Management of Patient with Urinary Disorder PDF

MANAGEMENT OF PATIENT WITH URINARY DISORDER PREPARED BY : MRS. CARMELA C. ASURO, MAN,RN Objective: 1. Identify factors contributing to upper and lower urinary tract infections (UTIs). 2. Use the nursing process as a framework for care of the patient with a UTI. 3. Differentiate betwe...

MANAGEMENT OF PATIENT WITH URINARY DISORDER PREPARED BY : MRS. CARMELA C. ASURO, MAN,RN Objective: 1. Identify factors contributing to upper and lower urinary tract infections (UTIs). 2. Use the nursing process as a framework for care of the patient with a UTI. 3. Differentiate between the various adult dysfunctional voiding patterns. 4. Develop a patient education plan for a patient who has mixed (stress and urge) urinary incontinence. 5. Identify potential causes of an obstruction of the urinary tract and management of the patient with this condition. Terminologies bacteriuria: more than 105 colonies of bacteria per milliliter of urine cystectomy: removal of the urinary bladder cystitis: inflammation of the urinary bladder frequency: voiding more often than every 3 hours ileal conduit: transplantation of the ureters to an isolated section of the terminal ileum, with one end of the ureters brought to the abdominal wall interstitial cystitis: inflammation of the bladder wall that eventually causes disintegration of the lining and loss of bladder elasticity  pyelonephritis: inflammation of the renal pelvis pyuria: white blood cells in the urine micturition: voiding or urination neurogenic bladder: bladder dysfunction that results from a disorder or dysfunction of the nervous system; may result in either urinary retention or bladder overactivity, resulting in urinary urgency and urge incontinence nocturia: awakening at night to urinate overflow incontinence: involuntary urine loss associated with overdistention of the bladder due to mechanical or anatomic bladder outlet obstruction  prostatitis: inflammation of the prostate gland ureterovesical or vesicoureteral reflux: backward flow of urine from the bladder into one or both ureters urethritis: inflammation of the urethra urethrovesical reflux: backward flow of urine from theurethra into the bladder urinary incontinence: involuntary or uncontrolled loss of urine from the bladder sufficient to cause a social or hygienic problem urosepsis: sepsis resulting from infected urine, most often a UTI  Overview of the Urinary Tract The urinary system's function is to filter blood and create urine as a waste by-product. The organs of the urinary system include the: kidneys, renal pelvis, ureters, bladder and urethra.  Two ureters. These narrow tubes carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters. Bladder. This triangle-shaped, hollow organ is located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder's walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours.  Two sphincter muscles. These circular muscles help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder. Nerves in the bladder. The nerves alert a person when it is time to urinate, or empty the bladder. Urethra. This tube allows urine to pass outside the body. The brain signals the bladder muscles to tighten, which squeezes urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax to let urine exit the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs. Facts about urine Normal, healthy urine is a pale straw or transparent yellow color. Darker yellow or honey colored urine means you need more water. A darker, brownish color may indicate a liver problem or severe dehydration. Pinkish or red urine may mean blood in the urine. https://www.hopkinsmedicine.org/health/wellness-and-prevention/anatomy-of- the-urinary-system#:  INFECTIONS OF THE URINARY TRACT Classifying Urinary Tract Infections Urinary tract infections (UTIs) are classified by location: the lower urinary tract (which includes the bladder and structures below the bladder) or the upper urinary tract (which includes the kidneys and ureters). They can also be classified as uncomplicated or complicated UTIs. Lower UTIs :Cystitis, prostatitis, urethritis Upper UTIs :Acute pyelonephritis, chronic pyelonephritis, renalabscess, interstitial nephritis, perirenal abscess Uncomplicated Lower or Upper UTIs :Community-acquired infection; common in young women and not usually recurrent Complicated Lower or Upper UTIs : Often nosocomial (acquired in the hospital) and related to catheterization; occur in patients with urologic abnormalities, pregnancy, immunosuppression, diabetes mellitus, and obstructions and are often recurrent  Risk Factors for Urinary Tract Infection Inability or failure to empty the bladder completely Obstructed urinary flow caused by: Congenital abnormalities, Urethral strictures, Contracture of the bladder neck ,Bladder tumors,Calculi (stones) in the ureters or kidneys, Compression of the ureters Decreased natural host defenses or immunosuppression Instrumentation of the urinary tract (eg, catheterization, cystoscopic procedures) Inflammation or abrasion of the urethral mucosa Contributing conditions such as: ✓ Diabetes mellitus (increased urinary glucose levels create an infection-prone environment in theurinary tract) ✓ Pregnancy ✓ Neurologic disorders ✓ Gout ✓ Altered states caused by incomplete emptying of the bladder and urinary stasis The mechanisms that works together to prevent infection and they include: The process of urinating washes most bacteria out of the urethra In females: Mucus secreting cells in the urethra help trap bacteria so it can’t move upward In males: the length of the urethra and the prostate and associated glands create secretions to shield bacteria from invading Several factors work to create a bactericidal effect: