MS Exam 1--WK3

Urinary Tract Infection

Urinary Tract Infection

· Infection of urinary tract can be upper, lower, & both

· UTIs in women are prevalent across the lifespan

· UTIs in men are prevalent in geriatrics (incontinence)

· Most often UTIs result from E.Coli

Risk for UTIs

Diabetes, Pregnancy, Neurological disorders, Stool incontinence, Immunosuppression, Obstructed urinary flow: (Stones, tumors, or compression), Inability to empty bladder

Infections of the Lower Urinary Tract

Interstitial Cystitis, Bacterial prostatitis, Bacterial urethritis

Interstitial Cystitis

Inflammation of the bladder

Bacterial prostatitis

Inflammation of the prostate

Bacterial urethritis

Inflammation of the urethra

Bacteria enter the urinary tract (UTI)

Infections of the Lower Urinary Tract

what is ascending and the most common?

Transurethral route

Transurethral route

Poor technique inserting catheter, poor Foley care, incorrect wiping, etc...

Antibacterial defenses

Sphincters, urine flow, large amounts of urinary output, and pH.

Females--lower UTI

Shorter urethra than males, incorrect wiping exposing E. coli to the urethra

Males--lower UTI

Enlarged prostate impeding urine flow leading to incomplete bladder emptying and urinary stasis

Lower UTI s/s

Burning, frequency, fever, cloudy urine, odor, & pain

lower UTI Older adults

nonspecific s/s; fatigue, nocturia, incontinence, confusion, lethargy, anorexia. **UTI is the most common cause of acute bacterial sepsis in patients 65+.

what can UTIs trigger in elderly patients?

episodes of intense delirium

Lower UTI Assessment

Urine cultures & gram stain to determine type & number of bacteria

purpose of tests?

rule out STIs

test results for lower UTIs?

· WBCs elevated; neutrophils elevated (bacteria)

Lower UTI Management

· Surgery if recurrent UTI causes abnormalities

· Increase fluid intake 3000mL per day

· Administer antibiotics, antimicrobials. Longer antibiotics work for men, pregnant women, pyelonephritis, & complicated UTIs. Long term antibiotics maybe used up to 7 months for recurrent episodes.

· Finish antibiotics

· Administer analgesics & antispasmodics

more lower UTI management

· Encourage voiding every 2-3 hrs, completely emptying bladder

· Monitor I & O, urine characteristics

· Complications: Sepsis & renal failure

· Women: wipe front to back, keep perineum clean & dry, void after intercourse.

· Educate pt on side effects of UTI & how to manage s/s

Pyridium

can turn your urine reddish- orange & protect their clothing. Med will stain clothes.

Upper UTIs

Pyelonephritis

Pyelonephritis

· Infection of renal pelvis & tubules.

how does Pyelonephritis present?

· chills, fever, leukocytosis, bacteriuria, pyuria, costovertebral pain & tenderness

where do upper UTIs develop?

Infection develops in the lower part of the body then moves up as its not treated then develops systemic s/s

upper UTIs diagnostics

· US

· CT Scan

· IV Pyelogram

· Nuclear Scan

· Urine cultures & sensitivity.

upper UTI management

· Bed rest until s/s subside

· Encourage fluids ** at least 1500mL per day

· Monitor I & Os

· Oliguria (less than 400mL per day * maintain low protein high calorie diet

· Observe for renal failure & edema

· Antibiotics: take entire course as prescribed always!!

Risk Factors for Urinary Incontinence

· Pregnancy-Vaginal delivery, episiotomy

· Menopause-Due to loss of estrogen

· Genitourinary surgery

· Pelvic muscle weakness

· Incompetent urethra due to trauma or sphincter relaxation

· High-impact exercise

· Diabetes

· Stroke

· Age-related changes

· Morbid Obesity

· Cognitive Disorders-Dementia, Parkinson's

· Medications-Diuretics

· Immobility-Caregiver or bathroom unavailable

Stress incontinence

· involuntary loss of urine as a result of sneezing, coughing, or changing position. Ex: Women w/ vaginal delivery or Men after prostatectomy (no pressure against urethra anymore)

Urge Incontinence

involuntary loss of urine associated w/ strong urge to void preceded by warning of. A few seconds to few minutes; leakage period to frequent. Urinate frequently is most common

Functional Incontinence

urinary tract function intact but severe cognitive impairment makes it difficult to identify the need to void or physial impairments. patient can't make it to restroom in time

Latrogenic Incontinence

· loss of urine due to extrinsic medical factors; can affect receptors responsible for bladder, neck closing pressure, bladder neck relaxes to point of incontinence.

