Renal and Urologic Problems

Renal and Urologic Problems Chapter 50 2 Learning Objectives  Understand the differences in the pathophysiology of the urologic conditions.  Formulate a plan of care for the patients diagnosed with urologic disorders.  Understand differences in localized vs systemic symptomology.  Predict plans of care and interventions for patients diagnosed with acute urologic disorders.  Implement nursing interventions based on symptomology.  Identify symptoms specific to each urologic disorder and nursing interventions to supplement. Infectious GU Disorders UTI, Pyelonephritis, Urethritis 3 • UTI is a general term for infection in the urinary system • Bacteria enter the urethra and travel upward o Lower UTI: urethra, bladder o Upper UTI: ureters, renal pelvis, kidney 4 Urinary Tract Infections (UTIs) ❖ Most common outpatient infection, most common HAI (CAUTIs) ❖ Causes:  Most common pathogen: Escherichia coli (E. coli) o 75% uncomplicated UTIs o 65% complicated UTIs  Less common pathogens: fungal and parasitic o Immunosuppressed o Diabetic or kidney problems o Received multiple courses of antibiotics o Live in or have traveled to certain developing countries Classification of UTI  By location: upper or lower o Pyelonephritis – renal parenchyma & collecting system o Cystitis – bladder o Urethritis – urethra o Urosepsis – systemic  By causative factors: o Uncomplicated ➢ Normal urinary tract o Complicated ➢ Structural or functional abnormality; underlying disease 5 6 UTI: Etiology and Pathophysiology  Urinary tract normally sterile  Normal defense mechanisms: 1. Complete bladder emptying 2. Ureterovesical junction competence 3. Ureteral peristalsis 4. Antibacterial properties (acidic pH, antimicrobial proteins)  Ascending infection: pathogens commonly originate in the perineum o Most are gram negative bacilli (E. coli, etc.) o Gram positive bacteria include strep, staph, & enterococcus  Descending infection: hematogenous spread 7 UTI: Risk Factors Table 50.2, pg 1196  Anatomic factors o Female, obesity, congenital defects, fistulas  Impaired immune response o Aging, DM, corticosteroids, immunosuppressants, HIV  Urinary stasis o Urinary retention, obstruction (stones, BPH, tumors)  Procedures o Catheters (“CAUTI”), cystoscopy  Functional disorders o Constipation, neurogenic sphincter dysfunction  Misc. o “nurse’s bladder,” intercourse, poor hygiene, pregnancy 8 UTI: Clinical Manifestations Lower Urinary Tract Symptoms (LUTS) Upper Urinary Tract Symptoms  May have nonspecific S&S  LUTS  Localized S&S  Systemic S&S  Dysuria  Fever, chills, malaise  Frequency, urgency  CVA tenderness (“flank pain”)  Hesitancy, retention  Suprapubic pain/discomfort  Urine Appearance Cloudy (sediment), hematuria  Older adults AMS/encephalopathy, fatigue, abdominal discomfort **may not have classic symptoms** 9 UTI: Clinical Manifestations Emptying Symptoms Storage Symptoms  Dysuria  Incontinence  Hesitancy  Nocturia  Intermittency  Nocturnal enuresis  Post-void dribbling  Urgency  Urinary retention (incomplete emptying)  Urinary frequency Diagnostic Studies 10 A. Urinalysis: o Nitrates o WBCs o Leukocyte esterase o Bacterial count >105 CFU/mL B. Urine culture/sensitivity: o Clean-catch urine sample o Catheter sample C. Imaging: Assess for obstruction to urine flow o Ultrasound o CT scan o Cystoscopy **Bacteriuria → only treat if symptomatic 11 UTI: Drug Therapy Uncomplicated Complicated ~ 3-day course Abx ~ 1 to 2-week course Abx • Trimethoprim/sulfame thoxazole (TMP-SMX) • Fluoroquinolones (Levofloxacin, ciprofloxacin) • Nitrofurantoin • Penicillins (ampicillin, amoxicillin) • Fungal: fluconazole • Cephalosporins • Fosfomycin Urinary analgesic: phenazopyridine (azo dye) **urine color change → orange / red** 12 UTI: Nursing Management Acute Care  Adequate fluids - dilutes urine and reduces irritation  Avoid irritating fluids and foods o Caffeine, carbonation, artificial sugars, acidic foods (spicy, citrus), chocolate, alcohol  Heating pad to suprapubic or lower back; warm shower or bath  Perineal