Urology

Urosepsis

• Urologic source of sepsis.
• Requires prompt diagnosis and treatment to prevent septic shock and possible death.

Signs and Symptoms of Sepsis

• Hypotension
• Tachycardia
• Fever
• Increased white blood cell count
• Infusion
• Possible organ failure
• Patient may be clammy or tired
• Tachypnea (increased respirations)

Risk Factors for Pyelonephritis

• Vesicoureteral reflux: Backward movement of urine from the bladder to the upper urinary tract.
• Lower urinary tract dysfunction:
  • Benign Prostatic Hyperplasia (BPH)
  • Urinary stones
  • Stricture: Narrowing of the ureters
• Catheter-associated urinary tract infection (CAUTI):
  • Bacteria introduced via catheter (foreign object).
  • Common in long-term care patients (SNFs).

Clinical Manifestations of Pyelonephritis

• Fatigue
• Chills
• Fever
• Vomiting
• General malaise
• Signs and symptoms of cystitis (lower UTI):
  • Dysuria (painful urination)
  • Frequency
  • Urgency
• Flank pain (key indicator):
  • Patients may describe it as lower back pain.

Diagnosis of Pyelonephritis

• History and Physical Examination (H&P):
  • Questions about frequency of bladder emptying.
  • History of STDs.
  • Hygiene practices.
  • Fluid intake (types of fluids).
• Physical Examination:
  • Costovertebral angle (CVA) tenderness.
• Lab Results:
  • Urinalysis:
    • Pyuria
    • Bacteriuria
    • Hematuria.
  • Urine Culture and Sensitivity:
    • Identifies bacteria and appropriate antibiotics.
  • Complete Blood Count (CBC) with WBC differential:
    • Leukocytosis (inflammatory response).
    • Immature neutrophils (bands).
  • Blood culture: To check for systemic infection.
• Diagnostic Studies:
  • Ultrasound: To assess for anatomic abnormalities or hydronephrosis.
  • CT urogram: To assess for signs of infection in the kidneys.

Management of Pyelonephritis

• Outpatient management is possible depending on symptom severity.
• Encourage adequate fluid intake, at least 32 ounces.
• NSAIDs for pain and antipyretics for fever.
• Follow-up urine culture to confirm clearance of infection.
• Drug Therapy:
  • Start with broad-spectrum antibiotics.
  • Adjust based on urine culture results.
• For severe cases:
  • Admit the patient.
  • Obtain culture and sensitivity and urinalysis.
  • Start IV antibiotics.

Key Considerations for Treatment

• Obtain urine culture before starting antibiotics.
• Manage pain while waiting culture results.
• For discharged patients, ensure adherence to antibiotic course to prevent resistance.
• Follow up with repeat urine culture to ensure infection is cleared.

Priority Problems

• Pain
• Impaired urinary elimination.

Health Promotion

• Identify and treat patients at risk for cystitis to prevent ascending UTI.
• Stress the importance of adherence to treatment and follow-up urine cultures.
• Educate patients to recognize early signs and symptoms of recurrence or relapse.
• Encourage fluids and rest.
• Some patients may need long-term, low-dose antibiotic therapy to prevent relapses.

Renal Calculi (Kidney Stones)

• Urolithiasis: Stones in the urinary tract.
• Nephrolithiasis: Stones in the kidneys.
• More common in men and Caucasians.
• Risk Factors:
  • Family history of stone formation.
  • Previous history of renal calculi.
  • Dehydration, especially in summer months.
• Contributing Factors:
  • Metabolic abnormalities (increased urine levels of calcium or oxalate).
  • Large intake of dietary proteins.
  • High intake of teas, juices, and colas.
  • Sedentary lifestyle.

Pathophysiology

• Urine contains more crystal-forming substances than the urine can dilute.
• Crystals build up and stick together forming renal calculi.
• Obstruction leads to pain.
• Factors impacting:
  • Urine pH (alkaline or acidic).
  • Obstruction.
  • UTIs.

Types of Urinary Stones

• Calcium oxalate/phosphate
• Struvite
• Uric acid
• Cystine

Clinical Manifestations

• Renal colic: Sharp, severe pain in the flank area, back, or lower abdomen.
  • Pain may radiate to the groin.
  • Patients may have difficulty walking or standing still.
• Nausea and vomiting due to severe pain.
• Common Sites of Obstruction:
  • Ureteropelvic junction (UPJ).
  • Ureterovesical junction (UVJ).

Complications of Renal Calculi

• Pyelonephritis.
• Kidney injury or kidney failure.
• Stricture and scarring.
• Renal infection.
• Hydronephrosis.
• Kidney damage.

