Urinary Tract Infection (UTI) Background 1.Bacterial infections of urinary tract are a very common reason to seek health services 2.Common in young females

Urinary Tract Infection (UTI)

Background1. Bacterial infections of urinary tract are a very

common reason to seek health services2. Common in young females and uncommon in males

under age 503. Common causative organisms a. Escherichia coli (gram-negative enteral

bacteria) causes most community acquired infections b. Staphylococcus saprophyticus, gram-positive

organism causes 10 – 15% c. Catheter-associated UTI’s caused by gram-

negative bacteria: Proteus, Klebsiella, Seratia, Pseudomonas


Normal mechanisms that maintain sterility of urine a. Adequate urine volume b. Free-flow from kidneys through urinary

meatus c. Complete bladder emptying d. Normal acidity of urine e. Peristaltic activity of ureters and competent

ureterovesical junction f. Increased intravesicular pressure preventing

reflux g. In males, antibacterial effect of zinc in

prostatic fluid


Pathophysiology1. Pathogens which have colonized urethra, vagina, or

perineal area enter urinary tract by ascending mucous membranes of perineal area into lower urinary tract

2. Bacteria can ascend from bladder to infect the kidneys

3. Classifications of infections a. Lower urinary tract infections: urethritis,

prostatitis, cystitis b. Upper urinary tract infection: pyelonephritis

(inflammation of kidney and renal pelvis)


Risk Factors1. Aging a. Increased incidence of diabetes mellitus b. Increased risk of urinary stasis c. Impaired immune response2. Females: short urethra, having sexual intercourse,

use of contraceptives that alter normal bacteria flora of vagina and perineal tissues; with age increased incidence of cystocele, rectocele (incomplete emptying)

3. Males: prostatic hypertrophy, bacterial prostatitis, anal intercourse

4. Urinary tract obstruction: tumor or calculi, strictures5. Impaired bladder innervation


Cystitis1. Most common UTI2. Remains superficial, involving bladder mucosa, which becomes

hyperemic and may hemorrhage3. General manifestations of cystitis a. Dysuria b. Frequency and urgency c. Nocturia d. Urine has foul odor, cloudy (pyuria), bloody (hematuria) e. Suprapubic pain and tenderness4. Older clients may present with different manifestations a. Nocturia, incontinence b. Confusion c. Behavioral changes d. Lethargy e. Anorexia f. Fever or hypothermia


Pyelonephritis1. Inflammation of renal pelvis and parenchyma (functional

kidney tissue)2. Acute pyelonephritis a. Results from an infection that ascends to kidney from

lower urinary tractRisk factors 1. Pregnancy 2. Urinary tract obstruction and congenital malformation 3. Urinary tract trauma, scarring 4. Renal calculi 5. Polycystic or hypertensive renal disease 6. Chronic diseases, i.e. diabetes mellitus 7. Vesicourethral reflux


Pathophysiology 1. Infection spreads from renal pelvis to renal cortex 2. Kidney grossly edematous; localized abscesses in

cortex surface 3. E. Coli responsible organism for 85% of acute

pyelonephritis; also Proteus, KlebisellaManifestations 1. Rapid onset with chills and fever 2. Malaise 3. Vomiting 4. Flank pain 5. Costovertebral tenderness 6. Urinary frequency, dysuria


Manifestations in older adults1. Change in behavior2. Acute confusion3. Incontinence4. General deterioration in condition


Chronic pyelonephritisa. Involves chronic inflammation and scarring

of tubules and interstitial tissues of kidneyb.Common cause of chronic renal failurec.May develop from chronic hypertension,

vascular conditions, severe vesicourteteral reflux, obstruction of urinary tract

d.Behaviors 1. Asymptomatic 2. Mild behaviors: urinary frequency,

dysuria, flank pain


Collaborative Care a. Eliminate causative agent b. Prevent relapse c. Correct contributing factors

Diagnostic Testsa. Urinalysis: assess pyuria, bacteria, blood cells in urine;

Bacterial count >100,000 /ml indicative of infectionb. Rapid tests for bacteria in urine 1. Nitrite dipstick (turning pink = presence of bacteria) 2. Leukocyte esterase test (identifies WBC in urine)c. Gram stain of urine: identify by shape and characteristic