hygiene during hospitalization  Recurrent and/or complicated UTI: o Sensitivity testing (Abx resistant?) and possibly suppressive or prophylactic antibiotics o Antibiotics 7 to 14 days or longer 13 UTI: Nursing Management Acute Care  Prevention of CAUTI: o Avoid unnecessary catheterizations ➢ Alternatives: condom cath, purewick o Early removal of indwelling catheters o Aseptic technique o Hand hygiene o Gloves for catheter care o Avoid dependent loops in the catheter o Keep catheter below bladder level 14 UTI: Nursing Management Patient Education o Empty bladder regularly and completely o Evacuate bowel regularly o Wipe front to back o Adequate fluid intake - fear of pain & frequency o Drugs and side effects - complete entire prescription o What to look for (improvement) o What to report to HCP 15 UTI: Nursing Management Patient Education o Void: regularly (every 3-4 hours) and before & after intercourse o Stop using diaphragm (temporarily) o Perineal hygiene ➢ Males - clean under foreskin ➢ Females - avoid vaginal douching and bubble baths Acute Pyelonephritis  ”Kidney infection” o Upper UTI  Inflammation of renal parenchyma and collecting system o Most common: bacteria (E.coli, Proteus, Klebisella, or Enterobacter from intestinal tract) o Other: fungi, protozoa, or viruses  Urosepsis - systemic infection from urologic source, both bacteriuria & bacteremia 16 17 Pyelonephritis: Etiology and Pathophysiology  Usually ascending route: initial colonization and infection of lower urinary tract from urethra o Risk factors - vesicoureteral reflux (urine moves from lower to upper urinary tract) or dysfunction of lower urinary tract (obstruction, stricture, or stones) o CAUTI - long-term care residents o Pregnancy-induced changes  Starts in renal medulla, spreads to cortex  Recurrent pyelonephritis → chronic pyelonephritis Clinical Manifestations  Classic: fever, chills, nausea, vomiting, malaise, flank pain  May have LUTS: dysuria, urgency, frequency  Costovertebral angle (CVA) tenderness to percussion on affected side 18 Diagnostic Studies  Urinalysis: pyuria, bacteriuria, hematuria; WBC casts  Urine cultures and sensitivities  Blood cultures  Decreased kidney function tests  Ultrasound o Anatomic abnormalities, hydronephrosis, stones  CT scan - preferred imaging study 19 Urinalysis, Infection Indicators 20 Interprofessional Care  Mild symptoms (outpatient or short inpatient) o Fluids, NSAIDs, follow-up cultures and imaging o Antibiotics: oral 5 to 14 days ➢ Sensitivity guided  Severe symptoms (as above except) o IV fluids until oral fluids tolerated o Combination parenteral antibiotics  Relapses → 6 weeks antibiotics  Recurrent → prophylactic antibiotics 21 Nursing Care: Education Table 50.6, pg 1200  Health promotion and maintenance o Similar to UTIs o Early treatment of UTIs to prevent ascending infection o Regular medical care for structural abnormalities  Patient teaching – increases adherence o Disease process o Take medications as prescribed o Follow-up care o Signs and symptoms of relapse or recurrence o Adequate fluid intake (8 glasses/day) The nurse identifies that the patient with the greatest risk for a urinary tract infection is: 22 Audience Response Question a. A 37-year-old man with renal colic associated with kidney stones. b. A 26-year-old pregnant woman who has a history of urinary tract infections. c. A 69-year-old man who has urinary retention caused by benign prostatic hyperplasia. d. A 72-year-old woman hospitalized with a stroke who has a urinary catheter because of urinary incontinence. 