Caring for Clients with Disorders of the Bladder and Urethra Practice Flashcards

Learning Objectives and Evaluation of Urinary Concerns

• Core Learning Objectives:

  • Explain urinary retention and the associated nursing management.

  • Discuss urinary incontinence etiology and nursing care.

  • Describe the pathophysiological changes in cystitis, interstitial cystitis, and urethritis.

  • Explain symptoms related to bladder stones.

  • Discuss the causes and treatments of urethral strictures.

  • Describe nursing care and treatment for malignant bladder tumors.

  • Identify various types of urinary diversion procedures and the components of a teaching plan for affected clients.

  • Apply Student Learning Outcomes (SLOs) including Safety, Patient-Centered Care, Evidence-Based Practice, and Nursing Judgment.

• Gerontologic Considerations in Urinary Assessment:

  • Assessment of older adults must include a diary maintained over at least $3$ days recording:

    • Time, amount, and type of fluid intake.

    • Time, amount, and type of all medications.

    • Time and amount of voiding, involuntary urine loss, and involuntary loss of stool.

  • Medication Review: Specific scrutiny for drugs that affect bladder emptying or cause constipation.

  • Substance Use: Documentation of amount and type of alcohol or illicit drug use.

  • Physical Indicators: Evaluation of constipation or fecal impaction, mobility, fatigue, muscle strength, balance, and history of falls.

  • Cognitivity and Neurological History: Assessment of cognition, history of atherosclerosis, and history of parkinsonian symptoms.

  • Environment and Support: Consideration of distance to the toilet, caregiver availability, caregiver ability, and caregiver stress levels.

  • Psychosocial Barriers: Recognition that clients may be reluctant to provide info due to embarrassment, the misconception that incontinence is a normal part of aging, or fear of institutionalization.

  • Nursing Priorities: Any new onset of urinary incontinence is a priority in nursing care plans to maintain quality of life. Physical and cognitive abilities must always be considered when instituting a bladder rehabilitation program.

Urinary Retention: Pathophysiology, Diagnosis, and Management

• Classification of Urinary Retention:

  • Acute Retention: Seen in complete urethral obstruction, following general anesthesia, or after the administration of drugs such as atropine or phenothiazines.

  • Chronic Retention (CUR): Typically seen in clients with prostatic enlargement or neurologic disorders resulting in a neurogenic bladder.

• Assessment Findings:

  • Acute Symptoms: Sudden inability to void, an urgent need to void, a distended bladder, and severe lower abdominal pain accompanied by a feeling of fullness and overall discomfort.

  • Chronic Symptoms: CUR may not produce obvious symptoms; the bladder stretches over time to accommodate large volumes without discomfort. The overstretched bladder fails to contract effectively, and the client may be unaware that emptying is incomplete.

• Diagnostic Findings:

  • Urinalysis: Standard testing for infection or other abnormalities.

  • Catheterization/Ultrasound: Used to determine postvoid residual (PVR) volume.

  • Urodynamic Testing: Employs video radiography.

  • Uroflowmetry: Measures the urine flow and the speed of bladder emptying.

  • Electromyography (EMG): Determines the electrical activity of the external sphincter during the voiding process.

  • Cystoscopy and Ureteroscopy: Direct examination of the bladder and urethra.

  • Computed Tomography (CT): Performed with contrast to identify bladder stones, tumors, cysts, or traumatic injuries.

• Medical and Surgical Management:

  • Acute Management: Immediate catheterization is required.

  • Chronic Management: May involve permanent drainage, surgery (common for men), or permanent indwelling catheters (for women).

  • Risks of Permanent Catheterization: Includes bladder stones, renal disease, bladder infection, and urosepsis.

  • Standard Urinary Catheter Types:

    • Pezzer

    • Malecot

    • Coude

    • Foley (available in uninflated and inflated configurations)

• Nursing Management for Retention:

  • Strictly monitor intake and output ($I\&O$).

  • Promote complete elimination and monitor voiding patterns.

  • Utilize bladder scanners for non-invasive assessment.

  • Health History: Ask about voiding frequency, amount passed, presence of pain/discomfort in the lower abdomen, pain on voiding, and difficulty starting the urinary stream.

  • Limit catheter use to essential situations to reduce infection risk.

Urinary Incontinence: Etiology and Clinical Manifestations

• Prevalence and Pathophysiology:

  • Estimated affects at least one-third of community-dwelling older adults and half of institutionalized older clients.

  • Incontinence is a symptom resulting from bladder or urethral dysfunction.

  • Mechanism: Failure of the urethral sphincters to hold urine, often due to trauma, prostate surgery, or relaxed pelvic muscles.

• Risk Factors:

  • Reproductive/Hormonal: Pregnancy, vaginal delivery, episiotomy, and menopause.

  • Physical/Lifestyle: Pelvic muscle weakness, immobility, high-impact exercise, obesity, and chronic cough (asthma, smoking, lung disease).

