Urinary Tract Infections (UTIs)

• The urinary tract exists as a sterile environment
• Urinary tract infections (UTIs) are the invasion of the urinary tract by bacteria
• UTIs most often arise from an ascending infection, starting at the external urinary meatus
• Infection ascends toward the bladder and kidneys
• The bacterium Escherichia coli, commonly found in feces is the primary cause of most UTIs
• Other less common pathogens include Staphylococcus saprophyticus, Klebsiella spp, and Enterobacter
• Lower UTIs include urethritis, prostatitis, and cystitis
• Upper UTIs include pyelonephritis and ureteritis
• UTIs are the most common health-acquired infection (HAI)
• People who have had a UTI often develop repeat infections
• Education on how to prevent repeat UTIs is crucial
• Aging increases the incidence of UTIs because of diminished immune function, diabetes, and estrogen decline in women
• Enlarged prostate and a neurogenic bladder that doesn't fully empty increase risk of UTIs
• UTI is the most common cause of acute bacterial sepsis in patients older than 65
• Contamination in the perineal and urethral areas, which can ascend the urinary tract, may occur from genital piercing, fecal soiling and sexual intercourse
• Infections such as vaginitis, epididymitis, or prostatitis can lead to UTIs
• Faulty valves causing reflux of urine do not maintain one-way urine flow along the urinary tract.
• Reflux can be congenital or acquired as a result of previous infections
• Female anatomic and genetic differences make women more susceptible to UTIs
• The short length of the female urethra and its proximity to the vagina and anus increase risk
• Some women with recurrent UTIs have a shorter distance from the urethra to anus
• Genetic factors may play a role in women having a certain phenotype for developing UTIs
• Instrumentation infection occurs from instruments or tubes inserted into the urinary meatus
• The most common cause of instrumentation infection is insertion of a urinary catheter
• Bacteria ascend around or within the catheter, and bacterial colonization begins within 48 hours of indwelling catheter insertion
• Previous UTIs might provide a reservoir of bacteria that can cause reinfection
• Stasis of urine in the bladder results from voiding infrequently or obstruction, which promotes bacterial growth

Nursing Care Tip

• When caring for a patient at risk for an internal catheter-associated urinary tract infection (CAUTI), limit the use of a urinary catheter
• Always use infection control procedures, and discontinue use as soon as possible
• CAUTI is a Never Event; hospitals won't be paid by Medicare for the costs of care if this condition occurs during hospitalization
• An external female catheter, the Purewick, keeps females who are incontinent dry without being invasive, and reduces the risk of CAUTI
• The Purewick is an external sponge/suction catheter placed between the labia and the gluteus muscles, attached to a suction device at the lowest setting

Signs and Symptoms

• UTIs are characterized by shared signs and symptoms with location-specific symptoms
• Decline in mental status and fever in a patient with an indwelling catheter meets diagnostic criteria for a UTI
• In older adults, the typical presenting symptom is generalized fatigue
• New-onset confusion or delirium may be present in the older adult, but a fever may not be

Urethritis

• Urethritis is inflammation of the urethra caused by a chemical irritant, bacterial infection, trauma, or exposure to a sexually transmitted infection (STI)
• Posttraumatic urethritis can occur with intermittent catheterization or instrumentation of the urethra
• Bubble bath, bath salts, and spermicidal agents are urethral irritants and should be avoided by anyone with a history of UTI
• Gonorrhea and chlamydia are STIs that can cause urethritis in men
• The male patient may have discharge from the penis; urinalysis and urine culture are used to diagnose urethritis
• Urethritis is treated on the basis of the cause; in cases of sexual transmission, sexual partners must also be treated
• Phenazopyridine (Pyridium), a urinary analgesic, treats dysuria, and it turns the urine orange

Urinary Tract Infection Summary

• Signs and symptoms: voiding urgency, frequency, and burning; cloudy, foul-smelling urine and hematuria
• Older adult: fatigue, confusion, and delirium
• Cystitis produces pelvic pain or pressure
• Pyelonephritis is associated with costovertebral tenderness, high fever, chills, and nausea/vomiting
• Urinalysis: white blood cells, red blood cells, casts, bacteria, positive for nitrites
• Urine culture: Positive
• Therapeutic Measures: antimicrobial for causative organism, encourage fluids and Phenazopyridine (Pyridium)
• Complications: pyelonephritis and urosepsis

