Care of Patients with Genitourinary Disease PDF

Care of Clients with problems in Kidney and Genitourinary System Marlon A. Allecer, RN Objectives At the end of the class, the students will be able to; describe the structure and function of the renal and urinary 01 systems, explain the role of the kidneys in regulating fluid a...

Care of Clients with problems in Kidney and Genitourinary System Marlon A. Allecer, RN Objectives At the end of the class, the students will be able to; describe the structure and function of the renal and urinary 01 systems, explain the role of the kidneys in regulating fluid and 02 electrolyte balance, acid–base balance, and blood pressure identify the diagnostic studies used to determine upper and 03 lower urinary tract function and related nursing implications Objectives At the end of the class, the students will be able to; discriminate between normal and abnormal assessment 04 findings of upper and lower urinary tract function, initiate education and preparation for patients undergoing 05 assessment of the urinary system Anatomy & P hysiology  Physical Assessment Health History 1.Patient’s chief concern or reason for seeking health care, onset of problem & its effect on patient’s quality of life 2.location, character( throbbing, sharp, dull or burning) and duration of pain, if present, & its relationship to voiding; factors that precipitate pain, & those that relieve it. 3.History of UTI, including past treatment or hospitalization for UTI 4.fever and chills 5.previous renal or urinary diagnostic tests or the use of indwelling urinary catheters 6.dysuria and when it occurs(initiation or termination) 7. hesitancy ,straining ,or pain during or after urination 8. Hesitancy, straining, or pain during or after urination. 9.hematuria or change in color or volume of urine 10. nocturia and date of onset 11.renal stone, or passage of stones or gravel in urine 12. female pt. & type(vaginal or ceasarian) of deliveries; the use of forceps; vaginal infection, discharge, or irritation; contraceptive practices 13. History of anuria(decreased urine production of less than 50 ml/24 hrs.) or other kidney problem. 14. Presence or history of genital lesions or sexually transmitted infections. 15. Use of tobacco, alcohol, or recreational drugs. 16. Any prescription & over-the-counter medications  Common Symptoms Pain GU pain is usually caused by distention of some portion of urinary tract as a result of obstructed urine flow or inflammation & swelling of tissues. Kidneys > location: CVA, may extend to umbilicus >character of pain: dull constant ache; if sudden distention of capsule, pain is severe, sharp, stabbing & colicky in nature Common Symptoms Kidneys > Associated s/sx: nausea, vomiting, diaphoresis, pallor, signs of shock > possible cause: acute obstruction, kidney stone, blood clot , acute pyelonephritis, trauma Bladder > location: suprapubic area > character of pain: dull, continuous pain that maybe intense with voiding; maybe severe if bladder is full Common Symptoms Bladder >associated s/sx.: urgency, pain at the end of voiding, painful straining > possible cause: over distended bladder, infection, interstitial cystitis, tumor Ureteral > location: CVA, flank, lower abdominal area, testis, or labium >character: severe, sharp, stabbing pain, colicky in nature > associated s/sx: nausea and vomiting ,paralytic ileus > possible cause: ureteral stone ,edema, or stricture(narrowing), blood clot Common Symptoms Prostatic > location: perineum and rectum > character of pain: vague discomfort, feeling of fullness in perineum, vague back pain >associated s/sx.: suprapubic tenderness , obstruction to urine flow; frequency, urgency, dysuria, nocturia > common cause; prostatic Ca, acute or chronic prostatitis Common Symptoms Urethral >location: in male- pain is felt along the penis to meatus ;in female urethra to meatus >character: pain is variable, most severe during & immediately after voiding > associated s/s: frequency, urgency, dysuria, Nocturia, urethral discharge > possible cause: irritation of bladder neck, infection of urethra, trauma, foreign body in lower urinary tract Changes in voiding > micturition is normally a painless function occurring approximately 8 times in 24 hours > average urine output is 1-2L/24hrs Common Problems associated with voiding 1. Frequency – frequent voiding- more than every 3 hours 2. Urgency- strong desire to void 3. Dysuria- painful or difficult voiding 4. Hesitancy- delay, difficultly in initiating voiding Common Problems associated with voiding 5. nocturia- excessive urination at night 6. incontinence- involuntary loss of urine 7. enuresis- involuntary voiding during sleep. 