Chapter 45

Management of Patients with Urinary Disorders

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Lower Urinary Tract Infections

Cystitis (inflammation of the urinary bladder), Prostatitis (inflammation of the prostate gland), and Urethritis (inflammation of the urethra). Upper UTI; Pylonephritis (inflammation of the renal pelvis), interstitial nephritis (inflammation of the kidney), and renal abscesses

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Lower Urinary Tract Infections

mechanisms maintain the sterility of the bladder:

the physical barrier of the urethra, urine flow, ureterovesical junction competence, various antibacterial enzymes and antibodies, and antiadherent effects mediated by the mucosal cells of the bladder.

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Risk Factors for UTIInability or failure to empty the bladder completelyObstructed urinary flowDecreased natural host defenses or immunosuppressionInstrumentation of the urinary tract (eg, catheterization, cystoscopic procedures)Inflammation or abrasion of the urethral mucosa

Contributing conditions: DM, Pregnancy, neurogenic disorders, Gout, and altered states caused by incomplete emptying of the bladder and urinary stasis

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Pathophysiology

Bacteria gain access to the bladder, attach to and colonize the epithelium of the urinary tract to avoid being washed out with voiding, evade host defense mechanisms, and initiate inflammation. Many UTIs result from fecal organisms that ascend from the perineum to the urethra and the bladder and then adhere to the mucosal surfaces.Escherichia coli is the most common agent

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Urethrovesical reflux: With coughing and straining, bladder pressure rises, which may force urine from the bladder into the urethra. (A) When bladder pressure returns to normal, the urine flows back to the bladder (B), which introduces bacteria from the urethra to the bladder. Ureterovesical reflux: With failure of the ureterovesical valve, urine moves up the ureters during voiding (C) and flows into the bladder when voiding stops (D). This prevents complete emptying of the bladder. It also leads to urinary stasis and contamination of the ureters with bacteria-laden urine.

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Routes of Infection

transurethral route (ascending infection), through the bloodstream (hematogenous spread), or by means of a fistula from the intestine (direct extension)

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Clinical Manifestations

About half of all patients with bacteriuria have no symptoms.dysuria (painful or difficult urination), burning on urination, frequency (voiding more than every 3 hours), urgency, nocturia, incontinence, and suprapubic or pelvic pain. Hematuria and back pain may also be present

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Gerontologic Considerations

High incidence of chronic illnessFrequent use of antimicrobial agentsPresence of infected pressure ulcersImmunocompromiseCognitive impairmentImmobility and incomplete emptying of bladderUse of a bedpan rather than a commode or toilet

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DiagnosisUA: puss cells > 4, ? hematouriaC&S.WBCs

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Medical Management

Pharmacological agents according to C&SPatient should be instructed to complete the antibiotic course

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UTIs – Nursing CareAssessmentImpaired Urinary EliminationReadiness for Enhanced Self Health ManagementTeaching

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Acute Pyelonephritis

Clinical ManifestationsChills, fever, leukocytosis, bacteriuria and pyuria. Low back pain, flank pain, nausea and vomiting, headache, malaise, and painful urination are common findings. Pain and tenderness in the area of the costovertebral angleSymptoms of lower UTI

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Medical managmenetOn out patient basis: AB for 2 weeksGood oral hydrationIf there is a relapse, AB for 6 weeksIf there is N&V > admission, IV Fluids and IV AB

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Chronic PyelonephritisClinical ManifestationsUsually asymptomatic unless an acute exacerbation occurs. Noticeable S&S may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss. Persistent and recurring infection may produce progressive scarring of the kidney resulting in renal failure

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Urinary IncontinenceInvoluntary urinationCauses of Transient Incontinence: DIAPPERS

Delirium

Infection of urinary tract

Atrophic vaginitis, urethritis

Pharmacologic agents (anticholinergics, sedatives, analgesics, diuretics, muscle relaxants, adrenergic

Psychological factors (depression, regression)

Excessive urine production (increased intake, diabetes insipidus, diabetic ketoacidosis)

Restricted activity

Stool impaction

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Urinary IncontinenceTypes

StressUrgeOverflowReflexFunctionalIatrogenic incontinencemixed incontinence

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Urinary Incontinence - TreatmentMedications

Anticholinergic agentsalpha-adrenergic Estrogen therapy

SurgeryBladder neck suspensionProstatectomy

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Urinary Incontinence - Treatment

Behavioral modificationKegal exerciseFluid managementTimed voiding (? Every 2 hours)

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Urinary RetentionOccurs when bladder cannot emptyMay be caused by obstructive or functional problem

Benign prostatic hypertrophySurgeryDrugsNeurologic diseases Trauma

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Urinary Retention - Manifestations

ManifestationsOverflow voiding (dribbling, frequency)IncontinenceS & S of UTI

hematuria, urgency, frequency, nocturia, and dysuria

Firm, distended bladderMay be displaced

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Urinary RetentionComplications

HydronephrosisAcute renal failureUrinary tract infection which may lead to urolithiasis or nephrolithiasis

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Suprapubic CathetersIs a temporary measure to divert the flow of urine from the urethra when the urethral route is impassable Inserting a catheter into the bladder through a suprapubic incision or puncture.

