Chapter 69: Care Of Pts With Urinary Problems

Question 0

Risk factors for infection

Answer 0

Several risk factors are associated with the occurrence of UTIs
ØObstruction (incomplete bladder emptying continuous pool of urine for bacteria to grow)
ØStones (calculi large can obstruct, rough surface irritates mucosa and bacteria can grow)
ØVesicouretheral reflux (bacteria laden urine backs up into ureters and kidneys risk of pyelonephritis)
ØDiabetes mellitus (excess glucose in urine medium for bacteria)
ØAlkaline or concentrated urine (promotes bacterial growth)
ØGender (women periuretheral, diaphragms, frequency of intercourse, new partner past year, bladder displacement after pregnancy
ØAge (urinary stasis incomplete bladder emptying large prostate, cystocele or prolapsed uterus in women, the use of anticholinergic drugs in older adults delays bladder emptying, fecal incontinence poor perineal hygiene, hypoestrogenism in older women affects cells of vagina and urethra making more susceptible to infection
ØSexual activity (Irritation of the perineum and urethra, spermicides alter vaginal pH, inadequate vaginal lubrication irritate urethra, women with bacterial vaginitis can introduce bacteria into man’s urethera
ØRecent use of antibiotics (antibiotics change the normal flora providing overgrowth)

Question 1

Different locations of UTIs

Answer 1

Urethritis: urethra
Cystitis: bladder
Prostatitis
Pyelonephritis: kidneys

Question 2

Cystitis

Answer 2

Cystitis is an inflammation of the bladder caused by irritation or, more commonly caused by infection from bacteria, viruses, fungi, or parasites moving up urinary tract from external urethra to bladder. Infectious cystitis is the most common of the UTIs.
ØCatheters: high risk factor in developing nosocomial cystitis. Within 48 hours of catheter insertion, bacterial colonization begins. About 50% of patients with indwelling catheters become infected within 1 week of catheter insertion.
˜Noninfectious cystitis is caused by irritation from chemicals or radiation. (Cytoxan, radiation, immunologic response as with SLE)
˜Interstitial cystitis is an inflammatory disease that has no known cause. Affects women more than men. UA negative. Pain & urgency
˜Infectious cystitis can lead to complications, including pyelonephritis and sepsis.
˜Urosepsis is the spread of the infection from the urinary tract to the blood stream and more common in older adults.
˜The most common cause of sepsis in hospitalized clients is a urinary tract infection. Ascending infections from cystitis with an indwelling catheter is a major source of such infections.

Question 3

Health promotion

Answer 3

˜Health Promotion and Maintenance con’t.
˜Changes in fluid intake patterns, urinary elimination patterns, and hygiene patterns can help prevent or reduce cystitis in the general population.
˜Teach a minimum of fluid intake of 1.5 to 2.5 L daily unless fluid restriction for health issues, drink water and not sweet drinks
˜Avoid urinary stasis urinate every 3-4 hours, void after intercourse
˜Shower daily and clean perineal area with mild soap and water, before intercourse, avoid scented toilet tissue, lubricants, avoid vaginal washes

Question 4

Manifestations UTI

Answer 4

˜The diagnosis of cystitis is based on history, physical exam, and laboratory data.
ØFrequency, urgency, and dysuria are the common signs and symptoms. Urine may be cloudy, foul smelling, or blood tinged.
ØClinical manifestations that may occur in the older adult may be something as vague as increasing mental confusion or frequent, unexplained falls, a sudden onset of incontinence or a worsening of incontinence , fever, tachycardia, tachypnea, and hypotension, even without any urinary symptoms, may be early sign of urosepsis, loss of appetite, nocturia, and dysuria are common symptoms.
˜Use standard precautions in the physical assessment and have patient empty bladder for urine specimen and palpation of bladder.

