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Title: Urinary%20Tract%20Infection%20(UTI)


1
Urinary Tract Infection (UTI)
  • Background
  • 1. Bacterial infections of urinary tract are a
    very common reason to seek health services
  • 2. Common in young females and uncommon in males
    under age 50
  • 3. Common causative organisms
  • a. Escherichia coli (gram-negative enteral
    bacteria) causes most community acquired
    infections
  • b. Staphylococcus saprophyticus, gram-positive
    organism causes 10 15
  • c. Catheter-associated UTIs caused by
    gram-negative bacteria Proteus, Klebsiella,
    Seratia, Pseudomonas

2
Urinary Tract Infection (UTI)
  • Normal mechanisms that maintain sterility of
    urine
  • a. Adequate urine volume
  • b. Free-flow from kidneys through urinary meatus
  • c. Complete bladder emptying
  • d. Normal acidity of urine
  • e. Peristaltic activity of ureters and competent
    ureterovesical junction
  • f. Increased intravesicular pressure preventing
    reflux
  • g. In males, antibacterial effect of zinc in
    prostatic fluid

3
Urinary Tract Infection (UTI)
  • Pathophysiology
  • 1. Pathogens which have colonized urethra,
    vagina, or perineal area enter urinary tract by
    ascending mucous membranes of perineal area into
    lower urinary tract
  • 2. Bacteria can ascend from bladder to infect the
    kidneys
  • 3. Classifications of infections
  • a. Lower urinary tract infections urethritis,
    prostatitis, cystitis
  • b. Upper urinary tract infection pyelonephritis
    (inflammation of kidney and renal pelvis)

4
Urinary Tract Infection (UTI)
  • Risk Factors
  • 1. Aging
  • a. Increased incidence of diabetes mellitus
  • b. Increased risk of urinary stasis
  • c. Impaired immune response
  • 2. Females short urethra, having sexual
    intercourse, use of contraceptives that alter
    normal bacteria flora of vagina and perineal
    tissues with age increased incidence of
    cystocele, rectocele (incomplete emptying)
  • 3. Males prostatic hypertrophy, bacterial
    prostatitis, anal intercourse
  • 4. Urinary tract obstruction tumor or calculi,
    strictures
  • 5. Impaired bladder innervation

5
Urinary Tract Infection (UTI)
  • Cystitis
  • 1. Most common UTI
  • 2. Remains superficial, involving bladder mucosa,
    which becomes hyperemic and may hemorrhage
  • 3. General manifestations of cystitis
  • a. Dysuria
  • b. Frequency and urgency
  • c. Nocturia
  • d. Urine has foul odor, cloudy (pyuria), bloody
    (hematuria)
  • e. Suprapubic pain and tenderness
  • 4. Older clients may present with different
    manifestations
  • a. Nocturia, incontinence
  • b. Confusion
  • c. Behavioral changes
  • d. Lethargy
  • e. Anorexia
  • f. Fever or hypothermia

6
Urinary Tract Infection (UTI)
  • Pyelonephritis
  • 1. Inflammation of renal pelvis and parenchyma
    (functional kidney tissue)
  • 2. Acute pyelonephritis
  • a. Results from an infection that ascends to
    kidney from lower urinary tract
  • Risk factors
  • 1. Pregnancy
  • 2. Urinary tract obstruction and congenital
    malformation
  • 3. Urinary tract trauma, scarring
  • 4. Renal calculi
  • 5. Polycystic or hypertensive renal disease
  • 6. Chronic diseases, i.e. diabetes mellitus
  • 7. Vesicourethral reflux

7
Urinary Tract Infection (UTI)
  • Pathophysiology
  • 1. Infection spreads from renal pelvis to renal
    cortex
  • 2. Kidney grossly edematous localized abscesses
    in cortex surface
  • 3. E. Coli responsible organism for 85 of acute
    pyelonephritis also Proteus, Klebisella
  • Manifestations
  • 1. Rapid onset with chills and fever
  • 2. Malaise
  • 3. Vomiting
  • 4. Flank pain
  • 5. Costovertebral tenderness
  • 6. Urinary frequency, dysuria

8
Urinary Tract Infection (UTI)
  • Manifestations in older adults
  • 1. Change in behavior
  • 2. Acute confusion
  • 3. Incontinence
  • 4. General deterioration in condition

9
Urinary Tract Infection (UTI)
  • Chronic pyelonephritis
  • a. Involves chronic inflammation and scarring of
    tubules and interstitial tissues of kidney
  • b. Common cause of chronic renal failure
  • c. May develop from chronic hypertension,
    vascular conditions, severe vesicourteteral
    reflux, obstruction of urinary tract
  • d. Behaviors
  • 1. Asymptomatic
  • 2. Mild behaviors urinary frequency, dysuria,
    flank pain

10
Urinary Tract Infection (UTI)
  • Collaborative Care
  • a. Eliminate causative agent
  • b. Prevent relapse
  • c. Correct contributing factors
  • Diagnostic Tests
  • a. Urinalysis assess pyuria, bacteria, blood
    cells in urine Bacterial count gt100,000 /ml
    indicative of infection
  • b. Rapid tests for bacteria in urine
  • 1. Nitrite dipstick (turning pink presence of
    bacteria)
  • 2. Leukocyte esterase test (identifies WBC in
    urine)
  • c. Gram stain of urine identify by shape and
    characteristic (gram positive or negative)
    obtain by clean catch urine or catheterization

