module 10: UTI, Pyelonephritis, Renal calculi, Orchitis/Epididymitis/BPH/Torsion, acute kidney injury, chronic kidney disease, & Renal failure

Urinary tract infection

Urinary tract infection

• Infection caused by pathogenic microorganisms in the urinary tract

• Classified by location

• 50% of all HAI

Pathophysiology of (lower) UTI

• Involves the bladder and urethra

• Bacteria gains access to the bladder, attaches to and colonizes the tract, evades host defenses, and initiates inflammation

• Result from fecal organisms ascending from the perineum to the urethera and bladder

• Reflux may occur with pressure moving urine back from the urethra to the bladder or from the bladder to the ureters

Risk factors of UTI

• Female gender

• Diabetes

• Pregnancy

• Neurological disorders

• Gout

• Altered states caused by incomplete bladder emptying

• Decreased natural host defenses or immunosuppression

• Inability or failure to empty the bladder completely

• Inflammation or abrasion of the urethral mucosa

• Instrumentation of the urinary tract

• Obstructed urinary flow caused by:

• Congenital abnormalities

• Urethral strictures

• Contracture of the bladder neck

• Bladder tumors

• Calculi (stones) in the ureters or kidneys

• Compression of the ureters

Causes of (lower) UTI

• Bacterial invasion

• Reflux

• Uropathogenic bacteria

• Via ascending infection, hematogenous spread, or direct extension

Clinical manifestations of (lower) UTI

• Uncomplicated lower UTI

  • Burning on urination

  • Urinary frequency

  • Urgency

  • Nocturia

  • Incontinence

  • Pain; back pain

  • Hematuria

• Complicated UTI

  • Asymptomatic or septic

Clinical manifestations of (lower) UTI in older adults

• Malaise

• Nocturia

• Urinary incontinence

• Foul smelling urine

• Buring

• Urgency

• Fever

• Altered LOC

Associated priorities of (lower) UTI

• Clean catch urine sample (midstream)

• Catheterized urine sample

• Urine cultures

  • 100,000 CFU/ml = infection

• Cellular studies

• Bladder scan

Usual treatment of (lower) UTI

• antibacterials/antibiotics

  • Bacteriacidals

  • Cephalosporins (ce-)

  • Fluroquinolones (-oxacin)

  • Penicillin (-icillin)

  • Trimethoprim-sulfamethoxazole

• Urinary analgesic agent

  • Phenazopyridine

    • Turns urine orange

Nursing considerations of (lower) UTI

• Pain relief

  • heat

• Education

• Increase fluids

• Avoidance of irritants

  • Coffee, tea, citrus, spices, cola, alcohol

• Frequent voiding

CAUTI

Catheter aquired urinary tract infection

Pyelonephritis

• A bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys

• Less common upper urinary tract infection

Causes of Pyelonephritis

• Upward spread of bacteria from the bladder

• spread from systemic sources reaching the kidneys via the blood stream

• Bacteria from a bladder infection ascending to the kidneys

• Incompetent ureterovesical valve or obstruction

  • Static urine increases bacterial growth

Acute manifestations of Pyelonephritis

• Chills

• Fever

• Leukocytosis

• Bacteriuria

• Pyuria

• Low back pain

• Flank pain

• Nausea

• Vomiting

• Headache

• Malaise

• Painful urination

  • Urgency frequency

Chronic manifestations of Pyelonephritis

• No symptoms of infection unless exasterbated

• Fatigue

• Headache

• Poor appetite

• Polyuria

• Excessive thirst

• Weight loss

• Can lead to chronic kidney disease

Associated priorities of Pyelonephritis

• Ultrasound

• CT scan

• IV pyelogram

• Urinalysis

• Culture and sensitivity

• Hydration

• Creatinine clearance

• BUN

• Creatinine

Treatment of acute Pyelonephritis

• Outpatient

• 2 weeks of antibiotics

  • Up to 6 weeks if infection is recurrent

• Follow up urine cultures

Treatment of chronic pyelonephritis

Long term prophylactic antimicrobial therapy

Nursing considerations of Pyelonephritis

• I&Os

  • 3-4L/day recommended

• Antipyretics and antibiotics

• Education

  • Prevention of infection

  • Fluid intake

  • Emptying of bladder

  • Hygiene

Renal calculi

• Stones in the urinary system

• Urolithiasis = stones in the urinary tract

• Nephrolithiasis = stones in the kidney

Pathophysiology of Renal calculi

• Stones form due to increase in calcium oxalate, calcium phosphate, and uric acid in urine