high osmolality and low PH of the urea, uromodulin presence (a protein synthesized in the kidneys), and the epithelial cells of the urinary tract When the bladder contracts, the ureterovesical junction (functional one-way valve where the ureters lead into the bladder) closes, thus preventing urine from ascending upwards into the upper urinary tract In the distal urethra, the urethral sphincter prevents the upward movement of bacteria  If bacteria were to successfully invade, the immune system recruits toll-like receptors (TLR4) which recognize the pathogen and further recruits neutrophils and macrophages to induce phagocytosis. The ability of the pathogen to produce infection is influenced by the virulence of the specific pathogen and individual’s specific immune response. If the immune system does not respond quick enough, the pathogen may be able to excessively multiply and inundate the individual’s defense mechanism, causing a UTI (McCance & Huether, 2019).  EXAMPLES OF MEDICATIONS USED TO TREAT UTIs AND PYELONEPHRITIS Drug Classes Generic (Brand) Name Major Indications Antibiotic Cephalexin (Keflex) Genitourinary infections Cephalosporin (first generation) Antibiotic Ampicillin (Principen) UTI—not commonly used alone due to Escherichia coli resistance Pyelonephritis Antibiotic Amoxicillin (Amoxil) UTI—not commonly used alone due to E. coli resistance Trimethoprim-sulfamethoxazole Cotrimoxazole (TMP-SMZ, UTI combination Bactrim Septra ) Pyelonephritis Antibiotic Nitrofurantoin (Macrodantin, UTI Urinary tract anti-infective Furadantin) Fluoroquinolone Ciprofloxacin (Cipro) UTI Antibiotic Pyelonephritis Fluoroquinolone Levofloxacin (Levaquin) Uncomplicated UTI Urinary analgesic agent Phenazopyridine (Pyridium) For relief of burning, pain and other symptoms associated with UTI  Nursing process for patient with Lower UTI Assessment Nursing Diagnosis Planning Nursing Evaluation Intervention History of signs ▪ Acute pain related to Major goals for the ▪ Relieving Pain Expected patient and symptoms infection within the patient may include ▪ Monitoring and outcomes may include: presence of urinary tract relief of pain and Managing Experiences relief of pain, frequency, ▪ Deficient knowledge discomfort, Potential pain urgency, hesitancy, about factors increased Complications Explains UTIs and and changes in predisposing the knowledge of ▪ Promoting Home their treatment urine patient to infection preventive measures and Community- Experiences no pattern of and recurrence, and treatment Based Care complications voiding detection and modalities, and urine is assessed prevention of absence of for volume, recurrence, and complications color, pharmacologic concentration, therapy cloudiness, and odor PATIENT EDUCATION Before and After Urodynamic Testing A physician or nurse will conduct an in-depth interview. Questions related to your urologic symptoms and voiding habits will be asked. You will be asked to describe sensations felt during the procedure. During the procedure, you might be asked to change positions (eg, from supine to sitting or standing). You may be asked to cough or perform the Valsalva maneuver (bear down) during the procedure. You will probably need to have one or two urethral catheters inserted so that bladder pressure and bladder filling can be measured. Another catheter may be placed in the rectum or vagina to measure abdominal pressure. You may also have electrodes (surface, wire, or needle)placed in the perianal area for electromyography(EMG). This may be uncomfortable initially during insertion and later during position changes.  Your bladder will be filled through the urethral catheter one or more times during the procedure. After the procedure, you may experience urinary frequency, urgency, or dysuria from the urethral catheters. Avoid caffeinated, carbonated, and alcoholic beverages after the procedure because these can further irritate the bladder. These symptoms usually decrease or subside by the day after the procedure. You might notice a slight hematuria (blood-tinged urine) right after the procedure (especially in men with benign prostatic hyperplasia). Drinking fluids will help to clear the hematuria. If the urinary meatus is irritated, a warm sitz bath may be helpful. Be alert for signs of a urinary tract infection after the procedure. Contact your physician if you experience fever, chills, lower back pain, or continued dysuria and hematuria. If you receive an antibiotic medication before the procedure, you should continue taking the complete course of medication after the procedure. This is a measure to prevent infection. PATIENT EDUCATION Preventing Recurrent Urinary Tract Infections Hygiene Shower rather than bathe in tub because bacteria in the bath water may enter the urethra. After each bowel movement, clean the perineum and urethral meatus from front to back. This will help reduce concentrations of pathogens at the urethral opening and, in women, the vaginal opening. Fluid Intake Drink liberal amounts of fluids daily to flush out bacteria. Avoid coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants. Voiding Habits Void every 2 to 3 hours during the day and completely empty the bladder. This prevents overdistention of the bladder and compromised blood supply to the bladder wall. Both predispose the patient to UTI. Precautions expressly for women include voiding immediately after sexual intercourse.  Therapy Take medication exactly as prescribed. Special timing of administration may be required. If bacteria continue to appear in the urine, long-term antimicrobial therapy may be required to prevent colonization of the periurethral area and recurrence of infection. For recurrent infection, consider acidification of the urine through ascorbic acid (vitamin C), 1000 mg daily, or cranberryjuice. If prescribed, test urine for presence of bacteria following manufacturer’s and health care provider’s instructions. Notify the primary health care provider if fever occurs or if signs and symptoms persist. Consult the primary health care provider regularly for follow-up.  