11
Urinary Tract Infection (UTI)
  • d. Urine culture and sensitivity identify
    infecting organism and most effective antibiotic
    culture requires 24 72 hours for results
    obtain by clean catch urine or catheterization
  • e. WBC with differential leukocytosis and
    increased number of neutraphils
  • 6. Diagnostic Tests for adults who have recurrent
    infections or persistent bacteriuria
  • a. Intravenous pyelography (IVP) or excretory
    urography
  • 1. Evaluates structure and excretory function of
    kidneys, ureters, bladder
  • 2. Kidneys clear an intravenously injected
    contrast medium that outlines kidneys, ureters,
    bladder, and vesicoureteral reflux
  • 3. Check for allergy to iodine, seafood,
    radiologic contrast medium, hold testing and
    notify physician or radiologist

12
Urinary Tract Infection (UTI)
  • b. Voiding cystourethrography instill contrast
    medium into bladder and use xray to assess
    bladder and urethra when filled and during
    voiding
  • c. Cystoscopy
  • 1. Direct visualization of urethra and bladder
    through cystoscope
  • 2. Used for diagnostic, tissue biopsy,
    interventions
  • 3. Client receives local or general anesthesia
  • d. Manual pelvic or prostate examinations to
    assess structural changes of genitourinary tract,
    such as prostatic enlargement, cystocele,
    rectocele

13
Urinary Tract Infection (UTI)
  • Medications
  • a. Short-course therapy 3 day course of
    antibiotics for uncomplicated lower urinary tract
    infection (single dose associated with recurrent
    infection)
  • b. 7 10 days course of treatment for
    pyelonephritis, urinary tract abnormalities or
    stones, or history of previous infection with
    antibiotic-resistant infections clients with
    severe illness may need hospitalization and
    intravenous antibiotics
  • c. Antibiotics commonly used for short and longer
    course therapy include trimethoprim-sulfamethoxazo
    le (TMP-SMZ), or quinolone antibiotic such as
    ciprofloxacin (Cipro)
  • d. Intravenous antibiotics used include
    ciprofloxacin, gentamycin, ceftriaxone
    (Rocephin), ampicillin

14
Urinary Tract Infection (UTI)
  • Possible outcomes of treatment for UTI,
    determined by follow-up urinalysis and culture
  • 1. Cure no pathogens in urine
  • 2. Unresolved bacteriuria pathogens remain
  • 3. Persistent bacteriuria or relapse persistent
    source of infection causes repeated infection
    after initial cure
  • 4. Reinfection development of new infection
    with different pathogen
  • f. Prophylactic antibiotic therapy with TMP-SMZ,
    TMP alone or nitrofurantoin (Furadantin,
    Nitrofan) may be used with clients who experience
    frequent symptomatic UTIs
  • g. Catheter-associated UTI removal of indwelling
    catheter followed by 10 14 day course of
    antibiotic therapy

15
Urinary Tract Infection (UTI)
  • Surgery
  • a. Surgical removal of large calculus from renal
    pelvis or cystoscopic removal of bladder calculi
    which serve as irritant and source of bacterial
    colonization may also use percutaneous
    ultrasonic pyelolithotomy or extracorporeal shock
    wave lithotripsy (ESWL)
  • b. Ureteroplasty surgical repair of ureter for
    stricture or structural abnormality
    reimplantation if vesicoureteral reflux clients
    usually return from surgery with catheter and
    ureteral stent in place for 3 5 days

16
Urinary Tract Infection (UTI)
  • Nursing Care Health promotion to prevent UTI
  • a. Fluid intake 2 2.5 L daily, more if hot
    weather or strenuous activity is involved
  • b. Empty bladder every 3 4 hours
  • c. Females
  • 1. Cleanse perineal area from front to back
  • 2. Void before and after sexual intercourse
  • 3. Maintain integrity of perineal tissues
  • a. Avoid use of commercial feminine hygiene
    products or douches
  • b. Wear cotton underwear
  • d. Maintain acidity of urine (use of cranberry
    juice, take Vitamin C, avoid excess milk and milk
    products, sodium bicarbonate)

17
Urinary Tract Infection (UTI)
  • Nursing Diagnoses
  • a. Pain Additional interventions include warmth,
    analgesics, urinary analgesics, antispasmodic
    medications
  • b. Impaired Urinary Elimination
  • c. Ineffective Health Maintenance Clients must
    complete full course of antibiotic therapy
  • Home Care Teaching prevention of infection and
    use alternatives to indwelling catheter whenever
    possible