8. polyuria- increase volume of urine voided 9. oliguria- urine output less than less than 0.5 ml/kg/h or > nitrogen combines w/ elements such as carbon, hydrogen & O2, to form urea, (chemical waste product)>> urea travels from your liver to your kidneys thru the bloodstream>> healthy kidneys filter urea & remove other waste products from the blood>> the filtered waste products leave the body through urine  End-product of muscle energy metabolism. is more specific for renal function test is not affected by dietary intake or hydration status normal value 0.6-1.2 mg/dl assess GFR can be elevated in cases of glomerulonephritis, pyelonephritis, acute tubular necrosis, nephrotoxicity, renal insufficiency and renal failure. can not be reabsorbed by the kidney tubules Serum Creatinine Blood Studies  All electrolytes are elevated in CRF except calcium and HCO3 Diuretics may alter serum electrolytes Serum Electrolytes Blood Studies  Erythropoietin activity RBC – significantly low in CRF WBC Platelets Complete Blood Count Blood Studies  KUB studies UTZ Intravenous Pyelography (IVP) or Excretory Urography Retrograde Urography MRI (with injection of contrast media) Renal Angiography Radiologic and Imaging Studies An x-ray study of the abdomen or kidneys, ureters & bladders may be performed to delineate the size, shape & position of the kidneys & to reveal urinary system abnormalities KUB (Kidney, Ureter & Bladder) Radiologic and Imaging Studies - non-invasive procedure that uses sound waves passed into the body through a transducer to detect abnormalities of internal tissues & organs. - Requires a full bladder, fluid intake is encouraged before the procedure. - Abnormalities such as fluid accumulation, masses, congenital malformations, changes in organ size & obstructions can be identified General Ultrasonography Radiologic and Imaging Studies  Non-invasive method of measuring urine volume in the bladder. Indicated for urinary frequency, inability to void after removal of an indwelling urinary catheter, measurement of postvoiding residual urine volume, inability to void post-op, or assessment of the need for catheterization. Scan head is placed on the pts abdomen & directed toward the bladder. It automatically calculates & displays urine volume. Bladder Ultrasonography Radiologic and Imaging Studies  Non-invasive method of measuring urine volume in the bladder. Indicated for urinary frequency, inability to void after removal of an indwelling urinary catheter, measurement of postvoiding residual urine volume, inability to void post-op, or assessment of the need for catheterization. Scan head is placed on the pts abdomen & directed toward the bladder. It automatically calculates & displays urine volume. Bladder Ultrasonography Radiologic and Imaging Studies  Noninvasive techniques that provide excellent cross- sectional views of the anatomy of the kidney & urinary tract.  Use to evaluate genitourinary masses, nephrolithiasis, chronic renal infections, renal or urinary tract trauma, metastatic disease.  Occasionally, oral or IV radiopaque contrast agent is used in ct scanning to enhance visualization. Computed tomography (CT scan) & Magnetic resonance imaging 1. Educate pt about relaxation techniques & explaining that he can communicate with the staff by means of a microphone inside. 2. Before pt enters the MRI room, all metal objects & credit cards are removed. Medication patches(nitroglycerin) that have a metal backing, w/c can cause burn. 3. Obtain pts history to det. the presence of any metal object(orthopedic hardware, pacemaker)- could malfunction, be dislodge or heat up as they absorb energy. Nursing Responsibilities Computed tomography (CT scan) & Magnetic resonance imaging Radiologic and Imaging Studies 4. A sedative can be prescribed for claustrophobic pts. 5. Prior to MRI of the urinary system, pt. needs to avoid alcohol, caffeine containing beverages & smoking at least 2 hrs & food at least 1 hr prior to the scan 6. Pt can continue to take meds except iron w/c can interfere w/ the imaging Nursing Responsibilities Computed tomography (CT scan) & Magnetic resonance imaging Radiologic and Imaging Studies  Require injection of a radioisotope(technetium 99m-labeled compound or iodine 123 hippurate) into the circulatory system; isotope is then monitored as it moves through the blood vessels of the kidneys. Scintillation camera is placed behind the kidney w/ the pt in a supine, prone or seated position.  