Module 15

Pathogens for Urinary Tract Infections

• E. Coli

• Candida albicans, indwelling catheter or asymptomatic

Upper Uti location

• Pyelonephritis

• Renal parenchyma, pelvis, and ureters

Lower Uti location

• Bladder (cystitis)

• Urethra (urethritis)

Urinary tract defense mechanisms

• Complete emptying with void

• Ureterovesical junction competence

• Ureteral peristalsis propels urine toward bladder

• Acidic pH (6.0-7.5)

• High urea

• Glycoproteins (inhibit bacterial growth)

UTI risk factors

• obstruction

• retention

• renal impairment

• foreign bodies

• anatomic factors

• comprised immune response

• functional disorders

Lower urinary tract symptoms

• emptying symptoms

• storage symptoms

• Hematuria and/or cloudy appearance

Upper urinary tract symptoms

• flank pain

• chills

• fever

• fatigue

• anorexia

Older adults UTI symptoms

• may not have classic symptoms

• delirium

• confusion

Diagnostic Studies for UTI

• Dipstick for nitrates, WBCs and leukocyte esterase

• Urine culture/sensitivity

• Ultrasound or CT scan

• History—recurring UTIs (2-3/yr); CAUTIs or HAI

UTI drug therapy

• Phenazopyridine (for burning, tingling, urgency)

• Antibiotics (empiric) for ~3 days

Uncomplicated UTI Drug therapy

• Trimethoprim/sulfamethoxaole

• Nitrofurantoin cephalexin

• Fosfomycin

• other” ampicillin, amoxicilin, cephalosporins

Complicated UTI drug therapy

• fluoroquinolones

Urinary analgesic

• Phenazopyridine (azo dye)

UTI Nursing Subjective Nursing Assessment

• past health history

• Medications

• surgery/other tx

• Functional health patterns

  • health management

  • Nutrition-metabolic

  • elimination

  • Cognitive-perceptual

  • sexuality-reproductive

UTI Nursing Objective Assessment

• General

• Urinary

• Diagnostic findings

UTI Nursing diagnosis/Nursing problems

• Impaired urinary system function

• acute pain

• lack of knowledge

UTI Goals

• Patient will have…

  • relief from bothersome symptoms

  • no upper urinary tract symptoms

UTI Patient Education

• Empty bladder regularly and completely

• Evacuate bowel regularly

• Wipe front to back

• Adequate fluid intake

• Perineal hygiene

• take antimicrobials as ordered

• void regularly before and after intercourse

• stop using diaphragm (temporarily)

Prevention of CAUTI

• avoid unnecessary catheterizations

• Early removal of indwelling catheters

• Aseptic technique

• Hand hygiene

• Gloves for catheter care

Urinary incontinence men vs women

• Men—common with BPH or prostate cancer; overflow incontinence from urinary retention

• Women—stress and urge incontinence

First Nursing intervention for Urinary incontinence

• Toileting schedule

  • choose first over purewick, pad, etc.

Urinary incontinence

• bladder pressure greater than urethral closure pressure

  • interference with bladder or sphincter contral

Urinary incontinence causes

• D: delirium, dehydration, depression

• R: restricted mobility, rectal impaction

• I: Infection, inflammation, impaction

• P: polyuria, polypharmacy

Stress Incontinence

• urine loss that occurs with physical effort, exertion, sneezing, coughing, laughing, or lifting objects

• Common in older women who have had children

Urge/Urgency Incontinence

• involuntary leakage associated with a sudden, strong urge to void

Overflow incontinence

• bladder becomes overfilled and pressure exceeds the sphincters ability to prevent urine passage, resulting in continuous dribbling or leakage

Urinary Incontinence Diagnostic Studies

• Urinalysis

• Post void residual

• Urodynamic studies

• Ultrasound

Urinary incontinence interventions

• Scheduled voiding regimens

• Pelvic floor muscle rehabilitation

• Anti-incontinence devices

• Containment devices

Acute urinary retention

• inability to pass urine

• Medical emergency

Chronic urinary retention

• incomplete emptying despite urination

Post void residual

• Normal—50-75 mL

• >100 mL—repeat or further evaluation with UTIs

• >200 mL— further evaluation

Acute Kidney Injury causes and diagnostic criteria

• Sudden onset

• Cause—acute tubular necrosis

• Diagnostic criteria Acute reduction in urine output and/or elevation in serum creatinine