• Found anywhere from the kidneys to bladder

• Vary in size from sand to an orange

Risk factors of Renal calculi

• Slow kidney drainage

  • Infection

  • Urinary stasis

  • Immobility

• Increased calcium levels in blood and urine

  • Hyperparathyroidism

  • Renal tubular acidosis

  • Cancer

  • Dehydration

  • Excess vitamin D

  • Excessive intake of milk

Clinical manifestations of Renal calculi

• Distention of renal pelvis and proximal ureter

  • Blocked flow = increased hydrostatic pressure

• Infection

  • Chills

  • fever

  • Frequency

  • Excruciating pain or discomfort

  • Hematuria

  • Pyuria

  • Tenderness

  • nausea , vomiting

  • Diarrhea and abdominal pain

s/s of Renal calculi

• Renal colic

  • Acute, wavelike pain radiating down to the thigh and genetalia

  • Nausea

  • Vomiting

  • Tenderness

Associated priorities of Renal calculi

• Noncontrast CT scan

• Ultrasound

• Blood chemistries

• 24 hour urine test

• Diet and family history

• Chemical analysis of stone once passed/removed

Usual treatment of Renal calculi

• Eradicate stone

• Determine type

• prevent nephron destruction

• control infection

• relieve obstruction

• NSAIDs + opioids

• Ureteroscopy

• Extracorporeal shockwave lithotripsy

• Endourologic percutaneous stone removal

Nursing considerations of Renal calculi

• Patient education

• Nutrition

• Fluids

• s/s of UTI

Prevention of renal calculi: Education

• Avoid protein intake

• Limit sodium (3-4g/day)

• Do not limit calcium

• Avoid oxalate containing foods (spinach, chocolate, peanuts)

• Fluid intake (q1-2 hours) to dilute urine

• Cranberry juice everyday

• Avoid activities leading to excessive sweating or dehydration

Ureteroscopy

• Visualizing the stone then destroying it

• Access to the stone via ureteroscope into the ureter then inserting a lazer or ultrasound device to remove stone

• Stent may be put in place to keep the ureter patent

Extracorporeal shockwave lithotripsy

• Noninvasis proceedure used to break up sones in the kidney

• After fragmentation of the stone, remnants are spontaneously voided

• High energy pressure/shock waves are generated via the abrupt release of energy transmitted through the tissues

• “The nurse should apply electrodes for continuous monitoring of the client's cardiac rhythm during ESWL. This monitoring allows the provider to synchronize shock waves with the R wave.” (ATI)

Endourologic percutaneous stone removal

• Nephroscope is introduced percutaneously to the renal parechyma,

• depending on the size, the stone is extracted via forceps or retrieval basket

Orchitis

Acute inflammation of one or both testes as a complication of systemic infection or an extension of an associated epididymitis caused by bacterial, viral, spirochetal, or parasitic organisms

Pathophysiology of Orchitis

Microorganisms reach the testes through the blood, lymphatic system, or traveling through the urethra, vas deferens, and epididymis

s/s of Orchitis

• Fever

• Pain

• Tenderness of the teste(s)

• Testicular swelling

• Penile discharge

• Blood in semen

• Leukocytosis

Usual treatment of Orchitis

• Either bacterial or viral treatment

• Bacterial

  • Antibiotics

  • Comfort measures

• Viral

  • Rest, ice, elevation

  • Analgesics

  • Antiinflammatory meds

Epididymitis

• Infection of the epididymis

• Spread from an infected urethra, bladder, or prostate

Risk factors of Epididymitis

• Recent surgery

• High risk sexual practices

• History of STI

• Prostate infections or UTIs

• Uncircumsized

• Enlarged prostate

• Indwelling catheter

Causes of Epididymitis

• Infection due to E. coli

• Urinary obstruction

• Infection that moves upwards through the urethra en ejaculatory duct, along the vas deferense, to the epididymis

Clinical manifestations of Epididymitis

• Develops over 1-2 days

• Low grade fever

• chills

• Heaviness feeling in testicle

• Tenderness

• Pain

• Soreness

• Swelling

• Discharge

• Bloody semen

• Pyuria and bacteriuria (pus and bacteria in urine)

• Frequency

• Urgency

• Dysuria

Associated priorities of Epididymitis

• Urinalysis

• Complete CBC

• Gram stain of drainage

• Culture

• STD and HIV testing

Usual treatment of Epididymitis

• Antibiotic dependent on causitive agent

• Local anesthetic to relieve pain (through spermatic cord)

• Reduction in activity

• Scrotal support

• Antiinflamatories

• Analgesics

• Sitz baths

• Epididymectomy for recurrent, incapacitating episodes

Nursing considerations of Epididymitis

• Never ignore testicular pain (can be confused for torsion = emergency)

