NU 352 - EXAM 2 - PP3 (INT FOR ALTERATIONS IN RENAL/ URINARY FUNCT)

Factors Contributing to Urinary Tract Infection

-Reflux

-Neurogenic bladder

-Recurrent UTIs

◦ Cytokine release = irritation = scarring

-Women

◦ Shorter urethra and proximity to vaginal flora

-Post-menopausal women

◦ Hormonal deficiency

◦ Pelvic floor weakness

-Young children

◦ Shorter urethra, shorter ureters

◦ Possible congenital abnormality

Urinary Reflux

look at picture

Infection: Urinary Tract Infection (UTI) Assessments

-Typical Lower UTI signs & symptoms

◦ Can include: Urinary frequency, discomfort/pain/burning (dysuria), urgency, lower abdominal cramping, nocturia

-Atypical presentations

◦ Children (especially under age 2) with nonspecific s/s: Irritability, persistent diaper rash, vomiting, diarrhea, anorexia

◦ Older adults: Non-localized abdominal discomfort, incontinence, weakness, possibly cognitive changes (confusion)

which collaborative intervention could the nurse expect for a client with a unrainy calculi composed of uric acid

-administer the medication allopurinol per oral route

Pts catheter is removed 4 days post TURP. He is experiencing urinary dribbling, which nursing intervention is appropriate

provide education on Kegel exercises

The RN caring for a child with acute glomerulonephritis is meeting with the family to discuss discharge instructions. select the most important topics

Restrict dietary intake of sodium, monitor and record fluid intake and output, monitor and record child weight

a 3 y.o child is diagnoses with early stage Wilms tumor. which action by the novice nurse indicates further instruction regarding care is needed

Firmly palpates the child’s abdomen during assessment

A pt with bladder cancer undergoes a surgical removal of the bladder and construction of an ileal conduit. Which findings indicate possible complications

The stoma appears dusky, client reports sharp abdominal pain and rigidity, stoma protrudes 3 inches from skin

what instructions would a nurse expect to give a client scheduled for a renal biopsy

withhold aspirin for several day prior to the procedure

a 4 y.o. with urinary vesicoureteral reflex is 2 days post op for bilateral ureteral re-implants. which assessment finding is most concerning

decreased oral fluid intake

the patient schedules for a cystoscopy asks the nurse for more info about the test. which is the best response

you may experience burning upon urination following the test

the nurse realizes that the parents of a child with nephrotic syndrome need further instruction when they make which statement

we will be happy about any weight gain because that is normal

UTI Nursing Interventions

• Early identification and treatment to prevent bladder scarring and worsening infection

• Specimen collection

• Administer anti-infective drugs as ordered (e.g. nitrofurantoin [Macrobid], cephalexin, or trimethoprim/sulfamethoxazole [BactrimDS])

• Increase oral fluid intake

• Promote relief of discomfort:

◦ Phenazopyridine, heating pad to abdomen, warm bath

◦ Patient education:

◦ Push oral fluids and complete all doses of antibiotic prescription

◦ Perineal factors (wipe front to back, void after intercourse, wear cotton underwear, avoid bladder irritants [coffee, citrus, cola, alcohol], etc.

Recurrent UTI Management

-Voiding Cystourethrogram (VCUG)

o Can diagnose congenital defects, difficulty emptying, urethral stricture, vesicoureteral reflux

-Conservative therapy

o Continuous low dose antibiotics

o Increased oral fluid intake

o Frequent urine cultures

-Procedural options

o Botox injection

o Ureteral reimplantation

Infection: Acute Pyelonephritis

-Bacterial infection in the kidney (renal pelvis, tubules, interstitial tissue)

-UTI s/s + flank pain, fever, chills, nausea/vomiting, CVA tenderness, elevated white blood cell (WBC) count

-Requires longer, stronger course of antibiotics than Lower UTI

-IV antibiotics if severe (symptoms or multiple bacteria noted in urine culture)

