Unit 15 - Urinary

Question 1

Lower UTIs

Answer 1

Cystitis, prostatitis, urethritis

Question 2

Upper UTIs

Answer 2

Acute pyelonephritis, chronic pyelonephritis, renal abscess, interstitial nephritis, perirenal abscess

Question 3

Uncomplicated Lower UTI

Answer 3

Community-acquired infection; common in young women and not usually recurrent

Question 4

Compliated Lower or Upper UTI

Answer 4

Often nosocomial (acquired in the hospital) and related to catheterization; occur in patients with urologic abnormalities, pregnancy, immunosuppression, diabetes mellitus, and obstructions and are often recurrent

Question 5

Pyelonephritis

Answer 5

Inflammation of kidney and renal pelvis

Question 6

Interstitial nephritis

Answer 6

inflammation of spaces between kidney tubules

Question 7

renal abscesses

Answer 7

pus filled cavity of kidney

Question 8

Urethrovesical reflux

Answer 8

reflux of urine from urethra into bladder (coughing, sneezing, straining causes pressure forcing urine from bladder to urethra and then back when pressure recedes)

Question 9

Ureterovesical reflux

Answer 9

reflux of urine from bladder to ureters, can cause bacteria to reach kidneys

Question 10

UTI Risk factors

Answer 10

Inability or failure to empty the bladder completely Obstructed urinary flow: Congenital abnormalities Urethral strictures
Contracture of the bladder neck
Bladder tumors
Calculi (stones) in the ureters or kidneys Compression of the ureters
Neurologic abnormalities Decreased natural host defenses or immunosuppression Instrumentation of the urinary tract (e.g., catheterization, cystoscopic procedures) Inflammation or abrasion of the urethral mucosa Contributing conditions: Diabetes mellitus (increased urinary glucose levels create an infection-prone environment in the urinary tract)
Pregnancy
Neurologic disorders
Gout
Altered states caused by incomplete emptying of the bladder and urinary stasis

Question 11

S+S of UTI

Answer 11

Dysuria
• Urgency
• Frequency
• Nocturia
• Suprapubic	or pelvic	pain
• Hematuria
• Back pain
• Incontinence
• Dullness on	percussion

Question 12

Gerontologic Considerations

Answer 12

Lack typical symptoms
• Altered	mental status
• Lethargy
• Anorexia
• New incontinence
• Low grade fever
• May still have	frequency, urgency and	dysuria

Question 13

Urosepsis

Answer 13

Sepsis resulting from infected urine, usually a UTI. Indwelling catheter. Can cause signs of septic shock

Question 14

Septicemia from UTI

Answer 14

Kidneys receive 25% cardiac output, with pyelonephritis can lead to bacteremia. Septicemia syndrome (vasodilatation, microvascular permeability, massive inflammatory response)

Question 15

S+S of urosepsis

Answer 15

hypo/hyperthermia
tachycardia
tachypnea
leukocytosis/leukopenia
>10% immature band forms``

Question 16

Urine dipstick:

Answer 16

bacteriuria

Leukocyte markers for leukocyte esterase and nitrites (Greiss test) (WB + Nitrites = infection). Elevated SG.

Question 17

Urinalysis (UA)

Answer 17

> WBC , bacteria >10^5

Question 18

Urine C&S

Answer 18

Clean catch + catheterization
Culture - determines infectious agents
Sensitivity - determines susceptibility of bacteria to Abx

Also differential dx: test for STDs

Question 19

Groups needing cultures when bacteriuria is present

Answer 19

All men (because of the likelihood of structural or functional abnormalities)
Women with a history of compromised immune function or renal problems
Patients with diabetes mellitus
Patients who have undergone recent instrumentation (including catheterization) of the urinary tract
Patients who have been recently hospitalized or who live in long-term care facilities
Patients with prolonged or persistent symptoms
Patients with three or more UTIs in the past year
Pregnant women
Postmenopausal women

Question 20

Pt Education for UTI

Answer 20

Shower rather than bath

After BM clean front to back

Question 21

Pt Education for UTI (Fluid intake)

Answer 21

Drink liberal fluids to flush

Avoid coffee tea colas alcohol and other irritants

Question 22

Pt education for UTI (Voiding habits)

Answer 22

Void q2/3 hr during day and completely empty bladder to prevent overdistention and compromised blood supply to bladder wall which can predispose to UTI.
Void after sex.

Question 23

Pt education for UTI (Therapy)

Answer 23

Take meds exactly as prescribed (short term 3-4 d, 7-10 d)
Long term Abx may be required (4-12 mo)
Special timing of admin may be required (bedtime)
Acidification of urine (OJ or cranberry juice)
Notify HCP if fever occurs or s+s persist
Consult PCP for follow up

Question 24

Tx for UTI

Answer 24

Uncomplicated 1-3 day resolution
Suppressive/prophylactic tx
Culture first if Sx persist

Question 25

Floroquinolones

Answer 25

ciprofloxacin (Cipro) levofloxacin (Levaquin) Tx of choice for uncomplicated (3 days) SE: Tendonitis/rupture, Rash, GI discomfort, *C-diff diarrhea, seizures Take 1 hr before or 2 hr after meals

Question 26

Sulfonamides for UTI

Answer 26

nitrofurantoin (Macrodantin) Ineffective with pts GFR < 50 Can cause periph. neuropathy

Question 27

Penicillins

Answer 27

Amoxicillin (Amoxil, Augmentin) PCN Allergies Highly resistant

Question 28

Urinary Analgesics

Answer 28

phenazopyridine (Pyridium) | Turns urine dark orange, might be confused with blood.

