ◦ Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination Objective data ◦ Fever ◦ Hematuria, foul-smelling urine, tender, enlarged kidney ◦ Leukocytosis, positive findings for bacteria, WBCs, RBCs, ultrasound, CT scan Nursing Diagnoses Acute pain Impaired urinary elimination Planning ◦ Patient will have Relief of pain Normal body temperature No complications Normal renal function No recurrence of symptoms Health promotion ◦ Early treatment for cystitis to prevent ascending infection Patient with structural abnormalities is at high risk Stress the need for regular medical care. Ambulatory and home care ◦ ◦ ◦ ◦ ◦ ◦ Need to continue drugs as prescribed Need for follow-up urine culture Identification of risk for recurrence Encourage adequate fluids. Rest to increase comfort Low-dose, long-term antibiotics to prevent re infections Appropriate use of analgesics Passage of urine without urgency Urine free of blood Adequate intake of fluids Question The nurse identifies the patient with the greatest risk for a urinary tract infection as a: 1. 37-year-old man with kidney stones. 2. 26-year-old pregnant woman who has a history of urinary tract infection. 3. 69-year-old man who has urinary retention caused by benign prostatic hyperplasia. 4. 72-year-old woman hospitalized with a stroke who has a urinary catheter because of urinary incontinence. Involves progressive, irreversible loss of kidney function Disease staging based on decrease in GFR ◦ Normal GFR 125 mL/min, which is reflected by urine creatinine clearance ◦ Last stage of kidney failure End-stage renal disease (ESRD) occurs when GFR <15 mL/min Defined as presence of ◦ Kidney damage Pathologic abnormalities Markers of damage Blood, urine, imaging tests ◦ Glomerular filtration rate (GFR) <60 mL/min for 3 months or longer Leading causes of ESRD ◦ Diabetes ◦ Hypertension Polyuria Oliguria Anuria ◦ Results from inability of kidneys to concentrate urine ◦ Occurs most often at night ◦ Occurs as Chronic kidney disease worsens ◦ 300-500 ml/day ◦ Urine output <40 mL per 24 hours Waste product accumulation ◦ As GFR ↓, BUN ↑ and serum creatinine levels ↑ BUN ↑ Not only by kidney failure but by protein intake, fever, corticosteroids, and catabolism N/V, lethargy, fatigue, impaired thought processes, and headache may occur. Altered carbohydrate metabolism ◦ Caused by impaired glucose use From cellular insensitivity to the normal action of insulin Defective carbohydrate metabolism ◦ Patients with diabetes who become uremic may require less insulin than before onset of CKD. Insulin dependent on kidneys for excretion Elevated triglycerides ◦ Hyperinsulinemia stimulates hepatic production of triglycerides. ◦ Altered lipid metabolism ↓ levels of enzyme lipoprotein lipase Important in breakdown of lipoproteins Potassium ◦ Hyperkalemia Most serious electrolyte disorder in kidney disease Fatal dysrhythmias Sodium ◦ May be normal or low ◦ Because of impaired excretion, sodium is retained. Water is retained. Edema Hypertension CHF Calcium and phosphate alterations Magnesium alterations Metabolic acidosis ◦ Results from Inability of kidneys to excrete acid load (primary ammonia) •Defective reabsorption/regeneration of bicarbonate •The average adult produces 80 to 90 mEq of acid per day. This acid is normally buffered by bicarbonate. •In kidney failure, plasma bicarbonate, which is an indirect measure of acidosis, usually falls to a new steady state at around 16 to 20 mEq/L (16 to 20 mmol/L). Hematologic System Anemia ◦ Due to ↓ production of erythropoietin ◦ (glycoprotein hormone that controls erythropoiesis or red blood cell production) From ↓ in functioning renal tubular cells Bleeding tendencies Defect in platelet function Infection ◦ Changes in leukocyte function ◦ Altered immune response and function ◦ Diminished inflammatory response Cardiovascular System Hypertension Heart failure Left ventricular hypertrophy Peripheral edema Dysrhythmias Uremic pericarditis Respiratory System Kussmaul respiration Dyspnea Pulmonary edema Pleural effusion (excess fluid that accumulates in the pleura, the fluid-filled space that surrounds the lungs) Predisposition to respiratory infection Gastrointestinal System Every part of GI is affected. ◦ Due to excessive urea Mucosal ulcerations Stomatitis with exudates and ulcerations, a metallic taste in the mouth, and uremic fetor (a urinous