Altered Urinary Patterns PDF

ELIMINATION PATTERNS  As blood passes from the afferent arteriole RESPONSES TO ALTERED URINARY into the glomerulus, water, electrolytes, and SYSTEM other particles (creatinine, urea n...

ELIMINATION PATTERNS  As blood passes from the afferent arteriole RESPONSES TO ALTERED URINARY into the glomerulus, water, electrolytes, and SYSTEM other particles (creatinine, urea nitrogen, Basic Concepts glucose) filtered across the glomerular KIDNEY: IMPORTANT ROLES membrane in the Bowman’s capsule to form 1. maintain body fluid volume and glomerular filtrate. composition  Large particles (blood cells, albumin, and 2. To filter waste products for elimination other proteins) - too large to filter through  allow the body to meet human need for the glomerular capillary walls  therefore elimination. these substances are NOT NORMALLY Other Functions: present in the filtrate or in the final urine.  regulate blood pressure and acid-base  180 L of glomerular filtrate is formed each balance day.  produce erythropoietin for red blood cell  average of normal glomerular filtration (RBC) synthesis rate: GFR 125 mL/min  convert vitamin D to an active form NOTE: If the entire amount of filtrate were  Ureters, bladder, and urethra: drainage excreted as urine death may occur quickly route for the excretion of urine. with dehydration. ANATOMY AND PHYSIOLOGY REVIEW  About 1 to 3 L is excreted each day as Kidneys urine. located retroperitoneally (behind  GFR and outside the peritoneal cavity)  Controlled by BP and blood flow. LOCATION on the posterior wall of the  When systolic pressure drops below abdomen— about 70 mm Hg, these processes from the 12th thoracic vertebra to cannot compensate and GFR stops. the 3rd lumbar vertebra in the adult 2. Tubular Reabsorption 4 to 5 inches (10 to 13 cm) long, 2  2nd process involved in urine to 3 inches (5 to 7 cm) wide and formation. ADULT about 1 inch (2.5 to 3 cm) thick. It  This reabsorption of most filtrate keeps KIDNEY weighs about 8 ounces (250 g). normal urine output at 1 to 3 L/day -Left kidney is slightly longer and and prevents dehydration narrow than the right kidney. Larger- Antidiuretic Hormones influencing renal than- may indicate renal obstruction or Hormone (ADH) and function. usual polycystic disease. Aldosterone kidneys Smaller- than- may indicate chronic kidney also known as vasopressin usual disease and affects arteriole kidneys constriction that alters ADH blood pressure FUNCTIONS Affects the amount of fluid Regulatory Functions – control fluid, electrolyte, and and solutes that exist in the acid-base balance. glomeruli capillaries. Promotes the absorption of PROCESSES THAT MAINTAIN FLUID, Aldosterone sodium in the DCT (distal ELECTROLYTE AND ACID-BASE BALANCE convoluted tubule). 1. Glomerular Filtration  is the first process in urine formation.  The kidney reabsorbs some of the glucose filtered from the blood but there is a limit to how much glucose the kidney can reabsorb  this limit is called the renal threshold for glucose reabsorption or the transport maximum for glucose reabsorption. usual renal threshold for 220 mg/dL glucose JMTT pg. 12   This means that a blood glucose level of RENAL/URINARY SYSTEM CHANGES 220 mg/dL or less, all glucose is ASSOCIATED WITH AGING reabsorbed and returned to the blood  Kidney losses cortical tissue and gets  with no glucose present in final smaller by 80 years of age urine.  This is caused by reduced renal blood  When blood glucose levels are greater flow  reduced ability of older adult to than 220 mg/dL, some glucose stays in filter blood and excrete waste products. the filtrate and is present in the urine.  Blood flow to the kidney decreases by Normally, almost all glucose and any about 10% per decade as blood vessels amino acids or proteins are reabsorbed thicken. and are not present in the urine. Glomerular filtration rate (GFR)  Decreases with age, especially after age 3. Tubular Secretion  3rd process involved in urine formation. 45.  Like glomerular filtration, it allows  By age 65, the GFR is about 65mL/min substances to move from the blood into (half rate of a young adult)  this the early urine. decline is more rapid in patients with  Potassium and hydrogen ions are some diabetes, hypertension, or heart failure of the substances that moved in this  as a result, the older patient has a way to maintain homeostasis of greater risk for fluid overload. electrolyte and pH. The Tubular Changes With Aging  Decrease the ability to concentrate urine  resulting in nocturnal polyuria (increased urination at night). HORMONAL FUNCTIONS  Along with an age-related impairment  Control red blood cell (RBC) formation, in the thirst mechanism  these blood pressure, and vitamin D changes increase the risk for activation. dehydration and hypernatremia  The kidneys produce renin, (increased blood serum sodium levels). prostaglandin, bradykinin, Hormonal Changes erythropoietin, and activated vitamin D.  include a decrease in renin secretion,  Other kidney products, such as the aldosterone levels, and activation of kinins, change renal blood flow and vitamin D. capillary permeability Urinary Changes  The kidneys also help break down and  Changes in the detrusor muscle excrete insulin. elasticity lead to decreased bladder capacity and reduced ability to retain urine. Renal Hormone Production Raises blood pressure NURSING PROCESS because of angiotensin (local Assessment RENIN vasoconstriction) and Patient History aldosterone (volume expansion) secretion. DEMOGRAHIC INFORMATION Regulate intrarenal blood  Sudden onset of hypertension in flow by vasodilation or patients older than 50 years = possible vasoconstriction. These kidney disease. Prostaglandins substances help regulate  In men older than 50 years, altered glomerular filtration, kidney urine patterns accompany prostate vascular resistance and renin disease. production. JMTT pg. 13 Anatomic Differences  Men rarely have UTI unless there are Nutrition History abnormalities such as ureteral reflux or  Usual diet and any recent changes prostate enlargement. in the diet.  