-Increase fluid intake

-Complication; can lead to urosepsis or chronic pyelonephritis → possibly acute or chronic kidney disease (CKD

infection: Urosepsis Assessment

-May occur with CAUTI

◦ CAUTI is the most common nosocomial infection

-Report s/s of urosepsis immediately. May include:

◦ Fever, chills, body aches

◦ Decreased BP, increased HR, increased RR

◦ Reduced urine output

◦ Nausea/vomiting

◦ Skin flushed unless moving into septic shock then pale and clammy

◦ Blood cultures positive for bacteria

◦ ↑ WBC count, blood cultures positive for bacteria

◦ Possible change in mental status

infection: Urosepsis Interventions

Interventions: Early & Aggressive (Stop the Sepsis)

-Administer as ordered for treatment and symptom relief:

◦ IV antibiotics

◦ IV fluids (fluid & electrolyte balance)

◦ Oxygenation if required

◦ Vasopressors to increase BP if required

◦ Antiemetics

◦ Antipyretics

Glomerular Disease: Glomerulonephritis

-Immune disease process (not infectious); many types

-Inflammation of glomerulus capillaries

-Can follow an infection e.g. strep (other types may not come after an infection)

-Acute or chronic

-Glomerulonephritis can lead to nephrotic syndrome &/or acute or chronic kidney disease

Glomerular Disease: Nephrotic Syndrome (NS)

-A type of glomerulonephritis

-Proteins leak OUT of blood and INTO urine

-Multiple causes: e.g. minimal change disease = autoimmune & outgrown by teen years (usually no permanent kidney damage)

-Acute or chronic

-Elevated BUN and serum creatinine

Glomerulonephritis & Nephrotic Syndrome (NS) Similar Signs/Symptoms

-Hypertension

-SOB, chest pain, dysrhythmia

-Edema

-Irritable or lethargic

-Nausea/vomiting

-Hypoalbuminemia

-Hyperlipidemia

-Oliguria

*additional signs

Glomerulonephritis

-Hematuria (cola- colored urine)

-UA = high RBCs & erythrocyte casts (highly suggestive of glomerulonephritis)

-Azotemia (kidneys are not removing nitrogen

Nephrotic Syndrome (NS)

-Generalized edema (major sign of nephrotic syndrome)

-Massive proteinuria (proteinuria is a hallmark sign for NS)

-Higher risk for VTE

Glomerulonephritis and Nephrotic Syndrome Interventions

-Fluid balance (check daily weight)

◦ Restrict sodium and possibly fluids

◦ Administer diuretics

◦ Prevent skin breakdown

-Monitor lab values

-Administer antihypertensive drugs, statins

-Moderate protein intake or if uremic (increasing waste products in the blood), needs protein & potassium restriction

-Liberal carbohydrate intake (provide energy and reduce catabolism of protein)

-Nephrotic syndrome- administer lipid-lowering agents to treat hyperlipidemia

-Reduce exposure to infection

-Prevention of glomerulonephritis by treating strep infections

-Limit activity (encourage initial rest period)

-Corticosteroids (especially with Nephrotic Syndrome)

-Check urine for albumin (protein) at home (urine dipstick)

-If relapse (especially with Nephrotic Syndrome): immunosuppressant e.g. cyclosporine

-Chronic: Chronic kidney disease (CKD) treatments and interventions

Urinary Obstruction

-Acute urinary retention = medical emergency!

-Chronic urinary retention

-Normal residual: ≤ 50 mL (or ≤ 100 mL older adult)

-Adult bladder should hold approximately 500 mL

-Increases risk of UTI

Calculi AKA Urolithiasis

Several types of stones:

-Calcium oxelate stones are most common, calcium phosphate, also struvite occurring with UTIs, uric acid, cystine…

Symptoms:

-Severe pain! Intractible flank discomfort/pain from spasms/pressure

-Nausea/vomiting

-Hematuria (may or may not be visible, but RBCs present in UA)

-Stone sizes vary

Interventions for Calculi

General Interventions:

-Drink plenty of fluids

-Exercise

-Pain medication as prescribed

-Strain urine to catch stone for analysis

-Monitor for infection

Specific Interventions:

-Reduce foods high in substance causing stones

◦ Reduce sodium (Ca stones) yes, sodium, not calcium!