Diagnostic Studies

• Non-contrast helical or spiral CT scan.
  • Non-contrast to avoid further kidney damage.
• Urinalysis:
  • Hematuria.
  • Crystalluria.
  • Urine pH assessment.
• Stone retrieval and analysis.

Management

• Acute Management:
  • Pain management (priority).
  • Treat infection.
  • Alpha-adrenergic blockers (e.g., Flomax) to relax smooth muscles and facilitate stone passage.
• Stone Retrieval and Analysis.
• Prevention of Further Stone Development:
  • H&P.
  • Gather information on family history, patient history, location/climate and current fluid intake and diet.
  • Nutritional assessment based on stone analysis.

Managing Patients with Calculi

• Treat their pain (priority).
• Prevent or treat infection.
• If patient receives contrast and is allergic:
  • The patient need to be aware that they had an allergic reaction.
  • Notify their provider and show their provider the relevant identification card/documentation.

Nutritional Therapy

• Adequate fluid intake: Avoid forcing fluids.
• Encourage patient to walk around if pain is managed.
• Decrease coffee, teas, and colas.
• Decrease sodium intake.

Priority Problems

• Acute pain
• Impaired urinary elimination
• Possible deficient knowledge

Goals

• Pain management.
• Relieving any obstructions.
• Patient understands how to prevent future kidney stone formation.
• Strain all urine.
• Lifestyle and diet changes if needed.
• Medication use and side effects.

Positions

• Sometimes sideline can help depending on location of patient's pain.
• Pacing can also help.

Kidney Injury

• Kidneys filter waste and help maintain the equilibrium of the body. Functions of the Kidneys:
  • Move Urine.
  • Get rid of waste and nitrogenous.
  • Maintain blood pressure.
  • Balance electrolytes.
  • Regulate PH.
  • Red blood cell production.
  • Vitamin d activation.
  • Maintain homeostasis.
• If the kidneys don't function, everything else will stop functioning as well.

Acute Kidney Injury (AKI)

• Rapid decline of renal function.
• Build-up of blood nitrogenous waste (azotemia).
• Lab values:
  • Increased BUN.
  • Increased creatinine.
  • Increased potassium.
  • Decreased GFR.
• Possible oliguria (low urine output: less than 400 mL/24 hours) or anuria (no urine output).
• AKI is reversible if caught early and treated.

Types of AKI

• Prerenal (before kidneys), number one cause of AKI: Decreased perfusion.
  • Heart failure.
  • Dehydration.
  • Hemorrhage.
  • Decreased GFR.
  • Oliguria.
• Intrarenal (actual damage to the kidneys):
  • Prolonged ischemia.
  • Nephrotoxins.
• Postrenal (after the kidneys):
  • Obstruction.
  • Renal Calculi.
  • BPH.
  • Malignancy.

Phases of AKI

• Oliguric Phase:
  • Can last one to seven days.
  • Fluid Volume:
    • Hypovolemia if Prerenal, treat with fluids.
    • Fluid retention: Distended neck veins, bounding pulse, edema, hypertension
    • If fluid overload is untreated: Diaphragm, lungs, heart and brain would lead to death.
  • Metabolic Acidosis: Decreased sodium bicarb production and increased acidosis. Kussmaul's respirations trying to breathe out carbon dioxide.
  • Electrolyte Imbalances. Sodium imbalance- may be normal or patient may show Hyponatremia due to fluid dilution, do not increase sodium intake because it is just being diluted.
  • Hyperkalemia due to the failure of potassium excretions which can lead to cardiac issues. Put patient on Tele to monitor heart.
  • Hematological Disorders.
    • Leukocytosis is primary one.
    • Number on reason patients die from AKI is due to Leukocytosis.
  • Waste Production.
  • Encephalopathy:
    • Difficulty concentrating. Confusion and can cause coma.
• Diuretic Phase:
  • The kidneys are now able to excrete out the fluid.
  • Kidneys don't have the ability to concentrate the urine.
  • Everything will be Hypo here because your kidneys have no way to concentrate urine. Hypokalemia, hyponatremia. and monitor for dehydration.
• Recovery Phase. Kidneys are finally returned to their normal functioning, it can take up to twelve months.
  Remember AKI is reversible.

Assessment

• H&P
• Serum creatinine, determine if AKI
• Adequate fluid volume in system.
  Common Reasons for AKI
• Prerenal, treat with fluids.
• Monitor for signs of hyperkalemia, most serious complication in AKI.