Women have a shorter urethra and  Excessive intake or omission of more commonly develop cystitis certain food categories? (bladder infection) because bacteria  Food and fluid intake? pass more readily into the bladder.  How much and what types of fluids History the patient drinks daily? (fluids  previous renal or urologic with a high calorie or caffeine problems including tumors, content). infections, stones, or urologic  Teach the patient the importance surgery of drinking about 3 L of fluid daily  Chronic health problems, (if other medical problem does not especially diabetes mellitus or require fluid restriction) to prevent hypertension. dehydration and cystitis.  Chemical exposures at the  High-protein intake or poor fluid workplace or with hobbies. intake can result in temporary  Exposure to hydrocarbons (ex. renal problems  increased risk Gasoline, oil), heavy metals for Calculi (stone) formation. (especially mercury and lead), and some gasses (ex. Chlorine, toluene) Medication History can impair kidney function  Patient’s prescription drugs may Health teaching: Avoid direct skin or mucous lead to renal impairment. membrane contact with these chemicals.  duration of drug use and whether Use of heroin, cocaine, methamphetamine, have been any recent changes in ecstasy, and volatile solvents (inhalants) has prescribed drugs also been associated with renal damage.  Drugs for diabetes mellitus,  Ask if s/he has ever been told hypertension, cardiac disorders, about the Past and current use of hormonal disorders, cancer, OTC drugs or agents, including arthritis, and psychiatric disorders dietary supplements, vitamins and are potential causes of renal minerals, herbal agents, laxatives, dysfunction. analgesics, acetaminophen, and  Antibiotics: Gentamicin - may also NSAIDs  many of these agents cause sudden renal dysfunction. affect renal function.  Past and current use of OTC drugs  Presence of protein or albumin in or agents, including dietary the urine. supplements, vitamins and  History of high blood pressure? minerals, herbal agents, laxatives,  Ask women about health problems analgesics, acetaminophen, and during pregnancy (ex. Proteinuria, NSAIDs  many of these agents high blood pressure, gestational affect renal function. diabetes, urinary tract infections). Family History and Genetic Risk Obtain information about  some disorders have a familial  Recent travel to geographic regions inheritance pattern that pose infections disease risks  Recent physical injuries Current Health Problems  Trauma  The effects of renal failure result in  Sexual contacts many changes in all body systems.  A history of altered patterns of  Recent upper respiratory urinary elimination problems, achy muscles or joints, chronic fatigue, or GI problems may be related to problems of kidney function. JMTT pg. 14   Ask about changes in urination ASSESSMENT OF THE KIDNEYS, URETERS, patterns such as nocturia AND BLADDER (urination at night), frequency, or  Auscultate before percussion and an increase or decreased in amount palpation because these activities of urine. can enhance bowel sounds and  The normal urine output for adults obscure abdominal vascular is about 1500 to 2000 mL/day, or sounds. within 500 mL volume of fluid  Inspect the abdomen and the flank ingested in a day. regions with the patient in both the  Ask about any loss of urinary supine and the sitting positions. incontinence, especially when  Observe the patient for asymmetry coughing, sneezing or laughing. (ex. Swelling) or discoloration (ex. Patients may also report a Bruising or redness) in the flank persistent dribbling of urine. region, especially in the  Pain associated with renal or costovertebral angle (CVA). ureteral irritation is often severe  Listen for a bruit by placing a and spasmodic. stethoscope over each renal artery  Pain that radiates into the perineal on the midclavicular line. area, groin, scrotum, or labia is  Renal palpation is usually described as renal colic  this pain performed by a physician or occurs with distention or spasm of advanced practice nurse. the ureter such as in an obstruction It can help locate masses and or the passing of stone. areas of tenderness in or  Renal colic pain may be around the kidney. intermittent or continuous and If tumor or aneurysm is may occur with pallor, diaphoresis, suspected, palpation may and hypotension. harm the patient.  Uremia is the build-up of  A distended bladder sounds dull when nitrogenous waste products in the percussed. blood a result of renal failure.  Patients with inflammation or infection Manifestations include anorexia, in the kidney or nearby structures may nausea and vomiting, muscle describe their pain as severe or as a cramps, pruritus (itching), fatigue constant, dull ache. and lethargy. ASSESSMENT OF THE URETHRA PHYSICAL ASSESSMENT  Using a good light source and  Assess the general appearance of wearing gloves, inspect the urethra the patient by examining the meatus and the  Check for a yellowish skin color and tissues around it. the presence of any rashes,  Record any usual discharges such bruising, or other discoloration. as blood, mucus or pus.  (+) edema, which with renal  Record the presence of lesions, disorders may be detected in the rashes, or other abnormalities of pedal (foot), pretibial (shin), and the penis or scrotum or of the labia sacral tissues, and around the eyes. or vaginal opening.  