Technetium scan provides info about kidney perfusion NUCLEAR SCANS Radiologic and Imaging Studies  Hippurate scan provides info about renal function such as GFR  Pt is encouraged to including fluid intake after procedure to promote excretion of the isotope. NUCLEAR SCANS Radiologic and Imaging Studies  Includes various tests such as excretory urography, intravenous pyelography(IVP), & infusion drip pyelography. A radiopaque contrast agent is administered IV. IV urography may be used as initial assessment of many suspected urologic conditions, especially lesions in the kidneys & ureters. INTRAVENOUS UROGRAPHY Radiologic and Imaging Studies  It also provides an approximate estimate of renal function. After the contrast agent(Na diatrizoate or meglumine diatrizoate) is administered IV, multiple x-rays are obtained to visualize drainage structures in the upper & lower urinary system INTRAVENOUS UROGRAPHY Radiologic and Imaging Studies  Pretest: Elicit allergy to iodine and seafood, NPO after midnight Intra-test: IV iodinated Dye is administered then X-ray is taken Post-test: Increase fluids to flush the dye. Documentation, VS monitoring INTRAVENOUS PYELOGRAM Radiologic and Imaging Studies  Catheters are advanced thru the ureters into the renal pelvis by means of cystoscopy. A contrast agent is then injected. Retrograde pyelography is performed if IV urography provides inadequate visualization of the collecting systems. Used before extracorporeal shock wave lithotripsy;in pts w/ urologic cancer who needs follow up & have allergy to IV contrast agents. Complications includes; infection, hematuria & perforation of the ureter. RETROGRADE PYELOGRAPHY Radiologic and Imaging Studies  Aids in evaluating vesicoureteral reflux(backflow of urine from the bladder into one or both ureters) & in assessing for bladder injury. A catheter is inserted into the bladder, & a contrast agent is instilled to outline the bladder wall. The contrast agent may leak through a small bladder perforation stemming from bladder injury but such leakage is usually harmless. Can also be performed w/ simultaneous pressure recordings inside the bladder. CYSTOGRAPHY Radiologic and Imaging Studies  Uses fluoroscopy to visualize the lower urinary tract & assess urine storage in the bladder. Used as a diagnostic tool to identify vesicoureteral reflux. A urethral catheter is inserted & a contrast agent is instilled into the bladder. When bladder is full & the pt feels the urge to void, the catheter is removed & the pt voids. VOIDING CYSTOUROGRAP HY Radiologic and Imaging Studies  Provides an image of the renal arteries. The femoral(or axillary) artery is pierced w/ a needle, & a catheter is threaded up thru the femoral & iliac arteries into the aorta or renal artery. Contrast agent is injected to opacify the renal arterial supply. Used to evaluate renal blood flow in suspected renal trauma, to differentiate renal cysts from tumors, & to evaluate hypertension RENAL Also used preop for renal transplantation ANGIOGRAPHY/ ANGIOGRAM Radiologic and Imaging Studies  Before the procedure, a laxative may be prescribed to evacuate the colon so that unobstructed x-ray can be obtained. Injection sites may be shaved. Peripheral pulse sites( radial, femoral, dorsalis pedis) are marked for easy access during postprocedural assessment. Nursing interventions RENAL ANGIOGRAPHY/ ANGIOGRAM Radiologic and Imaging Studies  After the procedure, vital signs are monitored until stable. If axillary artery was the injection site, BP is taken on the opposite arm. Injection site is examined for swelling & hematoma. Peripheral pulses are palpated & color & temp of the involved extremity are noted & compared w/ uninvolved extremity. Cold compresses applied to decrease edema & pain. Nursing interventions RENAL ANGIOGRAPHY/ ANGIOGRAM Radiologic and Imaging Studies  Used to help diagnose & evaluate the extent of renal disease. INDICATIONS FOR BIOPSY: unexplained acute renal failure; persistent hematuria or proteinuria; transplant rejection; glomerulopathies. A small section of the renal cortex is obtained either percutaneously(needle biopsy) or by open biopsy thru a small flank incision. Before biopsy –coagulation studies are done to identify risk of post-biopsy bleeding RENAL/ KIDNEY BIOPSY Radiologic and Imaging Studies  Contraindications: bleeding tendencies, uncontrolled hypertension; a solitary kidney; morbid obesity Pt is NPO 6-8 hrs. before the test IV line is established Urine specimen is collected & saved for comparison w/ post biopsy specimen. RENAL/ KIDNEY BIOPSY Radiologic and Imaging Studies  Needle biopsy The sedated pt is placed in a prone position with a sandbag under the abdomen. Skin at biopsy site is