• Bed rest

• Intermittent cold compresses

• Local heat

• Education to avoid straining, lifting, or sexual stimulation until infection is controlled (>4 weeks)

Benign prostatic hyperplasia

• Enlarged prostate

• Noncancerous enlargement or hypertrophy of the prostate

• Common in aging men

Pathophysiology of BPH

• Usually occur with elevated estrogen levels, when the prostate tissue becomes more sensitive to estrogen and less responsive to testosterone metabolites

• Enlarged lobes of the prostate may cause obstruction of the bladder neck, causing incomplete bladder emptying and retention

Risk factors of BPH

• Smoking

• Alcoholism

• Obesity

• Sedentary lifestyle

• HTN

• Heart disease

• DM

• High animal fat and protein diet

Causes of BPH

• Develops over time due to

  • resistance on prostatic urethra to mechanical and spastic effects

  • bladder pressure during voiding,

  • detrusor muscle strength

  • neurologic function

    • general health

Clinical manifestations of BPH

• Mild to sever UTI symptoms

• Urinary frequency

• Urgency

• Nocuria

• Hesitancy in starting urination

• decreased/intermittent force of stream

• Sensation of incomplete bladder emptying

• Abdominal straining

• Decrease in volume and force of stream

• Retention and UTIs

• Fatigue

• Anorexia

• Nausea

• Vomiting

• Pelvic discomfort

Associated priorities of BPH

• History

• Voiding diary; recording of voiding frequency and volume

• Urinalysis for blood and UTI

• Ultrasound

• CBC

• Cardiac and respiratory assessment

Usual treatment of BPH

• Lasix/loop diuretic to promote urination

• Catheterization

• Alpha blockers to relax the smooth muscle of bladder neck and prostate

  • Alfuzosin

  • Terazosin

  • Doxazosin

  • Tamsulosin

  • Side effects

    • Dizziness

    • Headache

    • Fatigue

    • Orthostatic hypotension

    • Sexual dysfunction

    • Rhinitis

• 5-alpha-reducatase inhibitors for hormonal manipulation

  • Finasteride

  • Dutasteride

  • side effects

    • Decreased libido

    • Ejaculatory dysfunction

    • Erectile dysfunction

    • Brest enlargement

    • Flushing

• Avoid saw palmetto and african plum

Surgical treatment of BPH

• Application of heat via transurethral probe

• Transurethral needle ablation and insertion of stent

• Transurethral resection of the prostat (TURP)

  • Surgical removal of the inner part of the prostate through an endoscope inserted through the urethra

Torsion

• A surgical emergency requiring immediate diagnosis to avoid loss of the testicle

• Rotation of the testes, twisting the blood vessels and spermatic cord = impeding arterial and venous supply to the testicle

Clinical manifestations of Torsion

• Testicular tenderness

• Elevated testis

• Thickened spermatic cord

• Swollen, painful scrotum

s/s of Torsion

• Sudden pain in the testicle

• Nausea

• Vomiting

• Lightheadedness

• Swelling

Usual treatment of Torsion

• Manual untwisting

• Surgery within 6 hours to untwist and anchor testes in position

Acute kidney injury (AKI)

• A rapid loss of renal function due to damage to the kidneys

• Rapid onset in hours and is potentially reversible

• 50% mortality

Pathophysiology of AKI

• Not always known but may have a specific cause

• May be reversible if identified and treated ASAP before impairment

• Reduced blood flow to the kidneys and inpaired function

Classification of AKI

• RIFLE system

  • Grades (causes)

    • Risk

    • Injury

    • Failure

  • Outcomes requiring renal replacement therapy

    • Loss

    • ESKD

Causes of AKI

• Hypovolemia

• Hypotension

• Reduced cardiac output

• HF

• Obstruction in the kidneys

• Blood clot

• Kidney stone

Nursing considerations of AKI

• Health History

• Medications

• Surgeries

• Hospilations

• Physical Examination

• Hydration levels

• I&Os

Prerenal category of AKI

• Hypoperfusion of the kidneys

• Sudden and severe drop in BP or interruption of blood flow to the kidneys caused by volume depletion, hypotention, and obstruction of renal vessels

