Focus on Urinary Tract Infection S. Buckley, N246, Fall, 2010, based on Mosby pp. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an.
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Focus on Urinary Tract Infection S. Buckley, N246, Fall, 2010, based on Mosby pp. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (UTI) • Second most common bacterial disease • Most common bacterial infection in women Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (UTI) (Cont’d) • Accounts for more than 8 million office visits per year • >100,000 people hospitalized annually due to UTI Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (Cont’d) • >15% patients who develop gram-negative bacteria infection die 33% of these caused by infections originating in urinary tract Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (Cont’d) • Bladder and its contents are free of bacteria in majority of healthy patients • Minority of healthy individuals have colonizing bacteria in bladder Called asymptomatic bacteriuria, and does not justify treatment Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (Cont’d) • Escherichia coli most common pathogen • Counts of 105 CFU/ml or more indicate significant UTI • (p. 1152, normal count: <104) • Counts as low as 102 CFU/ml in a person with signs/symptoms are indicative of UTI Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urinary Tract Infection (Cont’d) • Fungal and parasitic infections can cause UTIs • Patients at risk Immunosuppressed Have diabetes Undergone multiple antibiotic courses Traveled to certain underdeveloped countries Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Web resources; UTI • http://video.about.com/womenshea lth/Urinary-Tract-Infection.htm • basic images • http://www.youtube.com/watch?v= u11DfF6fuCM Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification • 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 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification • Upper versus lower (cont’d) Lower tract (LUTS) • • • Lower urinary tract Usually no systemic manifestations Example • Cystitis (inflammation of bladder wall) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Specific terms (to delineate the location of a UTI) • Urethritis=inflammation of urethra • Cystitis=inflammation of bladder wall • Pyelonephritis=inflammation of renal parenchyma and collecting system • Urosepsis=uti that has spread into the systemic circulation and is life-threatening Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Sites of Infectious Processes Fig. 46-1 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification (Cont’d) • Complicated versus uncomplicated Uncomplicated • • Occurs in otherwise normal urinary tract Usually only involves the bladder Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification • Complicated versus uncomplicated (cont’d) Complicated • Those with coexisting presence of • • • • • • Obstruction Stones Catheters Existing diabetes/neurologic disease Pregnancy-induced changes Recurrent infection Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification (Cont’d) • According to natural history Initial infection • • First or isolated Uncomplicated UTI in person who never had one or experiences one remote from a previous UTI (separated by period of years) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification • Natural history (cont’d) Recurrent Caused by second pathogen in a person who experienced a previous infection that was eradicated • If it occurs because original infection was not eradicated, it is classified as unresolved bacteriuria or bacterial persistence • Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification (Cont’d) • Unresolved bacteriuria Occurs when Bacteria resistant to antibiotic Drug discontinued before bacteriuria is completely eradicated • Antibiotic agent fails to achieve adequate concentrations in bloodstream or urine to kill bacteria • • Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Classification (Cont’d) • Bacterial persistence Occurs when Bacteria develop resistance to antibiotic agent • Foreign body in urinary system allows bacteria to survive • Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Urinary tract above urethra normally sterile • Defense mechanisms exist to maintain sterility/prevent UTIs Complete emptying of bladder Ureterovesical junction competence Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. UTI in children • Occurs in 3-5% of children, more often in girls, frequently develops into pyelonephritis (75% under age of 5), do not present with symptoms. • Controversy: more common in uncircumcized males. • At risk: premature babies, immunologic disease, family hx of reflux • Urinary tract abnormalities; neurogenic bladder, vesicoureteral reflux • Classic symptoms: enuresis, frequency, dysuria, fever, abdominal pain, abnormal voiding patterns, foul-smelling urine • Urinary symptoms in absence of bacteriuria suggests: vaginitis, urethritis, sexual molestation, the use of irritating bubble baths, pinworms, viral cystitis. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Sexual molestation • 1 in 4 girls is sexually abused before the age of 18 (US) • Worldwide, approximately 40 million children are subjected to child abuse each year (WHO, 20014). • Almost 80% initially deny abuse or are tentative in disclosing. • Children who have been victims of sexual abuse are more likely to experience physical health problems (e.g., headaches). • Victims of child sexual abuse report more symptoms of PTSD, more sadness, and more school problems than non-victims. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Defense mechanisms (cont’d) Peristaltic activity Acidic pH High urea concentration Abundant glycoproteins Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • Alteration of defense mechanisms increases risk of contracting UTI • Predisposing factors Factors increasing urinary stasis • Examples: BPH, tumor, neurogenic bladder Foreign bodies • Examples: Catheters, calculi, instrumentation Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Predisposing factors (cont’d) Anatomic factors • Examples: Obesity, congenital defects, fistula Compromising immune response factors • Examples: Age, HIV, diabetes Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Predisposing factors (cont’d) Functional disorders • Example: Constipation Other factors • Examples: Pregnancy, multiple sex partners (women) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. UTI’s in women • Urethra is short and close to vagina and rectum, • Peak incident in 15-24 yr. olds; correlates to hormonal and anatomic changes or puberty and sexual activity. • Pregnant women at increased risk • Intercourse, use of diaphragm, spermicide increase incidence of uti’s • Tx: increase fluids, urinate before and after sex, Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • Menopause factor in incidence of UTI Postmenopausal women have lower estrogen levels, ↓ in vaginal lactobacilli, ↑ in vaginal pH • Overgrowth of other organisms results Low-dose intravaginal estrogen replacement may be effective in treating recurrent UTIs Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • Organisms introduced via the ascending route from the urethra and originate in the perineum • Less common routes Bloodstream Lymphatic system Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • Gram-negative bacilli normally found in GI tract common cause • Urologic instrumentation allows bacteria to enter urethra and bladder Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • Contributing factor: Urologic instrumentation Allows bacteria present in opening of urethra to enter urethra or bladder • Sexual intercourse promotes “milking” of bacteria from perineum and vagina May cause minor urethral trauma Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • Rarely result from hematogenous route • For kidney infection to occur from hematogenous transmission, must have prior injury to urinary tract Obstruction of ureter Damage from stones Renal scars Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • Hospital-acquired UTI accounts for 31% of all nosocomial infections Causes • • Often: E. coli Seldom: Pseudomonas Catheter-acquired UTIs • Bacteria biofilms develop on inner surface of catheter Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (lower urinary tract) • Symptoms related to either bladder storage or bladder emptying Bladder storage • Urinary frequency • Abnormally frequent (> every 2 hours) • Urgency • Sudden strong desire to void immediately • Incontinence • Loss or leakage or urine Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Bladder storage (cont’d) • Nocturia • Waking up ≥2 times at night to void • Nocturnal enuresis • Complaint of loss of urine during sleep Bladder emptying • • Weak stream Hesitancy • Difficulty starting the urine stream Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Bladder emptying (cont’d) • Intermittency • Interruption of urinary stream while voiding • Postvoid dribbling • Urine loss after completion of voiding • Urinary retention • Inability to empty urine from bladder Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Bladder emptying (cont’d) • Dysuria • Difficulty voiding • Pain on urination Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) • Urine may contain visible blood or sediment (hematuria), giving cloudy appearance • (Flank pain, chills, and fever indicate infection of upper tract Pyelonephritis) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) • In older adults Symptoms often absent Experience nonlocalized abdominal discomfort rather than dysuria May have cognitive impairment Less likely to have a fever Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) • Patients with significant bacteriuria May have no symptoms Nonspecific symptoms such as fatigue or anorexia Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies • History and physical examination • Dipstick urinalysis Identify presence of nitrates, WBCs, and leukocyte esterase Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) • Urine for culture and sensitivity (if indicated) Clean-catch sample preferred Specimen by catheterization or suprapubic needle aspiration more accurate Determine bacteria susceptibility to antibiotics Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) • Imaging studies IVP or abdominal CT when obstruction suspected Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy • Antibiotics Selected on empiric therapy or results of sensitivity testing Uncomplicated cystitis • Short-term course (1 to 3 days) Complicated UTIs • Requires long-term treatment (7 to 14 days) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy • Antibiotics (cont’d) Trimethoprim/sulfamethoxazole (TMP/SMX) Used to treat uncomplicated or initial Inexpensive Taken BID • E. coli resistance to TMP-SMX ↑ • • • Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy • Antibiotics (cont’d) Nitrofurantoin (Macrodantin) • • Given three or four times a day Long-term use • Pulmonary fibrosis • Neuropathies Fluoroquinolones • • Treat complicated UTIs Example: Ciprofloxacin (Cipro) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (Cont’d) • Urinary analgesic 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 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy • Urinary analgesic (cont’d) Urised • • • Used in combination with antibiotics Used to relieve UTI symptoms Preparations with methylene blue tint urine blue or green Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (Cont’d) • Prophylactic or suppressive antibiotics sometimes administered to patients with repeated UTIs Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (Cont’d) • Suppressive therapy often effective on short-term basis Limited because of antibiotic resistance ultimately leading to breakthrough infections Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment • Health history Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer Antibiotics, anticholinergics, antispasmodics Urologic instrumentation Urinary hygiene Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment • Health history (cont’d) N/V, anorexia, chills, nocturia, frequency, urgency Suprapubic/lower back pain, bladder spasms, dysuria, burning on urination Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment (Cont’d) • Objective Data Fever Hematuria, foul-smelling urine, tender, enlarged kidney Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses • Impaired urinary elimination • Ineffective therapeutic regimen management Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Planning • Patient will have Relief from lower urinary tract symptoms Prevention of upper urinary tract involvement Prevention of recurrence Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Health Promotion Recognize individuals at risk • • • • Debilitated persons Older adults Underlying diseases (HIV, diabetes) Taking immunosuppressive drug or corticosteroids Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Health Promotion (cont’d) Emptying bladder regularly and completely Evacuating bowel regularly Wiping perineal area front to back Drinking adequate fluids (15 ml/lb) • 20% fluid comes from food Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. cystitis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Health Promotion (cont’d) Cranberry juice or cranberry essence may help decrease risk Avoid unnecessary catheterization and early removal of indwelling catheters Aseptic technique must be followed during instrumentation procedures Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Web resources • http://www.livestrong.com/video/17 94-urinary-tract-infection-healthbyte/ Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Health Promotion (cont’d) 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 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation (Cont’d) • Acute Intervention Adequate fluid intake Patient may think will worsen condition due to discomfort • Dilutes urine, making bladder less irritable • Flushes out bacteria before they can colonize • Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Acute Intervention (cont’d) Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods • Potential bladder irritants Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Acute Intervention (cont’d) Application of local heat to suprapubic or lower back may relieve discomfort Instruct patient about drug therapy and side effects Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Acute Intervention (cont’d) Emphasize taking full course despite disappearance of symptoms Second or reduced drug may be ordered after initial course in susceptible patients Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Acute Intervention (cont’d) Instruct patient to watch urine for changes in color and consistency and decrease in cessation of symptoms Counsel that persistence of lower tract symptoms beyond treatment, onset of flank pain, or fever should be reported immediately Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation (Cont’d) • 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 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Ambulatory and Home Care (cont’d) Temporarily discontinue use of diaphragm Instruct on follow-up care Recurrent symptoms typically occur 1 to 2 weeks after therapy Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Evaluation • • • • • Use of nonanalgesic relief measures Appropriate use of analgesics Pass urine without urgency Urine free of blood Adequate intake of fluids Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Pyelonephritis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. pyelonephritis • http://ehealthforum.com/videos/2211/kidney-infectionpyelonephritis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology • Inflammation of renal parenchyma and collecting system • (infection of kidneys and ureters) • Caused most commonly by bacteria • Fungi, protozoa, or viruses infecting kidneys can also cause Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • Urosepsis Systemic infection from urologic source Prompt diagnosis/treatment critical • Can lead to septic shock and death • Septic shock: Outcome of unresolved bacteremia involving gram-negative organism Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • Usually begins with colonization and infection of lower tract via ascending urethral route • Frequent causes Escherichia coli Proteus Klebsiella Enterobacter Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • Preexisting factor usually present Vesicoureteral reflux • Backward movement of urine from lower to upper urinary tract Dysfunction of lower urinary tract • • • Obstruction from BPH