Question 5

Cystitis Labs

Answer 5

˜Laboratory assessment for a UTI is a urinalysis performed on a clean-catch midstream specimen with testing for leukocyte esterase and nitrate. Routine UA needs 10ml
˜The combination of a positive leukocyte esterase and nitrate is 68% to 88% sensitive in the diagnosis of UTI.
˜A urine culture confirms the type of organism and the number of colonies and is indicated when the UTI is complicated or does not respond to usual therapy.
˜Occasionally the serum WBC count may be elevated, with the differential WBC count showing a “left shift.” This left shift indicates that the number of immature WBCs is increasing in response to the infection. The number of bands, or immature WBCs, is elevated. Left shift most often occurs with urosepsis and rarely occurs with uncomplicated cystitis, which is a local rather than a systemic infection.

Question 6

Drugs for cystitis

Answer 6

˜Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when the client takes the prescribed medication for the entire course and not just when symptoms are present.
˜Drugs used to treat bacteriuria and promote patient comfort include urinary antiseptics or antibiotics, analgesics, and antispasmodics decrease bladder spasm and promote bladder emptying)
˜Phenazopyridine discolors urine most commonly to a deep reddish orange. Many clients think they have blood in their urine when they see this. In addition, the urine can permanently stain clothing.
˜ The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives.

Question 7

Other therapy for cystitis

Answer 7

˜All four groups and more calories for the increased metabolism caused by infection.
˜Encourage to drink enough fluid to keep urine dilute if no fluid restrictions
˜Drink 50 mL of concentrated cranberry juice daily for a minimum of 3 to 4 weeks to be effective
ØCranberry juice is an irritant to the bladder with interstitial cystitis and is to be avoided as well as caffeine, carbonated beverages, and tomato products increase bladder irritation
˜Comfort measures
˜Sitz bath two to three times a day for 20 minutes

Question 8

Urethritis

Answer 8

˜Is an inflammation of urethra causing symptoms similar to UTI
˜In men, manifestations of urethritis are burning or difficulty with urination and a discharge from the urethral meatus, usually caused by sexually transmitted diseases.
˜In women, urethritis causes manifestations similar to those of bacterial cystitis.
˜Urethritis is most common in postmenopausal women and appears to be caused by tissue changes related to low estrogen levels.
˜Low estrogen levels decrease moisture and the type of secretions in the perineal area, predisposing it to the development of infection. Treated with estrogen creams. The client’s immune system, personal hygiene, and sexual practices do not place her at risk for developing urethritis.

Question 9

Urethral strictures.

Answer 9

˜Urethral strictures are narrowed areas that are idiopathic or caused by an STD or from trauma during catheterization, urologic procedures, or childbirth.
˜The most common symptom of urethral stricture is obstruction of urine flow. Rarely cause pain. May have overflow incontinence from a distended bladder.
˜Surgical treatment by urethroplasty—best chance of long-term cure (surgical removal of affected area with or without grafting to create a larger opening). Recurrence is high.
˜Dilation of urethra under local anesthesia is a temporary measure

Question 10

Incontinence

Answer 10

˜Continence is a learned behavior to control the time and place of urination and is unique to humans and some domestic animals.
˜Efficient bladder emptying from coordination between bladder contraction and urethral relaxation is needed for continence.
˜Incontinence is involuntary loss of urine causing social or hygienic problems.
˜Incontinence is not a normal consequence of aging or childbirth and often is a stigmatizing and an underreported health problem
˜The most common forms of adult urinary incontinence are stress incontinence, urge incontinence, overflow incontinence, functional incontinence, and a mixed form.

Question 11

Stress incontinence

Answer 11

˜Stress incontinence is the most common type. Its manifestations are loss of small amounts of urine during coughing, sneezing, jogging, or lifting.
˜Stress incontinence the patient cannot tighten the urethra enough to overcome the increased bladder pressure caused by contraction of the detrusor muscle. Common after childbirth and low estrogen levels after menopause (vaginal, uretheral, and pelvic floor muscles become thin and weak without estrogen)
˜Initial interventions for stress incontinence include keeping a diary, behavioral interventions, such as diet and exercise, and drugs or surgery as a last resort.
˜Maintaining a diary detailing times of urine leakage, activities, and foods eaten will aid in the diagnostic process by showing if there is a connection between specific factors that seem to trigger the incontinent episodes.
˜Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

Question 12

Incontinence hx

Answer 12

˜Assessment History
˜Efffective screening includes asking patients to respond “always,” “sometimes,” or “never” to these questions
˜Do you ever leak urine or water when you don’t want to?
˜Do you ever leak urine or water on the way to the bathroom?
˜Do you ever use pads, tissue, or cloth in your underwear to catch urine?