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Hydronephrosis, Hydroureter, and Urethral

Stricture

Outflow obstructionUrethral stricture

Causes bladder distention and progresses to the ureters and the kidneys

Hydronephrosis – Kidney enlarges as urine collects in the pelvis and kidney tissue due to obstruction in the outflow tractOver a few hours this enlargement can damage the blood vessels and the tubules

Hydroureter Effects are similar, but occurs lower in the ureter

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Causes of Obstruction

TumorStonesCongenital structural defectsFibrosisTreatment with radiation in pelvis

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Complication of Obstruction

If untreated, permanent damage can occur within 48 hoursRenal failure

Retention of Nitrogenous wastes (urea, creatinine, uric acid)Electrolytes (K, Na, Cl, and Phosphorus)Acid base balance impaired

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Renal Calculi

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Called nephrolithiasis or urolithiasisMost commonly develop in the renal pelvis but can be anywhere in the urinary tract

Renal CalculiVary in size –from very large to tinyCan be 1 stone or many stonesMay stay in kidney or travel into the ureterCan damage the urinary tractMay cause hydronephrosisMore common in white males 30-50 years of age

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Renal CalculiPredisposing factors

DehydrationProlonged immobilizationInfection ObstructionAnything which causes the urine to be alkalineMetabolic factors

Excessive intake of calcium, calcium based antacids or Vit DHyperthyroidismElevated uric acid

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Renal Calculi

Subjective symptomsSever pain in the flank area, suprapubic area, pelvis or external genitaliaMay radiate anteriorly and downward toward the bladder in females and toward the testis in males.If in ureter, may have spasms called “renal colic”Urgency, frequency of urinationN/VChills

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Renal Calculi

Objective symptomsIncreased temperaturePallorHematuria Abdominal distentionPyuriaAnuriaMay have UTI on urinalysis

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Renal Calculi- Manifestations

Kidney/PelvisMay be asymptomaticDull, aching flank pain

UreterAcute severe flank pain, may radiateNausea/vomitingPallorHematuria

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Renal Calculi- Manifestations

BladderMay be asymptomaticDull suprapubic painHematuria

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Renal Calculi

Diagnostic proceduresUrinalysis with C & SKUBIVPRenal CTKidney ultrasoundCystoscopy with retrograde pyleogram

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Renal CalculiTreatment

Most (> 1 cm) are passed without interventionMay need cystospy-- with basket retrieval

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Lithotripsy : Extracorporeal shock wave lithotripsy (ESWL) is the non-invasive treatment of urinary calculosis and biliary calculi to fragment the stone

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Renal Calculi-TreatementLasertripsy: stone and is destroyed by the laser

Lithotomy: surgical removal of stone

Pylelolithotomy – removal from renal pelvis

Urolithotomy – removal from the ureter

Nephrolithotomy – removal from kidney

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Nutritional TherapyCalcium Stones

? Restrict Ca, protein, and Na. liberal amount of water.

Uric Acid Stoneslow-purine diet to reduce urinary excretion of uric acid (shellfish, mushrooms, and organ meats), limit protein, Allopurinol.

Avoid food contain oxylate: spinach, strawberries, chocolate, tea, peanuts, and wheat bran

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Renal CalculiAssessment

History and physical examLocation, severity, and nature of painI/OVital signs, looking for feverPalpation of flank area, and abdomen? N/V

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Renal CalculiNursing interventions

Primary is to treat pain – usually with opioidsAmbulateForce fluids, may have IV

Watch for fluid overload

Strain urine – send stone to lab if passedAccurate I/OMedicate N/V

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Renal CalculiSurgical removal

Routine pre and post op careMay return with catheter, drains, nephrostomy tube and ureteral stent – must maintain patency and may need to irrigate as orderedMeasure drainage from all tubes – need at least 30 cc/hrWatch site for bleedingMay need frequent dressing changes due to fluid leakage, or may have collection bag

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Renal Calculi

Discharge and preventionContinue to force fluids post dischargeMay need special diet

Stones are analyzed for calcium or other mineralsMay need to watch products with calcium

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Cancer of the Urinary Tract

Bladder cancerKidney tumors

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Bladder CancerBladder cancer is 4th leading cause of cancer deaths.More common in men than womenCancers arising from the prostate, colon, and rectum in males and from the lower gynecologic tract in females may metastasize to the bladder

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Risk factor for bladder cancer

Cigarette smoking: risk increase with number of years and packs smokedExposure to environmental carcinogens: dyes, rubber, leather, ink, or paintRecurrent or chronic bacterial infection of the urinary tractBladder stonesHigh urinary pHHigh cholesterol intakePelvic radiation therapy

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Bladder Cancer - Manifestations

Painless hematuriaFrequencyUrgencyDysuria

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Bladder Cancer Diagnostic tests

Bladder ultrasoundUrinalysisUrine cytologyCystoscopyBiopsy

TreatmentMedicationsSurgery: remove tumor or bladder, Urinary Diversions

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Cutaneous Urinary Diversions

A. conventional ileal conduit,

B. cutaneous ureterostomy

C. vesicostomyD. nephrostom

y

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continent urinary diversions

A. Indiana pouch

B. & C the Kock pouch, also called a continent ileal diversion

D. Ureterosigmoido-

stomy.

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Kidney TumorsUncommonRenal cell carcinoma most common primary tumorCan occur anywhere, Often metastasizeRisk factors

SmokingObesityRenal calculi

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Kidney Tumors - Manifestations

May be silentFlank painPalpable massFever, fatigueWeight loss, anemia, polycythemiaHypercalcemia, hypertension, or hyperglycemia

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Kidney Tumors – Interdisciplinary Care

Diagnostic testsRenal ultrasoundCT scanKidney biopsy

TreatmentRadical nephrectomy

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Bladder and Kidney Cancer – Nursing Care

AssessmentDiagnosing, Planning, and Implementing

Impaired Urinary EliminationRisk for Impaired Skin IntegrityDisturbed Body Image

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Bladder and Kidney Tumors – Nursing Care

Diagnosing, Planning, and Implementing

Acute PainIneffective Breathing PatternDisturbed Body Image

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