odor of the breath) GI bleeding •Anorexia, nausea, vomiting •may develop if CKD progresses to ESRD and is not treated with dialysis. Neurologic System Expected as renal failure progresses ◦ Attributed to ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ↑ nitrogenous waste products Electrolyte imbalance Metabolic acidosis Axonal atrophy Demyelination of nerve fibers Restless leg syndrome Muscle twitching Irritability Decreased ability to concentrate Peripheral neuropathy Altered mental ability Seizures Coma Dialysis encephalopathy Musculoskeletal System CKD mineral and bone disorder ◦ Systemic disorder of mineral and bone metabolism ◦ Results in skeletal complications and extra-skeletal (vascular) calcifications • As kidney function deteriorates, less vitamin D is converted to its active form, resulting in decreased serum levels. • To absorb calcium from the GI tract, activated vitamin D is necessary. • Thus decreased active vitamin D levels result in less calcium absorption from the intestine, and therefore decreased serum calcium levels. Integumentary System Pruritus • includes dry skin, calcium-phosphate deposition in the skin, and sensory neuropathy. •The itching may be so intense that it can lead to bleeding or infection secondary to scratching. Reproductive System Infertility ◦ Experienced by both sexes Decreased libido Low sperm counts Sexual dysfunction Female-decreased levels of estrogen, progesterone, and luteinizing hormone, causing an ovulation and menstrual changes Men experience loss of testicular consistency, decreased testosterone levels, and low sperm counts Sexual function may improve with maintenance dialysis and may become normal with successful transplantation. Psychologic Changes Personality and behavioral changes Emotional ability Withdrawal Depression •Changes in body image caused by edema, integumentary disturbances, and access devices (e.g., fistulae, catheters) may contribute to the development of anxiety and depression. History and physical examination Dipstick evaluation(detects protein- albumin) Albumin-creatinine ratio (first morning void) GFR Renal ultrasound Renal scan CT scan Renal biopsy Nutritional Therapy Protein restriction ◦ Benefits are being studied. Water restriction Intake depends on daily urine output. Sodium restriction ◦ Diets vary from 2 to 4 g, depending on degree of edema and hypertension. ◦ Sodium and salt should not be equated. Salt substitutes should not be used because they contain potassium chloride. Potassium restriction ◦ 2 to 3 g ◦ High-potassium foods should be avoided. Acute kidney failure Onset- sudden Cause-tubultar necrosis Dx-acute reduction in UO and/or elevation of serum creatinin Mortality rate-high-60% Primary cause of death-infection TABLE-1,2 and3, ch 47, page 1165 Movement of fluid and molecules across a semi permeable membrane from one compartment to another. Two dialysis are available ◦ Peritoneal ◦ Hemodialysis ◦ Table 47-13, page 1182 UI is an uncontrolled leakage of urine ◦ Cause: infection, urinary retention, restricted mobility, fecal impaction, drugs, prostate inlargment UR is the inability to empty the bladder ◦ Cause: bladder outlet obstruction and /or decreased the contraction strength of bladder muscle Stress incontinence; coughing laughing, sneezing, lifting, exercising (Increase in intra abdominal pressure) Urge incontinence :involuntary urination, periodic leakage but also frequent and in large amount Overflow incontinence: distended bladder, small frequent urination Reflex incontinence :Fequent, moderate and equally during the day and night Incontinence after trauma or surgery: alteration in control of proximal and distal sphincter of urethra Functional incontinence: loss of urine resulting from cognitive, functional or environmental factors Lifestyle modifications: weight reduction, smoking cessation, decrease caffeine intake, fluid modification, etc Scheduling voiding regimens Pelvic floor muscle exercises or training: Kegels Anti- incontinence devices: surgical treatment Drugs Minimize the risk: ◦ avoid intake of large volumes of fluid over short period of time, ◦ avoid alcohol, coffee intake and hot tea(it increase the urgency of urination, distention of the bladder. ◦ Take warm shower or bath and attempt to urinate while in the bathtub or shower. ◦ Indwelling or intermittent catheterization- straight cath i/o.