Upper Urinary Tract Infection ACUTE PYELONEPHRITIS – bacterial infection of the renal parenchyma that can be organ- and/or life-threatening and that often leads to renal scarring. The bacteria in these cases have usually ascended from the lower urinary tract but may also reach the kidney via the bloodstream. Clinical Manifestations acutely ill with chills and fever, leukocytosis, bacteriuria,pyuria. Low backpain, flank pain, nausea and vomiting, headache, malaise, painful urination pain and tenderness in the area of the costovertebral angle.  CHRONIC PYELONEPHRITIS - Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis Clinical Manifestations usually has no symptoms of infection unless an acute exacerbation occurs. Noticeable signs and symptoms may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss. Persistent and recurring infection may produce progressive scarring of the kidney, resulting in renal failure  ADULT VOIDING DYSFUNCTION Condition Voiding Dysfunction Treatment Neurogenic Disorders Cerebellar ataxia Incontinence or dyssynergia Timed voiding; anticholinergic agents Cerebrovascular accident Retention or incontinence Anticholinergic agents; bladder retraining Dementia Incontinence Prompted voiding; anticholinergic agents Diabetes mellitus Incontinence and/or incomplete bladder Timed voiding; EMG/biofeedback; pelvic floor nerve emptying stimulation; anticholinergic/antispasmodic agents; well- Multiple sclerosis Incontinence or incomplete bladder emptying controlled blood glucose levels Timed voiding; EMG/biofeedback to learn pelvic muscle Parkinson’s disease Incontinence exercises and urge inhibition; pelvic floor nerve stimulation; antispasmodic agents Anticholinergic/antispasmodic agents Spinal Cord Dysfunction Acute injury Urinary retention Indwelling catheter Degenerative disease Incontinence and/or incomplete bladder EMG/biofeedback; pelvic floor nerve stimulation; emptying anticholinergic agents Non-Neurogenic Disorders Inability to initiate voiding in public bathrooms Relaxation therapy; EMG/biofeedback “Bashful bladder” Urgency, frequency, and/or urge incontinence EMG/biofeedback; pelvic floor nerve stimulation; bladder Overactive bladder drill ; anticholinergic agents Acute urine retention Catheterization Post-general surgery Incontinence Mild: biofeedback; bladder drill ; pelvic floor nerve Postprostatectomy Incontinence with cough, laugh, stimulation Stress incontinence sneeze, position change Moderate/severe: surgery—artificial sphincter Mild: biofeedback: bladder drill ; periurethral bulking with collagen Moderate/severe: surgery  Urinary Incontinence Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sneezing, coughing,or changing position (Miller, 2009). Iatrogenic incontinence refers to the involuntary loss of urine due to extrinsic medical factors, predominantly medications. One such example is the use of alpha-adrenergic agents to decrease blood pressure. Mixed urinary incontinence, which encompasses several types of urinary incontinence, is involuntary leakage associated with urgency and also with exertion, effort, sneezing,or coughing (Miller, 2009). Causes of Transient Incontinence: DIAPPERS Delirium Infection of urinary tract Atrophic vaginitis, urethritis Pharmacologic agents (anticholinergic agents, sedatives,alcohol, analgesic agents, diuretics, muscle relaxants,adrenergic agents) Psychological factors (depression, regression) Excessive urine production (increased intake, diabetes insipidus,diabetic ketoacidosis) Restricted activity Stool impaction Urinary Retention The inability to empty the bladder completely during attempts to void. Chronic urine retention often leads to overflow incontinence (from the pressure of the retained urine in the bladder). Residual urine is urine that remains in the bladder after voiding. In a healthy adult younger than 60 years of age, complete bladder emptying should occur with each voiding. In adults older than 60years of age, 50 to 100 mL of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. Urinary retention can occur postoperatively in any patient, particularly if the surgery affected the perineal or anal regions and resulted in reflex spasm of the sphincters. General anesthesia reduces bladder muscle innervation and suppresses the urge to void, impeding bladder emptying.  Urinary retention ✓ diabetes, ✓ prostatic enlargement, ✓ urethral pathology (infection, tumor, calculus), ✓ trauma (pelvic injuries), ✓ pregnancy, ✓ neurologic disorders such as stroke, spinal cord injury, multiple sclerosis, Parkinson’s disease. ✓ Some medications cause urinary retention either by inhibiting bladder contractility or by increasing bladder outlet resistance (Karch, 2008). PATIENT EDUCATION Strategies for Promoting Urinary Continence Increase your awareness of the amount and timing of all fluid intake. Avoid taking diuretics after 4 PM. Avoid bladder irritants, such as caffeine, alcohol, and aspartame (NutraSweet). Take steps to avoid constipation: Drink adequate fluids, eat a well-balanced diet high in fiber, exercise regularly, and take stool softeners if recommended. Void regularly, five to eight times a day (about every 2 to 3 hours): First thing in the morning Before each meal Before retiring to bed Once during the night if necessary Perform all pelvic floor muscle exercises as prescribed,every day. Stop smoking (smokers usually cough frequently, which increases incontinence).