23 Audience Response Question Answer: D A 72-year-old woman hospitalized with a stroke who has a urinary catheter because of urinary incontinence. Rationale: UTIs are the most common health care-associated infection (HAI) and are mainly a result of the use of indwelling catheters (CAUTIs). CAUTIs lead to extended hospital stays, increased health care costs, and increased mortality. Chronic Pyelonephritis  Repeat infections → infiltration of parenchyma by inflammatory cells → inflammation & fibrosis → loss of functioning nephrons & atrophy o Often r/t anatomic abnormalities o Rarely: substantial inflammation from infection  Diagnosis: radiologic imaging and biopsy  Treatment: treat infection & underlying contributing factors 24  Can progress to end-stage renal disease (ESRD) Urethritis  Inflammation of the urethra (bacteria or viral most common) o Chlamydia, gonorrhea, herpes, trichomonas, o Males - often sexually transmitted; has discharge o Females - diagnosis more difficult; + WBCs, - bacteria o Sx: LUTS, penile burning, discharge o Treatment: antimicrobials, comfort, sitz baths o Patient teaching: avoid vaginal sprays, perineal hygiene, no sex for 7 days, and if STD - contact partners 25 26 Immunologic Kidney Disorders Glomerulonephritis and Nephrotic Syndrome 27 Glomerulonephritis  Inflammation of the glomeruli  3rd leading cause of ESRD in United States  May also see tubular and interstitial changes with vascular scarring  Associated conditions: kidney infections, nephrotoxic drugs, immune disorders, systemic diseases May be acute or chronic: Table 50.8, pg 1204  Acute = sudden symptoms; temporary or reversible o Most common: Acute Poststreptococcal Glomerulonephritis 28  Chronic = slow, progressive; irreversible renal failure 29 Glomerulonephritis  Clinical Manifestations: o Generalized edema (periorbital first, then anasarca) o Hypertension o Oliguria and reddish-brown urine (protein/blood) o Abdominal or flank pain o Some patients may be asymptomatic 30 Glomerulonephritis  Diagnostics: o Patient Hx: 1 - 6 weeks prior infection of the tonsils, pharynx, or skin (e.g., streptococcal sore throat, impetigo) by nephrotoxic strains of group A βhemolytic streptococci o More common in children 5-7y and adults >60y o Urinalysis: ➢ Hematuria ➢ Proteinuria (mild to severe) o Lab work: Crt, BUN, eGFR o Streptozyme test → presence of strep antibodies o Renal biopsy 31 Glomerulonephritis: Nursing Care  >90% recover completely w/ supportive care  If + strep, give abx  Promote rest until HTN and urine changes resolve  Manage edema o Salt and fluid restriction o Diuretics  Manage hypertension - medication if severe  Diet - restrict protein if proteinuria is severe  Monitor urine output and kidney function 32 Chronic Glomerulonephritis  Syndrome of permanent and progressive renal fibrosis → can progress to ESRD o May have no history of kidney disease o May have autoimmune or genetic origin (Alport syndrome - inherited)  Symptoms develop slowly; unaware o Found coincidentally with abnormal UA, increased BP, or increased serum creatinine  Decreased renal function causes ESRD over several years 33 Chronic Glomerulonephritis  Clinical Manifestations o Hematuria, proteinuria, urinary excretion of formed elements (RBCs, WBCs, casts) o Increased BUN and creatinine; uremia  Diagnosis o H&P, exposure to drugs (NSAIDs), microbial infections, and viral infections o Evaluate for immune disorders o Ultrasound and CT scan; renal biopsy  Treatment: depends on cause o Symptomatic and supportive care 34 Nephrotic Syndrome  Glomerulus excessively permeable to plasma protein → proteinuria → low albumin and edema  Etiology and clinical manifestations: o Minimal change disease most common cause in children o 1/3 of adults have systemic disease (DM, lupus, etc.) o Massive proteinuria → foamy urine → hypoalbuminemia → peripheral edema (ascites, anasarca) o HTN, hyperlipidemia o Immune response altered → increased infection risk o Hypocalcemia and skeletal abnormalities o Hypercoagulability → thromboembolism risk 35 Severe Proteinuria 36 Nephrotic Syndrome: Treatment and Nursing Care  Treatment depends on cause o Corticosteroids and cyclophosphamide o Manage diabetes o ACE inhibitor, ARB, diuretics o Antihyperlipidemic drugs o Anticoagulants o Low-sodium, moderate protein diet; small, frequent meals  Nursing - manage edema; provide support o Daily weights, accurate I & O, measure abdomen & extremities o Avoid infection 37 Terminology  Anuria  Bacteriuria  Dysuria  Frequency  Hematuria  Oliguria  Pyuria  Urgency