Renal Case Studies & Questions (Part 2)
Case Study 3
Urinary Tract Infection (UTI)
Scenario
You are working in the ED when M.Z.’s daughter brings her mother in. M.Z. is an 89-year-old
widow with a 4-day history of dysuria, back pain, incontinency, and severe mental confusion.
M. Z. had been discharged from the hospital two weeks earlier after having a total hip
replacement. You note that M. Z. had a foley catheter during her previous hospital stay. M.
Z.’s most current VS are 118/60, 88, 18, 99.4° F. The medical director ordered several lab
tests on admission. The results were as follows: WBC 11,000, CMP (complete metabolic
profile) WNL (within normal limits). Postvoid catheterization for residual urine yielded 100 ml,
and UA (urinalysis) showed WBC’s present, RBC small, bacteria many. The urinary C&S
(culture and sensitivity) results were as follows: E. coli (Escherichia coli) > 100,000 colonies,
sensitive to ciprofloxacin, trimethoprim/sulfamethoxazole, and nitrofurantoin.
1. Do you think M. Z. has cystitis or pyelonephritis? Why?
M.Z has pyelonephritis
Infection of kidneys in the upper urinary tract.
Older population has more comorbidities
Severe mental cognition can occur with either
Dysuria, back pain, fever, chills occurs in pyelonephritis
E.Coli
2. What physical assessment technique might the physician or nurse perform to assess M.
Z. for possible pyelonephritis?
Ultrasound/CT scan to check for obstruction
CVA tenderness
3. Explain the new onset of M. Z.’s mental confusion.
M.Z. new onset of mental confusion is caused by the accumulation of E.coli in the urine
4. Is M. Z.’s postvoid residual urine normal? What should normal postvoid residual be?
M.Z.’s postvoid residual volume is not normal, it is 100mL Normal postvoid residual should be
between 30-50mL
5. What specific findings in a urinalysis indicate the presence of a urinary tract infection?
(Hint: refer to your notes for UTI under diagnostic tests).
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Positive leukocyte esterase.
Positive nitrite.
Presence of WBC’s and/or RBC’s.
Presence of ≥ 100,000 colonies/mL of bacteria.
6. What is the association between M.Z.’s UTI and the organism found in her urine culture?
E. coli bacteria from feces contamination can enter the bladder via the urethra leading to
infection of the urinary tract. Improper sterile technique from foley insertion, wipes back to
front
7. What are some factors that predisposed M. Z. to the development of UTI?
- female, 89 years old
- foley catheter 2 weeks prior
8. M.Z.’s UTI is responding to antibiotics and her mental status has cleared. She is being
discharged on trimethoprim/sulfamethoxazole 160/800 mg po for seven more days, as
well as phenazopyridine prn. What should M. Z. and her daughter be taught about these
medications?
- Phenozopyridine:
- Action: Exerts an analgesic and anesthetic effect on the urinary mucosa.
- red/orange urine is normal
- can cause bladder spasms
- trimethoprim/sulfamethoxazole: Monitor for allergies to this drug.
- Trimethoprim/sulfamethoxazole may be used in low doses once daily for UTI
prophylaxis in people with chronic, recurring UTI’s
- watch for hepatic necrosis, crystalluria, severe exfoliative rashs (wear
sunscreen/protective clothing)
- Notify HCP (skin rash, sore throat, fever, mouth sores, unusual bleeding)
9. What other measures should you teach M. Z. to help cure her UTI and also to prevent a
recurrence of infection? (Hint: refer to your notes for patient teaching for cure and
prevention of UTI and also teaching for women only).
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Emphasize need to take full course of antibiotics.
Explain the difference between any adjunct meds taken for pain and the antibiotics.
Void every 2 – 3 hours or try not to delay voiding.
Drink at least 2 to 3 liters of fluid a day (unless contraindicated).
Conflicting studies suggest drinking 300 mL of cranberry juice daily may help.
(acidification of urine)
Teach s/s of UTI.
Avoid coffee, tea, alcohol, and other fluids that are urinary irritants.
Female
Wipe front to back.
Avoid bubble baths, nylon underwear, and scented toilet tissues.
Wear loose-fitting cotton underwear.
Empty bladder before and after intercourse.
Avoid vigorous cleaning of the perineum with harsh soaps.
Avoid douching.
Urinate when you feel the need. Don’t “hold it in.”