infiltrated w/ local anesthetic Biopsy needle is introduced inside the renal cortex Location of needle is confirmed by fluoroscopy or ultrasound RENAL/ KIDNEY BIOPSY Radiologic and Imaging Studies  Open biopsy Preparation is similar to any major abdominal surgery Nursing interventions: After biopsy, Iv fluids are administered to help clear the kidneys & prevent clot formation. Post renal colic respond to analgesic agents RENAL/ KIDNEY BIOPSY Radiologic and Imaging Studies Urinary Tract Disorders Management of Patients with urinary disorder URINARY TRACT DISORDERS Management of Patients with UTIs are caused by pathogenic urinary disorder microorganisms in the UT (normal UT is sterile above the urethra) Are classified as upper or lower UT & further classified as uncomplicated or complicated, depending on other patient- related conditions and whether the UTI is recurrent & the duration of the infection. URINARY TRACT DISORDERS Management of Patients with disorder urinary Uncomplicated UTI are mostly community acquired. Complicated UTIs occur in people w/ urologic abnormalities or recent catheterization & are acquired often during hospitalization. UTI is the 2nd most common infection in the body.  Bacterial cystitis- inflammation of the urinary LOWER bladder. UTI Urinary Tract Disorder Bacterial prostatitis- inflammation of the prostate gland. Bacterial urethritis- inflammation of the urethra. Causative agent: E. coli, Pseudomonas & Enterococcus UPPER UTI Urinary Tract Disorder Acute or chronic pyelonephritis- inflammation of the renal pelvis Interstitial nephritis- inflammation of the kidney Renal abscesses LOWER UTI Urinary Tract Disorder SEVERAL mechanisms maintain the sterility of the bladder: 1. Physical barrier of the urethra 2. Urine flow 3. Ureterovesical junction competence 4. Various antibacterial enzymes & antibodies 5. Antiadherent effects mediated by the mucosal cells of the bladder- LOWER UTI Urinary Tract Disorder RISK FACTORS: 1.Inability or failure to empty the bladder completely. 2.Obstructed urinary flow caused by: congenital abnormalities, urethral strictures, contracture of the bladder neck, bladder tumors, calculi in the ureters or kidneys, compression of the ureters. LOWER UTI Urinary Tract Disorder 3. Decreased natural host defenses or immunosuppression 4. Instrumentation of the urinary tract (catheterization, cystoscopic procedure) 5. Inflammation or abrasion of the urethral mucosa LOWER UTI Urinary Tract Disorder Glycosaminoglycan- a hydrophilic protein that normally exerts a nonadherent protective effect against various bacteria. LOWER UTI RISK FACTORS: Urinary Tract Disorder 1.Inability or failure to empty the bladder completely. 2.Obstructed urinary flow caused by: congenital abnormalities, urethral strictures, contracture of the bladder neck, bladder tumors, calculi in the ureters or kidneys, compression of the ureters. 3.Decreased natural host defenses or immunosuppression LOWER UTI Urinary Tract Disorder 4. Instrumentation of the urinary tract (catheterization, cystoscopic procedure) 5. Inflammation or abrasion of the urethral mucosa 6. Contributing conditions such as: female gender, diabetes, pregnancy, neurologic disorders, gout, altered states caused by inc emptying of the bladder & urinary stasis.  Routes of infection: Bacteria enters the UT LOWER UTI in 3 ways Urinary Tract Disorder 1.Transurethral route(ascending infection)- most common route of infection, in w/c bacteria from fecal contamination colonize by means of the urethra. Short urethra & sexual intercourse forces bacteria from urethra into urinary bladder. 2.Hematogenous spread(thru the bloodstream) 3.Direct extension(by means of fistula from the intestine) LOWER UTI Urinary Tract Disorder S/s of uncomplicated lower 1.burning on urination 5.Incontinence 2. Urinary frequency(voiding6.Suprapubic pain more than q 3 hours) 7.Hematuria 3.Urgency 8.Back pain 4.Nocturia LOWER UTI Urinary Tract Disorder bacterial colony counts, cellular studies (microscopic hematuria is present in about half of pts w/ UTI; Pyuria occurs in pts w/ UTI, kidney stones, interstitial nephritis & renal tuberculosis) , & urine cultures In uncomplicated UTI, the strain of bacteria determines the choice of antibiotic. URINE CULTURE: 105 CFU/ml of clean catch midstream or catheterized specimen LOWER UTI Urinary Tract Disorder OTHER STUDIES: > CT scan- detect pyelonephritis or abscesses. > Ultrasonography-detect obstruction abscesses, tumors & cyst. > Transrectal ultrasonography- assess prostate & bladder; procedure of choice for pts w/ recurrent UTI > cystourethroscopy-to visualize the ureters or detect