Auscultate the lungs to determine  Urethral irritation is suspected whether fluid is present. when the patient reports  Weigh the patient and take his or discomfort with urination her blood pressure as a baseline for DIAGNOSTIC EVALUATION later comparisons  Nursing Responsibility: Educate  Assess the patient’s level of patient about the purpose, what to consciousness and level of expect, and any possible side alertness. Record any deficits in effects concentration, thought processes,  Manage Anxiety Voiding in the or memory. presence - cause guarding, a JMTT pg. 15  natural reflex inhibiting voiding due 2. Proteinuria to situational anxiety. B Microalbuminuria early sign of DM URINALYSIS AND URINE CULTURE (excretion of 20 to nephropathy. clinical information about 200 mg/dL of Urinalysis kidney function and helps protein in the diagnose other diseases urine) determines whether bacteria Caused by fever, (DM) urine are present in the urine Transient strenuous exercise, culture proteinuria identify the antimicrobial and prolonged Urine therapy suited for the particular standing. Sensitivity strains identified glomerular diseases, malignancies, collagen URINE COLOR diseases, diabetes, dilute urine (diuretic persistent preeclampsia, use, DI, alcohol use, proteinuria hypothyroidism, heart Colorless to pale excess fluid intake, failure, exposure to yellow glycosuria, and kidney heavy metals, and the disease) use of medications Yellow to milky Pyuria, infection, (NSAIDs and ACE white vaginal cream inhibitors) Multiple vitamin 3. pH Bright yellow preparations  a measure of urine acidity or alkalinity Hgb breakdown, RBC,  A pH value less than 7 is acidic and a Pink to red gross blood, post- value greater than 7 is alkaline. surgery (bladder,  A diet high in certain fruits and prostate), medications vegetables result in a more alkaline Concentrated urine urine. Orange to amber (dehydration), excess  A high-protein diet produces more bilirubin, medication acidic urine. (nitrofurantoin) 4. GLUCOSE  filtered in the glomerulus  Urine clarity and odor  When the blood glucose rises above  Urine pH and specific gravity 220 mg/dL, the renal threshold for  Tests to detect protein, glucose, and reabsorption is exceeded and some ketone bodies in the urine (proteinuria, glucose is present in the urine  renal glycosuria, and ketonuria, common in those patients with respectively) infection or those with long-standing  Microscopic examination: RBCs diabetes mellitus. (hematuria), white blood cells (pyuria), 5. KETONE BODIES casts (cylindruria), crystals  Are formed from the incomplete (crystalluria), and bacteria (bacteriuria) metabolism of fatty acids.  urine telomerase activity levels –  Normally there are no ketones in the detection of Bladder Ca urine. 6. PROTEINS ABNORMALITIES/PERTINENT FINDINGS:  such as albumin, is not normally present 1. HEMATURIA (MORE THAN 3 RBCS PER in the urine. HIGH-POWER FIELD)  Levels greater than 300 mg/24 hr, or  acute infection (cystitis, urethritis, or 200 mcg/min, are abnormal. prostatitis), renal calculi, and neoplasm; bleeding disorders; malignant lesions; and medications (warfarin (Coumadin) SPECIFIC GRAVITY  degree of concentration of the urine and heparin)  Normal: 1.010 to 1.025  When fluid intake decreases, specific gravity normally increases. JMTT pg. 16   With high fluid intake, specific gravity decreases IMAGING ASSESSMENT  Patients with kidney disease = urine- plain film of the specific gravity does not vary with fluid X-ray of the abdomen obtained intake, and the patient’s urine is said to kidneys, ureters, without any specific and bladder (KUB): preparation; shows have a fixed specific gravity. gross anatomic   Urine-specific gravity: diabetes features and obvious insipidus, glomerulonephritis, and stones, strictures, severe renal damage. calcifications, or   Specific gravity: diabetes, nephritis, obstructions in the and fluid deficit. urinary tract Provide information OSMOLALITY about tumors, cysts,  most accurate measurement of the Computed abscesses, masses, kidney’s ability to dilute and Tomography obstruction, and renal concentrate urine blood vessels. Assessment of kidney S. osmolality 280 to 300 mOsm/kg size, cortical thickness, and status of the Ultrasonography calices. The test can Urine osmolality 200 to 800 mOsm/kg identify obstruction in 24-hour urine 300 to 900 mOsm/kg the urinary tract, sample tumors, cysts and other masses without RENAL FUNCTION TESTS the use of a contrast  Renal function test results may be dye. within normal limits until the GFR is reduced to less than 50% of normal May be for diagnosis 1. CREATININE CLEARANCE and treatment; used  detects and evaluates progressions of to examine bladder kidney disease trauma.  Test measures volume of blood cleared Cystoscopy of endogenous creatinine in 1 minute Cystoscopy may be  Provides an approximation of GFR used to remove 2. CREATININE LEVEL bladder tumours or an  creatinine is the end-product of muscle enlarged prostate energy metabolism gland.  Normal: 0.6 – 1.2 mg/dL Test used to examine 3. BUN urethral trauma.  urea is the nitrogenous end product of protein metabolism Both procedures  Normal values: 10-20 mg/dL (3.6-7.1 Cystourethroscopy identify causes of mmol/dL) urinary tract  Older adults: 60-90 yr: 8.23 mg/dL obstruction. (2.9-11.1 mmol/L)  Older than 90 yr: 10-31 mg/dL (3.6- ANALYSIS/NURSING DIAGNOSIS 11.1 mmol/L)  Impaired Urinary Elimination as 4. BUN-TO-CREATININE RATIO evidenced by frequency, urgency,  Evaluates hydration status. hesitancy, dysuria, and nocturia  Elevated ratio: hypovolemia  Urge Urinary Incontinence as evidenced  Intrinsic Kidney Disease: Normal ratio by frequency, urgency, loss of urine with elevated BUN before reaching toilet, and voiding in small or large amounts JMTT pg. 17   Urinary Retention as evidenced by CONTRIBUTING CONDITIONS sensation of bladder fullness, dribbling  female gender, DM, pregnancy, urine, dysuria and bladder retention neurologic disorders, gout  Stress Urinary Incontinence as  Decreased natural host defenses or evidenced by dribbling urine with immunosuppression increased abdominal pressure, urinary  Inability or failure to empty the bladder urgency, and urinary frequency completely  Acute Pain (Cognitive-Perceptual)  Inflammation or abrasion of the  Ineffective Health Maintenance (Health urethral mucosa Perception-Health Management)  Instrumentation of the urinary tract (like catheterization, cystoscopic CARE OF THE PATIENTS WITH URINARY procedures) PROBLEMS  Congenital abnormalities: Urethral  Urinary problems are common and strictures, Contracture of the bladder costly. neck, Bladder tumors, calculi (stones)  Life-threatening complications are rare in the ureters or kidneys, and with urinary problems, patients may compression of the ureters have significant functional, physical and psychological changes that reduce PATHOPHYSIOLOGY quality of life.  bacteria gain access to the bladder > attach and colonize the epithelium of INFECTIONS OF THE