Management of Patients
With
Urinary Disorders
Urinary Tract Infections
• The second most common reason persons seek health care
• A common site of health acquired infection
• Lower UTI
– Cystitis
– Prostatitis
– Urethritis
• Upper UTI
– Pyelonephritis: acute and chronic
– Interstitial nephritis
– Renal abscess and perirenal abscess
Factors Contributing to UTI
•
•
•
•
•
•
Function of glycosaminoglycan (GAG)
Urethrovesical reflux
Uretherovescal reflux
Uropathogenic bacteria
Shorter urethra in women
Risk factors
Routes of infection:
1.
2.
3.
Up the urethra: ascending infection ( most common route)
Through the blood stream (hematogenous spread).
By means of a fistula from the intestine ( direct extension)
•
Risk factors:
1.
2.
3.
4.
5.
6.
Inability or failure to empty the bladder completely
Obstructed urinary flow
Decrease natural host defense or immunosuppression
Instrumentation of the urinary tract
Inflammation or abrasion of the urethral mucosa
Contributing conditions : DM, pregnancy, neurological disorders,
gout.
Urethrovesical Reflux and
Uretherovesical Reflux
Bladder Infection with Long-Term
Catherization
Lower Urinary tract infections: …
•
1.
2.
3.
•
1.
2.
Pathophysiology: for infection to occur
bacteria must gain access to the bladder,
attach to and colonize the epithelium of the urinary tract
to avoid being washed out with voiding,
evade host defense mechanisms, and initiate inflammation
Most UTI’s results from
fecal organism
Reflux: Urethrovesical reflux ( backward flow of urine from
the urethra into the bladder
Clinical manifestations:
•
•
1.
2.
3.
4.
5.
about half patient with Bacteriuria have no symptoms.
Uncomplicated:
pain and burning on urination,
frequency,
urgency, nocturia, incontinence,
Suprapubic or pelvic pain,
and Hematuria with low back pain may presented
•
Complicated UTI: manifestations may range from asymptomatic
bacteriuria to a gram-negative sepsis with shock
Assessment and Diagnostic findings:
1.
2.
3.
Colony count: at least 100,000 colony per ml of urine
on a clean catch midstream or cathetarized specimen is
a major criterion for infection
Cellular studies: microscopic hematuria ( greater than 4
RBC’s per high power field, Pyuria ( greater than 4
WBC’s per high power field)
Urine culture: urine culture remains the gold standard
in documenting a UTI and can Identify the specific
organism present
Medical management:
1. A cute pharmacologic therapy:
• single dose administration, short course (3-4 days)
medication regimen, or 7-10 day therapeutic course used
in treating uncomplicated lower UTI.
2. Long term pharmacologic therapy:
• If infection reoccurs within 2 weeks after completing
antimicrobial therapy, another short course of full-dose
antimicrobial therapy, followed by a regular bedtime
dose of an antimicrobial agent be prescribed
• If there is no recurrence, medication may taken every
other night for 6-7 months
Cont…
• Patient education include:
1. Hygiene (shower rather than bathe tube
2. Fluid intake: drink enough fluid, avoid coffee, tea, colas,
alcohol
3. Voiding Habits: void every 2-3 hours, void immediately
after sexual intercourse
4. therapy: take medication exactly as prescribed, if
recurrence take long term treatment
Upper UTI
1.
•
•
1.
2.
3.
4.
Acute pyelonephritis: is bacterial infection of the renal pelvis,
tubules, and interstitial tissue of one or both kidneys
Upper UTI is associated with the antibody coating of the bacteria in
the urine
Pathophysiology:
Ascending of bacteria from the urethra, then to bladder to reach the
kidney
Rarely from the blood ( less than 3%)
Ureterovesical reflux
Urinary tract obstruction, bladder tumor, strictures, benign prostatic
hyperplasia, and urinary stones
Cont…..
•
•
1.
2.
3.
4.
5.
•
Usually these pt has enlarged kidneys with interstitial
infiltration of inflammatory cells which may lead to
destruction and atrophy of the kidney
Clinical manifestation:
Acutely ill with chills and fever,
leukocytosis,
Bacteriuria and Pyuria,
Flank pain.
Dysuria and frequency may associated.
Assessment and Diagnostic findings: US, CT scan to locate
any obstruction, urine culture and sensitivity may
performed
Medical management:
• patient usually treated as outpatient if they are not
dehydrated, not experiencing nausea or vomiting
and not showing S/S of sepsis
• For outpatient, a 2-weeks course of antibiotic is
recommended , 6 weeks therapy may needed if
relapse is seen, follow up urine culture is done 2
weeks after completion of antibiotic therapy
Nursing Process: The Care of the Patient
with a UTI—Assessment
• Symptoms may include pain and burning upon
urination; frequency; nocturia; incontinence;
suprapubic, pelvic, or back pain; hematuria; and
change in urine or urinary pattern
• About half are asymptomatic
• Assess voiding patterns, association of symptoms
with sexual intercourse, contraceptive practices,
and personal hygiene
• Gerontologic considerations
• Assessment of urine, urinalysis, and urine cultures
• Other diagnostic tests
Nursing Process: The Care of the Patient
with a UTI—Diagnoses
• Acute pain
• Deficient knowledge
Collaborative Problems/Potential
Complications
• Sepsis
• Renal failure
Nursing Process: The Care of the Patient
with a UTI—Planning
• Major goals may include relief of pain and
discomfort, increased knowledge of
preventive measures and treatment
modalities, and absence of complications.