  • Medical Conditions: Diabetes mellitus, stroke, Parkinson’s disease, Alzheimer’s disease, spinal cord injury, and Multiple Sclerosis.

  • Iatrogenic/Environmental: Genitourinary surgery, incompetent urethra, medications (diuretics, sedatives, antidepressants, hypnotics, opioids), and unavailability of toilets or caregivers.

• Temporary Incontinence Triggers:

  • Infections (UTIs) and constipation.

  • Beverages: Alcohol, caffeine, decaffeinated tea and coffee, and carbonated drinks.

  • Food/Additives: Artificial sweeteners, corn syrup, high-spice foods, high-sugar foods, and acidic/citrus fruits.

  • Medications: Heart/blood pressure meds, muscle relaxants, and large doses of Vitamins $B$ or $C$.

• Assessment and Diagnostic Findings:

  • Symptoms: Complaints of urgency, frequency, leaking during coughing/sneezing, or total loss of control.

  • Diagnostics: Urine culture and sensitivity, cystoscopy, cystogram, urodynamics, and pelvic ultrasound.

• Types of Urinary Incontinence:

  • Stress: Involuntary loss due to sudden intra-abdominal pressure (sneezing, coughing) with an intact urethra.

  • Urge (Overactive Bladder): Strong urge to void without enough time to reach the toilet; often neurologic.

  • Mixed: Features of two or more types (e.g., Stress and Urge).

  • Overflow: Involuntary loss caused by an overdistended bladder failing to empty completely.

  • Transient: Sudden onset, temporary, lasting less than $6$ months; caused by delirium, infection, etc.

  • Functional: Inability to identify the need to void or physical inability to reach the bathroom.

  • Reflex: Spontaneous voiding caused by uninhibited bladder contractions and reflexes.

  • Total: Continuous and unpredictable loss of urine.

Treatment and Nursing Care for Incontinence

• Medical and Surgical Management:

  • Pharmacology:

    • Anticholinergics: Oxybutynin chloride (Ditropan) and Tolterodine tartrate (Detrol).

    • Alpha-Blockers: Tamsulosin (Flomax) specifically for males to relax the bladder neck and prostate.

  • Procedures:

    • Bladder Augmentation: Increases storage capacity.

    • Periurethral Bulking: Collagen injection into urethral walls to improve closing pressure.

    • OnabotulinumtoxinA (Botox): Injected into bladder muscle for OAB; helps relaxation and storage; repeated every $3$ months.

    • Artificial Sphincter: Implanted device inflated to prevent loss and deflated to urinate.

• Surgical Support for Urinary Structures:

  • Retropubic Suspension: Open abdominal procedure anchoring the bladder/urethra to the pelvic wall via vagina and pubic ligaments.

  • Anterior Repair: Tightening the vaginal wall under the urethra to support the bladder.

  • Transvaginal Needle Suspension: Attaching the bladder/urethra to the pubic bone/rectum tissue via vaginal and suprapubic incisions.

  • Sling Procedures: Synthetic or natural material (thigh/abdomen) placed under the bladder neck like a hammock and secured to the abdominal wall or pelvic bone.

  • Sacral Nerve Stimulator: A pacemaker-like device implanted in the abdomen emitting electrical pulses to the sacral nerve to control contractions.

  • Urethroplasty: Surgical repair of structures damaged by trauma.

• Nursing Management and Bladder Training:

  • Maintain continence: Assess mobility, restraints, and sedative use.

  • Bladder Training: Pelvic floor exercises (Kegels); scheduled voiding (intervals of $2$ to $4$ hours); prompted voiding (prompting and praising).

  • Barrier and Collection Devices: Condom catheters, drip collectors, and protective pads/pants.

  • Home Strategies:

    • Monitor fluid intake timing; avoid diuretics after $4$ p.m.

    • Avoid irritants: Caffeine, alcohol, and NutraSweet (aspartame).

    • Manage constipation: Fiber, fluids, exercise, stool softeners.

    • Voiding Schedule: Upon waking, before meals, before bed, and nightly as needed.

    • Hygiene: Frequent perineal cleansing to control odors; avoid perfumes/scented powders which can irritate skin or intensify odors.

    • Environmental Protection: Plastic covers for mattresses/chairs, with a sheet placed between skin and plastic.

Inflammatory Disorders: Cystitis, Interstitial Cystitis, and Urethritis

• Cystitis (Bladder Inflammation):

  • Etiology: Usually bacterial (fecal contamination); also caused by instrumentation (cystoscopy/catheter), prostatitis, BPH, pregnancy, sexual intercourse, radiation, or hygiene irritants.

  • Diagnostic Findings: Microscopic urinalysis shows increased RBCs and WBCs; culture and sensitivity (C&S) for antimicrobial selection; IVP or retrograde pyelograms for recurrent cases.