URINARY TRACT the urinary tract > evade host defense by pathogenic mechanisms > initiate inflammation Urinary tract microorganisms in the INFECTION OCCURS BECAUSE OF THE infections (UTIs) urinary tract FOLLOWING:  Disruption in the activity of GAG Note: Normal urinary tract is sterile above the (Glycosaminoglycan) - a hydrophilic urethra protein; exerts a nonadherent 2nd most common infection in the body protective effect; attracts water molecules to form a water barrier CLASSIFICATION (BY LOCATION) (defensive layer between the bladder 1. Upper Urinary Tract Disorder and the urine) = Less common  Disruption of the normal bacterial flora a) pyelonephritis (inflammation of the of the vagina and urethral area renal pelvis) an obstruction to free- b) nephritis (inflammation of the kidney) flowing urine. With c) kidney abscesses coughing, sneezing, or CLASSIFICATION (DEPENDS ON RECURRENCE AND DURATION) straining, the bladder Reflux Uncomplicated common in young (urethrovesical pressure increases, Community- women and not reflux) which may force urine acquired infection usually recurrent from the bladder into - urologic the urethra. When the abnormalities or pressure returns to Complicated recent catheterization normal, the urine - often acquired flows back into the during hospitalization bladder, bringing into the bladder bacteria LOWER URINARY TRACT INFECTIONS from the anterior Mechanisms that maintain sterility of the portions of the bladder: urethra. 1. physical barrier of the urethra Refers to the backward 2. urine flow flow of urine from the 3. ureterovesical junction competence Ureterovesical or bladder into one or vesicoureteral both ureters. When 4. antibacterial enzymes and antibodies reflux 5. antiadherent effects mediated by the the ureterovesical mucosal cells of the bladder valve is impaired by JMTT pg. 18  congenital causes or  Within 48 hours of catheter insertion, ureteral abnormalities, bacterial colonization begins. the bacteria may reach About 50% of patient with indwelling the kidneys and catheters become infected within 1 week of eventually destroy catheter insertion. them. Term used to describe ORGANISMS OTHER THAN BACTERIA ALSO Bacteriuria the presence of CAN CAUSE CYSTITIS bacteria in the urine.  Fungal infections such as caused by Candida, can occur during long-term CYSTITIS antibiotic therapy because antibiotics  is an inflammation of the bladder. It can change normal protective flora. be caused by irritation or, more  Patients, who are severely commonly, by infection from bacteria, immunosuppressed, are receiving viruses, fungi or parasites. corticosteroids or other The most common of immunosuppressive agents, or having Infectious cystitis the UTIs. diabetes mellitus, acquired immune Inflammatory disease deficiency syndrome (AIDS) are at a Non-infectious that has no known higher risk for fungal UTIs. cystitis cause.  Noninfectious cystitis may result from Is the presence of chemical exposure, such as to drugs (ex. bacteria in the urine Cyclosphosphamide [Cytoxan, Bacteriuria and can occur with any Procytox]), from radiation therapy, and urologic infection. from immunologic responses, as with systemic lupus erythematosus (SLE).  If bacteriuria is without symptoms  Urosepsis is the term used to describe of infection, it is called colonization. for the spread of infection from the  Colonization, asymptomatic urinary tract to the bloodstream bacteriuria, is more common in  Sepsis from any source is a systemic older adults. infection that leads to overwhelming organ failure, shock and death. ETIOLOGY AND GENETIC RISK  Genetically, invading bacteria with HEALTH PROMOTION AND MAINTENANCE special adhesions are more likely to  Although cystitis is common, in many cause ascending UTIs that start in the cases it is preventable. urethra or bladder and move up into  In health setting reducing the use of the ureter and the kidney. indwelling urinary catheters is the  The most common organisms in major prevention strategy. infectious cystitis are from the intestinal  When catheters must be used, strict tract. attention to sterile technique during  About 90% of UTIs: Escherichia coli. insertion can reduce the risk for UTIs  Less common organisms include: and adequate perineal and catheter Staphylococcus saprophyticus, care. Kleibsiella pneumonia, and organisms  Catheters must be removed as early as from the Proteus and Enterobacter possible. species.  Changes the fluid intake patterns, urinary elimination patterns, and hygiene patterns can help prevent or  In most cases, organisms first grow in reduce cystitis in the general the perineal area, then move into the population. urethra as a result of irritation, trauma,  Teach all people to have a minimum or catheterization of the urinary tract, fluid intake of 3 L daily unless fluid and finally ascend to the bladder. restriction is needed for another health  Catheters are the most common factor problems placing patient at risk for UTIs in the  Encourage people to drink more water hospital setting. rather than sugar-containing drinks. JMTT pg. 19   Teach people to avoid urinary stasis by computed tomography (CT) – may be urinating every 3 to 4 hrs rather than needed to locate the site of obstruction waiting until the bladder is full. or the presence of calculi.  Encourage everyone either to bathe  Cystoscopy may be performed when daily or thoroughly wash perineal and the patient has recurrent UTIs (more urethral areas daily. than 3 to 4 years). Cystoscopy is needed to accurately PHYSICAL ASSESSMENT/CLINICAL diagnose interstitial cystitis. MANIFESTATIONS  Frequency, urgency, and dysuria are the common manifestations of a COMMON NURSING DIAGNOSES AND urinary tract infection (UTI), but other COLLABORATIVE PROBLEMS manifestations may be present.  