Interventions
• Prevention: avoid indwelling catheters, care of
catheters
• Personal hygiene
• Medications as prescribed: antibiotics, analgesics,
and antispasmodics
• Application of heat to the perineum to relieve pan
and spasm
• Increased fluid intake
• Avoidance of urinary tract irritants such as coffee,
tea, citrus, spices, cola, and alcohol
• Frequent voiding
• Patient education
2. Chronic pyelonephritis:
• Repeated of a cute pyelonephritis may lead to chronic
pyelonephritis
• Clinical manifestations: usually no symptoms of infection, S/S
may include fatigue, headache, poor appetite, polyuria,
excessive thirst, and weight loss
• Persistent and recurring infection may produce progressive
scaring of the kidney, with renal failure as the end result
• Assessment and diagnostic findings: Intravenous urogram,
Measurement of creatinine clearance, BUN and creatinine
levels, and urine culture
Complication:
• ESRF, hypertension, and formation of kidney stones
• Medical management: Antibiotics depends on U/C,
careful monitoring of renal function is important while
giving medication due to the alteration of kidney
function
• Nursing Management: Monitor I&O, encourage fluid(3-4
L/day) unless contraindicated, Assess Temp. every 4 hrs,
administer antibiotic as prescribed,Teach the pt the
preventive measures of UTI
Urinary Incontinence
• An underdiagnosed and underreported
problem that can have significant impact on
the quality of life and decrease independence,
and which may lead to compromise of the
upper urinary system
• Urinary incontinence is not a normal
consequence of aging
• Risk factors
Types of Urinary Incontinence
•
•
•
•
•
•
•
Stress
Urge
Reflex
Overflow
Functional
Iatrogenic
Mixed incontinence
Patient Teaching
• Urinary incontinence is not inevitable and is
treatable
• Management takes time (provide encouragement
and support)
• Develop and use a voiding log or diary
• Behavioral interventions
• Medication teaching related to pharmacologic
therapy
• Strategies for promoting continence
Cont…
II.
Pharmacological therapy:
1.
Anticholinergic agents: (oxybutynin, dicyclomic) which inhibit
bladder contraction, first line medication for urge incontinence
Tricyclic antidepressant (impramine): decrease bladder contraction
as well as strengthen bladder neck resistance
Estrogen: restoring the mucosal integrity, vascular, and muscular
integrity of the urethra
2.
3.
III.Surgical management: surgical correction of the
bladder and urethra if the patient not responding to the
previous management
III. Neurogenic Bladder:
•
Is a dysfunction of the bladder due to a lesion of the nervous system caused
by spinal injury, spinal tumor, herniated vertebral disk, multiple sclerosis,
infection, congenital anomalies, and DM.
•
1.
Pathophysiology:
Spastic (or reflex) bladder: is the most common type and is caused
•
•
by any spinal cord injury above the voiding reflex arc ( Upper motor neuron
lesion).
The result is a loss of conscious sensation and cerebral motor control.
A spastic bladder empties on reflex, with minimal or no controlling
influence to regulate its activity
Cont..
2. Flaccid bladder: caused by lower motor neuron lesion,
commonly result from trauma.
• Mainly recognized in DM Pt..
• The bladder continues to fill and becomes greatly
distended, and overflow incontinence occurs. The
bladder is not contracted forcefully at any time.
Because of sensory loss the patient feels no discomfort.
Medical management:
•
•
•
•
•
Prevention of overdistention of the bladder
Emptying the bladder frequently and completely
Maintaining urine sterility with no stone formation
Maintain adequate bladder capacity without reflux
Pharmacological therapy: Parasympathomimetic medication
(Urecholine)
• Surgical management: to correct bladder neck contractures or
vesicoureteral reflux, perfoming some type of urinary
diversions procedures
Urinary Retention
• Inability of the bladder to empty completely
• Residual urine: amount of urine left in the
bladder after voiding
• Causes include age (50–100 mL in adults older
than age 60 due to decreased detrusor muscle
activity), diabetes, prostate enlargement,
pregnancy, neurologic disorders, medications
• Assessment
• Nursing measures to promote voiding
• Complication:
1. may lead to chronic infection which may lead
to calculi formation,
2. polynephritis,
3. sepsis,
4. back flow of urine lead to deterioration of
the kidney,
5. leakage of the urine may lead to peripheral
skin damage
Nursing Management:
1.