Cystitis

• Cystitis is inflammation of the bladder wall, usually caused by a bacterial infection, and E. coli causes most UTIs
• Cystitis can also result from catheter use, chemical irritants, medications, or radiation therapy
• Chronic interstitial cystitis, or painful bladder syndrome, has no known cause
• Urinalysis or sometimes cystoscopy is used for diagnosis
• Urinalysis findings for cystitis include cloudy urine, WBCs, bacteria, sometimes red blood cells (RBCs), positive nitrites, and positive leukocyte esterase (pyuria)
• Urine culture and sensitivity are done if indicated
• Bacterial cystitis is often treated with nitrofurantoin (Macrobid, Macrodantin), sulfamethoxazole and trimethoprim (Bactrim, Septra), or fosfomycin (Monurol)
• Finish all prescribed medications to prevent bacterial resistance and have a follow-up urinalysis or culture is important; and encourage fluids to flush the bladder

Pyelonephritis

• Pyelonephritis is infection of one or both kidneys, which can be serious
• Bacteria can travel from the ureters to the bladder and then up to the kidneys
• Young women and older adults experience this infection most
• Risk factors for uncomplicated pyelonephritis include a history of UTIs within the past year, sexual intercourse, or spermicide use
• Complicated pyelonephritis risk factors are diabetes, weak immune system, or structural or obstruction problems
• High fever, chills, nausea/vomiting, flank pain, and costovertebral tenderness indicate pyelonephritis
• Urinalysis shows cloudy urine, bacteria, WBCs, pyuria, positive nitrites, and casts
• Urine culture will have 100,000 or more colony-forming units (CFU) per milliliter
• In acutely ill patients, blood cultures may be obtained
• Antibiotics are given orally or intravenously
• After treatment, there is usually no lasting kidney damage; however, frequent kidney infections can result in scarring and loss of kidney function

Urosepsis

• Urosepsis is sepsis caused by a UTI
• Septic shock and death can result, so prompt treatment is essential
• Older adults are at greater risk for urosepsis

Nursing Process For the Patient

• Ask what the patient's usual pattern of voiding is and if changes have occurred. Document the presence of a catheter, recent urinary instrumentation, or surgery
• Note the presence of signs or symptoms. Inspect the urine for volume, color, concentration, cloudiness, blood, or foul odor, and review urinalysis and culture results

Nursing Diagnoses, Planning, and Implementation

• Acute Pain related to inflammation and infection of urinary structures and administer phenazopyridine (Pyridium) as ordered to relieve pain, and apply heat to suprapubic area to relieve discomfort
• Ineffective Health Maintenance Behaviors related to lack of knowledge on preventing and resolving UTIs
• Suggest eating foods that may prevent UTIs, including polyphenols (cranberry or blueberry products, coffee, black tea, and dark chocolate)
• Encourage drinking fluids, including water to produce clear light-yellow urine, to prevent dehydration and flush bacteria from urinary tract
• Void as soon as the urge occurs or every 3 hours while awake to empty the bladder and lower bacterial counts, reduce stasis, and prevent infection
• Wipe from front to back to prevent spreading bacteria from anal area to urinary meatus and wear cotton crotch underwear/avoid constricting clothing
• Avoid perfumed feminine hygiene products, bubble bath and bath salts, scented toilet paper, and tub baths
• Void after sexual intercourse, report signs and symptoms of UTI and finish all prescribed antibiotic medications as directed to prevent recurrent infection or resistance to antibiotics

Medication Used to Treat Urinary Tract Infections

• Fosfomycin (Monurol) is an antibiotic that you only need one dose for a UTI
• Diarrhea is a common side effect that subsides when medication is stopped, and is dissolved in 1/2 cup of cool water to drink immediately
• Nitrofurantoin (Macrobid, Macrodantin) is effective against E. coli, enterococci, Staphylococcus aureus, Klebsiella spp., and Enterobacter
• Avoid taking with antacids, but take with food or milk and full glass of water
• Effective against Escherichia coli, Klebsiella spp., and Serratia, Beta-Lactam Antibiotics, e.g. ceftriaxone (Rocephin) and cefepime (Maxipime) and aztreonam (Azactam)
• Check allergies and renal function
• Flouroquinolones are effective against E. coli, Klebsiella spp., Pseudomonas, and other organisms like ciprofloxacin (Cipro) and levofloxacin (Levaquin)
• Do not give if pregnant; absorption may be decreased if given within 2 hr of aluminum antacids
• Give with large amounts of water and avoid sunlight or wear sunscreen of 30 HPF or more; report tendon aches promptly as tendon may rupture