Medical Interventions

• Insulin and sodium bicarb:
  • Draw the potassium into the cells, and it's a temporary temporary fix.
• Kayexalate:
  • Excretes the potassium through feces and colon.
  • Contraindication: Bowel obstruction.
• If conservative therapy is not getting the patient to improve:
  • These patients may need to be on dialysis temporarily.

Management Nutrition

• Limit protein intake.
• Increase dietary fat so patient has enough energy.
• Restrict sodium because patient is excreting it out.
• Older population is more susceptible to AKI, and are at a higher risk for dehydration which is that prerenal cause, right is a fluid a perfusion issue.

Nursing Assessment

• Close monitoring of the vitals.
• Strict Intake and output.
• Monitoring the lungs.
• Assessing the mental status and looking at lab values and know trends to see if treatments are working.
• Priority problems fluid volume excess and, dysrhythmias, risk for infection.
  Goal to completely recover reverse any type of kidney damade.

Key Health Promotions

• Identify individuals that may be at a higher-risk for, developing AKI. Example: elderly, patient who recently had surgery or blood transfusion.
• Key to monitor these patients with the Is and Os daily, and to weigh them daily.
• Important to asses for hyper and hypovolemia and asses and treat any type of hyperkalemia that they may have.
• Key to use aseptic technique to prevent any infections.
• On an ambulatory basis, once they have recovered, we are going to tell the patient to follow up care education of how to we many prevent it in the future.

Chronic Kidney Disease

• Progressive, irreversible loss of kidney function.
• Defined by:
  • Kidney damage.
  • Low glomerular filtration rate (GFR), less than 60 mL/min for longer than 3 months.
• Two leading causes: Diabetes and hypertension.
  • Diabetes damages blood vessels impairing the ability to filter out the waste.
  • Hypertension increases blood pressure damaging the arteries around the kidneys which makes it harder, it makes it weaker and this impairs blood flow to kidneys.
  • Diabetes the longer the patient lives, frequent blood tested are performed to catch kidney problems before it is to late.
• Patients are often asymptomatic for a very long time.
  • Key: Knowing what is similar among AKI and CKD, and then what is different because management will be different.
    Patients body will naturally try to protect everything that body function, eventually this will fail.
    *Clinical manifestations:
  • Impact entire body KD key thing is to remembering what's similar and then the key thing is going to be whats different and how do we manage it. What is calcium and phosphate alteration? Calcium and phosphate alteration is because patients have very specific disease called CKD MBD.
• There aren't enough red blood cells produced. Kidney produces what? Read blood cells through development of erythropoietin, thats why you see a need me being an issue. Patients because of all that waste being built up here start seeing somatitis or altercations occur their mouth, its their stomach, their esophagus system.
  *CKD Mineral and Bone Disorder (CKD-MBD).
  Need to go back into vitamin D activation part of your kidneys.
  Needs Calcium+ vitamin D these two are needed absorbed calcium which is what regulates a parathyroid, right going to cause a drop in decrease in calcium (hypocalcemia is part of that) calcium regulation (parathtroid) releases parathyroid hormone, that's when we will have decrease calcium. It is also going to cause an increased level of Phosphorus (Hyperphosphatemia) in you system.
  Lab values: Hy[pocalcemia- unique in CKD.

The whole body system is going to be in affected if we cant manage it. Release increased levels of phosphorus.

*Patient can have uremic frost. Due to urea coming out. Smell distinct.

Diagnostic Studies

• H&P- always going to be your number one (always want to get H&P)

• Dipstick Evaluation looking for Protein first indicator that the patient has kidney failure. Look for protein.
  Key Goal for CKD: Preserving the existing function of the kidneys, we aren't trying to get everything back cause is impossible.

• Goals are different for CKD.
  Goal is COMPLETELY recovery kidneys; because is reversible, complete recovery of that kidney.
  CKD preservation of the existing function kidneys, reduce of cardio vascular disease, prevent compilations

Consistence measures, correction extra cellular fluid volume overload. INO modification of the fluids they CAN have, dietary lifestyle restriction modifications, nutrient therapy with the limit the protein intake increase the fat consumption because that needs to give the bodies energy, calcium simulation and phosphate binders. Anti hyper sensitive, lower pressure with potassium. They have to take any medication the need to be adjusted with.
*HYPERKALEMIA same for ACUTE kd.
*Hypertension- ACE inhibitors and ARB.
We're going to try to avoid using it for as long as we can.

• We are gonna try to protract that until its need; but they have to on hemodialysis or peritoneal dialysis.
  Nutrition *Protein intake has to lower and limit until you put patinet on dialysis for peritoneal or homolydisis.

Sodium Restrictions

Very similar as AKI, but phosphate its going to, make different between CKD and AKI.

