Transcript Urinary System Ch 45-47

Zoya Minasyan RN MSN-Edu
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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
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Are immunosuppressed
Have diabetes
Have undergone multiple antibiotic courses
Have traveled to certain Third World countries
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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
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Complicated versus uncomplicated
◦ Uncomplicated
 Occurs in otherwise normal urinary tract
 Usually involves only the bladder
◦ Complicated
 Those with coexisting presence of
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Obstruction
Stones
Catheters
Existing diabetes/neurologic disease
Pregnancy-induced changes
Recurrent infection
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Bacterial persistence
◦ Occurs when
 Bacteria develop resistance to antibiotic agent. Foreign
body in urinary system allows bacteria to survive
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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
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Urinary tract above urethra normally sterile
Defense mechanisms exist to maintain
sterility/prevent UTIs.
◦ Complete emptying of bladder
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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)
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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.
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Symptoms related to bladder storage or bladder emptying
◦ Bladder storage
 Urinary frequency
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Abnormally frequent (> every 2 hours)
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Sudden strong desire to void immediately
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Waking up ≥2 times at night to void
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Complaint of loss of urine during sleep
 Urgency
 Incontinence
 Loss or leakage of urine
 Nocturia
 Nocturnal enuresis
◦ Bladder emptying
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Weak stream
Hesitancy
Difficulty starting the urine stream
Intermittency
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Interruption of urinary stream while voiding
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Urine loss after completion of voiding
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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
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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.
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History and physical examination
Dipstick urinalysis
◦ Identify presence of nitrates, WBCs,
and leukocyte esterase.
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Urine for culture and sensitivity
(if indicated)
◦ Clean-catch sample preferred
◦ Specimen by catheterization or suprapubic needle
aspiration more accurate
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Determine susceptibility of bacteria to antibiotics
Imaging studies
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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
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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
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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
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Objective data
◦ Fever
◦ Hematuria, foul-smelling urine, tender, enlarged
kidney
◦ Leukocytosis, positive findings for bacteria, WBCs,
RBCs, pyuria, ultrasound, CT scan, IVP
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Impaired urinary elimination
Ineffective self-health management
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Patient will have
◦ Relief from lower urinary tract symptoms
◦ Prevention of upper urinary tract involvement
◦ Prevention of recurrence
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Health promotion
◦ Recognize individuals at risk.
 Debilitated persons
 Older adults
 Underlying diseases (HIV, diabetes)
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Taking immunosuppressive drug or corticosteroids
Emptying bladder regularly and completely
Evacuating bowel regularly
Wiping perineal area front to back
Drinking adequate fluids
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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
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Ambulatory and home care
◦ Emphasize compliance with drug regimen.
 Take as ordered.
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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.
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Use of nonanalgesic relief measures
Appropriate use of analgesics
Passage of urine without urgency
Urine free of blood
Adequate intake of fluids
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Inflammation of renal parenchyma(consisting
of the nephrones) and collecting system
Caused most commonly by
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bacteria
Fungi
protozoa
viruses
Cortical surface shows grayish white areas of inflammation and abscess
formation (arrow).
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Urosepsis
◦ Systemic infection from urologic source
 Can lead to septic shock and death.
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Septic shock: Outcome of unresolved
bacteremia involving gram-negative organism.
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Usually begins with colonization and infection of
lower tract via ascending urethral route.
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Frequent causes
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Escherichia coli
Proteus
Klebsiella
Enterobacter
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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.
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Health history
◦ Nausea, vomiting, anorexia, chills, nocturia,
frequency, urgency
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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
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Nursing Diagnoses
Acute pain
Impaired urinary elimination
Planning
◦ Patient will have
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Relief of pain
Normal body temperature
No complications
Normal renal function
No recurrence of symptoms
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Health promotion
◦ Early treatment for cystitis to prevent ascending
infection
 Patient with structural abnormalities is at high risk
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Stress the need for regular medical care.
Ambulatory and home care
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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
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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.
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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
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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
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Leading causes of ESRD
◦ Diabetes
◦ Hypertension
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Polyuria
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Oliguria
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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
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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.
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Altered carbohydrate metabolism
◦ Caused by impaired glucose use
 From cellular insensitivity to the normal action of insulin
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Defective carbohydrate metabolism
◦ Patients with diabetes who become uremic may require
less insulin than before onset of CKD.
 Insulin dependent on kidneys for excretion
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Elevated triglycerides
◦ Hyperinsulinemia stimulates hepatic production of
triglycerides.
◦ Altered lipid metabolism
 ↓ levels of enzyme lipoprotein lipase
 Important in breakdown of lipoproteins
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Potassium
◦ Hyperkalemia
 Most serious electrolyte disorder in kidney disease
 Fatal dysrhythmias
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Sodium
◦ May be normal or low
◦ Because of impaired excretion, sodium is retained.
 Water is retained.
 Edema
 Hypertension
 CHF
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Calcium and phosphate alterations
Magnesium alterations
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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
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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
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↑ 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
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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.
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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.
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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.
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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
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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
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UI is an uncontrolled leakage of urine
◦ Cause: infection, urinary retention, restricted
mobility, fecal impaction, drugs, prostate
inlargment
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UR is the inability to empty the bladder
◦ Cause: bladder outlet obstruction and /or
decreased the contraction strength of bladder
muscle
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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
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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
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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.