strictures, calculi or tumors LOWER UTI Urinary Tract Disorder MEDICAL MANAGEMENT Involves pharmacologic therapy and patient education. The nurse educates the patient about prescribed medication regimens & infection prevention measures. LOWER UTI PHARMACOLOGY THERAPY Urinary Tract Disorder Ideal medication for UTI: antibacterial that eradicates bacteria from the UT w/ minimal effects on the fecal & vaginal flora, thereby minimizing vaginal yeast infection. Short course(3 -4 days) or 7-10 days of medication for the treatment to be effective Pt is instructed to take all doses prescribed, even if relief of symptoms occurs. LOWER UTI Urinary Tract Disorder EXAMPLES OF MEDS GIVEN TO LOWER UTIs Drug class: anti-infective, urinary tract G(B)N: nitrofurantoin(Macrodantin, Furadantin) Indication: UTI DC: Bactericidal G(B)N: cephalexin(Keflex) I: Genitourinary infection LOWER UTI EXAMPLES OF MEDS GIVEN TO Urinary Tract Disorder LOWER UTIs DC: Cephalosporin G(B)N: cefadroxil(Duticef, untracef) I: UTI DC: Fluoroquinolone G(B)N: ciprofloxacin(Cipro); ofloxacin(Floxin); norfloxacin(Noroxin); gatifloxacin(Zymar) I: UTI, pyelonephritis LOWER UTI EXAMPLES OF MEDS GIVEN TO Urinary Tract Disorder LOWER UTIs DC: Fluoroquinolone G(B)N: levofloxacin(Levaquin) I: uncomplicated UTI DC: Penicillin G(B)N: ampicillin(Principen, Omnipen) amoxicillin(Amoxil) LOWER UTI EXAMPLES OF MEDS GIVEN TO Urinary Tract Disorder LOWER UTIs DC: Trimethoprim-sulfamethoxazole combination G(B)N: co-trimoxazole(Bactrim, Septra) I: UTI, pyelonephritis DC: Urinary-analgesic agent G(B)N: phenazopyridine(Pyridium) I: for relief of burning, pain, & other symptoms associated w/ UTI LOWER UTI Urinary Tract Disorder NURSING DIGANOSIS FOR LOWER UTI Acute pain related to infection w/in the urinary tract. Deficient knowledge about factors predisposing the patient to infection & recurrence, detection & prevention of recurrence, & pharmacologic therapy. LOWER UTI Urinary Tract Disorder POTENTIAL COMPLICATIONS Sepsis(urosepsis) Renal failure, w/c may occur as the long- term result of either an extensive or inflammatory process. LOWER UTI Urinary Tract Disorder NURSING INTERVENTIONS FOR LUTI Relieving pain- is quickly relieved once effective antimicrobial therapy is initiated. - Antispasmodic agents may also be useful in relieving bladder irritability & pain. - Analgesic agents & the application of heat to the perineum. - Encouraged to drink liberal amounts of fluid to promote renal bld flow & flush the bacteria. LOWER UTI Urinary Tract Disorder NURSING INTERVENTIONS FOR LUTI UT irritants(coffee, tea, citrus, spices, colas, alcohol) are avoided. Frequent voiding(q 2-3 hrs) is encouraged to empty bladder completely Relieving pain- is quickly relieved once effective antimicrobial therapy is initiated. Antispasmodic agents may also be useful in relieving bladder irritability & pain. LOWER UTI Urinary Tract Disorder NURSING INTERVENTIONS FOR LUTI Analgesic agents & the application of heat to the perineum. Encouraged to drink liberal amounts of fluid to promote renal blood flow & flush the bacteria. UT irritants(coffee, tea, citrus, spices, colas, alcohol) are avoided. LOWER UTI Urinary Tract Disorder NURSING INTERVENTIONS FOR LUTI Frequent voiding(q 2-3 hrs.) is encouraged to empty bladder completely meticulous daily perineal care maintaining a closed system using the catheter port to obtain a specimen LOWER UTI Urinary Tract Disorder NURSING INTERVENTIONS FOR LUTI Careful assessment of vs & level of consciousness may warn of impending sepsis Promoting home & community-based care: Educating patients about self-care The nurse implements education that meets patient’s needs. LOWER UTI Urinary Tract Disorder NURSING INTERVENTIONS FOR LUTI Health related behaviors that prevent recurrent UTIs including: a. practicing careful personal hygiene. b. increasing fluid intake to promote voiding & dilution of urine. c. urinating regularly & more frequently d. adhering to therapeutic regimen UPPER Urinary Tract Disorders UPPER UTI Urinary Tract Disorder PYELONEPHRITIS is a bacterial infection of the renal pelvis, tubules, & interstitial tissue of one or both kidneys. CAUSES: a. upward spread of bacteria from the bladder - An incompetent ureterovesical valve, obstruction (BPH, tumors) in the UT increases the susceptibility of the kidneys to infection. UPPER UTI Urinary Tract Disorder PYELONEPHRITIS b. spread from systemic sources reaching the kidney via the bloodstream. Ex: TB can reach the kidney causing abscesses. PYELONEPHRITIS may be acute or chronic. UPPER UTI Urinary Tract Disorder PYELONEPHRITIS Acute pyelonephritis leads to