Sulfonamides

• Effective against E. coli used for uncomplicated UTIs like trimethoprim-sulfamethoxazole (Bactrim, Septra)
• Do not give if allergic to sulfa or if pregnant; dose may need adjustment with renal disease
• Avoid sunlight or wear sunscreen of 30 SPF or more and take with large amounts of water

Urinary Analgesic

• phenazopyridine (Pyridium) is a topical analgesic that changes urine color to red-orange
• Relieves pain urgency and frequency associated with UTI but avoid in renal insufficiency and changes urine glucose testing

Urological Obstructions

• Urinary tract obstruction interferes with the flow of urine along the urinary tract with partial or complete obstruction rapidly or slowly
• Since urine will back up from the point of blockage, it will eventually distend the kidney (hydronephrosis) and increasing pressure on the structures of the kidney
• If not relieved, this pressure can damage the kidney, impair its function, and ultimately lead to CKD

Urethral Strictures

• A urethral stricture is a narrowing of the lumen of the urethra from scar tissue
• It creates a diminished urinary stream, dysuria, frequency, and frequent UTIs, and it occurs from injury, STIs, tissue trauma from use of catheters or surgical instruments and enlarged prostate
• Treatment includes catheterization to drain the obstructed urine; mechanical dilation and endoscopic urethrotomy and surgical repair (urethroplasty)

Renal Calculi (Urolithiasis)

• Renal calculi (urolithiasis) are stones in the urinary tract, that form in the kidney (nephrolithiasis) but may form in the ureter (ureterolithiasis)
• Crystals start to form when (1) urine is too concentrated, such as calcium, oxalate phosphorus or uric acid and (2) substances such as citrate inhibits stone formation
• Crystals combine with other substances and form a calculus
• The main types of stones are calcium, uric acid, struvite, and cystine and most stones are made of calcium oxalate
• Renal calculi range from the size of a grain of salt to large staghorn stones caused by urease-producing bacteria in chronic UTIs

Etiology

• Stone formation has numerous causes, specifically to the type of stone
• Nonmodifiable risk factors include genetics, family history of stones, cystinuria, diabetes mellitus, gout (men), hypertension, certain intestinal disorders or bypass surgery, obesity and chronic UTI
• Modifiable risk factors include inadequate fluid intake, medications such as aspirin, indinavir (Crixivan), topiramate (Trokendi XR, Topamax), triamterene (Dyrenium), vitamin C supplements and vitamin D, and calcium supplements between meals
• Dietary habits such as a diet low in calcium, phytate, and potassium or high in fructose, oxalate, animal protein/ vitamin C, sodium, and sucrose also influence stone formation
• Specific causes and ways to prevent stones are determined through analysis of the passed stone
• Stones are more common in men than in women, and recurrence rises once you have one

Signs and Symptoms

• Stones can pass asymptomatically, but pain usually occurs when the stone moves
• The most common symptoms are mild to severe pain (renal colic, flank pain) that occurs in waves and hematuria

Complications

• Obstructed urine flow leads to hydroureter and hydronephrosis, if the obstruction is not relieved, shock and sepsis can occur leading to CKD

Prevention

• Adequate hydration (2–3 quarts) daily is recommended and sweetened beverages and grapefruit juice should be avoided and the DASH or Mediterranean diet are recommended
• Encourage the patient to walk, which promotes the excretion of stones, and Urocit-K (potassium citrate) might be prescribed

Kidney Stone Diets

• Calcium oxalate stones: limit sodium and animal protein, and consume adequate calcium to bind with oxalate, and follow low oxalate diets that limits beets, chocolate, spinach, rhubarb, nuts, peanuts, and sweet potatoes
• Calcium phosphate stones: reduce dietary sodium and animal protein, avoiding cola beverages, and getting adequate calcium help prevent stones
• Uric acid stones: limit high-purine foods, alcohol and gravy and eat increased fruits and veg