Management of Incontinence

· PCP may not treat due

· Sometimes incontinence can be reversible

· Elderly incontinence: inability to maintain independence lifestyle, increased dependence on caregivers

· Behavioral therapies are the first choice-Kegel exercises, fluid management, voiding habits.

· Pharmacologic therapy works best when used as an adjunct to behavioral interventions.

Medications for Incontinence

· Anticholinergics inhibit bladder contraction for urge incontinence.

· Tricyclic antidepressants (amitriptyline) increase bladder neck resistance and decrease bladder contraction for each type of incontinence.

· Pseudoephedrine (Sudafed) to improve retention for stress incontinence.

urine retention

Associated w/ overflow incontinence: bladder distends until incontinence occurs

what drugs can induce urine retention?

antihypertensives (hydralazine), Antiparkinson (levodopa), Antihistamines, Anticholinergics, antispasmodics, sedatives, anesthesia

Residual urine

urine that remains in the bladder after voiding

what are the ranges of residual urine?

· <60 = no residual

· >60 = 50-100mL normal due to decreased contractility of muscle

complications of urine retention

renal calculi, pyelonephritis, & sepsis

what is most required w/ urine retention?

Decompression w/ urethral catheter

some more treatment for urine retention?

· Promote voiding by assisting pt to bathroom every 2 hours, normal position of elimination, Crede's maneuver (applying pressure over bladder)

Crede's maneuver

applying pressure over bladder

Neurogenic bladder

Spastic(reflex) and Flaccid(hypotonic)

Spastic(reflex) bladder

• more common in result of upper spinal cord lesion, too many contractions of bladder

Flaccid(hypotonic)bladder

less common result of lower spinal cord lesion, not able to contract the bladder. Bladder distends until overflow incontinence occurs

causes of neurogenic bladder

Spinal cord, injury, MS, Parkinson's, Stroke, Spina Bifada, Diabetes

Neurogenic bladder Interventions

• Continue self cath, condom cath/ purewick, low calcium diet to prevent renal calculi due to stasis & encouragement of mobility & ambulation.

med for neurogenic bladder

Bethanechol (Urecholine) to increase contraction of muscle

What do you never do?

NEVER REMOVE A CATHETER THAT UROLOGY HAS PLACED W/ OUT AN ORDER

Calculi

Stones are formed when urinary concentrations of calcium, oxalate, & uric acid increase-75% of stones are Ca based (Do not worry about the struvite or cysteine stones)

Urolithiasis

stones in urinary tract

Nephrolithiasis

stones in the kidneys

What do s/s depend on?

· the presence of obstruction, infection, and edema, but pain is common

calculi s/s

• Severe flank pain (VS changes indicating pain), Fever, Diaphoresis, N/V, Hematuria, Oliguria/anuria if flow obstructed (emergency finding)

calculi diagnostics

• Urinalysis: evaluate pH, specific gravity, & osmolality

• Xray: confirm presence of stone

• CT/MRI or Renal Ultrasound

Extra Corporeal Shock Wave Lithotripsy (ESWL)

· Noninvasive

ESWL procedure

· Lie on a water-filled cushion, surgeon uses X-rays or ultrasound tests to precisely locate the stone.

· High-energy sound waves pass through the body without injuring it and break the stone into small pieces.

· Small pieces move through the urinary tract and out of the body more easily than a large stone.

what is monitored during the ESWL

· Cardiac monitoring as waves is synchronized to the R wave

how long does ESWL take?

about 1 hour

what must you do after ESWL procedure?