Acute pain related to bladder spasm  Hesitancy or difficulty in initiating urine  Deficient Knowledge (risk factors for stream cystitis and drug regimen) related to  Low back pain information misinterpretation or  Nocturia unfamiliarity with information  Incontinence resources  Hematuria  Urge Urinary Incontinence related to  Pyuria – pus in the urine irritation of bladder stretch receptors  Bacteriuria causing spasm (ex. Bladder infection)  Retention  Risk for Impaired Skin Integrity related to moisture from incontinence  Suprapubic tenderness or fullness  Risk for Sepsis  Feeling of incomplete bladder emptying INTERVENTIONS NON SURGICAL MANAGEMENT RARE CLINICAL MANIFESTATIONS  Fever DRUG THERAPY  Chills  antiseptics or antibiotics, analgesics and  Nausea and Vomiting antispasmodics  Malaise  Antifungal agents are prescribed for  Flank pain fungal infections  Urine may be cloudy, foul smelling  Amphotericin B is most often given in daily bladder instillations, and or blood tinged ketoconazole (Nizoral) is given orally  Vaginal discharges and irritation –  Antispasmodic drugs decrease bladder are more indicative of vaginal spasm and promote complete bladder infection. emptying  Women often report burning with  Antibiotic therapy is used for bacterial urination UTIs  3-day course of LABORATORY ASSESSMENT trimethoprim/sulfamethoxazole or Urinalysis: fosfomycin is effective in treating  The presence of 100,000 colonies/mL uncomplicated, community-acquired or the presence of three or more WBCs UTIs in women (pyuria) with RBCs (hematuria) –  Longer antibiotic treatment (7 to 21 indicates infection. days) is required for hospitalized Urine Culture: patients, those with complicating  Confirms the type of organism and the factors, such as pregnancy, indwelling number of colonies catheters, or stones, and those with Serum WBC count may be elevated diabetes or immunosuppression  Long-term antibiotic therapy is used for OTHER DIAGNOSTIC ASSESSMENT chronic, recurring infections caused by  If urinary retention and obstruction of structural abnormalities or stones. urine outflow are suspected, urography, abdominal sonography or JMTT pg. 20   Trimethoprim 100 mg daily may be used for long-term management of the UPPER URINARY INFECTIONS older patient with frequent UTIs is a bacterial infection  For women who have recurrent UTIs PYELONEPHRITIS in the kidney and after intercourse, one low-dose tablet renal pelvis  upper of trimethoprim (TMP) urinary tract.  Estrogen used as an intravaginal cream may prevent recurrent UTIs in PATHOPHYSIOLOGY postmenopausal woman  presence of active organisms in the kidney or the effects of kidney URINARY ELIMINATION MANAGEMENT infection  The goal is to maintain an optimal is the active bacterial urinary elimination pattern infection; Involves  Nursing interventions for the ACUTE acute tissue management of cystitis focus on PYELONEPHRITIS inflammation, tubular comfort cell necrosis, and possible abscess NUTRITION THERAPY formation  The diet should include all food groups - Results from and include more calories for the repeated or continued increased metabolism caused by upper urinary tract infection infection or the effects  Urge patient to drink enough fluid to CHRONIC of such infections. maintain diluted urine throughout the PYELONEPHRITIS - Occurs with a urinary day and night unless fluid restriction is tract defect, needed for another health problems obstruction, or, most  The daily drinking of 50 mL of commonly, when concentrated cranberry juice appears urine refluxes from to decrease the ability of bacteria to the bladder back to adhere to the epithelial cells lining the the ureters urinary tract  Cranberry juice must be consumed for 3 ETIOLOGY AND GENETIC RISK to 4 weeks to be effective  Single episodes of acute  Avoiding caffeine, carbonated pyelonephritis: may result from the beverages, and tomato products may entry of bacteria, especially during decrease bladder irritation during pregnancy, obstruction, or reflux cystitis  Chronic pyelonephritis – usually occurs with structural deformities or COMFORT MEASURES obstruction with reflux  A warm sitz bath taken two or three  Acute or chronic pyelonephritis – times a day for 20 minutes may provide occurs often in patients who have comfort and some relief of local undergone manipulation of the urinary symptoms tract (ex. Placement of catheter), those  If burning with urination is severe or with diabetes mellitus or chronic renal urinary retention occurs, teach the stones, or those who overuse analgesics patient to sit in the sitz bath and urinate  Escherichia coli – is the most common into the warm water pyelonephritis-causing organism  Enterococcus fecalis – is common in SURGICAL MANAGEMENT hospitalized patients  Surgery for cystitis treats the conditions  Both organisms are in the intestinal that increase the risk for recurrent UTIs tract (ex. Removal of obstructions and repair  Other organisms: Proteus mirabilis, of vesicoureteral reflux) Klebsiella, and pseudomonas  Procedures may include cystoscopy to aeruginosa identify and remove calculi or  When the infection is bloodborne, obstructions common infecting organisms include: JMTT pg. 21  Staphylococcus aureus and the Candida IMAGING ASSESSMENT and Salmonella species  X-ray of the kidneys, ureters, and bladder (KUB) and IV urography INCIDENCE AND PREVALENCE  Cystourethrogram is indicated to  Chronic pyelonephritis is commonly associated with vesicoureteral reflux or some patients other anatomic abnormalities and is  Radionuclide scintillation (ex. more common in women Gallium scan)  After 65 years of age, rates of pyelonephritis for men increase greatly COMMON NURSING DIAGNOSES AND because of the increased incidence of COLLABORATIVE PROBLEMS prostitis  Acute Pain (flank and abdominal) related to inflammation and infection CLINICAL MANIFESTATIONS  Infection or Risk for Infection related to inadequate primary defences (urinary ACUTE PYELENONEPHRITIS stasis) or instrumentation  Fever  Deficient Knowledge regarding medical diagnosis and therapy related to  Chills unfamiliarity with information  Tachycardia and tachypnea resources  Flank, back, or loin pain  Activity Intolerance related to fatigue,  Tender costal vertebral angle (CVA) debilitation, and generalized weakness  Abdominal, often colicky, associated with infection discomfort  Fear (of Development of Chronic Kidney  Nausea and vomiting Disease) related to inability to control  General malaise and fatigue recurrent infections  Potential for Sepsis and Septic Shock  Burning, urgency, or frequency of urination INTERVENTIONS  Nocturia NON SURGICAL MANAGEMENT CHRONIC PYELONEPHRITIS  Interventions include the use of drug  Hypertension therapy, nutrition and fluid therapy,  Inability to conserve sodium and teaching to ensure the patient’s  Decreased urine concentrating understanding of the treatment ability (nocturia)  Tendency to develop hyperkalemia DRUG THERAPY at first broad spectrum and acidosis ANTIBIOTIC antibiotics THERAPY (ciprofloxacin, LABORATORY ASSESSMENT gentamicin) for 2  Urinalysis – shows positive weeks course leukocyte esterase and nitrite URINARY a more specific dipstick test and the presence of ANTISEPTIC DRUGS antibiotic is prescribed WBC and bacteria. (EX. after urine and blood  = Occasional RBC, WBC casts and NITROFURANTOIN culture and sensitivity [MACRODANTIN]) protein may be present. results are known.  