Nephrolithiasis

• Costovertebral angle pain and hematuria
• Ureterolithiasis causes severe, colicky (wavelike) pain from obstructed urine flow
• Radiating flank, side, or lower abdominal pain radiating to genitalia, intense urge Void, frequency, dysuria, reduced output occur
• Hematuria irritation from stone
• Nausea/vomiting with severe pain Bladder stones are associated with hematuria, and oliguria with obstruction of bladder outlet
• Get a computed tomography (CT), renal ultrasound, abdominal x-ray and blood tests for calcium, uric acid, BUN, and creatinine
• Two 24-hour urine collections, urinalysis showing hematuria and urine pH

Therapeutic Measures

• Small stones: hydration, analgesics, alpha blocker (Tamsulosin)
• Large stones, symptomatic: IV fluids, pain control, thiazide diuretic, allopurinol (Zyloprim)
• Lithotripsy
• Surgery: Percutaneous nephrolithotomy, ureteroscopy, cystoscopy, cystolitholapaxy

Diagnostic Tests

• Blood tests which includes BUN and creatinine assess renal function and urinalysis assess for hematuria and infection
• Imaging tests for renal stones and hydronephrosis include noncontrast computed tomography (CT) or renal ultrasound

Therapeutic Measures

• Small renal calculi, usually less than 10 mm, are treated with hydration and pain medication
• Strain all urine to detect passage of stones, drinking 2 to 3 quarts of fluids and NSAIDs are used as treatment
• Surgical intervention may be needed depending on the location and size of the stone, the presence of obstruction/infection
• Only rarely is open surgery required

Cystoscopy

• Cystoscopy (wire basket removal) is used for small stones in the bladder, and cystolitholapaxy is used for larger stones; wash it using an irrigating solution

Ureteroscopy

• The ureteroscope to view the stone; then remove with a wire basket or broken up with laser or electrohydraulic energy to be flushed out in the urine. A stent may be placed for up to 2 weeks

Lithotripsy

• Lithotripsy uses sound shock waves or laser energy to break the stone into small fragments
• Examples: shock-wave lithotripsy (SWL), laser lithotripsy, and percutaneous ultrasonic lithotripsy
• For SWL, the patient is sedated or anesthetized and ultrasonic shock waves outside the body on the stone
• Blood-tinged urine (pink) and back soreness for several days are expected; also increase fluid intake and strain urine to catch stone fragments for analysis

Nursing Process Data Collection

• The health history may identify a family or patient history of previous stone formation
• Recent history of UTI, diet/activity changes, or other risk factors for renal calculi is needed

Priority Nursing Diagnoses

• Pain from obstruction by, or movement of a stone within the urinary tract to tolerable level within 30 minutes of report of pain; monitor pain (Renal colic pain typically occurs in the flank or costovertebral angle and may radiate to the abdominal, pelvic, and genital areas) and medication
• Apply heat if needed and encourage ambulation to facilitate the passage of the stone through the urinary system and Risk for Infection (Monitor temperature and urine) with education
• Encourage adequate fluid intake to dilute urine to facilitate the passage of stones

Hydronephrosis

• Hydronephrosis is distention of the renal pelvis and calices from obstruction of urine flow caused by a stricture in a ureter or the urethra, renal calculi, tumors, or an enlarged prostate.
• Immediate treatment of hydronephrosis is to relieve the urinary retention, often by inserting a urinary catheter or a ureteral stent
• A nephrostomy tube can be inserted directly into the kidney pelvis to drain urine into a collecting bag in an nephrostomy site

Tumors of the Renal System

• Cancer of the bladder is the most common cancer of the urinary tract.
• Specific chemicals have been discovered within cigarette smoke. Those chemicals are passed to the kidneys through the bloodstream and collect in the urine which damages the cell

Cancer of the Bladder

• Bladder cancer usually causes painless hematuria and may discover a presence of blood cells in the urinalysis
• Cystoscopy with biopsy is the preferred diagnostic test
• Treatment depends on the type and staging (severity) of the bladder cancer.
• For early-stage cancers that affect the inside lining of the bladder, intravesical therapy with chemotherapy or immunotherapy are used to instill into the bladder to trigger the immune
• Transurethral resection of the bladder that occurs to cancerous tissue uses a resectoscope and cauterization

Urinary diversions

• An ileal conduit is when a section of the ilem or colon is removed and is used as a conduit for urine and then the remaining portions of the bowel are put back together
• Isolated sections of the bowel is closed on one end, the ureters are stitched into it, and the other end is brought out as a stoma on the abdomen (urostomy) that then continuously drains urine

Cancer of the Kidney

• Cancer of the kidney is among the 10 most common cancers in both men and women Kidney cancer is diagnosed most often in those age 65 to 74 and is twice as likely than women.