◦ Limit oxalates: (oxalate stones)

◦ Limit high protein (Purine or uric acid stones)

-Medications as prescribed:

◦ Struvite stones: Antibiotics

◦ Uric acid stones: Allopurinol to reduce uric acid

-Procedures:

◦ Stents, lithotripsy or surgical removal

*Lithotripsy (high-energy shock waves or a laser to break large kidney or urinary tract stones into tiny pieces)

Obstruction: Benign Prostatic Hyperplasia (BPH)

Urinary S/S :

◦Difficulty starting/stopping urine stream

◦Reduced urine stream

◦Dribbling urine after urination

◦Nocturia

◦Frequent UTIs may occur

◦ Due to urethrovesical reflux

Interventions for BPH

◦ Patient education (”waitful watching”)

-Limit fluids prior to bedtime

-Kegel exercises

◦ Pharmacologic therapy:

-Alpha-adrenergic blockers, e.g. terazosin (Flomax) or doxazosin

-Antiandrogens, e.g. finasteride

◦ Then, surgical procedure options:

-Urolift

-TURP

Urolift

The UroLift System should not be used if the patient

has:

•Prostate volume of >100 cc

•Urethra conditions that may prevent insertion of

delivery system into bladder

•Urinary incontinence due to incompetent sphincter

•Current urinary tract infection

•Current gross hematuria

•A known allergy to nickel, titanium or stainless steel

(do not memorize)

TURP Patient Education (Transurethral Resection of the prostate)

-Hold blood thinners prior to procedure (this is true for Urolift procedure as well)

-Kegel exercises can help decrease dribbling that may occur within first few weeks postop

-Blood in urine is expected for 24-48 hours

-Avoid constipation & bladder irritants

-Increase fluids and urinate every 2-3 hours

-Report s/s infection

-No heavy lifting or intercourse for 4-6 weeks

-Risk for retrograde ejaculation or erectile dysfunction

Post-TURP Continuous Bladder Irrigation (CBI)

*If urine is more bloody (red):

-Increase rate of continuous or frequency of intermittent irrigation

*If outflow obstructed i.e. no urine output:

-Release any kinks in catheter and tubing

-If no kinks, stop irrigation

-Call provider for order for manual irrigation

*If bladder spasms occur:

-Check for clots and irrigate

-Belladonna & opium (B & O) suppositories or other anti-spasmodics may help

Kidney cancer

-Removal of kidney = Nephrectomy

-Wilms Tumor:

◦ Nephroblastoma in children (usually under 5 years old, up to age 8

◦ Do not palpate the abdomen! Will see a firm mass on one side of abdomen/flank. WHY? TUMOR RUPTURE RISK!

◦ S/S: Fever, constipation, loss of appetite, N/V, hematuria, initially painless mass, then abdominal pai

Bladder cancer

-Signs/symptoms:

-Painless hematuria is most common sign

-Frequent urination

-Dark urine

-Diagnosed via cystoscopy and biopsy

-Intravesical (within the bladder) chemo agents:

-BCG Live = Vaccine for tuberculosis also used as treatment for bladder cancer (stimulates certain cells of immune system)

-Retain for 2 hours before voiding, then flush with liberal amounts of oral fluid intake

Bladder Cancer (Continued): TURBT

-Transurethral resection of bladder tumor (TURBT)

-Post-op care after TURBT

◦ Increase fluids

◦ Monitor urine color (red flecks in urine are normal for 7-10 days post-op)

◦ Sitz baths/analgesics for comfort

-Cancer recurrence can happen— will need regular cystoscopies for follow-u

Urinary Diversions for Bladder Cancer: Ileal Conduit (incontinent) Urinary Diversion

-Ileal Conduit most common

-Part of ileum (6-8 inches) is used as conduit

-Ureters attached to conduit & one end is abdominal stoma

-Bilateral ureteral stents initially

-Conduit has no valve so continuous drops of urine flow from it (must wear collection bag)