Urine culture NUTRITION THERAPY  Blood cultures  Ensuring that the patient’s nutritional  Other blood tests: C-reactive intake has adequate calories from all protein and erythrocyte food groups for healing to occur sedimentation rate  Fluid intake is recommended at 2 to 3 L/day unless another health problems requires fluid restriction JMTT pg. 22 SURGICAL MANAGMENT  Uric acid (8%) cause by increased  Surgical interventions are used to urate excretion, fluid depletion, and correct structural problems causing  Cystine (3%) inherited defect in urine reflux or obstruction of urine renal absorption of amino acid and outflow or to remove the source of infection make up the less common stones  IV antibiotics are given to achieve adequate blood levels or sterile blood TYPES OF KIDNEY STONES THREE CONDITIONS INVOLVED IN STONE culture results FORMATION:  Slow urine flow – resulting in SURGICAL PROCEDURES supersaturation of the urine with the is needed for removal particular element PYELOLITHOTOMY of a large stone in the (Ex: calcium) that first becomes renal pelvis that blocks crystallized and later becomes stones. urine flow and causes  Damage to the lining of the urinary tract infection (Ex: abrasions from crystals) removal of the kidney,  Decreased inhibitor substances in the NEPHRECTOMY which is the last resort urine that would prevent when all measures to supersaturation and crystal clear the infection aggregation. have failed  High urine acidity  forms uric acid ureter repair or and cystine stones. revision  performed  High urine alkalinity  forms calcium URETEROPLASTY to patients with poor phosphate and struvite stones ureter valve closure or  Drugs (triamterene, indinavir and dilated ureters acetazolamide) – contribute to stone URETERAL preserves kidney formation. REIMPLANTATION function and  When the stones occludes the ureter (THROUGH eliminates infections. ANOTHER SITE IN and blocks the flow of urine, the ureter THE BLADDER dilates  causing enlargement of the WALL) ureters called hydroureter.  Hematuria (bloody urine) may result UROLITHIASIS from damage to the urothelial lining.  is the presence of calculi (stones) in the  If the obstruction is not removed, urinary tract urinary stasis can cause infection and  Stones often do not cause symptoms impair kidney function on the side of until they pass into the lower urinary the blockage  hydronephrosis tract, where they can cause (enlargement of the kidney )and excruciating pain permanent kidney damage may is the formation of develop. Nephrolithiasis stones in the kidney is the formation of Ureterolithiasis stones in the ureters ETIOLOGY AND GENETIC RISK  90% of patients who form stones TYPES OF STONES have a metabolic risk factor   About 75% of stones contain excessive amounts of calcium are calcium as one part of the stone absorbed through the intestinal complex, which may be calcium tract. oxalate (2nd most frequent crystal  Urinary stasis, urinary retention, to cause stone) or calcium immobility, and dehydration phosphate.  Diuretics (except the use of  Struvite (15%) also called triple thiazides for calcium oxalate phosphate composed of Ca, Mg, Ammonium PO4. JMTT pg. 23 INCIDENCE/PREVALENCE  X-rays of the kidneys, ureter and  The incidence of stone disease is high bladder (KUB); IV urograms; or and varies with geographic location, computed tomography (CT) – stones race, and family history are easily seen  The incidence is higher in men. Struvite  Noncontrast helical CT – has the stones are twice as common in women highest sensitivity for identification of urinary stones  IV urography – is useful for identifying ASSESSMENT/CLINICAL MANIFESTATION whether the urinary tract is obstructed  Severe pain, commonly called renal  Renal ultrasonography – creates colic – is the major manifestation of images of structures of varying density stones like solid structures such as stones are extremely dense; therefore the images  Flank pain – suggests that the stone is of stones are clear. in the kidney or upper ureter  Flank pain that extends toward the abdomen or to the scrotum and testes PAIN RELIEF MEASURES or the vulva – suggests that the stones  Nonsurgical and surgical approaches are in the ureters or bladder. are used to assist the patient with a kidney stone achieve an acceptable  Nausea, vomiting, pallor and diaphoresis – often accompany the degree of pain relief. pain  Frequency and dysuria – occur when a NON-SURGICAL MANAGEMENT stone reaches the bladder.  