Cancer signs and symptoms

• The three classic symptoms symptoms of kidney cancer are hematuria, dull pain in the flank area, and a mass in the area
• Diagnostic tests include a cystoscopy and pyelogram, ultrasound examination of the kidneys, CT scan of the abdomen, and MRI

Kidney cancers treatments

• Surgery is the commonly used treatment for cancer of the kidney, using a radical nephrectomy along with the adrenal gland and other surrounding structures
• After nephrectomy, postoperative care is to monitor urine output. Report changes in urine amount or color, bleeding, or signs of infection

Renal System Trauma

• Causes of trauma to the kidney, ureters, and bladder include motor vehicle accidents, sports injuries, falls, and gunshot and stab wounds. Bladder trauma or rupture may occur with pelvic fractures or trauma from a blow to the lower abdomen when the bladder is full
• Data collection includes a history of the injury and inspection of the abdomen and flank for asymmetry, bruising, or swelling with Diagnostic tests include urinalysis, ultrasound, CT, and MRI

Polycystic Kidney Disease

• Polycystic kidney disease is a hereditary disorder that can result in CKD.
• The cysts are grapelike and contain serous fluid, blood, or urine. The patient typically first shows signs of the disease in adulthood including dull heaviness in the flank or lumbar region and hematuria

Chronis Renal Disease (Diabetic Nephropathy)

• Diabetes is the most common cause of Diabetic
• Nephropathy and Risk factors include chronic hyperglycemia, hypertension, high cholesterol, genetic predisposition, and smoking
• In the early stages of diabetic nephropathy, strict control of blood glucose levels (A1C less than 7%) and blood pressure helps slow the progress of the disease and reduce symptoms

Glomerulonephritis

• Glomerulonephritis is most commonly associated with a group A beta-hemolytic streptococcal infection 6 to 10 days after a streptococcal infection of the throat or skin and in turn is caused by antibodies
• Symptoms of glomerulonephritis include hematuria, proteinuria, electrolyte imbalances, renal insufficiency, edema, hypertension, and thrombotic events
• Glomerulonephritis is diagnosed with urinalysis, which shows protein, casts, or RBCs
• Urine is dark or cola-colored from old RBCs and may be foamy because of proteinuria Most cases of acute glomerulonephritis resolve spontaneously

Acute Kidney Injury (AKI):

• Sudden (hours to days) loss of the kidneys' ability to clear waste products and regulate fluid and electrolyte balance
• AKI has three major mechanisms of injury which includes hypoperfusion, direct tissue injury, and hypersensitivity reactions causing rapid damage to the kidney
• AKI is often classified as prerenal, intrarenal, or postrenal.
• Prerenal (before the kidney) injury are decreased blood pressure from dehydration or blockage in the arteries
• Intrarenal (inside the kidney) injury are ischemia, toxins, and reduced blood flow
• Postrenol(after the kidney) injury is caused by an obstruction of blocks urine flow out of the body

Three phases of AKI

• Initiating phase which happens right at renal injury and lasts until symptoms occur
• Oliguric phase where urine production is less then 400mL in 24 hours
• Diuretic phase where kidneys produce Osmotic diuresis and urine is produced 1-3L/day
• Recovery phase where recovery begins and GFR rises which last up to a year

Chronic Kidney Disease

• CKD is one of the eighths leading cause of deaths
• CKD has to with progressive deterioration in renal function in which the body cannot maintain metabolic/fluid/ electrolyte balance
• The result is accumulation of Nitrogenous waste in the blood with uremia and CKD affects each system body

Therapeutic measures

• Patients with CKD can have complex dietary requirements and need the guidance of a dietitian who specializes in renal treatment
• Fluid may vary patient has from to urine out put

Dialysis

• Started when patients exhibit severe fluid over load and high levels of serum potassium as well as electrolyte Imbalance and symptoms of uria
• Involves the movement of diffusion of particles (area of higher concentration to a lower area)
• In hemodialysis it involves and artificial Kidnney and a blood is run through the dialyzing solution
• A treatment typically takes 3–4 hours weekly
• Peritoneal Dialysis is continues as it happens inside the abdomen through A solution that flows inside in the abdomen collecting the waste and pulling it out at the same time with it, and you must use sterile technique*