enlargement of the kidneys w/ interstitial infiltrations of inflammatory cells. Abscesses may be noted on or w/in the renal capsule & at the corticomedullary junction resulting to atrophy & destruction of tubules & the glomeruli. UPPER UTI Urinary Tract Disorder PYELONEPHRITIS In chronic pyelonephritis, the kidney become scarred, contracted & non- functioning. Chronic pyelonephritis is a cause of CKD. UPPER UTI Urinary Tract Disorder PYELONEPHRITIS CLINICAL MANIFESTATIONS: Fever Leukocytosis( increased in the # of white blood cell) Bacteriuria Pyuria Low back pain Flank pain UPPER UTI Urinary Tract Disorder PYELONEPHRITIS Nausea & vomiting Malaise Painful urination pain & tenderness in the CVA upon PE urgency & frequency UPPER UTI Urinary Tract Disorder PYELONEPHRITIS Nausea & vomiting Malaise Painful urination pain & tenderness in the CVA upon PE urgency & frequency UPPER UTI Urinary Tract Disorder ASSESSMENT & DIAGNOSTIC FINDINGS: Ultrasound study or CT scan- to locate obstruction in the UT. Relief of obstruction is essential to prevent complications & eventual kidney damage. IV pyelogram- indicated in functional & structural renal abnormalities  Radionuclide UPPER UTI imaging w/ gallium citrate Urinary Tract Disorder & indium 111-use to identify sites of infection that cannot be visualized on CT scan or ultrasound. Urine culture & sensitivity tests – to determine the causative organism ; to determine appropriate antimicrobial agents. UPPER UTI Urinary Tract Disorder MEDICAL MANAGEMENT: acute uncomplicated pyelonephritis - treated on an outpatient basis if not exhibiting acute symptoms of sepsis(hypothermia, unconsciousness), dehydration, nausea or vomiting outpatient- 2 wk course of antibiotics is recommended.  MEDICAL UPPER UTI MANAGEMENT: Urinary Tract Disorder Pregnant- hospitalized for 2-3 days of parenteral antibiotic therapy then shifted to oral antibiotic once the pt is afebrile & showing clinical improvement. For relapse- antibiotic for up to 6 wks. Urine culture is done 2 wks. after completion of antibiotic therapy. Hydration w/ oral or parenteral fluids is essential. UPPER UTI Urinary Tract Disorder CHRONIC PYELONEPHRITIS Repeated bouts effect (RBE) of acute pyelonephritis may lead to chronic pyelonephritis UPPER UTI Urinary Tract Disorder CLINICAL MANIFESTATIONS: - Usually has no symptoms of infection unless an acute exacerbation(sudden worsening) occurs. - Noticeable s/s: fatigue, headache, poor appetite, polyuria, excessive thirst, weight loss. - Persistent & recurring infection may produce scarring of the kidney, resulting in renal failure. UPPER UTI Urinary Tract Disorder Assessment & diagnostic findings: - IV urogram - measurement of creatinine clearance, blood urea nitrogen, creatinine levels UPPER UTI Urinary Tract Disorder COMPLICATIONS: - ESRD, from progressive loss of nephrons sec to chronic inflammation & scarring. - HPN - formation of kidney stones UPPER UTI Urinary Tract Disorder MEDICAL MANAGEMENT: - eradication of bacteria if detected in urine. Long term use of prophylactic antimicrobial therapy to limit recurrence of infection & renal scarring. * Impaired renal function alters the excretion of antimicrobial agents & necessitates careful monitoring of renal function, especially if meds are toxic to the kidneys UPPER UTI Urinary Tract Disorder NURSING MANAGEMENT: 1. I &O are measured & recorded. - Unless contraindicated, 3-4 L of fluids/day is encouraged to dilute urine, decrease burning on urination & prevent dehydration. 2. Temperature is monitored q 4 hrs; antipyretic & antibiotics are given as prescribed. UPPER UTI Urinary Tract Disorder 3. Symptomatic pts. -often more comfortable on bedrest. 4. Pt. education focuses on prevention of further infection by adequate fluids, empty bladder regularly & perform perineal care. Importance of taking medication & keeping ff-up appointments. UPPER UTI Urinary Tract Disorder Urolithiasis & Nephrolithiasis Urolithiasis= stones in the urinary tract Nephrolithiasis = kidney stone Ureterolithiasis = ureter stone Cystolithiasis = bladder stone UPPER UTI Urinary Tract Disorder The stone is usually calcium phosphate, calcium oxalate and uric acid. – Struvite(magnesium ammonium phosphate) = acid ash diet is recommended (meat/fish, eggs, cereals) – Staghorn = large stone UPPER UTI Urinary Tract Disorder PREDISPOSING FACTORS CONTRIBUTING TO STONE FORMATION: Anatomic derangement such as polycystic kidney dse, horseshoe kidneys, chronic strictures & medullary sponge dse Pts w/ IBD & in those w/ ileostomy or bowel resection- these pts absorb more oxalate. Medications known to cause stones include