Renal and Urological Problems

Nursing Management: Renal and Urological Problems

Infectious and Inflammatory Disorders of the Urinary System

  • A wide range of renal and urological disorders contribute to impaired elimination.

  • The diverse causes of these disorders may involve infectious, immunological, obstructive, metabolic, collagen-vascular, traumatic, congenital, neoplastic, and neurological mechanisms.

Urinary Tract Infection (UTI)

  • Definition: The most common bacterial infection in women.

  • Common Pathogen: Escherichia coli is the most common pathogen that causes a UTI.

Classification of UTIs

  • Upper or Lower UTI:

    • Upper UTI: Infection involving the renal parenchyma, pelvis, and ureters; typically causes fever, chills, and flank pain.

    • Lower UTI: Confined to the bladder, does not usually present systemic symptoms.

  • Complicated or Uncomplicated:

    • Uncomplicated UTIs: Occur in an otherwise normal urinary tract, usually only involve the bladder.

    • Complicated UTIs: Include existing obstruction, stones, catheters, diabetes or neurological diseases, or pregnancy-induced changes.

Aetiology and Pathophysiology

  • Organisms are typically introduced via the ascending route from the urethra, originating in the perineum.

  • Common culprits include gram-negative bacilli from the gastrointestinal tract.

  • Gram-positive organisms such as streptococci, enterococci, and Staphylococcus saprophyticus can also cause UTIs.

Signs and Symptoms

  • Painful urination.

  • Abdominal or back pain.

  • Fever.

  • Sepsis.

  • Decreased kidney function.

Lower Urinary Tract Symptoms (LUTS)

  • Emptying Symptoms:

    • Hesitancy: Difficulty starting the urine stream.

    • Intermittency: Delay between initiation and beginning of urine flow.

    • Post-void dribbling: Urine loss after completing voiding.

    • Urinary retention or incomplete emptying: Inability to empty from the bladder.

  • Storage Symptoms:

    • Urinary frequency: Occurring more than eight times in 24 hours.

    • Urgency: Sudden, strong desire to void immediately.

    • Incontinence: Involuntary urine loss.

    • Nocturia: Awakened by urge to void two or more times during sleep.

    • Nocturnal enuresis: Loss of urine during sleep.

Diagnostic Studies and Interprofessional Care

  • Diagnostic:

    • History and physical examination.

    • Urinalysis: Obtain midstream, 'clean-catch' voided specimen.

    • Urine culture and sensitivity (if indicated).

    • Imaging studies: CT urogram, Intravenous pyelogram, cystoscopy, ultrasound (if indicated).

  • Interprofessional Therapy Uncomplicated UTI:

    • Antibiotics:

    • Trimethoprim/sulfamethoxazole.

    • Trimethoprim (if allergic to sulfa).

    • Nitrofurantoin.

    • Patient Teaching: Adequate fluid intake (six 250 mL glasses/day).

  • Recurrent Uncomplicated UTI:

    • Repeat urinalysis, urine culture and sensitivity testing.

    • Imaging study (if indicated).

    • Sensitivity-guided antibiotic therapy (ampicillin, amoxicillin, first-generation cephalosporin, fluoroquinolones).

    • Consider a 3- to 6-month trial of prophylactic antibiotics, and post-coital prophylaxis with specific agents.

Nursing Management: Urinary Tract Infection

  • Nursing Assessment:

    • Subjective Data:

    • Health history including previous UTIs, surgeries, medications (antibiotics, anticholinergics, antispasmodics).

    • Functional health patterns: urinary hygiene, nutritional intake (nausea, vomiting, anorexia).

    • Objective Data:

    • General assessment: fever, chills.

    • Urinary findings: haematuria, cloudy urine, tender kidneys.

  • Nursing Implementation:

    • Health Promotion: Encourage proper urinary hygiene, adequate fluid intake, and regular bladder emptying.

    • Prevention of CAUTI: Minimize catheter use, employ aseptic techniques, and ensure hand hygiene.

    • Acute Care: Ensure adequate hydration and patient comfort while avoiding bladder irritants.

Patient Teaching: UTI

  • Emphasize:

    1. Completion of all prescribed antibiotics.

    2. Proper hygiene practices.

    3. Regular urination before and after sexual intercourse.

    4. Adequate fluid intake.

    5. Reporting symptoms of recurrent UTI.

    6. Consideration of cranberry juice for prevention.

Acute Pyelonephritis

  • Aetiology and Pathophysiology:

    • Inflammation of the renal parenchyma.