If the answer is always or sometimes, proceed with a focused assessment

Question 13

Assessment of incontinence

Answer 13

˜Assess the abdomen to estimate bladder fullness, to rule out palpable hard stool, and to evaluate bowel sounds.
˜With a physician’s order, determine the amount of residual urine by portable ultrasound or catheterizing the patient immediately after voiding.
˜In women, inspect external genitalia to determine whether there is apparent urethral or uterine prolapse, cystocele, or rectocele with pelvic floor muscle weakness.
˜Imaging is rarely needed unless surgery is being considered.

Question 14

How to reduce stress incontinence

Answer 14

With appropriate therapy, the patient with urinary incontinence is expected to develop urinary continence by no urinary leakage between voiding and no urine leakage with increased abdominal pressure (e.g., sneezing, laughing, lifting).
˜Interventions include keeping a diary, behavioral therapy, and drugs.
˜Drugs such as estrogen increased blood flow and tone of muscles around the vagina and urethra, improving ability to contract those muscles. Anticholinerics/Antispasmodics cause bladder muscle relaxation and suppressing the urge to void. Tricyclic antidepressants have anticholinergic actions and block acetylcholine receptors to relieve urinary incontinence.
˜Pelvic floor (Kegel) exercise therapy strengthens the muscles of the pelvic floor for both men and women. Improvement takes several months but notice a positive change in 6 weeks.
˜Biofeedback devices and electrical stimulation devices to strengthen urethral contractions.
˜Stress incontinence may be corrected by vaginal, abdominal, or retropubic surgeries with varying success rates.
˜Postoperative care assess for and intervene to prevent or detect complications.
˜For prevention of movement or traction on the bladder neck. Secure the urethral catheter with tape or a tube holder.
˜If a suprapubic catheter is used, monitor the dressing for urine leakage and other drainage.
˜Catheters are usually left in place until the patient can void easily and less than 50 mL residual urine.

Question 15

Urge incontinence

Answer 15

˜Urge incontinence is the perception of an urgent need to urinate as a result of bladder contractions regardless of the volume of urine in the bladder, also known as overactive bladder (OAB).
˜Overacticity may have no known cause or may be the result of abnormal detrusor contractions due to a stroke or other neurological problems, urinary tract problems, irritation from concentrated urine or artificial sweeteners, caffeine, alcohol, and citric intake. Drugs such as diuretics and nicotine also irritate the bladder.
˜Interventions for patients with urge incontinence or overactive bladder include behavioral interventions and drugs; surgery is not recommended.
ØDrugs—anticholinergics and tricyclic antidepressants antihistamines not know how they work.
ØDiet therapy—avoid caffeine, alcohol, artificial sweeteners, and citric intake.
ØBehavioral interventions—exercises, bladder training, habit training, electrical stimulation

Question 16

Overflow incontinence

Answer 16

˜ The bladder becomes over distended and urine leaks out. Can be related to urethra stricture
Also known as reflex incontinence related to neurologic impairment (hypotonic bladder).
˜Interventions:
ØSurgery to relieve obstruction prostate surgery and repair prolapsed uterus.
ØIntermittent catheterization usually for long-term problems
ØClients of any age with a variety of impairments and disabilities can participate in intermittent self-catheterization. The two main requirements are that the client be cognitively intact and can reach the area.
ØDrug therapy to increase bladder pressure.
ØBehavioral Therapy (bladder compression)
•In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate) can initiate voiding.