antacids, acetazolamide(Diamox), vit D, laxatives, & high doses of aspirin. UPPER UTI Urinary Tract Disorder CLINICAL MANIFESTATION: increase in hydrostatic pressure & distension of the renal pelvis & proximal ureter. due to obstruction of urine flow excruciating pain & discomfort. renal pelvis stone- intense, deep ache in the CVA, hematuria, pyuria, renal colic(pain suddenly becomes acute w/ CVA tenderness+ nausea & vomiting); Diarrhea & abdominal discomfort UPPER UTI CLINICAL MANIFESTATION: Urinary Tract Disorder Ureteral stones- ureteral obstruction= acute, excruciating, colicky, wavelike pain that radiates down the thigh & to the genitalia; ureteral colic Bladder stones= irritation associated w/ UTI & hematuria. bladder neck stone=urinary retention UPPER UTI Urinary Tract Disorder Assessment & diagnostic findings: x-rays of the kidneys, ureters, & bladder(KUB), ultrasonography, IV urography, or retrograde pyelography. Blood chemistries & a 24-hr urine test for measurement of Ca, uric acid, creatinine, Na, pH & total volume UPPER UTI Urinary Tract Disorder Dietary & medication histories & family history of renal stones are obtained to identify predisposing factors. Stones recovered=chemical analysis is carried out to determine composition(eg. urate stones-suggest disturbance in uric acid metabolism) UPPER UTI Urinary Tract Disorder MEDICAL MANAGEMENT: - Eradicate the stone; determine the stone type; prevent nephron destruction; control infection & relieve obstruction. - relieve the pain(renal or utereral colic) until its cause can be eliminated - Opioid analgesic agents are administered to prevent shock & syncope from excruciating pain. UPPER UTI Urinary Tract Disorder - NSAIDs are effective in treating renal stone pain (provides specific pain relief, reduce swelling & facilitate passage of stone.) - Hot baths or moist heat to the flank area - Fluids are encouraged unless contraindicated. Drink 8-10 8-ounce glasses of water daily or IV fluids to keep the urine dilute. A urine output exceeding 2L/day is advisable. UPPER UTI Urinary Tract Disorder Determine the CAUSE and type of stone (calcium or uric acid) Encourage ambulation If its calcium give ammonium chloride ; liberal fluids If its uric acid- low purine diet; Allopurinol is prescribed UPPER UTI Urinary Tract Disorder If its cystine- low-protein diet, urine is alkalinized, fluid intake is inc Oxalate stones- dilute urine is maintained; intake of oxalate is limited UPPER UTI Urinary Tract Disorder PT. EDUCATION Avoid CHON intake; CHON is restricted to 60g/day to decrease urinary excretion of Ca & uric acid. Na intake of 3-4 g/day is recommended; Table salt & high Na foods should be reduced (Na competes w/ Ca for reabsorption in the kidneys. UPPER UTIdiets are not recommended. Low-Ca Urinary Tract Disorder Avoid intake of oxalate-containing foods (spinach, strawberries, tea, peanuts) During the day, drink fluids every 1-2 hours. Drink 2 glasses of H2O at bedtime & an additional glass at each nighttime awakening. UPPER UTI Urinary Tract Disorder Avoid activities leading to sudden increases in environmental temperatures. Contact your primary provider at the 1st sign of UTI. UPPER UTI Urinary Tract Disorder MANAGEMENT: Antibiotics prophylactically I & O, strain urine (stone must be submitted to lab to identify the type of stone) Drugs: – Na cellulose phosphate (combines w/ the Ca & some minerals in food preventing Ca from reaching the kidneys where the stones are formed)  – Thiazide UPPER UTI (increases tubular Urinary Tract Disorder reabsorption, decreasing calculi formation in the kidney tubules) – Cholestyramine (binds oxalates in the feces) – Allopurinol (decreased uric acid formation) – Antibiotics (chronic UTI is a precursor to calculi formation) UPPER UTI Urinary Tract Disorder – Narcotics and NSAID for pain management – Antispasmodic (Probanthine) – Rowatinex to dissolve stone UPPER UTI Urinary Tract Disorder SURGICAL INTERVENTION: indicated if the stone does not respond to other forms of treatment. Nephrolithotomy- incision into kidney w/ removal of the stone. Nephrectomy-removal of the nonfunctional kidney UPPER UTI Urinary Tract Disorder Pyelolithotomy(pelvis) Ureterolithotomy (ureter Cystotomy (bladder); cystolitholapaxy- crushing stone in the bladder using an instrument.  