• Volume depletion

• Impaired cardiac efficiency

• Vasodilation

Prerenal AKI characteristics

• Increased BUN

• Increased creatinine

• Decreased output

• Sodium <20mEq/L

• Normal sediment

• Urine osmolality >500mOsm

• Increased urine specific gravity

Intrarenal category of AKI

• Result of damage to the glomerui or tubules

• due to inflammation, toxins, drugs, infection, or reduced blood supply

• Prolonged renal ischemia

• Nephrotoxic agents

• Infection

Intrarenal AKI characteristics

• Increased BUN

• Increased creatinine

• Decreased output

• Sodium >40mEq/L

• abnormal casts and debris

• Urine osmolality ~350mOsm

• low urine specific gravity

Postrenal category of AKI

• Results from obstruction of the distal end of the kidney

• Due to stones, blood clots. BPH, malignancies, and pregnancy

• Obstruction

Postrenal AKI characteristics

• Increased BUN

• Increased creatinine

• Decreased output or anuria

• Sodium <20mEq/L

• Normal sediment

• Varying osmolality

• varying urine specific gravity

Initiation phase of AKI

• Initial insult to the kidney

• Changes in electrolytes and initially decreased urine output

Oliguria phase of AKI

• increase of concentrations (urea, creatinine, uric acid, electrolytes, etc)

• Uremia = concentrated urine

• Monitoring of BUN, creatinine, and GFR

Diuresis phase of AKI

• Gradual increase in urine output

• Lab values stabilize and decrease

• Filtration of urea and creatinine have not returned to normal

• Observe for dehydration

Recovery phase of AKI

• Improvement of renal function

• 3-13 months

• Normal labs

Renal failure

Decreased renal function with increasing nitrogen retention

Clinical manifestations of Renal failure

• Critically ill and lethargic

• CNS s/s = drowsiness, headache, muscle twitching, seizures

Associated priorities of Renal failure

• Evaluation of urine

• Kidney contour

• Lab values

Usual treatment of Renal failure

• Restoration of normal chemical balance

  • Potssium levels = cation exchange resins

  • EKG changes = IV dextrose 50%, insulin, calcium replacement

• Fluids

• Diuretics to initiate diuresis

  • Loop

  • Thiazide

• Blood transfusions

• Dialysis

• Nutritional support

Nursing considerations of Renal failure

• Monitoring fluid and electrolytes

• Reduce metabolic rate

  • Prevention of fever and infection

• Promotion of pulmonary function

  • Positioning

  • Coughing

• Preventing infection

  • Asepsis

• Skin care

• Psychosocial support

Hemodialysis

procedure that circulatess the patient’s blood through a machine to remove waste products and excess fluid

Hemodialysis access

• AV fistula (atery and vein fused together)

  • Central line catheter for dialysis until fistula or shunt is ready

• Shunt

• Graft catheter

Hemodialysis interval

• 3-4 hours

• 3 days/week

• Outpatient

Hemodialysis actions

• The blood, with toxins and wastes, is diverted fro, the patient to a machine where the toxins are filteres and clean blood is returned to the body

• Diffusion moves the toxins and wastes

• Osmosis moves the excess fluid

• ultrafiltration moves the fluid from high to low pressure

Peritoneal dialysis

procedure that uses the patient’s perironeal membrane as the semipermiable membrane to exchange fluid and solutes

Peritoneal dialysis access

abdomen

Peritoneal dialysis actions

• Removal of toxic substances and wates for patients unable to undergo HD or transplantation

• Peritoneal membrane thatcovers the abdominal organs and lines the abdominal wals serves as the semipermiable membrane

• Sterile dialysate fluid with dextrose and electrolytes is put into the peritoneal cavity through a catheter

• Toxins begin to clear from the blood

• Diffusion

• Clearance

• Ultrafiltation

Continuous renal replacement therapy

methods used to replace normal kidney function by circulating the patient’s blood through a hemofilter

Chronic kidney disease

• Kidney damage rewuiring permanent RRT/dialysis

• ESKD

Pathophysiology of Chronic kidney disease

• Renal function delines, causing the end products of protein metabolism (that are normally excreted) to accumulate in the blood

• Uremia develops and effects the whole body

Clinical manifestations of Chronic kidney disease

• End stage kidney disease (ESKD)

• Behavior changes

• Confusion; disorientation

• Seizures

• Ecchymosis

• HTN

• Pitting edema

• Engorged neck veins

• Crackles

• Tachypnea

• Anorexia, nausea, vomiting

• Anemia

• Infertility

• Fractures

• Loss of muscle strength

Associated priorities of Chronic kidney disease

Maintain kidney function and homeostasis for as long as possible

Usual treatment of Chronic kidney disease

• Dialysis

• Calcium and phosphorus binders (binds dietary phosphorus in the GI tract)

• Antihypertensives

• Fluid restriction

• Low sodium diet

• Diuretics

• Erythropoitin to continue RBC production

Nursing considerations of Chronic kidney disease

• Assess fluid status

• Potential sources of imbalance

• Renal dietitian

• Self care and independence

• Education

• Emotions; support; quality of life