Oliguria (scant urine output) or anuria Drug Therapy – is needed most in the first 24 to (absence of urine output) – suggests 36 hours when pain is most severe. obstruction, possibly at the bladder Opioid analgesics – are often needed to control neck or urethra the severe pain cause by stones in the urinary EXAMINE THE PATIENT TO DETECT tract BLADDER DISTENTION Morphine (Statex) – are often given IV for rapid  The patient may appear pale, ashen, pain relief and diaphoretic and suffer from NSAIDs such as ketorolac (Toradol) excruciating pain. Spasmolytic drugs such as oxybutynin chloride  Increase temperature and pulse (Ditropan) and propantheline bromide (Pro-  Decrease BP banthine, Propanthel) DIAGNOSTIC FINDINGS COMPLEMENTARY AND ALTERNATIVE  Urinalysis – performed to patients with THERAPY suspected calculi  Relaxation techniques such as hypnosis  Hematuria is a common finding: blood and imagery, therapeutic or healing may make the urine appear smoky or touch, and acupuncture rusty  Assisting the patient with positioning  RBCs are usually caused by stone- can often aid in pain reduction induced direct trauma on the lining of  Breathing techniques such as those the ureter, bladder or urethra used in childbirth, can also help patient  WBC and bacteria may be present as a to relax result of urinary stasis  Increased turbidity (cloudiness) and OTHER MANAGEMENT TECHNIQUES  Avoid overhydration and odor indicate that infection may also be underhydration in the acute phase to present help make the passage of stone less  Urinary pH is measured to determine painful the acidity or alkalinity  Strain the urine and teach the patient to  Serum WBC count is elevated with strain it to monitor for stone passage infection  Send the stone to the laboratory for  Increases in the serum calcium, serum analysis because preventive therapy is phosphate, or serum uric acid levels based on stone composition JMTT pg. 24 LITHOTRIPSY, ALSO KNOWN AS OPEN SURGICAL PROCEDURES EXTRACORPOREAL SHOCK WAVE  when other stone removal attempts LITHOTRIPSY (ESWL) have failed or when risk of a lasting  is the use of sound, laser, or dry shock injury to the ureter or kidney is waves to break the stones into small possible fragments. OPEN Into the ureter  The patient receives conscious sedation URETEROLITHOTOMY during the procedure Into the kidney pelvis  Continuous ECG monitoring for PYELOLITHOTOMY NEPHROLITHOTOMY Into the kidney dysrhythmia and fluoroscopic observation for stone destruction is maintained POSTOPERATIVE CARE  Follow routine procedures for  After lithotripsy, strain the urine to assessment of patient who has received monitor the passage of stone fragments anesthesia.  Bruising may occur on the flank of the  Monitor the amount of bleeding from affected side after ESWL incisions and in the urine.  Cystine stones are often resistant to  Maintain adequate fluid intake. ESWL  Strain the urine to monitor the passage of stone fragments. SURGICAL MANAGEMENT  Teach the patient how to prevent future  Minimally invasive surgical (MIS) stones through dietary changes procedures include stenting, retrograde ureteroscopy, and percutaneous ureterlithotomy and nephrolithotomy. INTERVENTION PREVENTION INTERVENTIONS INCLUDE 1. STENTING  Giving antibiotics, either to eliminate an  Is performed with a stent, where a small existing infection or to prevent new tube that is placed in the ureter by infections and ureteroscopy.  Maintaining adequate nutrition and  The stents dilate the ureter and fluid intake  because infection always enlarges the passageway for the stone occurs with struvite stone formation or stone fragments  Drug therapy is the most common  A Foley catheter may be placed to intervention facilitate passage of the stone through  Broadspectrum antibiotics such as the urethra aminoglycosides (ex. Gentamicin 2. RETROGRADE URETEROSCOPY (Garamycin) and cephalosporin (Keflex,  Is an endoscopic procedure. The Novo-Lexin) uretoscope is passed through the  Acetohydroxamic acid (Lithostat) and urethra and bladder into the ureter. hydroxyurea (Hydrea) Once the stone is seen, it is removed  Serum creatinine levels are monitored using grasping baskets, forceps, or in patients receiving acetohydroxide loops. acid  stopped if creatinine levels are  A Foley catheter may be placed to above 2 mg/dL facilitate passage of stone fragments through the urethra 3. PERCUTANEOUS URETEROLITHOTOMY NUTRITION THERAPY AND NEPHROLITHOTOMY  Ideally includes adequate calorie intake  is the removal of a in the ureter or with a balance of all food groups kidney through the skin.  Encourage a fluid intake sufficient to  The patient lies prone on the side and dilute urine to a light color throughout receives local or general anesthesia the 24-hour day (typically 2 to 3 L/day)  Monitor patient for complications after unless another health problem requires procedure that includes bleeding at the fluid restriction site or through the tube, pneumothorax, and infection JMTT pg. 25 CHRONIC KIDNEY DISEASE  Kidney nephron damage has occurred PATHOPHYSIOLOGY and there may be slight elevations of Is a progressive, metabolic wastes because not enough CHRONIC KIDNEY irreversible kidney healthy nephrons remain to DISEASE (CKD) injury and kidney compensate completely for damaged function that does not nephrons. recover.  Increased output of dilute urine may occur at this stage of CKD and, if the  When kidney function is too poor to problem is untreated at this stage can sustain life, CKD becomes end-stage cause severe dehydration. kidney disease (ESKD)  Careful management of fluid volume, THE FOLLOWING TERMS USED WITH RENAL blood pressure, electrolytes, dietary FAILURE INCLUDE: intake, and other diseases (ex. Heart build-up of nitrogen- disease, diabetes) can prevent further AZOTEMIA based wastes in the damage and slow progression blood  In moderate CKD, GFR reduction azotemia with clinical continues and ranges between 30 to 59 UREMIA symptoms mL/min. UREMIC SYNDROME  Nephron damage has continued, and the remaining nephrons cannot KEY FEATURES OF UREMIA manage metabolic wastes, fluid  Metallic taste in the mouth balance, and electrolyte balance.  Anorexia  Dietary restrictions of fluid, proteins  Nausea and electrolytes are needed  Vomiting  Over time, patients progress to severe  Muscle cramps CKD (the fourth stage), GFR ranges  Itching between 15 to 29 mL/min and end- stage kidney disease (ESKD, the fifth  Fatigue and lethargy stage), and GFR is less than 15 mL/min.  Hiccups  Excessive amounts of urea and  Edema Creatinine build up in the blood, and the  Dyspnea kidneys cannot maintain homeostasis.  Paresthesia  Severe fluid, electrolyte, and acid-base imbalances occur. STAGES OF CHRONIC KIDNEY DISEASE  Without renal replacement therapy   The kidneys fail in an organized fashion fatal complications are likely to occur involving five stages based on estimated glomerular filtration rate ETIOLOGY AND GENETIC RISKS (GFR).  