INTERVENTIONAL PROCEDURES: UPPER UTI (PUL) percutaneous ultrasonic Urinary Tract Disorder lithotripsy -Nephroscope is inserted to kidney, an ultrasonic waves disintegrates stones followed by suction and irrigation Laser lithotripsy = non invasive procedure  – Post nursing care = increase fluids, UPPER UTI Urinaryencourage Tract Disorder ambulation, strain urine and watch out for obstruction and bleeding ESWL extra corporeal shock wave lithotripsy Client is immersed to water, shock waves disintegrate stones (non invasive) UPPER UTI Urinary Tract Disorder – Post nursing care = increase fluids, encourage ambulation, strain urine and watch out for obstruction and bleeding Uteroscopy - Uteroscope is inserted into the ureter, insert a laser, electrohydraulic lithotriptor/ultrasound device= fragment & remove the stones  Endourologic UPPER UTI methods of stone removal: Urinary Tract Disorder >percutaneous nephrostomy orpercutaneous nephrolithotomy -nephroscope is inserted thru the percutaneous route into the renal parenchyma. Stone is extracted w/ forceps. UPPER UTI Chemolysis Urinary Tract Disorder - stone dissolution using infusions of chemical solutions(alkaline agent: acetylcysteine will dissolve cysteine calculi, acidifying agents) to dissolve the struvite stone. -percutaneous nephrostomy>warm chemical solution is allowed to flow continuously > solution exits in the ureter or nephrostomy tube. - pressure inside renal pelvis is monitored during the procedure.  UPPER UTI Urinary Tract Disorder NURSING DIAGNOSIS: Acute pain related to inflammation, obstruction & abrasion of the urinary tract. Deficient knowledge regarding prevention or recurrence of renal stones.  UPPER UTI Urinary Tract Disorder POTENTIAL COMPLICATIONS: Infection & urosepsis(from UTI & pyelonephritis) Obstruction of the UT by a stone or edema w/ subsequent acute renal failure  UPPER UTI Urinary Tract Disorder NURSING MANAGEMENT: Relieving pain - Opioid analgesic agents (IV or IM) - encouraged to assume position of comfort. - Pain level is monitored closely & increase in severity is reported promptly.  UPPER UTI Urinary Tract Disorder Monitoring & managing potential complications - Increased fluid intake or IV fluids are prescribed for pts who cannot take oral fluid - Monitor urine output & patterns of voiding - ambulation in encouraged  UPPER UTI Urinary Tract Disorder - All urine is strained through gauze. Any blood clots in the urine is crushed. - Instruct pt. to report decreased urine volume, bloody or cloudy urine, fever & pain. - Instruct pt to report sudden increase in pain intensity. V/S are closely monitored  UPPER UTI Urinary Tract Disorder *UTIs maybe associated w/ renal stones due to obstruction. All infection should be treated w/ antibiotics before dissolving the stone  UPPER UTI Urinary Tract Disorder MALE REPRODUCTIVE ORGAN: Testes are formed in the abdominal cavity near the kidney During last month of fetal life they descend into the groin (spermatic cord) Internal inguinal canal to the scrotum Testes descend into the scrotum Testes are encased by the scrotum (slightly lower temperature than the rest of the body to facilitate spermatogenesis) UPPER UTI Urinary Tract Disorder Seminiferous tubules (sperm) Leydig’s cells (testosterone) Prostate gland (alkaline fluid) Bulbourethral glands, Cowper’s Glands (alkaline fluid) - Seminal vesicle (nutrients: fructose UPPER UTI Urinary Tract Disorder BENIGN PROSTATIC HYPERTROPHY: Slow enlargement of the prostate Men over 40 year (prostate gland enlargement begins) On the latent phase it will constrict the urethra which interferes in urination UPPER UTI Urinary Tract Disorder SIGNS AND SYMPTOMS: SUBJECTIVE Frequency Urgency Difficulty initiating stream Incomplete emptying of the bladder after urination UPPER UTI Urinary Tract Disorder OBJECTIVE Nocturia Hematuria Weak stream Urinary retention Biopsy reveals hyperplasia Rectal Examination PROSTATISM – late manifestation (cancer, high PSA(prostate specifi antigen), CEA (carcinoembryogenic antigen) UPPER UTI MANAGEMENT: Urinary Tract Disorder Urinary obstruction (divert urine by coude catheter, cystostomy-surgically created connection bet urinary bladder & skin) Finasteride (Proscar) - can stop glandular hyperplasia Medical and Surgical Intervention UPPER UTI Urinary Tract Disorder Promote measures to relieve urinary retention - alternating warm and cold compress - offer a bedpan - open the faucet - provide privacy - catheterization UPPER UTI Urinary Tract Disorder TURP transurethral resection of the prostate Resectoscope or laser is inserted to urethra to resect prostate Supra pubic prostatectomy Surgical incision at the pubis Perineal prostatectomy Surgical incision at the perineum area (may lead to impotence) UPPER UTI Urinary Tract Disorder POST TURP Following this procedure CBI (continuous bladder irrigation) must be instituted for the sole purpose of preventing clot formation that may obstruct urine outflow.