  • Symptoms: Urgency, frequency, low back pain, dysuria, suprapubic pain, cloudy/smelling urine, and terminal hematuria (at the end of the stream). Bacteremia adds chills and fever.

  • Meds: Ciprofloxacin, Fosfomycin, Levofloxacin, Nitrofurantoin, and Sulfamethoxazole/Trimethoprim. Phenazopyridine (local anesthetic) for discomfort; Methenamine for long-term recurrent UTI management.

• Interstitial Cystitis (IC) / Painful Bladder Syndrome:

  • Pathophysiology: Chronic inflammation of mucosa leading to disintegration of lining and loss of elasticity. Characterized by pinpoint hemorrhages and potentially Hunner’s ulcers (superficial erosion).

  • Assessment: Frequent, painful voiding of small volumes; pain described as searing or burning; pain occurs as soon as a tiny amount of urine enters the bladder; painful intercourse common.

  • Diagnostics: Biopsy reveals scarring/hemorrhage. Cystoscopy shows inflamed mucosa and small bladder capacity.

  • Treatments: Elmiron (Pentosan polysulfate) is the most effective bladder protectant; Amitriptyline for pain/depression; DMSO instillation; TENS units for endorphin release.

  • Nursing: Advise avoidance of spicy/acidic foods, carbonation, caffeine, and high Vitamin $C$. Referral to chronic pain centers or support groups is essential.

• Urethritis (Urethra Inflammation):

  • Etiology: More common in men (often STIs like Chlamydia or Ureaplasma). In women, secondary to vaginal infections or chemicals (bubble baths, soaps).

  • Symptoms: Discomfort ranges from tickling to severe burning; urethral discharge and itching. Fever in men may indicate extension to prostate or testes.

  • Nursing: Emphasize finishing antibiotics, fluid intake, and warm sitz baths. Use strict sterile technique for catheter changes and provide frequent perineal care.

Obstructive Disorders: Bladder Stones and Urethral Strictures

• Bladder Stones:

  • Cause: Chronic urinary retention, urinary stasis, BPH, or immobility.

  • Symptoms: Hematuria, cloudy urine, suprapubic pain, difficulty starting stream, and feeling of incomplete emptying.

  • Surgical Management: Cystolitholapaxy (transurethral stone crushing) for small stones; suprapubic incision for large stones.

  • Dietary Management: Low-purine for uric acid stones; low-oxalate for calcium oxalate stones (limit calcium only if type II absorptive hypercalciuria is present). Increase overall fluid intake.

  • Nursing Care: Monitor for gross hematuria; strain all urine through gauze; notify provider if temperature exceeds $101^{\circ}\text{F}$ ($38.3^{\circ}\text{C}$); encourage consumption of at least $10$ large glasses of fluid daily.

• Urethral Strictures:

  • Pathophysiology: Narrowing that results in backup of urine (hydroureter/hydronephrosis) and potential bladder diverticula (outpouching) where bacteria stagnate.

  • Symptoms: Slow/spraying stream, dribbling, dysuria, hesitancy, and nocturia.

  • Management: Dilatation using instruments expanding from $6\text{-F}$ or $8\text{-F}$ up to $24\text{-F}$ or $26\text{-F}$. Periodic dilatation is often required indefinitely. Surgery (Urethroplasty) is utilized if dilatation fails.

  • Nursing: Warn that urine may be blood-tinged; use sitz baths for discomfort; ensure post-urethroplasty catheters are securely anchored.

Bladder Cancer and Urinary Tract Trauma

• Bladder Cancer:

  • Risk Factors: Tobacco use (leading cause), cigarette/secondhand smoke (3x risk), environmental carcinogens (dyes, paint, ink, rubber), and occupations (hairdressers, machinists, truck drivers).

  • Assessment: Painless hematuria is the most common first symptom. Later symptoms include pelvic/back pain, urinary retention, weight loss, and swelling in feet.

  • Diagnostics: Cystoscopy with biopsy, CT with needle biopsy, ultrasound for size, and urine tumor marker tests.

  • Management: Partial cystectomy (segmental) for small tumors; Radical cystectomy (bladder and lower third of ureters removed) requires a urinary diversion procedure.

  • Nursing Focus: Observe for leakage from anastomosis, assess for peritonitis signs, promote positive body image, and teach stomal care/diversion management.

• Urinary Tract Trauma:

  • Etiology: Gunshot/stab wounds, crushing injuries, or forceful blows causing tears or hemorrhage.

  • Assessment: Symptoms include anuria, hematuria, abdominal pain (indicating leakage into peritoneal cavity), and shock.

  • Nursing Responsibility: Recognition of abnormal findings is the primary task. Hematuria or lack of output in a catheterized trauma client is a critical indicator of injury.

  • Potential Surgeries: Nephrectomy, nephrostomy tube insertion, ureter reanastomosis, or cystostomy (temporary/permanent bladder opening).