Ch 55 Management of Patients with Urinary Disorders PDF

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Management of Patients with Urinary Disorders. Lecture notes....

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Ch 55 Management of Patients with Urinary Disorders Infections of the Urinary Tract • •

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UTIs are caused by pathogenic microorganisms (the normal urinary tract is sterile above the urethra) Lower UTIs o Bacterial cystitis: inflammation of the urinary bladder o Bacterial prostatitis: inflammation of the prostate o Bacterial urethritis: inflammation of the urethra Upper UTIs o Most common o Includes acute and chronic pyelonephritis: inflammation of the renal pelvis. o Interstitial nephritis: inflammation of the kidney o Kidney abscesses The urinary tract is the most common site for nosocomial infection (hospital acquired) o The use of catheters is the leading cause

Lower Urinary Tract Infections • •

For infection to occur, bacteria must gain access, colonize, evade and initiate inflammation. Most UTIs result from fecal organisms. It is important to teach the patient to wipe from front to back; from clean to dirty.

Factors Contributing to UTI • •

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Bacterial invasion if the urinary tract Reflux o Urethrovesical reflux: obstruction to free-flowing urine; the reflux (backward flow) of the urine from the urethra into the bladder. Can be caused by coughing, sneezing, or straining. o Ureterovesical or vesicoureteral reflux: refers to the backwards flow of urine from the bladder into one or both of the ureters. o Uropathogenic Bacteria ▪ Bacteriuria: bacteria in the urine ▪ A clean-catch midstream urine specimen is used to check for bacteria. ▪ The organism most frequently responsible for UTIs are mostly found in the lower GI tract, Escherichia coli. Routes of Infection o Bacteria enter the urinary tract in three ways: ▪ Transurethral: most common route; often from fecal contamination; women have short urethras that offer little resistance to the movement of bacteria ▪ Bloodstream

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▪ By means of fistula from the intestine Risk Factors (chart 55-2 pg1616) o Diabetes o Pregnancy o Neurologic disorders o Gout o Inability or failure to empty the bladder.

Factors that contribute to UTIs in older adults • • • • • •

Cognitive impairment Frequent use of antimicrobial agents High incidence of multiple chronic medical conditions Immunocompromise Immobility and incomplete emptying of bladder Obstructed flow of urine

Assessment and Diagnostic Findings • • • • •

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Pain, burning upon urination, frequency, nocturia, incontinence, hematuria. About half are asymptomatic Association of symptoms with sexual intercourse, contraceptive practices, and personal hygiene Gerontologic considerations Assessment of urine, urinalysis, and urine cultures o Uti is diagnosed by the amt of bacteria in the urine culture. o Colony count greater than 100,000 CFU/mL o Pyuria (WBCs) occurs in all pts with UTI Other diagnostic tests o Test for STIs may be performed because acute urethritis caused by sexually transmitted organisms (Chlamydia, gonorrhea, herpes simplex) or acute vaginitis infections (caused by trichomonas or candida) may be responsible for symptoms similar to UTI.

Diagnoses • •

Acute pain related to infection Deficient Knowledge about: o Factors predisposing patient to infection and recurrence o Detection and prevention of recurrence o Pharmacological therapy ▪ Anti-effective: nitrofurantoin (Macrodantin, Furadantin); cephalexin (Keflex ▪ Cephalosporin: cefadroxil (Duricef, Ultracef) ▪ Fluroquinolone: Ciprofloxacin (Cipro), ofloxacin (Floxin)

▪ Urinary analgesic agent: Phenazopyridine (Pyridium) o Daily intake of cranberry juice can help prevent and control symptoms of UTI o Collaborative Problems/Potential complications ▪ Sepsis (Urosepsis) ▪ Acute Kidney injury ▪ Chronic kidney disease Planning •

Major goals may include: o Relief of pain and discomfort o Increased knowledge of preventive measures and treatment modalities o Absence of complications

Interventions • • • • • • •

Relieving pain Medications as prescribed: antibiotics, analgesics, and antispasmodics Application of heat to the perineum to relieve pain and spasm Increased fluid intake Avoidance of urinary tract irritants such as coffee, tea, citrus, spices, cola, and alcohol Frequent voiding Patient education

Adult Voiding Dysfunction •

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Urinary Incontinence: involuntary or uncontrolled loss of urine o Stress incontinence: involuntary loss of urine through an intact urethra as a result from sneezing, coughing or changing positions. o Urge incontinence: the involuntary loss of urine associated with a strong urge to void that can’t be suppressed. o Functional incontinence: the lower urinary tract function is intact, but other factors, such as cognitive impairment (Alzheimer dementia), pt is unable to identify the need to void. o Iatrogenic incontinence: the involuntary loss od urine due to extrinsic medical factors, medications (alpha adrenergic medications) o Mixed urinary incontinence: involuntary leakage associated with urgency and also the exertion, effort, sneezing, or coughing. Residual urine: urine remaining in the bladder after voiding

Behavioral Therapy • •

Pelvic floor muscle exercises (Kegel exercises) Voiding diary, biofeedback, verbal instruction, and physical therapy

Pharmacological Therapy • • •

Anticholinergic agents inhibit bladder contraction and are considered first-line medications for urge incontinence. Tricyclic antidepressants (amitriptyline {Elavil}) can also decrease cladder contractions Sudafed can be used to treat stress incontinence.