Question 17

Functional incontinence

Answer 17

Commonly with dementia
˜Causes of functional or chronic intractable incontinence vary greatly and is related to impaired cognition or neuromuscular limitations, so the focus of intervention is treatment of reversible causes.
˜Interventions:
ØTreatment of reversible causes
ØUrinary habit training (if incontinence not reversible)
ØFinal strategy—containment of urine (absorbent pads and briefs, protection of patient’s skin to prevent breakdown).
ØNonsurgical applied devices, containment, and catheterization.
ØUrinary catheterization
•In-dwelling catheters are used only as a last resort because of the risk for ascending urinary tract infections and sepsis. The use of containment pads should be attempted as a means of controlling wetness first. If the client has skin breakdown, an in-dwelling catheter can be placed temporarily until the area has healed.

Question 18

Urolithiasis

Answer 18

˜Is the presence of calculi (stones) in urinary tract
˜Stones often do not cause symptoms until they pass into the lower urinary tract, where they can cause excruciating pain.
˜Nephrolithiasis is stones in the kidney and ureterolithiasis is stones in the ureter.
Etiology & Genetic Risk
˜The exact mechanism of stone formation is not known. Refer to table “Metabolic defects that commonly cause calculi.”
˜At least 90% of patients who form stones have a metabolic risk factor.
˜A diet high in calcium is not believed to cause stones unless a metabolic problem or kidney tubule defect already exists.
˜Data suggest that a norma-calcium diet that is relatively low in animal protein, sodium or both may help prevent stone formation.
˜Urinary stasis, urinary retention, immobility, and dehydration all increase the risk for stones to form

Question 19

Incidence and cultural urolithiasis

Answer 19

The incidence of stone disease in most common in the southeastern United States, Japan, and Western Europe. Calcium stone disease is more common in men than in women and tends to occur in young adults or during early middle adulthood. Kidneys stone disease occurs more often in young adults than older adults and more commonly among white people (Brenner, 2008). For patients in these higher-risk groups, nursing care includes teaching family members, as well as patients, about the manifestations of a stone and interventions to reduce stone formation.

Question 20

Assessment urolithiasis

Answer 20

The greatest risk factor for calculus formation is a history of a previous stone.
˜The major manifestation of stones is severe pain, commonly called renal colic, most intense when the stone is moving or when the ureter is obstructed. Nausea, vomiting, pallor, and diaphoresis often accompany the pain. Vital signs may be moderately elevated with pain; body temperature and pulse are elevated with infection. Blood pressure may decrease if the severe pain causes shock.
˜Oliguria or anuria suggests obstruction, possibly at the bladder neck or urethra.
˜Urinary tract obstruction is an emergency and must be treated immediately to preserve kidney function.
˜Stones are easily seen on x-rays of the kidneys, ureters, and bladder, IV urograms, or computed tomography.
˜Urinalysis may show hematuria, RBCs, WBCs.
˜

Question 21

Interventions urolithiasis

Answer 21

˜Pain-relief measures: Nursing interventions focus on pain management and prevention of infection and urinary obstruction. Most patients can expel the stone without invasive procedures and this will depend on the size, composition, and location. The larger the stone and the higher up in the urinary tract, the less likely it will pass. Important to capture passed stone for laboratory analysis.
˜Drug therapy
ØOpioid analgesics first 24 to 36 hours to control pain
ØToradol (NSAID), risk for bleeding delay surgery.
ØCAM therapies such as relaxation, hypnosis , imagery, healing touch, acupuncture
˜Avoiding over and under hydration in acute phase to make passage of stone less painful.

Question 22

Lithotripsy

Answer 22

˜Lithotripsy, also known as extracorporeal shock wave lithotripsy, is the use of sound, laser, or dry shock waves to break the stone into small fragments. Patient undergoes conscious sedation. Topical anesthetic cream applied to skin site, continuous monitoring by ECG. About 500 to 1500 shock waves are applied in 30 to 45 minutes. The shock waves can cause bleeding into the tissues through which the waves pass on the affected side. Application of ice can reduce the extent and discomfort of the bruising on the affected side.

