MS Exam 1--WK3

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Urinary Tract Infection

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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

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Risk for UTIs

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

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Infections of the Lower Urinary Tract

Interstitial Cystitis, Bacterial prostatitis, Bacterial urethritis

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Interstitial Cystitis

Inflammation of the bladder

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Bacterial prostatitis

Inflammation of the prostate

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Bacterial urethritis

Inflammation of the urethra

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Bacteria enter the urinary tract (UTI)

Infections of the Lower Urinary Tract

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what is ascending and the most common?

Transurethral route

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Transurethral route

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

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Antibacterial defenses

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

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Females--lower UTI

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

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Males--lower UTI

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

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Lower UTI s/s

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

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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+.

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what can UTIs trigger in elderly patients?

episodes of intense delirium

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Lower UTI Assessment

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

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purpose of tests?

rule out STIs

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test results for lower UTIs?

· WBCs elevated; neutrophils elevated (bacteria)

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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

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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

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Pyridium

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

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Upper UTIs

Pyelonephritis

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Pyelonephritis

· Infection of renal pelvis & tubules.

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how does Pyelonephritis present?

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

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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

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upper UTIs diagnostics

· US

· CT Scan

· IV Pyelogram

· Nuclear Scan

· Urine cultures & sensitivity.

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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!!

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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

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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)

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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

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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

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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.

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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.

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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.

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urine retention

Associated w/ overflow incontinence: bladder distends until incontinence occurs

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what drugs can induce urine retention?

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

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Residual urine

urine that remains in the bladder after voiding

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what are the ranges of residual urine?

· <60 = no residual

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

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complications of urine retention

renal calculi, pyelonephritis, & sepsis

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what is most required w/ urine retention?

Decompression w/ urethral catheter

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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)

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Crede's maneuver

applying pressure over bladder

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Neurogenic bladder

Spastic(reflex) and Flaccid(hypotonic)

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Spastic(reflex) bladder

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

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Flaccid(hypotonic)bladder

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

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causes of neurogenic bladder

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

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Neurogenic bladder Interventions

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

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med for neurogenic bladder

Bethanechol (Urecholine) to increase contraction of muscle

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What do you never do?

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

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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)

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Urolithiasis

stones in urinary tract

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Nephrolithiasis

stones in the kidneys

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What do s/s depend on?

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

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calculi s/s

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

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calculi diagnostics

  • Urinalysis: evaluate pH, specific gravity, & osmolality

  • Xray: confirm presence of stone

  • CT/MRI or Renal Ultrasound

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Extra Corporeal Shock Wave Lithotripsy (ESWL)

· Noninvasive

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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.

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what is monitored during the ESWL

· Cardiac monitoring as waves is synchronized to the R wave

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how long does ESWL take?

about 1 hour

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what must you do after ESWL procedure?

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

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Goals and interventions of calculi

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

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nursing care of calculi

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

· Strain all urine for passage of calculus

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Pain management of calculi

opioids, NSAIDS, antispasmodics

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If stones are Ca -

reduce animal protein, limit sodium intake, Ca intake individualized

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Hydronephrosis

  • Swelling of the kidney due to a buildup of urine

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priority when pt has hydronephrosis?

  • Relieving the obstruction in the ureter

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how do you relieve the obstruction in the ureter?

stenting

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most common s/s of cancer of the bladder

Painless gross hematuria

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Tx of cancer of the bladder

medications, radiation, or surgery

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what is often needed with cancer of the bladder?

  • Creation of urinary diversion (urostomy & nephrostomy)

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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

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Ileal Conduits

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

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

mucous

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who uses ileal conduits?

pt w/ bladder cancer

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what are conduits that collect stool?

Kock's Pouch

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Nursing Management of conduits

  • Monitor urine output closely during initial period

  • Educate pt on managing device at home.

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what to monitor with ileal conduit?

stoma site

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monitoring stoma site

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

o Inspect surrounding skin for irritation from urine

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BPH (benign prostatic hyperplasia) treatments--meds

tamulosin and finasteride

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Alpha adrenergic blockers (tamulosin)

improve flow

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DHT- lowering medications (finasteride)

decrease testosterone & size of prostate

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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

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Surgical treatment of BPH

o Minimal invasive therapy

o Surgical resection

o TURP (Transurethral Resection of the Prostate)

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Transurethral Resection of the Prostate (TURP)

· Benchmark for surgical treatment for BPH

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TURP procedure

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

o Continuous bladder irrigation to keep output light pin

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what should you avoid with TURP?

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

· Avoid bladder stimulants (caffeine and alcohol)

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Prostate Cancer

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

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prostate cancer risk factors

· age, familial predisposition, and African American race

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prostate cancer early s/s

few or no symptoms

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What may be the first manifestations of prostate cancer?

Symptoms of metastasis

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Manifestations of prostate cancer

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

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Treatment of prostate cancer

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

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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

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Disorders Affecting the Testes & Adjacent Structures

Orchitis, Epididymitis, Testicular torsion, Testicular cancer

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which of these disorders is an EMERGENCY?

Testicular torsion

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Testicular torsion

o Sudden testicular pain

o Must be reduced within 6 hours or loss of testicle

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Orchitis

inflammatory response to systemic infection or epididymitis

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Orchitis s/s

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

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tx of orchitis

Treat causative problem (could be same as epididymitis)

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Epididymitis

inflammation (infection?) of the epididymis

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