The causes of CKD are complex. More  Progression toward ESKD in at-risk than 100 different disease processes patients starts with a gradual decrease can result in progressive loss of kidney in GFR. function  In the first stage – the person may have a normal GFR (greater than 90 mL/min) 2 MAIN CAUSES OF ESKD ARE: with normal kidney function and no 1. Hypertension obvious kidney disease. 2. Diabetes mellitus  Although no manifestations of renal  In addition, infection and genetic failure are usually present at this stage, kidney diseases can lead to ESKD. if the patient is stressed with infection,  African-American patients are four- fluid overload or dehydration  renal times more likely to develop ESKD function at this stage can appear reduced. and seven times more likely to have  In the next stage, mild CKD – GFR is hypertensive ESKD reduced, ranging between 60 to 89 mL/min. JMTT pg. 26 INCIDENCE/PREVALENCE irregular patterns, or a pericardial  The number of patients being friction rub. treated for CKD is increasing.  Assess the jugular veins for  More than 24% of patients with distention and assess for edema of ESKD die during the first year of the feet, shins, and sacrum and treatment. around the eyes.  ESKD occurs more often in men than  Shortness of breath with exertion in women. and at night  suggests fluid  The greatest increase in ESKD is in volume excess patients 65 years of age and older RESPIRATORY MANIFESTATIONS OF CKD PHYSICAL ASSESSMENT/CLINICAL ALSO VARY: MANIFESTATIONS  Uremic fetor or uremic halitosis –  Chronic kidney disease (CKD) causes the breath smells like urine. changes in many body systems.  Deep sighing, yawning and  Most manifestations are related to shortness of breath changes in fluid volume, electrolyte  Observe the rhythm, rate and depth and acid-base imbalances, and build of breathing up of nitrogenous wastes increased rate of TACHYPNEA breathing NEUROLOGIC MANIFESTATIONS increased depth of  Observe for problems ranging from HYPERPNEA breathing lethargy to seizures or coma  which extreme increases in indicate uremic encephalopathy. rate and depth of  Lethargy and daytime drowsiness KUSSMAUL ventilation  occur  Inability to concentrate or decrease RESPIRATIONS with severe metabolic attention span acidosis.  Seizures  A few patients have pneumonitis, or  Coma uremic lung.  Slurred speech Assess for thick sputum, reduced  Asterixis coughing, tachypnea, and fever.  Tremors, twitching, or jerky movements A pleural friction rub may be  Myoclonus heard.  Ataxia (alteration in gait) Patients often have pleuritic pain  Paresthesia with breathing.  Dialysis is used to treat CKD when Auscultate the lungs for crackles neurologic problems result.  Manifestations of encephalopathy are resolve with dialysis. HEMATOLOGIC MANIFESTATIONS ANEMIA CARDIOVASCULAR MANIFESTATIONS OF  Check for indicators of anemia such as CKD AND UREMIA RESULT FROM: fatigue, pallor, lethargy, weakness,  Fluid volume excess, hypertension, shorter of breath and dizziness heart failure (HF), pericarditis, and ABNORMAL BLEEDING potassium-induced dysrhythmias.  Observe for bruising, petechiae,  Assess for signs of reduced sodium purpura, mucous membrane and water excretion. bleeding in the nose or gums,  Circulatory fluid overload, if abnormal vaginal bleeding, or untreated leads to HF, pulmonary intestinal bleeding (black, tarry edema, peripheral edema and stools [melena]). hypertension.  Assess the heart and rhythm; listen for extra sounds (particularly an Sз), JMTT pg. 27  calcium, phosphate, bicarbonate, GI MANIFESTATIONS haemoglobin, and hematocrit.  Anorexia  Also monitor GFR for trends.  Nausea  Urinalysis  Vomiting Early stages of CKD,  Metallic taste in the mouth urinalysis shows excessive  Changes in taste acuity and sensation  Uremic colitis (diarrhea) protein, glucose, RBCs,  Constipation WBCs and decreased or  Uremic gastritis (possible GI bleeding) fixed specific gravity.  Uremic fetor (breath odor) Urine osmolarity is  Stomatitis decreased  Diarrhea  Stools are tested for occult blood IMAGING ASSESSMENT MUSCULOSKELETAL MANIFESTATIONS  Few x-tray findings are abnormal with  Muscle weakness and cramping CKD.  Bone pain  Bone x-rays of the hand can show renal osteodystrophy.  Pathologic fractures  With long-term ESKD, the kidneys have  Renal osteodystrophy – from poor shrunk and may be 8 to 9 cm or smaller absorption of calcium and  this small size results from atrophy continuous bone calcium and fibrosis. resorption.  If CDK progresses suddenly, a kidney URINARY MANIFESTATIONS ultrasound or computed tomography  Skin Manifestations of CKD occur as (CT) scan without contrast medium may a result of uremia: Polyuria, be used to rule out an obstruction nocturia (early)  Oliguria, anuria (later) INTERVENTIONS  Proteinuria  The nutritional needs and diet  Hematuria restrictions for the patient with CKD vary according to the degree of  Diluted, straw-like appearance remaining kidney function and the type as pigments is YELLOWISH of replacement therapy used deposited in the skin COLORATION as reported by some NUTRITION THERAPY DARKENING OF THE African Americans  The purpose of nutrition therapy is to SKIN provide the food and fluids needed to which appears as a prevent malnutrition ANEMIA OF CKD faded suntan on light- CAUSES skinned patients. COMMON CHANGES INCLUDE SALLOWNESS SEVERE PRURITUS a distressing problem  Control of protein intake (ITCHING) of uremia  Fluid intake limitation a layer of urea crystals  Restriction of potassium, sodium, from evaporated and phosphorus intake UREMIC FROST sweat, may appear on  Taking vitamin and mineral the face, eyebrows, supplements axilla, and groin of  Eating enough calories to meet patients with advances metabolic need uremic syndrome  Assess for bruises (echymoses), purple PHARMACOLOGIC THERAPY patches (purpura) and rashes  Phosphate binding agents such as calcium acetate, calcium bicarbonate, LABORATORY ASSESSMENT sevelamer hydrochloride (renagel).  Monitor the blood values for  Calcium and vitamin D supplements Creatinine, BUN, sodium, potassium, JMTT pg. 28  Antihypertensive drugs and cardiac medications  Antiseizure agents such as diazepam, phenytoin  Erythropoietin – Epogen IV or given SQ 3 times a week JMTT pg. 29