Nursing Assessment Questions: (Priority problems, what are they? What's priority

-Fluid volume excess
Fluid Volume excess: that is the priority problem.Yes
Electrolyte imbalance=Yes.
Imbalance nutrition less than body requirements: Yes. So those all come secondary to fluid volume excess. This that why the patients are feeling this ways because the patient has extra fluids. (They are all there but is because fluid the volume excess is the priority problems.

To manage these patients most of the patients has to go to manage on out patient. Can manage out patient, patients need to manage by outpatient most of the time. So if some reason they have to have and admitted in patent.

• Diet compliance (is key and most important thing).
• Knowing the side effects for the patient, education and also tell than how important monitor their blood pressure.
  The explanation to the patient when you have to put the patients on homolyzedisis or prolidiness,

Patients on peritoneal how the process looking like.
Are you interesting to be on kidney transplant? and get and to get on the list. It's just good to offer the patients. Are good reason.
The is no record recovery like but to electrolyte back and give and back by gain exitable
Outcome: is alittle bit DIFFERENT- NO RECOVERY of the kidney function.
But do that for them that have dialysis and that is a different thing: because we can give that dialysis.

Take you example on work that why is important the complaisant with the patients
Has important to compliance and education; but in more than this patient; because you know, for a fact it happen.

Dialysis Treatment - 2 types

*Peritoneal Dialyses:
This needs to be a surgery, and you did a catterer throw the area ( abdomen area), this can happens so close to the period the treatment or a delay; It can treat to the moment or delay that what will happen for this patients.
So close the catterer 3 different phase for the treatment, in fuild that when the fluido go inside for amount; close the clinic and is going to be seated there or we want to do with this patient for the duration and time in drain face (when is get the protein out).

• The number number #complicantion, is Peritonitis. That need to be take care a lot. *Also, pulmonary compilcation because the patient its going to have more fluid in and cause the problem.
  There for patients COPD isn't get dialysis.
  Benifits for this types: more flexibility to get treatment. Don't needs to have the patient to travels.
  is not that have the pain, but or is not it can to it with you wake up and don't stay time.

*Hemolydisis;
This can make with your provider, and the access with (AV fistula or av cuff for hemolydisis)
This need some time ago, to have the vascular access: CVC; until for AV fistule
Or to cuff.
always we wants 6 to 6 matches to have the patient that have good or success for transplant.
dont just always do for what the machine wants is take vitals and weight before you start, assessment. and you also do post assessment. is very importnat always. what's the leading to the patient of this that are the 2: diabetis and hypeprotension so is safety assume for the patiens and get anti hypertension med.
*so, and no.
always needs to check. because is rapidly remove can bottom OUT to this paitients and the is also the less for it.
The heparatesis that can give the Heparitsis C is not to happen. becausue the are very cleaning

**Med Formin with anti hypertension medicine is never given. If your patient is hypertensive, hold the medicine before treatment and given back them afterwards if they need.
Questions an how a person who in dilasiss what should do or no what does they did

Kidney Transplant

Happen for most of the pateints it waiting than hundred of patience, is one of 3 than 5 waiting for kidneys to happens, it cause if for doneting organd. can survive is great is so much greater to get the 2 donors: descest. with donors the surviving 90 % for get on year after, it works better to have an actual persong giving the donor the rate if survive and 97 % and it for the 1 year this shows.
Benifits Reverse the path what have
-elimanting the Dilation
-eliminate to have the diatery and less style.
But that never mean does that mean to to anything. just because i does have to restrictions;
What have the conter indicaciones and what does it happens
*conterindicaction for malignancies. that never that mean to the kindey. cause what dose do to what you are doing to the patients
Immung subration that is why for not work.
Patient the you have the cancer not work becausse your Imugenes Suppressant for a long time.
some person: HIV can't to it not worth more, the patient the have a new organ;
pateint that had infections actived, any patient that had heart disease.
Obssives, substain Abusive becausse the patients never do what they gonna does.
From a Nursing a: Expect; we have the help with emotianal preparation with the donair or recitent.
Patient that we can have for immunosubrience so after the imurate 90 .
And catter 7, for sign of the patient to reject
affected for immunosubrested, it never to work, because is can not managed to the top what i was for you
What i you have and for all the years or what were looking for, what symptoms do or show
Affections: oliguare
-what patients: it had fever, to get high
-pain
-tenderness.
Swilling
Pain
Does patient; needs in asolation or no .
Pateints they had lupus, cause is what happens to is well what manage for their type of disease.
Some take for cortiosteriod why, what do for. is you can take. and why do to make it work? and is working to the side?
Questions that i gonna asked:
If you get kidney transplant can do can you do whatever to do?