Question 23

Surgical treatment urolithiasis

Answer 23

˜Minimally invasive surgery include stenting, retrograde ureteroscopy, and percutaneous ureterolithotomy and nephrolithotomy.
˜Post operative if a patient develops a high temperature the elevated temperature indicates a possible infection. Treatment must be initiated as soon as possible to prevent septic complications.
˜Open surgical procedures when other stone removal attempts have failed or when risk for a lasting injury to the ureter or kidney is possible, an open ureterolithotomy (into the ureter) phelolithotomy (into the kidney) procedure may be performed.
˜Preop: Explain procedure, what to expect, NPO and bowel prep.
˜Postop: Post recovery assessment and vital signs (as noted above), monitor amount of bleeding from incisions and in the urine, I&O, strain urine,

Question 24

Urolithiasis interventions

Answer 24

Preventing Infection
˜Control of infections before invasive procedures is critical for the prevention of urosepsis. Appropriate antibiotics are given to either eliminate an existing infection or to prevent new infections, and maintaining adequate nutrition and fluid intake.
˜Drug therapy is the most common intervention such as broad-spectrum antibiotics aminoglycosides. Struvite stones (alkaline), periodic and long-term monitoring of the urine for infection is needed.
˜Nutrition therapy includes adequate caloric intake and balance in all food groups, and high intake of fluids (3 L/day or more) if no fluid restrictions.
˜Preventing Obstruction (drugs, diet, and fluid intake)
˜A high intake of fluids (3L/day or more) is sufficient to provide a diluted urine helps prevent dehydration, promotes the flow of urine, and decreases the chance of crystals forming a stone. Remember, dehydration contributes to the precipitation of minerals to form a stone.
˜Diet modificaton depends on the type of stone formed. In secondary hyperoxaluria is caused by an excessive ingestion of foods containing large amounts of oxalate, such as spinach, rhubarb, Swiss chard, collard greens, cocoa, beets, wheat germ, pecans, peanuts, okra, chocolate, and lime peel.
˜Drug therapy is based on the what is causing the stone formation and the type of stone formed. Teach the patient the reason for the drug, and assess for side effects or adverse drug reaction.

Question 25

Hypercalciuria

Answer 25

˜Hypercalciuria include thiazide diuretics (Diuril, HydroDIURIL) that promote calcium reabsorption from the kidney tubules back into the body, thereby reducing urine calcium loads.

Question 26

Hyperoxaluria

Answer 26

Hyperoxaluria (high levels of oxalic acid in the urine) allopurinol (Zyloprim) and vitamin B6 (pyridoxine) are used. For patients with chronic gout, allopurinol helps prevent stone formation or urate (uric acid) stones. In addition, To reduce the client’s level of uric acid, he or she must avoid any food that contains purine. This is found primarily in organ meats, poultry, and fish.

Question 27

Cystinuria

Answer 27

˜Cystinuria (high levels of cystine in the urine) use AMPG and Capoten when hydration and urine alkalinization have not been successful.
˜Other measures to help pass the stone more quickly, is to encourage to walk as often as possible, check urine pH daily, and strain all urine with filter paper to collect passed stone and fragments.

Question 28

Urothelial cancer

Answer 28

˜Urothelial cancers are malignant tumors of urothelium, lining of transitional cells in kidney, renal pelvis, ureters, urinary bladder, and urethra, and mostly the bladder
ØSmoking is known to be a factor that greatly increase the risk of bladder cancer. Neither alcohol use, prescription drug use (except medications that contain phenacetin), nor recreational drug use are known to increase the risk of developing bladder cancer.
ØExposure to toxins, especially used in the hair dressing, rubber, paint, electric cable, and textile industries, increases the risk for bladder cancer.

Question 29

Assessment and manifestations urithelial cancer

Answer 29

˜Physical assessment observe the overall appearance of the patients, especially skin color and general nutritional status. Inspect, percuss, and palpate the abdomen for asymmetry, tenderness, and bladder distention.