Question 29

Acute Pyelonephritis

Answer 29

Lower UTI S+S: Fever, chills, leukocytosis, lower back pain , flank pain, NV, HA, malaise, CVA tenderness Englarged kidneys, abcesses on renal capsule. Complication - could relapse and become asymptomatic and chronic

Question 30

Chronic Pyelonephritis

Answer 30

Asymptomatic unless acute exacerbation S+S: HA, fatigue, poor appetite, polyuria, excessive thirst, wt loss Complication: ESRD (kidneys scar and contract and nonfunctional)

Question 31

Dx Complicated UTI

Answer 31

IV urogram and degree of renal dysfunction via measurements of BUN, creatnine, creatnine clearance. CT scan for obstruction. Urine C+S. Voiding cystouretherography

Question 32

Tx for Pyelo

Answer 32

Outpatient if no dehydration, n/v, or sepsis sx. 2 week abx . Parenteral admin in hosp. to rapidly est. drug levels trimethoprim-sulfamethoxazole (Bactrim, TMP/SMX) Cipro gentamicin 3rd gen cephalosporin. **Use with caution of pt has renal or liver dysfunction. NSAID and Tylenol for fever and discomfort Fluids 3-4 L /day

Question 33

BPH Sx

Answer 33

Obstructive sx, similar to UTI Frequency, nocturia, urgency, hesitancy, straining, decrease in volume and force of stream, dribbling, sensation of incomplete emptying, acute retention, recurrent UTI.

Question 34

Dx Studies for BPH

Answer 34

``` H+P w/ digital rectal exam UA Labs: PSA + Creatinine Transrectal Ultrasound TRUS Uroflowmetry Post Void Residual PVR Cystourethroscopy ```

Question 35

Risk factors for BPH

Answer 35

AA younger, smoking, ETOH, HTN, heart disease, DM, diet.

Question 36

BPH Pharma

Answer 36

5-alpha reductase inhibitors finasteride (Proscar), dutasteride Interfere with conversion of testosterone to DHT to decrease size SE: decreased libido and ejaculate volume, ED Alpha Blockers amsulosin (Flomax) doxazosin (Cardura) terazosin (Hytrin) prazosin (Minipress) Relax smooth muscle, does not decrease hyperplasia, sx relief SE: Ortho hypo, dizzy, retrograde ejaculation, nasal congestion Herbal: Saw palmetto Sx relief, reverses hyperplasia SE: GI, bleeding risk (stop before dental/surgical) Better tolerated and cheaper, may be as effective

Question 37

BPH Minimally Invasive Therapy

Answer 37

``` Coude (curved) catheter for uroretention Transurethral microwave thermotherapy TUMT Transurethral needle Ablation TUNA Laser prostatectomy Intraprostate urethral stents ```

Question 38

Invasive therapy BPH

Answer 38

Transurethral Resection of Prostate TURP Transurethral incision of prostate TUIP ``` Suprapubic/ Perineal/ Retropubic/ Robotic/ Laparoscopic prostatectomy ```

Question 39

Prostatectomy Preop care

Answer 39

: Reduce anxiety, relieve discomfort (bedrest, analgesics). Watch void pattenrs, bladder distention, assist w/ catheterization.

Question 40

Prostatectomy Postop care

Answer 40

Maintenance of fluid volume balance,- irrigation causes excess fluid retention. Observe for JVD, S3 gallop, crackles. Monitor UO record. Electrolyte imbalances (Na), increased BP, confusion, resp. distress. Hemorrhage monitor for tachy, hematuria, restlessness, pallor, dec. hct and hgb. UO should be 0.5ml/kg/hr pain relief - determine cause (incisional or bladder spasm - severe cramping suprabpubic). Feeling of pressure and fullness in bladder. Secure drainage to leg to decrease tension. Dont sit for prolonged time, will increase intrabdominal pressure (bleeding and discomfort)