Urinary Diversions for Bladder Cancer: Bowel Pouch (continent) Urinary Diversion

-Internal pouch (similar to ileal conduit) except portion of bowel is structured to prevent leakage

-Must be catheterized every 4-6 hours

-No external bag required

-May wear bandage to catch mucus & small amount of drainage

Urinary Diversion Post-op Care

-Post-op: Assess for peritonitis and stoma ischemia/necrosis

-Abdominal pain/distention

-Nausea/vomiting

-Paralytic ileus

-Patient education:

-Moderate mucus in urine is normal

-Stoma will shrink gradually

-Appliance application (teach catheterization only if continent diversion)

-Encourage high fluid intake

-Meticulous skin care around stoma

-Oral ascorbic acid to ↓pH of urine

-Address impact on body image and sexuality

-Prevent urinary reflux into stoma to prevent infection (bag care)

*Assess stoma every 4 hours, should be red or pink

Urinary Catheter Types

Ureteral Stent

-Prevent or relieve obstructed urine flow

-Provides pain relief

-Extend length of ureters into renal pelvis

-Eventually removed or replaced

-Placed with cystoscopy, location verified per X-ray

Nephrostomy Tube

◦ Surgically placed thru skin into kidney pelvis

◦ Never kink/clamp!

◦ Handle with aseptic technique

◦ Irrigate if ordered

◦ Record urine amount separate but add total

◦ Report excessive drainage around tube or excessive pain

Urinary: Foley & Suprapubic Catheters

-Foley bed bag and leg bag

-Catheter location surgically diverted to directly above pubic bone (can be temporary or permanent)

GU Tests & Interventions (Genitourinary)

1. Urinalysis (UA) and/or Culture & Sensitivity: Clean catch specimen OR obtain from catheter

• May need to refrigerate specimen if not analyzed right away

2. 24-hour urine collection: May need to discard first void (depending on lab), restart if any voids missed

3. Post-void residual: Bladder scan or intermittent catheterization

*What is the acceptable residual amount

4. Intravenous pyelogram (IVP)

• Uses contrast dye

• No dye if allergy to IODINE or SHELLFISH!

• Contraindicated in pregnancy (x-ray and dye)

• Nephrotoxic contrast dye: Force fluids after procedure to eliminate contrast dye and prevent kidney damage

5. X-rays of kidney, ureters & bladder (KUB); Administer bowel prep IF ordered

6. Cystoscopy: Provider places scope into bladder; burning sensation & pink-tinged urine normal after procedure

7. Renal biopsy

o No aspirin or anti-coagulants for days before and provider decides when patient can resume after

o Pressure dressing after; possible bedrest for up to 24 hours. Some bloody urine expected for few days but not bright red blood or clots

o Assess for s/s of UTI

o No lifting heavy objects for 5-7 days

o May have pain at site for first few hour

General Discharge Teaching Post- GU Procedures (Review)

1. Contact HCP if increased bleeding, clots, increasing abdominal pain or severe

burning/irritation with urination, or inability to pass urine

2. Any s/s infection, fever, body aches, etc.

3. No heavy lifting and strenuous exercise

4. Restrictions on sexual activity may be included

5. Instructions to avoid straining for BM

Urine Characteristics Summary

-Lithotripsy = Red first several days (longer if stent left in place)

-TURP = Red to pink with some clots for 24-48 hours—closed irrigation may be used

-TURBT = Light red or pink; should not be bright red with clots. Red flecks 7-10 days post TURBT

-Cystoscopy = Pink-tinged urine for a few days

-Renal biopsy = Some blood in urine for few days but not bright red or clots

Sample Question

Is the following statement true or false?

Older adult patients often lack the typical symptoms of UTI and sepsis.

True
-Rationale: Older adult patients often lack the typical symptoms of UTI and sepsis. The incidence of bacteriuria in older adults differs from that in younger adults. Bacteriuria increases with age and disability, and women are affected more frequently than men. UTI is the most common infection of older adults. Early symptoms include malaise, nocturia, urinary incontinence, or a complaint of foul- smelling urine.