· Must strain urine once at home & return stones to MD for analysis

Goals and interventions of calculi

address relief of pain, prevention of recurrence, and absence of complications

nursing care of calculi

· Encourage fluid intake (3L +); IV fluids if ordered

· Strain all urine for passage of calculus

Pain management of calculi

opioids, NSAIDS, antispasmodics

If stones are Ca -

reduce animal protein, limit sodium intake, Ca intake individualized

Hydronephrosis

• Swelling of the kidney due to a buildup of urine

priority when pt has hydronephrosis?

• Relieving the obstruction in the ureter

how do you relieve the obstruction in the ureter?

stenting

most common s/s of cancer of the bladder

Painless gross hematuria

Tx of cancer of the bladder

medications, radiation, or surgery

what is often needed with cancer of the bladder?

• Creation of urinary diversion (urostomy & nephrostomy)

RF for bladder cancer

CIGARETTE SMOKING, Environment carcinogens (dyes, rubber, lether, ink, pain), Pelvic radiation therapy, Cancers from prostate, colon, & rectum, Bladder stones, High urinary pH, Recurrent or chronic bacterial infections of urinary tract

Ileal Conduits

• Piece of bowel used to create new "bladder" the kind of bowel used & the kind of bladder made decides the conduits name.

what may be in the urine used of pts with ileal conduits?

mucous

who uses ileal conduits?

pt w/ bladder cancer

what are conduits that collect stool?

Kock's Pouch

Nursing Management of conduits

• Monitor urine output closely during initial period

• Educate pt on managing device at home.

what to monitor with ileal conduit?

stoma site

monitoring stoma site

o Should be beefy red. Purple, black, pale = ischemia or necrosis

o Inspect surrounding skin for irritation from urine

BPH (benign prostatic hyperplasia) treatments--meds

tamulosin and finasteride

Alpha adrenergic blockers (tamulosin)

improve flow

DHT- lowering medications (finasteride)

decrease testosterone & size of prostate

what to know about finasteride?

o Teratogenic! Avoid if childbearing age

o Measures to reduce pain & spasms

o Catheter for acute condition; unable to void

Surgical treatment of BPH

o Minimal invasive therapy

o Surgical resection

o TURP (Transurethral Resection of the Prostate)

Transurethral Resection of the Prostate (TURP)

· Benchmark for surgical treatment for BPH

TURP procedure

· Patient will usually have a 3-way catheter post procedure

o Continuous bladder irrigation to keep output light pin

what should you avoid with TURP?

· Avoid heavy lifting and sexual activity for 2-6 weeks

· Avoid bladder stimulants (caffeine and alcohol)

Prostate Cancer

· Second most common cancer and the second most common cause of cancer death in men

prostate cancer risk factors

· age, familial predisposition, and African American race

prostate cancer early s/s

few or no symptoms

What may be the first manifestations of prostate cancer?

Symptoms of metastasis

Manifestations of prostate cancer

Symptoms of urinary obstruction, blood in urine or semen, painful ejaculation

Treatment of prostate cancer

· therapeutic vaccine, radiation brachytherapy, prostatectomy, TURP, hormonal therapy, or chemotherapy

what to educate a pt with prostate cancer?

home care

regaining bladder continence

Avoidance of straining, heavy lifting, long car trips (6-8 wks)

Diet: encourage fluids and avoid coffee, alcohol, & spicy foods

Assessment & referral of sexual issues

Disorders Affecting the Testes & Adjacent Structures

Orchitis, Epididymitis, Testicular torsion, Testicular cancer

which of these disorders is an EMERGENCY?

Testicular torsion

Testicular torsion

o Sudden testicular pain

o Must be reduced within 6 hours or loss of testicle

Orchitis

inflammatory response to systemic infection or epididymitis

Orchitis s/s

swelling, blood in semen, tenderness, s/s of co-occurring infection

tx of orchitis

Treat causative problem (could be same as epididymitis)

Epididymitis

inflammation (infection?) of the epididymis