Stricture Urinary stone Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • Commonly starts in renal medulla and spreads to adjacent cortex • Recurring episodes lead to scarred, poorly functioning kidney and chronic pyelonephritis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology (Cont’d) • One of most important risk factors Pregnancy-induced physiologic changes in urinary system Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations • • • • • Mild fatigue Chills Fever Vomiting Malaise Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) • Flank pain • Lower urinary tract symptoms characteristic of cystitis • Costovertebral tenderness usually present on affected side • Manifestations usually subside in a few days, even without therapy Bacteriuria and pyuria still persist Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies • History • Physical examination Palpation for CVA pain • Laboratory tests Urinalysis Urine for culture and sensitivity CBC with differential Blood culture (if bacteremia is suspected) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) • Ultrasound • CT scan Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) • Urinalysis shows pyuria, bacteriuria, and varying degrees of hematuria • WBC casts indicate involvement of renal parenchyma • CBC will show leukocytosis with increase in immature bands Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) • Imaging studies (IVP or CT) requiring intravenous injection of contrast metals Usually not obtained in early stages to prevent possible spread of infection • Ultrasonography of urinary system to identify anatomic abnormalities or presence of obstructing stone Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) • Imaging studies also used to assess complications of pyelonephritis Impaired renal function Scarring Chronic pyelonephritis Abscesses Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) • If bacteremia is a possibility, close observation and vitals monitoring are essential • Prompt recognition and treatment of septic shock may prevent irreversible damage or death Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care • 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 starting therapy Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) • Drug therapy Antibiotics • Parenteral in hospital to rapidly establish high drug levels NSAIDs or antipyretic drugs • • Fever Discomfort Urinary analgesics Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) • Relapses may be treated with 6week course of antibiotics • Follow-up urine culture and imaging studies Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) • Reinfections treated as individual episodes or managed with long-term therapy Prophylaxis may be used for recurrent infection Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment • Health history Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer Antibiotics, anticholinergics, antispasmodics Urologic instrumentation Urinary hygiene Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment • Health history (cont’d) Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment (Cont’d) • Objective Data Fever Hematuria, foul-smelling urine, tender, enlarged kidney Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses • Acute pain • Impaired urinary elimination Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Planning • Patient will have Relief of pain Normal body temperature No complications Normal renal function No recurrence of symptoms Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Health Promotion Early treatment for cystitis to prevent ascending infections Patient with structural abnormalities is at high risk • Stress for regular medical care • Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation (Cont’d) • Ambulatory and Home Care Need to continue drugs as prescribed Need for follow-up urine culture Identification of risk for recurrence or relapse Encourage adequate fluids Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Ambulatory and Home Care (cont’d) Rest to increase comfort Low-dose, long-term antibiotics to prevent relapses or reinfections Explain rationale to enhance compliance Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Evaluation • • • • • Use of nonanalgesic relief measures Appropriate use of analgesics Pass urine without urgency Urine free of blood Adequate intake of fluids Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study • 27-year-old female with urgency to urinate, frequent urination, and urethral burning during urination • Symptoms began 48 hours ago Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) • Urine has strong odor and cloudy appearance • History of recurring urinary tract infections since 22 years of age when she got married Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) • Allergic to penicillin • Temperature 98.6° F orally • Blood pressure 114/64 mm Hg Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) • Urinalysis results Color: dark yellow pH: 6.5 Nitrates: positive Leukocytes: large amount Trace occult blood Urine culture: E. coli >106 CFU/ml • Sensitivity to ampicillin, nitrofurantoin, ciprofloxacin, cephalexin, TMP-SMX Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Discussion Questions 1. What type of urinary tract infection does she probably have? 2. Why might she be having recurring infections? Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Discussion Questions (Cont’d) 3. What is the priority of care for her? 4. What teaching should be done with her? Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.