˜Clinical manifestations blood in the urine is often the first major sign of bladder cancer. It may be gross or microscopic, and is usually painless and intermittent.

˜Psychosocial assessment of patient’s emotions and response to tentative diagnosis of bladder cancer. Reluctant to seek treatment suspect STD. Assess coping and support system.

Question 30

Treatment of urothelial cancer

Answer 30

˜Cystoscopy with retrograde urography is usually performed to evaluate painless hematuria and a biopsy of a visible bladder tumor can be performed.
˜Therapy for the patient with bladder cancer usually begins with surgical removal of the tumors for diagnosis and staging of disease.

˜Prophylactic immunotherapy with intravesical instillation of bacille Calmette-Guérin (BCG), a live virus compound, is used to prevent tumor recurrence of superficial cancers.
ØIntravesical chemotherapy involves instilling the chemotherapy agents directly into the bladder. The side effects are local, not systemic.
˜Tumors confined to the bladder mucosa are treated by simple excision, whereas those that are deeper but not into the muscle layer are treated with excision plus intravesical chemotherapy.
˜Complete bladder removal with additional removal of surrounding muscle and tissue offers the best chance of a cure for large, invasive bladder cancers.
˜Chemotherapy and radiation therapy are used in addition to surgery.

˜Four alternatives are used after cystectomy: ileal conduit, continent pouch, bladder reconstruction also known as neobladder, and ureterosigmoidostomy

Question 31

Ileal conduit

Answer 31

˜A cystectomy with an ileal conduit has a stoma. A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis.
˜The goal for the client who is scheduled to undergo a procedure such as an ileal conduit is to have a positive self-image and a positive attitude about his body image. discussing the procedure candidly with a former client will foster such feelings, especially when the current client has an opportunity to ask questions and voice concerns to someone with first-hand knowledge of the procedure.

Question 32

Different ostomies

Answer 32

˜Cutaneous ureterostomy an external pouch covers the ostomy to collet urine. ET will focus on the wound, the skin, and urinary drainage.
˜Kock’s pouch, a continent reservoir, may have a penrose drain, and Medena catheter in the stoma that removes lymphatic fluid and secretions, and urine drainage so that suture lines can heal.
˜Neobladder 2-4 days in ICU with drain and irrigation. Later irrigation can be performed with intermittent catheterization. No sensation due to sensory nerves not attached. Learn cues to void such as prescribed times or pressure.
˜Some drains are permanent or temporary and internal (no drainage to the outside) or external to drain urine into a pouch or bag. For this type of drainage system, urine output remains constant. A decrease in amount of drainage is cause for concern and must be reported to the surgeon or nephrologist, as is leakage around the catheter..

Intervention needed is drain is pulled out.

Question 33

Teaching ostomy care

Answer 33

˜Teaching plan upon discharge
˜Teach the patient and family about drugs, diet and fluid therapy, the use of external pouching systems, and the techniques for catheterizing a continent reservoir.
˜May need electrolyte replacement to prevent long-term deficits. Avoid food that produce gas can cause incontinence if diversion uses intestinal tract.
˜Weight loss the first few weeks after surgery; dietician to collaborate.
˜Self care activities (pouch application, skin care, pouch care, methods of adhesion and drainage, intermittent catheterization), body image, sexual functioning, self-esteem.
˜Toileting practices men sit if GI diversion, impotence cystectomy.
˜Refer to the United Ostomy Association and the American Cancer Society for educational materials and local chapters for support.

Question 34

Bladder trauma

Answer 34

˜Bladder trauma can be caused by penetrating or blunt injury to the lower abdomen.
˜Penetrating injury may occur by stabbing, gunshot wound, or other trauma in which objects pierce the abdominal wall.
˜Blunt trauma compresses the abdominal wall and the bladder.
˜Bladder trauma, other than a simple contusion, requires surgical intervention.
˜Fractures should be stabilized before bladder repair
˜Nursing interventions prior to surgical intervention