(gram positive or negative); obtain by clean catch urine or catheterization


d. Urine culture and sensitivity: identify infecting organism and most effective antibiotic; culture requires 24 – 72 hours for results; obtain by clean catch urine or catheterization

e. WBC with differential: leukocytosis and increased number of neutraphils

6. Diagnostic Tests for adults who have recurrent infections or persistent bacteriuria

a. Intravenous pyelography (IVP) or excretory urography 1. Evaluates structure and excretory function of

kidneys, ureters, bladder 2. Kidneys clear an intravenously injected contrast

medium that outlines kidneys, ureters, bladder, and vesicoureteral reflux

3. Check for allergy to iodine, seafood, radiologic contrast medium, hold testing and notify physician or radiologist


b. Voiding cystourethrography: instill contrast medium into bladder and use xray to assess bladder and urethra when filled and during voiding

c. Cystoscopy 1. Direct visualization of urethra and bladder

through cystoscope 2. Used for diagnostic, tissue biopsy,

interventions 3. Client receives local or general anesthesiad. Manual pelvic or prostate examinations to assess

structural changes of genitourinary tract, such as prostatic enlargement, cystocele, rectocele


Medications a. Short-course therapy: 3 day course of antibiotics

for uncomplicated lower urinary tract infection; (single dose associated with recurrent infection)

b. 7 – 10 days course of treatment: for pyelonephritis, urinary tract abnormalities or stones, or history of previous infection with antibiotic-resistant infections; clients with severe illness may need hospitalization and intravenous antibiotics

c. Antibiotics commonly used for short and longer course therapy include trimethoprim-sulfamethoxazole (TMP-SMZ), or quinolone antibiotic such as ciprofloxacin (Cipro)

d. Intravenous antibiotics used include ciprofloxacin, gentamycin, ceftriaxone (Rocephin), ampicillin


Possible outcomes of treatment for UTI, determined by follow-up urinalysis and culture

1. Cure: no pathogens in urine 2. Unresolved bacteriuria: pathogens remain 3. Persistent bacteriuria or relapse: persistent source

of infection causes repeated infection after initial cure 4. Reinfection: development of new infection with

different pathogen f. Prophylactic antibiotic therapy with TMP-SMZ,

TMP alone or nitrofurantoin (Furadantin, Nitrofan) may be used with clients who experience frequent symptomatic UTIs

g. Catheter-associated UTI: removal of indwelling catheter followed by 10 – 14 day course of antibiotic therapy


Surgery a. Surgical removal of large calculus from renal

pelvis or cystoscopic removal of bladder calculi which serve as irritant and source of bacterial colonization; may also use percutaneous ultrasonic pyelolithotomy or extracorporeal shock wave lithotripsy (ESWL)

b. Ureteroplasty: surgical repair of ureter for stricture or structural abnormality; reimplantation if vesicoureteral reflux; clients usually return from surgery with catheter and ureteral stent in place for 3 –5 days


Nursing Care: Health promotion to prevent UTIa. Fluid intake 2 – 2.5 L daily, more if hot weather or

strenuous activity is involvedb. Empty bladder every 3 – 4 hoursc. Females 1. Cleanse perineal area from front to back 2. Void before and after sexual intercourse 3. Maintain integrity of perineal tissues

a. Avoid use of commercial feminine hygiene products or douches

b. Wear cotton underwear d. Maintain acidity of urine (use of cranberry juice,

take Vitamin C, avoid excess milk and milk products, sodium bicarbonate)


Nursing Diagnoses a. Pain: Additional interventions include

warmth, analgesics, urinary analgesics, antispasmodic medications

b. Impaired Urinary Elimination c. Ineffective Health Maintenance: Clients

must complete full course of antibiotic therapy

Home Care: Teaching: prevention of infection and use alternatives to indwelling catheter whenever possible

Client with Urinary CalculiBackground1. Urinary calculi are stones in urinary tract a. Nephrolithiasis: stones form in kidneys b. Urolithiasis: stones form in urinary tract outside

kidneys2. Highest incidence in southern and Midwestern states 3. Males more often affected than females (4:1) 4. Most common in young and middle adults B. Risk factors 1. Majority of stones are idiopathic (no demonstrable

cause) 2. Prior personal or family history of urinary calculi 3. Dehydration: increased urine concentration 4. Immobility 5. Excess dietary intake of calcium, oxalate, protein 6. Gout, hyperparathyroidism, urinary stasis, repeated UTI

infection

Client with Urinary CalculiPathophysiology1. Factors leading to lithiasis include supersaturation (high

concentration of insoluble salt in urine), pH of urine2. Types of calculia. Calcium stones (calcium oxalate, calcium phosphate) 1. Associated with high concentrations of calcium in blood or

urine 2. Genetic linkb. Uric acid stones 1. Associated with high concentration of uric acid in urine 2. Genetic link 3. More common in males 4. Associated with goutc. Sturvite stones 1. Associated with UTI caused by bacteria Proteus 2. Stones are very large 3. Staghorn stones in renal pelvis and calycesd. Cystine stones: Associated with genetic defect