Patient Education • • • • • • •

Urinary incontinence is not inevitable and is treatable Management takes time (provide encouragement and support) Education verbally and in writing (Chart 55-9) Develop and use a voiding log or diary Behavioral interventions Medication education related to pharmacologic therapy Strategies for promoting continence

Urinary Retention • • • • •

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The inability to empty bladder completely Overflow incontinence: involuntary urine loss associated with over distention of the bladder. In an older adult, 50 to 100 mL of urine may remain after voiding because of the decreased contractility of the detrusor muscle. Can occur postoperatively; general anesthesia reduces bladder muscle and suppresses the urge to void, impeding bladder emptying. May result from diabetes, prostatic enlargement, urethral pathology, trauma (pelvic injuries), pregnancy, neurologic disorders (stroke, spinal cord injury, MS, or Parkinson’s), and medications. Assessment o Last void and how much? o Small amounts of urine frequently? o Dribbling? o Pain of discomfort in the lower abdomen? o Is the pelvic area swollen? Indicative of urine retention and a distended bladder. o Does postvoid bladder ultrasound test reveal residual urine?

Urolithiasis and Nephrolithiasis • •

Calculi (stones) in the urinary tract or kidney Pathophysiology o Stones are formed in the urinary tract when urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increase. o Stones may be found anywhere from the kidney to the bladder and may be the size of and orange (large) or the size of sand or gravel (smaller)

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o Contributing factors: infection, urinary stasis, and periods of immobility. Causes: may be unknown o Causes of hypercalcemia. ▪ Hyperparathyroidism ▪ Renal tubular acidosis ▪ Cancers ▪ Dehydration ▪ Excessive intake of vitamin D Depends on location and presence of obstruction or infection Pain and hematuria Diagnosis: radiography, blood chemistries, and stone analysis; strain all urine and save stones Clinical manifestations o If the pain suddenly becomes acute, with tenderness over the costovertebral area, and nausea and vomiting occur, the patient is having an episode of renal colic o Stones lodged in the ureter cause acute excruciating, colicky, wavelike pain that radiates down the thigh and to the genitalia. Pt has desire to void, but little urine is passed; it usually contains blood. This is called ureteral colic. o Pt is able to pass stones 0.5 to 1 cm in diameter. o Stones larger than 1 cm in diameter must be removed and fragmented (broken by lithotripsy) Nutritional Therapy o Unless contraindicated, pt with kidney stones should consume eight to ten 8-oz glasses of water daily o A urine output exceeding 2L/day is advisable. Interventional Procedures o If the stone does not pass spontaneously ▪ Ureteroscopy: involves first visualizing the stone, and then destroying it. an ureteroscope is inserted into the ureter and then a laser is inserted, electrohydraulic lithotripter, through the ureteroscope to fragment and remove the stone. ▪ extracorporeal shock wave lithotripsy (ESWL): noninvasive procedure used to break up stones in the calyx of the kidney. In ESWL, a highenergy amplitude pressure, or shock wave, is generated by the abrupt release of energy and transmitted through water and soft tissue. ▪ endourologic (percutaneous): used to extract kidney calculi that cannot be removed by other procedures. o Nephrolithotomy: incision into the kidney with removal of the stone

Genitourinary Trauma •

Ureteral Trauma: caused by motor vehicle crashes, sports injuries, falls and assaults

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Bladder trauma: pelvic fractures from a blow to the lower abdomen when the bladder is full Urethral trauma: occur with blunt trauma to the lower abdomen of pelvic region Medical management: control hemorrhage, pain and infection; monitor for oliguria, shock, s/s acute peritonitis Surgical management: suprapubic catheter, surgical repair Nursing management: o Assess frequently o Instruction about incision care and adequate fluid intake o Changes to report: fever, hematuria, flank pain

Urinary tract Cancers • •

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Bladder, kidney and renal pelvis, ureters, other structures such as prostrate Cancer of bladder: o More common after age 55 years o Leading cause of death o Smoking increases risk 50%; refer to Chart 55-13 S/S: visible painless hematuria; pelvic or back pain may indicate metastasis Diagnosis: ureteroscopy, excretory urography, CT, MRI, ultrasonography Management o Medical management: depends on the grade and stage of the tumor ▪ Chemotherapy ▪ Radiation o Surgical management: ▪ Transurethral resection or fulguration ▪ Followed by bacille Calmette–Guérin (BCG) treatment ▪ Cystectomy ▪ Urinary diversion

Urinary Diversion •

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Reasons: bladder cancer or other pelvic malignancies, birth defects, trauma, strictures, neurogenic bladder, chronic infection or intractable cystitis; used as a last resort for incontinence Cutaneous urinary diversion: ileal conduit, cutaneous ureterostomy, vesicostomy, nephrostomy o Ileal conduit: the oldest and most common of the urinary diversion ▪ The urine is diverted by implanting the ureter into a 12cm loop of ileum that is led out through the abdominal wall Continent urinary diversion: Indiana pouch, Kock pouch, uretherosigmoidostomy...