• Potentially reversible

Chronic Kidney Disease onset and common cause

• Gradual over years

• Diabetic nephropathy, hypertension, glomerulonephritis, cystic disease, urologic diseases

CKD diagnostic criteria

• GFR <60 mL/min/1.73m² for >3 months

CKD outcome

• progressive and irreversible

• Cause of death—cardiovascular disease

CKD cause for Clinical Manifestations

• Result of retained substances

  • urea

  • Creatinine

  • Phenols

  • Hormones

  • Electrolytes

  • Water

  • Uremia

CKD early clinical manifestations

• no change in urine output

• Polyuria may be present related to diabetes

• Progression—increasing fluid retention; need diuretic

• After period on dialysis, patients may become anuric

CKD Clinical Manifestations

• Uremia

• Altered carb metabolism

• Elevated triglycerides

• Metabolic acidosis

• Anemia—fatigue

• Systemic

CKD Diagnostic studies

• dipstick evaluation of protein

• Albuminuria

• Urinalysis

• Renal ultrasound, scan, CT scan, biopsy

• ALbumin-to-creatinine ratio

• Serum BUN, creatinine, creatinine clearance, electrolytes, lipids, hemoglobin, hematocrit

• GFR

CKD Management (stages 1-4)

• control hypertension, hyperparathyroid disease, anemia, dyslipidemia

• Correct ECF volume overload or deficit

• Treat CF disease

• Nutritional and drug therapy

Hypertension management

• Weight loss

• DASH diet

• Antihypertensives

  • ACEs/ARBs if diabetic

Hyperkalemia Management

• restrict high potassium foods

• IV glucose and insulin

• Sodium polystyrene sulfonate (kayexalate)

• Patiromer (Veltessa)

• Dialysis—most effective

Anemia Management

• Erythropoietin

  • IV or subcut

  • SE: thromboembolism, HTN

• Iron supplemements

  • SE: gastric irritation, constipation

  • Stool may be dark in color

• Folic acid supplements

• Avoid blood transfusions

  • Increase development of antibodies

  • May lead to iron overload

Dyslipidemia management

• statins (HMG-CoA reductase inhibitors)

• fibrates (fibric acid derivatives)

CKD nutritional therapy

• necessary starting stage 3

• Protein intake should be limited until dialysis is initiated, then can be restricted less

• fluid restriction with Hemodialysis—depends on daily urine output

  • 600 mL plus what was taken off dialysis

  • Daily weight essential

• Sodium restricts—vary from 2-4 g/day

• Potassium restriction—limit 2-3 grams

CKD Nursing Diagnsosi/Clinical Problems

• Fluid imbalance

• Electrolyte status

• Difficulty coping

• Impaired nutrition

CKD Nursing Assessment

• Complete History

• Long-term health problems

• Medications—OTC, prescribed, herbal

• Dietary habits

• Support systems

CKD Health Promotion

• Identify people at risk

• Regular checkups with urinalysis and GFR

• Prevent progression of CKD and CV disease if identified as risk

• Patient teaching, ambulatory care

Dialysis

• Movement of fluid/molecules across a semipermeable membrane from one compartment to another

• Used to correct fluid and electrolyte imbalances and removes waste products in kidney failure

Two methods of Dialysis

• Peritoneal dialysis

• Hemodialysis

When is dialysis started

• When a patient’s uremia can no longer be adequately treated conservatively

• GFR <15 mL/min/1.73 m²

• Nephrologist determines when

• Uremic complications require dialysis

• End stage renal disease in some cases

End stage renal disease treated with dialysis because…

• There is a lack of donated organs

• Some patients are physically or mentally unsuitable for transplantation

• Some patients do not want transplants

Diffusion

movement of particles from higher concentration to lower concentration

Osmosis

movement of water from low solute concentration to higher solute concentration

Ultrafiltration (PD and HD)