Development and location of calculi within the urinary tract

Client with Urinary Calculi

Manifestations: depends upon size and location of stones1. Calculi affecting kidney calices, pelvis a. Few symptoms unless obstructed flow b. Dull, aching flank pain2. Calculi affecting bladder a. Few symptoms b. Dull suprapubic pain with exercise or post voiding c. Possibly gross hematuria3. Calculi affecting ureter, causing ureteral spasm a. Renal colic: acute, severe flank pain of affected

side, radiates to suprapubic region, groin, and external genitals

b. Nausea, vomiting, pallor, cool, clammy skin 4. Manifestations of UTI may occur with urinary

calculi


Complications1. Obstruction: manifestations depend upon speed of

obstruction development; can ultimately lead to renal failure

2. Hydronephrosis: distention of renal pelvis and calyces; unrelieved pressure can damage kidney (collecting tubules, proximal tubules, glomeruli) leading to gradual loss of renal function

a. Acute: colicky pain on affected side b. Chronic: few manifestations: dull ache in back

or flank c. Other manifestations: hematuria, signs of UTI,

GI symptoms


Collaborative Care 1. Relief of acute symptoms 2. Remove or destroy stone 3. Prevent future stone formation Diagnostic Tests 1. Urinalysis: hematuria, possible WBCs and

crystal fragments, urine pH helpful to diagnose stone type

2. Chemical analysis of stone: All urine must be strained and saved; stones or sediment sent for analysis

3. 24-urine collection for calcium, uric acid, oxalate to identifiy possible cause of lithiasis

4. Serum calcium, phosphorus, uric acid: identify factors in calculi formation

Client with Urinary Calculi 5. KUB xray (kidney, ureters, bladder): flat plate to

identify presence and location of opacities 6. Renal ultrasonography: sound waves to detect

stones and detect hydronephrosis 7. CT scan of kidney: identify calculi, obstruction,

disorders 8. IVP 9. Cystoscopy: visualize and possibly remove calculi

from urinary bladder and distal ureters

Medications 1. Treatment of acute renal colic: analgesia and

hydration 2. Narcotic such as intravenous morphine sulfate,

NSAID, large amounts of fluid by oral or intravenous routes

Percutaneous ultrasonic lithotripsy

Client with Urinary Calculi3. Medications to inhibit further lithiasis according to analysis of

stone: a. Thiazide diuretics: promotes reduction of urinary calcium

excretion b. Potassium citrate: used to alkalinize urine for stones

formed in acidic urine (uric acid, cystine, and some calcium stones)

Dietary Management: Prescribed to change character of urine and prevent further lithiasis

1. Increased fluid intake to 2 – 2.5 liters daily, spaced throughout day

2. Limited intake of calcium and Vitamin D sources if calcium stones

3. Phosphorus and/or oxalate may be limited with calcium stones

4. Low purine (rich meats) diet for clients with uric acid stones


Lithotripsy: Use of sound or shock waves to crush stones 1. Extracorporeal shock-wave lithotripsy: acoustic

shock waves aimed under fluoroscopic guidance to pulverize stone into fragments small enough to be eliminated in urine; sedation or TENS used to maintain comfort during procedure

2. Percutaneous ultrasonic lithotripsy: nephroscope inserted into kidney pelvis through small flank incision; stone fragmented using small ultrasonic transducer and fragments removed through nephroscope

3. Laser lithotripsy: stone is disintegrated by use of laser beams; nephroscope or ureteroscope used to guide laser probe

4. Stent may be inserted into affected ureter after procedure to maintain patency after lithotripsy procedures


Surgery1. May be indicated as treatment depending on stone

location, severe obstruction, infection, serious bleeding

2. Types: a. Ureterolithotomy: incision into affected ureter

to remove calculus b. Pyelolithotomy: incision into and removal of

stone from kidney pelvis c. Nephrolithotomy: surgery to remove staghorn

calculus in calices and renal parenchyma d. Cystoscopy: crushing and removal of bladder

stones through cystocope; stone fragments irrigated out of bladder with acid solution


Nursing Care 1. Focus on comfort during renal colic, diagnostic

procedures, ensure adequate urine output, prevent future stone formation

2. Health promotion: adequate fluid intake for all clients, adequate weight-bearing activity to prevent bone resorption, hypercalcuria, prevention of UTI

Nursing Diagnoses 1. Acute Pain a. Adequate pain management b. Intensity of pain can cause vaso-vagal

response; client may experience hypotension, syncope; client safety must be maintained


