Urinary Tract Infections (UTIs) Overview

urethritis-inflammation of uerthra..............prostatitis..........cystitis-inflammation of bladder wall

Urgency • Frequency • Burning • Cloudy urine • Foul-smelling urine • Hematuria • Dark Urine 5

Stasis of Urine Contamination Instrumentation infection Faulty valves Previous UTIs Female Anatomic/Genetic Differences Aging

pyelonephritis-infection of one or both kidneys..............ureteritis

Costovertebral tenderness – High fever – Chills – Nausea/vomiting

Sepsis that occurs from an untreated UTI – Drop in BP, Increase in HR, Temp and RR – Changes in mental status – Organ failure – Blood cultures x 2 8

Phenazopyridine (Pyridium) • Antibiotics Medications • Foods to prevent UTI (polyphenols) • Encourage increased fluid consumption • Void Q3-4 Hours while awake • Hygiene • Avoid tight clothing • Void after sex Nonpharmacological 9

From point of obstruction Urine backs up • (distention of kidney) Hydronephros is occurs------ then Builds up pressure---then Kidney damage ---then Impaired function then ------CKD

Narrowing of the lumen of the urethra (scar tissue) • Causes – Diminished urinary stream – Frequency – Urgency – Dysuria – Frequent UTI’s 11

Catheterization • Mechanical dilation • Endoscopic urethrotomy • Urethroplasty • Implantation of stent 12

Pathophysiology • Minerals and salts • High uric acid • Substances that inhibit stone formation are low Types • Calcium • Uric acid • Struvite • Cystine 13

RENAL CALCULI (UROLITHIASIS) 14 • DM, gout, HTN, intestinal disorders, obesity, Genetics Medical conditions Chronic high pH Chronic UTI • ASA, indinavir, topiramate, triamterene, vitamin C supplements, vitamin D, calcium supplements, Dehydration Excessive sweating DIET• low in calcium, phytate, and potassium • high in fructose, oxalate, animal protein, vitamin C, sodium, and sucrose Medication

nephrolithiasis • Flank Pain • Hematuria ...............Ureterolithiasis • Severe colicky pain • Flank, side, or lower abdominal pain • Intense urge to void • Frequency • Dysuria • Hematuria • N/V.............. Bladder Stones• Hematuria • Oliguria 15

Blood Tests • BUN/creatinin e • Calcium • Uric acid ----------Urinalysis • Hematuria • Crystals • WBC • Bacteria------------ 24-hour urine collection • Calcium • Sodium • Uric acid • Oxalate • Citrate • Creatinine -----------------Imaging test • Noncontrost CT • Renal ultrasound • IV pyelography

Hydration – 2-3 quarts daily • Avoid sweetened beverages and grapefruit juice • DASH diet and Mediterranean diet recommended • Ambulate • Urocit-K (potassium citrate)

L E S S T H A N 1 0 M M I N S I Z E Hydrate • 2-3 quarts of fluid Pain control • NSAIDs • Opioids • Heat Strain all urine • Stone analysis Alpha-blocker • Tamsulosin (Flomax

Cystoscopy(goes in head of penis and tap away the calculi) Ureteroscopy Lithotripsy • Shock-wave • Laser Percutaneous Nephrolithotomy 18

Caused by years of damage from elevated glucose levels to small blood vessels in kidneys Reduce risk in DM patients • Control BGL • Control HTN • Control weight • Smoking cessation • Caution with NSAIDs Strict control of BGL – AIC <7 • Strict control of HTN – ACE inhibitors – ARBs • Cholesterol control – statins 23

Massive loss of protein through urine Can be caused by many different conditions Increased glomerular permeability which leads to protein (albumin) being filtered into urine instead of staying in blood

Anasarca(widespread edema) Ascites.... Low serum total protein and albumin Elevated serum cholesterol .....Foamy urine ..........Elevated BP

Average blood glucose concentration over the past 2-3 months

Decrease pressure • ACE inhibitors/ARBs Interventions for edema • Loop diuretics • Sodium restriction • Daily weights • Strict I&Os • Abdominal girth measurements • Skin breakdown prevention Prevention of infection Dietary consult • Protein consumption

Inflammation of the glomerulus • Altered filtration allows proteins, WBCs, RBCs, and electrolytes to be excreted in urine

Post- streptococcal infection-Usually, strep throat or skin infection.......................Goodpasture Syndrome-autoimmune...........................Chronic Glomerulonephritis-Progressive inflammation of glomerulus

Oliguria • Fluid overload – HTN – Edema – electrolyte imbalance • Flank pain • Dark “cola-colored” urine – Sometimes foamy urine • Urinalysis – Hematuria – Proteinuria • Serum BUN/Creatinine – May be elevated • Ultrasound • X-Ray • Biopsy

Acute disease usually resolves with symptomatic Tx within a week • Goal is prevention of progression to CKD – Rest – Edema treatment • Fluid restrictions • Na restrictions – Protein restriction • if increased BUN/creatinine – Education focused on prevention