• PD—glucose in dialysate

• HD—pressure gradient

Peritoneal dialysis access

• obtained by inserting a catheter through the anterior abdominal wall

• Must be sterile—prevent peritonitis

Phases of PD cycle

• Inflow (fill)—2-3 L over 10 minutes

• Dwell (equilibration) 20-30 minutes—8 hrs

• Drain 15 to 30 minutes

• Cycle is repeated

PD solutions

Automated peritoneal dialysis

Cycler delivers the dialysate during sleep times and control fill, dwell, and drain phases; alarms and monitors for safety

Continuous Ambulatory peritoneal dialysis

Manual exchange four times during the day

PD complications

• Exit site infection

• Peritonitis

• Hernias

• Lower back problems

• Bleeding

• protein loss

• Pulmonary complications

  • decreased lung expansion, protein loss—monitor nutrition

Effectiveness of chronic PD

• Short training program; 3-7 days

• Advantages

  • Simplicity

  • Home-based program

  • Increasing patient participation

  • No need for special water systems

  • Equipment set-up is relatively simple

Hemodialysis Vascular Access sites

• Requires rapid blood flow and access to a large blood vessel

• Obtaining vascular access is one of the most difficult problems

• Arteriovenous fistulas and grafts; temporary vascular acces

Arteriovenous fistulas and grafts

• Created in forearm or upper arm—preferred access for HD

• Fistula allows arterial blood flow through vein; becomes “arterialized”

• Placed 3 months before HD—needs to mature

• Feel “thrill” or hear “bruit” due to high velocity of blood flow

Arteriovenous grafts (AVGs)

• Synthetic material surgically placed under the skin to form a “bridge” between artery )brachial) and vein (antecubital)

• Healing time—2 to 4 weeks

• More likely to get infected or form clots

  • if infected, may need to be removed

AV Fistulas and Grafts Risks and safety

• Distal ischemia (steal syndrome)

  • Pain distal to access site

  • Numbness or tingling of fingers

  • Poor capillary refull

• Aneurysms

• Safety

  • No BP, venipunctures, or IV line

  • Prevent infection and clotting

Temporary vascular access

• Catheter insertion of internal jugular or femoral vein when immediate access is needed

• Double lumen/Triple lumen

  • Blood removal

  • Blood return

• Risks: high infection, dislodgment, and malfunction

• Never flush a dialysis catheter

Hemodialysis Dialyzers

• Plastic cartridge that contain thousands of parallel hollow tubes or fibers; semipermeable membranes

  • Blood is pumped from top into fibers

  • Dialysate pumped from bottom and bathes the outside of the fibers

  • Ultrafiltration, diffusion, and osmosis occur

  • When blood reaches end—returned via single tube to patient

HD Procedure—before treatment

• Assessments

  • fluid status

  • Vascular access

  • temperature

  • Monitor VS every 30 to 60 minutes

• Two large bore needles placed in fistula or graft

• Heparin is added to prevent clotting

• Dialysate delivery and monitoring system is used

HD Procedure—after treatment

• Dialyzer/blood lines primed with saline solution to eliminate air

• Terminated by flushing with saline to return all blood to patient

• Needles removed and firm pressure applied

HD settings and schedules

• Most treated in a community-based center

  • dialyzed for 3-4 hrs. 3 days/wk

• Short daily HD, long nocturnal HD, home HD

HD complications

• Hypotension

• Muscle cramps

• Loss of blood

• Hepatitis—8% to 10% hepatitis C

HD effectiveness

• Cannot fully replace normal functions of kidneys

• Can ease many of symptoms

• Can prevent certain complications

• CV disease carries high mortality rate

• Infectious complications 2nd leading cause of death

HD nursing goals—help patient to…

• Have a healthy self-image

• Return to highest level of function

Continual Renal Replacement Therapy Nursing interventions

• Obtain weights

• Monitor and document laboratory values daily for fluid and electrolyte balance

• Assess hourly intake and output, VS, and hemodynamic status

• Care for site to prevent infection

CRRT versus HD

• Blood pump is slower than HD

• Continuous rather than intermittent

• Fluid volume can be removed over days vs hours

• Solute removal (no dialysate required) in addition to osmosis and diffusion

• Less hemodynamic instability

• Doesn’t require constant monitoring by HD nurse; need ICU nurse

• Doesn’t require complicated HD equipment