Impaired Urinary Elimination a. Teaching client and strain all urine; send recovered

stones for analysis b. Complete obstruction causes hydronephrosis on

involved side; other kidney continues forming urine; monitor BUN, Creatinine

c. Maintain patency and integrity of all catheters; all catheters need to be labeled, secured, and sterility maintained

3. Deficient Knowledge: Client participation in treatment and prevention

Home Care 1. Education regarding management current treatment

and prevention 2. Clients may be discharged with catheters, tubes,

dressings; home care referral

Urinary Tract Tumor

Background 1. Malignancies in urinary tract: 90% bladder; 8%

renal pelvis; 2% ureter, urethral; 5 year survival rate for bladder cancer is 94%

2. Bladder cancer: 4 times higher in males than females; 2 times higher in whites than blacks; occurs over age 60

B.Risk factors 1. Carcinogens in urine a. Cigarette smoking b. Occupational exposure to chemicals and dyes 2. Chronic inflammation or infection of bladder

mucosa

Urinary Tract Tumor

Pathophysiology 1. Tumors arise from epithelial tissue which

composes the lining 2. Tumors arise as flat or papillary lesions 3. Poorly differentiated flat tumor invades directly and

has poorer prognosis 4. Metastasis commonly involves pelvic lymph nodes,

lungs, bones, liver

Manifestations 1. Painless hematuria is presenting sign in 75% cases;

may be gross or microscopic and may be intermittent 2. Inflammation may cause manifestations of UTI 3. May have few outward signs until obstructed urine

flow or renal failure occurs

Urinary Tract Tumor

Collaborative Care 1. Removal or destruction of cancerous tissue 2. Prevent invasion or metastasis 3. Maintain renal and urinary function

Diagnostic Tests 1. Urinalysis: diagnosis of hematuria 2. Urine cytology: microscopic examination of cells for

tumor or pre-tumor cells in urine 3. Ultrasound of bladder: detection of bladder tumor 4. IVP: evaluation of structure and function of kidneys,

ureters, bladder 5. Cystoscopy, ureteroscopy: direct visualization,

assessment, and biopsy of lesion(s) 6. CT scan or MRI: determine tumor invasion, metastasis

Urinary Tract Tumor

Medications 1. Immunologic or chemotherapeutic agent

administered by intravesical instillation used as primary treatment of bladder cancer or to prevent recurrence following endoscopic removal of tumor

2. Agents include Bacillus Calmette-Guerin (BCGLive, TheraCys), doxorubicin, mitomycin C

3. Adverse reactions include bladder irritation, frequency, dysuria, contact dermatitis

Radiation Therapy 1. Adjunctive therapy used treatment of urinary

tumors 2. Used to reduce tumor size prior to surgery,

palliative treatment

Urinary Tract Tumor

Surgery1. Cystoscopic tumor resection by a. Excision b. Fulguration: destruction of tissue using high

frequency electric current c. Laser photocoagulation: light energy to destroy tumor2. Radical cystectomy: standard treatment to treat invasive

cancers; removal of bladder and adjacent muscles and tissues

a. Males: includes prostate and seminal vessels b. Females: hysterectomy, salpingo-oophorectomy3. Client needs to have urinary diversion done to provide for

urine collection and drainage through ileal conduit or continent urinary diversion (ureters are implanted in portion of ileum which is surgically made into a reservoir for urine and stoma brought to surface of abdomen)

Urinary Tract Tumor

Nursing Care 1. Treatment with recovery from initial treatment 2. Continual care for recurrence 3. Management for elimination 4. Coping with cancer diagnosis

Health Promotion 1. Encouragement of clients not to smoke 2. Smoking cessation programs 3. Periodic examination of urinalysis and

possibly urine cytology

Urinary Tract TumorNursing Diagnoses1. Impaired Urinary Elimination2. Risk for Impaired Skin Integrity a. Urine is irritating to skin around stoma b. Care includes using appliance with adhesives and

sealants c. Urine will have shreds of mucus in it from bowel d. Collection bag emptied frequently (every 2 hours)

during day e. Connected to bedside drainage bag while asleep3. Disturbed Body Image a. Abdominal stoma requiring drainage appliance or

regular catheterization of stoma to drain urine b. Removal of reproductive organs has made client sterile c. Side effects from chemotherapy or radiation d. Risk for infection

Urinary Tract Tumor

Home Care1. Involves continual surveillance for

cancer recurrence2. If client has had urinary diversion

surgery requires teaching regarding stoma and skin care

3. Home care referral4. Smoking cessation

Documents

Urinary Tract Infection (UTI) Background 1.Bacterial infections of urinary tract are a very common reason to seek health services 2.Common in young females