Question 41

Prostatectomy Postop complications

Answer 41

Hemorrhage: clots can obstruct flow. Bright red blood is aterial (surgical intervention), dark red is venous (can be stopped by PCP inflation). HOB slightly elevated to avoid incr. pressure. Monitor VS, admin meds, fluids, and blood. Accurate IO, monitor drainage system patency. Infection - avoid rectal thermos and tubes. sitz baths. Monitor for sx of infection. DVT - LMWH, assess for DVT, stockings. Cath obstruction - admin diuretic to keep patent. observe for abd distention which could indicate blockage. Suprapubic dullness. Monitor urine color, VS, restlessness, pallor, diaphoresis. Fluid in drainage bag must = fluid infused. Sexual dysfunction Self care . Perform Kegel exercises, as they may help with regaining urinary control: Tense the perineal muscles by pressing the buttocks together; hold this position; relax. This exercise can be performed 10 to 20 times each hour while sitting or standing. Try to interrupt the urinary stream after starting to void; wait a few seconds and then continue to void. While the prostatic fossa heals (6 to 8 weeks), avoid activities that produce Valsalva effects (straining, heavy lifting), as this may increase venous pressure and produce hematuria. Avoid long motor trips and strenuous exercise, which increase the tendency to bleed. Note that spicy foods, alcohol, and coffee may cause bladder discomfort. Maintain fluid intake to avoid dehydration, which increases the tendency for a blood clot to form and obstruct the flow of urine. Report signs of complications, such as bleeding, passage of blood clots, a decrease in the urinary stream, urinary retention, or symptoms of UTI, to the urologist.

Question 42

Nephro/urolithiasis

Answer 42

Stones in kidney/urinary tract FOrmed with high concentrations of calcium oxalate, calcium phosphate, and uric acid. S+S depend on location, obstruction, infection. Similar regardless of cause

Question 43

Calcium calculi

Answer 43

``` Majority of stones Hypercalcemia Hyperparathyroidism Renal tubular acidosis Tumors that increase Vit D prod Dehydration ```

Question 44

Uric acid stones

Answer 44

Gout Alteration in purine metabolism Increaed uric acid prod

Question 45

Struvite

Answer 45

Recurrent UTIs Neurogenic bladder Foreign bodies Increased urine alkalinity

Question 46

Cysteine stones

Answer 46

Rare inherited defect in renal absorption of cysteine

Question 47

Renal pelvis stone pain

Answer 47

Intense deep aching in CVA Hematuria and pyuria Radiating downward

Question 48

Ureter obstruction from stone

Answer 48

Ureteral colic - acute excruciating colicky wavelike pain radiating down to thigh

Question 49

Bladder stone pain

Answer 49

Bladder irritation and uti | Hematuria

Question 50

Renal colic

Answer 50

Sudden acute pain CVA tenderness NV diarrhea and discomfort Pallor and cold clammy skin

Question 51

Stones Dx

Answer 51

``` H+P: Diet, meds, and history KUB Xrays Ultrasound IV Urography Retrograde pyelography VCUG 24h urine test for Ca, uric acid, urine creatnine, Na, pH, total volume Stone chemical analysis Blood: WBC BUN creatnine ```

Question 52

Stones nursing mgmt

Answer 52

``` Pain mgmt - opiods and NSAIDs Hydration to increase prssure to drive stone down , mainstay of therapy, >2L UO recommended. Dietary changes per type of stone. Conrol infection Strain urine for stones I/O, VS Cessation of stone generating meds. Limit Na to 3-4g/day Possible uric acid meds ```

Question 53

Stones surgeries

Answer 53

Ureteroscopy Extracorporeal shock wave lithotripsy (ESWL) SE: possible obstruction from fragments Percutaneous stone removal Nephrolithotomy, cystotomy SE: hemorrhage

Question 54

Stones Pt teaching

Answer 54

Avoid stone causing meds: Antacids, Vit D, Laxatives, high dose aspirin Limit Na intake Avoid oxalate foods: spinach, rhubarb, tea, panuts, wheat bran Drink 2 glasses H20 at night to prevent urine concentration Avoid dehydration Notify HCP of S+S of infection

Question 55

Acute glomerulonephritis

Answer 55

Inflammatory disease of glomeruli Antigen-antibody response to infection: Group A Beta-hemolytic strep, impetigo,shingles, EBV, hep, HIV Result is inflamation of glomerular capillaries and GFR ``` Mild to severe Azotemia and uremia Proteinuria Hematuria HTN Periorbital and peripheral edema Increased BUN and cretnine Oliguria Fluid Overload Neurologic sx Elderly - circulatory overload ```

Question 56

CHronic glomerulonephritis

Answer 56

``` Glomerular destruction from repeated injury HTN, DM, Hyperlipidemia, SLE Major complications: Renal failure or ESRD Hyperkalemic Metabolic acidosis Anemia Hypoalbuminemia Increased phosphorous level Decreaed Vit D and Ca Decreased GFR Mental status changes Impaired Nerve conduction Cardiac enlargement and pulmonary edema ```

Question 57

Glomerulonephritis Mgmt

Answer 57

Assess for previous infections (sore throat, skin lesions) Physiologic assessments: fluid and electrolyte , cardiac and neuro status Strict IO and daily weight Monitor VS Diet restrict Protein Na and fluid Meds as indicated: antiHTN, diuretics, biologics, Teach importance of followup care.

Question 58

TUR Syndrome

Answer 58

absorption of irrigation fluid interoperatively, can lead to bradycardia, hyponatremia, confusion