    • Causative Agents: Bacterial (e.g., E. coli, Proteus), fungi, protozoa, viruses.

    • Commonly begins in the renal medulla and spreads to the cortex.

Signs and Symptoms

  • Mild fatigue, chills, fever, vomiting, malaise, flank pain.

  • LUTS characteristic of cystitis.

Interprofessional Care

  • Diagnostic Studies:

    • History and physical examination, urinalysis, urine culture, imaging studies, blood work (WBC count).

  • Therapy:

    • Outpatient with broad-spectrum antibiotics for mild symptoms, shifting to sensitivity-guided therapy as needed.

    • Hospitalization and parenteral antibiotics for severe symptoms.

Nursing Management

  • Planning: Aims for normal renal function, body temperature, and no symptom recurrence.

  • Nursing Implementation: Educate about medication adherence and follow-up, encourage fluid intake, and rest.

Chronic Pyelonephritis

  • Description: Continuous kidney infection leading to inflammation and fibrosis, potential loss of renal function.

Immunological Disorders: Glomerulonephritis

  • Definition: Inflammation affecting both kidneys equally; can be acute or chronic.

  • Causes: Include infections, immune diseases (SLE, IgA nephropathy), vasculitis, and other conditions.

Urinary Obstruction

  • Definition: Anatomical or functional condition impeding urine flow affecting the system above the obstruction. Severity depends on location, duration, pressure, and urinary stasis.

Consequences of Urinary Obstruction

  • Increased bladder pressure leading to reflux, hydroureter, hydronephrosis, and potential renal atrophy with long-term obstruction.

Urinary Tract Calculi: Aetiology and Pathophysiology

  • High concentration urine forms crystals leading to stones. Factors include urine pH and solute load.

Risk Factors for Urinary Tract Calculi

  • Metabolic, genetic, dietary, lifestyle factors affecting stone formation.

Types of Urinary Calculi

  • Calcium oxalate, calcium phosphate, struvite, uric acid, cystine with various treatment protocols.

Signs and Symptoms of Kidney Stones

  • Severe flank pain, nausea, vomiting, with signs associated with UTIs.

Nursing Management: Urinary Tract Calculi

  • Assessment: Subjective and objective data regarding history, symptoms, and diagnostics including imaging.

  • Nursing Implementation: Lifestyle changes, pain management, and straining all urine.

Strictures

  • Definition: Narrowing of the ureter or urethra due to trauma or inflammatory changes affecting urine flow.

  • Symptoms: Reduced urinary stream, post-void dribbling, frequency, and potential acute urinary retention.

Renal Vascular Problems

  • Include nephrosclerosis, renal artery stenosis, and renal vein thrombosis impacting kidney function and management options.

Hereditary Kidney Diseases

  • Primarily involve cystic changes impacting renal function, evaluation via radiological imaging.

Polycystic Kidney Disease (PKD)

  • Two forms: childhood (autosomal recessive) and adult (autosomal dominant). Symptoms include hypertension, haematuria, and abdominal discomfort.

Urinary Tract Tumours: Kidney Cancer

  • Most commonly renal cell carcinoma; risk factors include smoking and certain occupational exposures. Symptoms often manifest in advanced stages.

Urinary Tract Tumours: Bladder Cancer

  • Transitional cell carcinoma is prevalent with associated risks from smoking and history of chronic UTI. Symptoms include haematuria and bladder irritability.

Interprofessional Care for Urinary Tumours

  • Emphasis on diagnostic imaging, surgical intervention, and multidisciplinary support.

Urinary Incontinence

  • Diverse types including stress, urge, overflow, reflex, and functional, each requiring tailored management approaches.

Interventions for Urinary Incontinence

  • Lifestyle modifications, scheduled voiding regimens, and use of devices like pessaries or external catheters.

Urinary Retention

  • Characterized by inability to empty the bladder. Causes include outlet obstruction or weak bladder contraction; interprofessional care may include catheterization and medications.

Medications to Reduce Voiding Dysfunction

  • Including anticholinergics, adrenergic antagonists, and hormone therapies tailored to specific incontinence types.

Indications for Catheterization

  • Emergency relief measures, diagnostic procedures, or management of chronic conditions.

Complications of Catheterization

  • Risks include CAUTI, bladder spasms, and urethral injury; careful technique and maintenance are critical.

Types of Catheters

  • Include urethral, ureteral, suprapubic, and nephrostomy tubes with specific applications and care protocols.

Surgery of the Urinary Tract

  • Indications include neoplasms, obstruction due to calculi, or congenital defects requiring surgical correction or renal transplant.