Rapid onset of decreased kidney function Combination of hypoperfusion, tissue injury/damage, and inflammation Causes waste products to accumulate in the bloodstream (azotemia) Kidneys are unable to filter waste products and may leak other products into urine Usually, reversible

Prerenal • Decreased perfusion to kidneys Intrarenal • Damage to nephrons Postrenal • Obstruction

Nephrotoxins – Diagnostic Contrast Media (Dyes) – Medications – Heavy Metals – Organic Solvents

Antibiotics: – Aminoglycosides – gentamycin, neomycin, tobramycin – Amphotericin B – Cephalosporins – Cefazolin, Cefdinir, Cefepime – Sulfonamides - Bactrim – Tetracyclines – doxycycline, Vibramycin • Analgesics – Acetaminophen – NSAIDs – Salicylates – ASA • Contrast media • Other meds: – ACE inhibitors – Amphetamines – Cisplatin – Dextran – Heroin – Interleukin-2 – Mannitol 34

Initiating • Time of renal injury – occurrence of symptoms -------------------------OLIGURIC<400mL of urine in 24 h • Fluid retained • Electrolytes imbalances • Waste products not excreted (azotemia) • Metabolic acidosis - ----------------DIURETIC• Kidneys begin to excrete 1 – 3L/day • Dehydration/hypotension are a concern • Monitor for hypovolemia, hyponatremia, hypokalemia, hypotension - ----------------Recovery• GFR rises • BUN and creatinine decrease

Correcting the cause – prevent permanent damage • Treat s/sx – Restore fluid/electrolyte balance – DC nephrotoxic drugs – Bypass – Obstructions – Short-term CRRT

Alternative to dialysis • Removes fluid and solutes in a controlled continuous manner • Uses temporary vascular access • Blood flows through the hemofilter: excess fluids and solutes flow into bag – Remaining blood returns to the patient via venous access – May give electrolytes through access • Nursing considerations – Hourly vitals – Monitor vascular access – Strict I&O – Electrolytes – Daily weights

Check creatinine/GFR before contrast dye or medication administration • Monitor levels routinely as indicated • Follow hydration protocols for contrast dye • Prevention of kidney stones

Gradual progressive, irreversible deterioration in renal function. – Unable to maintain metabolic, fluid and electrolyte balance – Nitrogenous waste accumulates – Uremia occurs • Diagnosed when 75% of nephron function is lost – Renal insufficiency s/sx occur • ESRD occurs when 90% function is lost – BUN and creatinine are always elevated 39

ABG – Metabolic Acidosis decreased RBCs – elevated BUN - elevated Creatinine - elevated Magnesium - elevated Potassium - elevated Sodium – elevated........ Calcium – decreased----------------------------stage 1 slight decrease 90 or greater.....stage 3 moderate decrease 45-59.......stage 5 dialysis/transplant <15

Disturbance in Water Balance – Edema – SOB – Crackles/wheezes – HTN – Polyuria, oliguria, or anuria • Disturbance in Electrolyte Balance – Hypernatremia – water retention, edema, HTN – Hyponatremia due to vomiting or diarrhea – confusion – Hyperkalemia – muscle weakness, abdominal cramping, diarrhea, confusion – Hypocalcemia – increased risk for fractures – Hyperphosphatemia – severe itching 41

Disturbance of Removal of Waste Products – Azotemia – Weakness/fatigue – Confusion, seizures, – Asterixis – N/V – lack of appetite – Metallic taste – Yellowish skin – Itching – Uremic Frost • Disturbance in Maintaining Acid-Base Balance – hydrogen excretion affected – Metabolic acidosis • Disturbance in Hematologic Function – anemia 42

Depends on pt’s condition High calorie, low fat Protein restriction unless on dialysis Na+/K+/phosphorus restriction Supplements Fluid restriction as needed Can be anorexic and have N/V

Tx for hyperkalemia • Kayexalate, insulin (+D50), Lasix, albuterol • Place on cardiac monitor – Vitamin/electrolyte supplements • Ex: Calcium gluconate – Sodium Bicarbonate – Diuretics for fluid overload – Sevelamer hydrochloride (Renagel) – Control HTN – Control DMII

Definitive tx of CKD/ESRD/uncontrolled hyperkalemia • Intermittent artificial blood filtration –Vascular Access • Temporary- central line • Permanent- AV fistula or graft

PERITONEAL DIALYSIS • Continuous Dialysis Done by Patient – Peritoneal membrane used to filter out waste via peritoneal vessels – Peritoneal catheter inserted between layers of the peritoneum • Exchange Process 1. Fill 2. Dwell 3. Drain

Thrill- palpable tremor Bruit- swishing sound when auscultating PROTECT Postoperative • Neurovascular Checks – What do you do if there are concerns? • Elevate, ROM, control pain