Promote normal urinary elimination:
•
Provide privacy, ensure the environment and position is conducive
to voiding, assisting the patient to use bathroom, and offering
reassurance
Applying warmth to relax sphincter
Simple trigger techniques, such as turning on the water while
voiding attempt, stroking the abd or inner thigh, tapping above the
pubic area
After surgery the prescribed analgesia should be given
•
•
•
Cont…
2.
3.
Promote urinary elimination: Catheterization is used to
prevent overdistention of the bladder
Promote home and community-based care:
•
•
•
•
•
Provide easy, safe access to the bathroom
Installing support bars in the bathroom
Placing a bedpan or urinal within easy reach
Leaving a light on the bedroom, and bathroom
Wearing clothing that is easy to remove
Chart 45-8 (Strategies for promoting Urinary Continence:
Catheterization (1585)
•
•
1.
2.
3.
4.
5.
6.
Is the introduction of the catheter through the urethra into the
bladder for the purpose of withdrawing urine.
Indications:
relieve urinary tract retention,
monitor accurate urine output in critically ill patients,
promote urinary drainage,
prevent urinary leakage in patient with advance pressure ulcer,
obtain a sterile urine specimen,
emptying the bladder before, during, after surgery and before
certain diagnostic procedure.
Types of catheters:
1. Indwelling urethral catheter (Folly’s catheter) is remains
in the place for continuous drainage . Types (Double and
triple lumen catheter).
2. Intermittent catheter: is used to drain the bladder for
short time (5-10 min)
3. Suprapubic catheter: it is surgical inserted into the
bladder through a small incision above the pubic area.
Nursing Management during catheterization:
1. Assessing the patient and the system:
2. Assessing for age-related complication: infection,
elderly patient doesn’t exhibit the S/S of infection
but any physical and mental changes should be
considered and reported.
3. Minimizing trauma: using proper size, use
lubricate, proper technique, and securing the
catheter
Cont….
4. Bladder retraining after indwelling catheterization: chart
45-10).
• place patient on timed voiding schedule usually every 2-3
hours
• the patient instructed to void as scheduled
• scan the bladder for residual urine
• if more equal or more than100 ml straight catheter may
inserted for complete bladder emptying.
5. Assisting with intermittent self catheterization every 4-6
hours and at bed time (or when ever needed)
Cont…..
5. Prevent infection in the catheterized patient:
• Use aseptic technique during insertion of the catheter
• Use sterile closed urinary drainage system
• Prevent contamination of the closed system: never disconnect the
tubing, the drainage bag should not touch the floor
• The bag and collecting tubing are changed if contamination occurs, if
urine flow become obstructed, if tubing start to leak.
• Clamp the urine drainage if you raised the system above the kidneys
level
• Ensure free flow of urine
Cont…
•
•
•
•
•
•
Empty the collection bag frequently
Never irrigate the catheter routinely
Never disconnect the tubing to collect urine sample
Avoid routine catheter changes
Wash the perineal area with soap and water at least twice a day
Monitor the patient’s voiding when the catheter is removed. The
patient must void within 8 hours
• Instruct the patient to drink measure fluid fro 8 am- 10 pm and stop
drinking after 10pm
Urolithiasis and Nephrolithiasis
•
•
•
•
Calculi (stones) in the urinary tract or kidney
Pathophysiology
Causes; may be unknown
Manifestations
– Depend upon location and presence of
obstruction or infection
– Pain and hematuria
• Diagnosis: x-ray, blood chemistries, and stone
analysis; strain all urine and save stones
Potential Sites of Urinary Calculi
Methods of Treating Renal Stones
Methods of Treating Renal Stones
Methods of Treating Renal Stones
Patient Teaching
•
•
•
•
•
•
•
Signs and symptoms to report
Follow-up care
Urine pH monitoring
Measures to prevent recurrent stones
Importance of fluid intake
Dietary teaching
Medication teaching as needed
Urinary Diversion
• Reasons: bladder cancer or other pelvic
malignancies, birth defects, trauma, strictures,
neurogenic bladder, chronic infection or
intractable cystitis; used as a last resort for
incontinence
• Types:
– Cutaneous urinary diversion: ileal conduit, cutaneous
ureterostomy, vesicostomy, nephrostomy
– Continent urinary diversion: Indiana pouch, Kock
pouch, uretherosigmoidostomy
Cutaneous Urinary Diversions
Continent Urinary Diversions
Nursing Diagnoses: Preoperative
• Anxiety
• Imbalanced nutrition
• Deficient knowledge
Nursing Diagnoses: Postoperative
•
•
•
•
•
Risk for impaired skin integrity
Acute pain
Disturbed body image
Potential for sexual dysfunction
Deficient knowledge