Case Study 4
Renal Calculi (Urolithiasis or Kidney Stones)
Scenario
It is a hot summer day, and you are an RN in the ED. S.R., an 18-year-old woman, presents
at the ED with severe left flank and abdominal pain, and N/V. S. R. appears pale and
diaphoretic. She paces about the room doubled-over and is clutching her abdomen. S.R.
tells you that the pain started suddenly early this morning and has been pretty steady for the
last 4 hours. She gives a history of working outside as a landscaper and takes little time for
water breaks. Her PMH includes 3 kidney stone attacks, all during summer months. She also
reports that her uncle has had kidney stones in the past. Exam findings: her abdomen is soft
and without tenderness, but her left flank is extremely tender to palpation. You place S.R. in
one of the exam rooms and take the following VS: 188/98, 90, 20, 99° F. Urinalysis shows
RBC 50–100 on voided specimen, WBC zero. CT scan reveals a renal calculus in the left
upper ureter.
1. Based on the information in the above case study, what are the factors that may have
predisposed S.R. to formation of kidney stones?
- Working outside, little time for water breaks
- PMH of 3 kidney stone attacks
- Uncle had kidney stones in the past (+ family hx)
- Summer months, dehydration
2. Identify the various methods that can be used to treat a patient with a kidney stone. (Hint:
refer to nursing considerations and other treatments in your notes).
Retrograde ureteroscopy: use for stones that are larger
Stenting
Lithotripsy
- mild pain (ibuprofen, acetaminophen, naproxen sodium)
- severe pain (morphine)
- check urine pH daily
- frequent ambulation
- Drink at least 3L of fluid a day
- teach s/s of UTI (Frequency, Urgency, Hesitancy, Dysuria, Nocturia, Hematuria, Cloudy,
foul-smelling urine (Pyuria)., Incontinence, Bladder spasms or feeling of bladder pressure)
S. R. is discharged home with instructions to strain all urine and return if she experiences
pain unrelieved by the pain medication or increased N/V (nausea and vomiting).
3. What specific instructions will you give S.R. about her urine, fluid intake, medications, and
activity?
- Check urine pH daily
- Toradol IV
- Drink 3L of fluid daily to promote passage of kidney stones
- Can take ibuprofen, acetaminophen, and naproxen for mild pain
- Morphine for severe pain
- If pt has UTI, must take full course of antibiotics
- Frequent ambulation daily to promote passage of stones
S.R. returns to the ED that night with pain unrelieved by the pain medication, nausea and
vomiting and increased blood in her urine. Lab studies show the following abnormal results:
BUN 30 mg/dL and creatinine 3.6 mg/dL. She is being held in the ED.
4. A large kidney stone can cause chronic infection and urine flow obstruction. What may be
the impact of this problem on her long-term kidney function?
Kidney stones can slowly destroy the function units of the kidneys (nephrons), infection,
acute renal failure if left untreated
Since S. R. is unable to pass the stone, it is decided to schedule her for lithotripsy in the
morning.
5. Describe lithotripsy, and pre and post procedure care and teaching.
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Lithotripsy
• Also known as extracorporeal shock wave lithotripsy.
• Uses sound waves to break the stone into small fragments to be passed.
• Client receives conscious sedation(topical anesthesia) and has an EKG.
• The lithotriptor is aimed at the stone which is visualized with flouroscopy.
Preop
• Assess for pain/discomfort, N/V, diarrhea, and abdominal distention.
• S/S of UTI (chills, fever, frequency and hesitancy)
• S/S of obstruction (frequent urination of small amounts, oliguria, or anuria)
• Inspect urine for blood/strain urine for calculi
Post op
• Strain urine for calculi
• Send stones to lab for chemical analysis
• Teach S/S of complications (urinary retention/infection)
• Teach follow up to assess kidney function
• Increase fluid intake (3L of fluid a day), to assist with passage of stones;
frequent ambulation
• Expect hematuria, should disappear after 4-5 days
• If there is stent in ureter, hematuria is expected until stent is removed, expected
to have flank pain
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Check temp daily. Notify HCP if temp is <38C or 101F, pain is unrelieved by
medications
Inform pt that bruise may be observed on the treated side of the back
Assess pt ability to monitor urinary pH
Teach s/s of stone formation, obstruction, and infection for the prevention of
stone formation
Teach actions, importance, and SE of medications
S.R.’s lithotripsy was successful and she passed many small fragments of stone in the days
after the procedure. Pathologic examination of the stone reported it to be calcium oxalate.
6. Because S.R.’s stone has been reported as calcium oxalate, what are the main food
restrictions that would be recommended?
Oxalate foods (spinach, strawberries, rhubarb, chocolate, tea, peanuts, black tea, and wheat
bran)
7. If S. R.’s stone had been composed of calcium phosphate, struvite, uric acid or cystine,
what general type of food would need to be restricted?
Uric acid: Avoid purines (Organ meats, poultry, fish, red wines and sardines, shellfish,
anchovies, asparagus, mushrooms)
Cystine, Calcium phosphate: Limit animal protein intake (meat/dairy)
Struvite: Avoid phosphate (dairy, red organ meats, whole grains)