18
Client with Urinary Calculi
  • Background
  • 1. Urinary calculi are stones in urinary tract
  • a. Nephrolithiasis stones form in kidneys
  • b. Urolithiasis stones form in urinary tract
    outside kidneys
  • 2. Highest incidence in southern and Midwestern
    states
  • 3. Males more often affected than females (41)
  • 4. Most common in young and middle adults
  • B. Risk factors
  • 1. Majority of stones are idiopathic (no
    demonstrable cause)
  • 2. Prior personal or family history of urinary
    calculi
  • 3. Dehydration increased urine concentration
  • 4. Immobility
  • 5. Excess dietary intake of calcium, oxalate,
    protein
  • 6. Gout, hyperparathyroidism, urinary stasis,
    repeated UTI infection

19
Client with Urinary Calculi
  • Pathophysiology
  • 1. Factors leading to lithiasis include
    supersaturation (high concentration of insoluble
    salt in urine), pH of urine
  • 2. Types of calculi
  • a. Calcium stones (calcium oxalate, calcium
    phosphate)
  • 1. Associated with high concentrations of calcium
    in blood or urine
  • 2. Genetic link
  • b. Uric acid stones
  • 1. Associated with high concentration of uric
    acid in urine
  • 2. Genetic link
  • 3. More common in males
  • 4. Associated with gout
  • c. Sturvite stones
  • 1. Associated with UTI caused by bacteria Proteus
  • 2. Stones are very large
  • 3. Staghorn stones in renal pelvis and calyces
  • d. Cystine stones Associated with genetic defect

20
Development and location of calculi within the
urinary tract
21
Client with Urinary Calculi
  • Manifestations depends upon size and location of
    stones
  • 1. Calculi affecting kidney calices, pelvis
  • a. Few symptoms unless obstructed flow
  • b. Dull, aching flank pain
  • 2. Calculi affecting bladder
  • a. Few symptoms
  • b. Dull suprapubic pain with exercise or post
    voiding
  • c. Possibly gross hematuria
  • 3. Calculi affecting ureter, causing ureteral
    spasm
  • a. Renal colic acute, severe flank pain of
    affected side, radiates to suprapubic region,
    groin, and external genitals
  • b. Nausea, vomiting, pallor, cool, clammy skin
  • 4. Manifestations of UTI may occur with urinary
    calculi

22
Client with Urinary Calculi
  • Complications
  • 1. Obstruction manifestations depend upon speed
    of obstruction development can ultimately lead
    to renal failure
  • 2. Hydronephrosis distention of renal pelvis and
    calyces unrelieved pressure can damage kidney
    (collecting tubules, proximal tubules, glomeruli)
    leading to gradual loss of renal function
  • a. Acute colicky pain on affected side
  • b. Chronic few manifestations dull ache in back
    or flank
  • c. Other manifestations hematuria, signs of UTI,
    GI symptoms

23
Client with Urinary Calculi
  • Collaborative Care
  • 1. Relief of acute symptoms
  • 2. Remove or destroy stone
  • 3. Prevent future stone formation
  • Diagnostic Tests
  • 1. Urinalysis hematuria, possible WBCs and
    crystal fragments, urine pH helpful to diagnose
    stone type
  • 2. Chemical analysis of stone All urine must be
    strained and saved stones or sediment sent for
    analysis
  • 3. 24-urine collection for calcium, uric acid,
    oxalate to identifiy possible cause of lithiasis
  • 4. Serum calcium, phosphorus, uric acid identify
    factors in calculi formation

24
Client with Urinary Calculi
  • 5. KUB xray (kidney, ureters, bladder) flat
    plate to identify presence and location of
    opacities
  • 6. Renal ultrasonography sound waves to detect
    stones and detect hydronephrosis
  • 7. CT scan of kidney identify calculi,
    obstruction, disorders
  • 8. IVP
  • 9. Cystoscopy visualize and possibly remove
    calculi from urinary bladder and distal ureters
  • Medications
  • 1. Treatment of acute renal colic analgesia and
    hydration
  • 2. Narcotic such as intravenous morphine sulfate,
    NSAID, large amounts of fluid by oral or
    intravenous routes

25
Percutaneous ultrasonic lithotripsy
26
Client with Urinary Calculi
  • 3. Medications to inhibit further lithiasis
    according to analysis of stone
  • a. Thiazide diuretics promotes reduction of
    urinary calcium excretion
  • b. Potassium citrate used to alkalinize urine
    for stones formed in acidic urine (uric acid,
    cystine, and some calcium stones)
  • Dietary Management Prescribed to change
    character of urine and prevent further lithiasis
  • 1. Increased fluid intake to 2 2.5 liters
    daily, spaced throughout day
  • 2. Limited intake of calcium and Vitamin D
    sources if calcium stones
  • 3. Phosphorus and/or oxalate may be limited with
    calcium stones
  • 4. Low purine (rich meats) diet for clients with
    uric acid stones

27
Client with Urinary Calculi
  • Lithotripsy Use of sound or shock waves to crush
    stones
  • 1. Extracorporeal shock-wave lithotripsy
    acoustic shock waves aimed under fluoroscopic
    guidance to pulverize stone into fragments small
    enough to be eliminated in urine sedation or
    TENS used to maintain comfort during procedure
  • 2. Percutaneous ultrasonic lithotripsy
    nephroscope inserted into kidney pelvis through
    small flank incision stone fragmented using
    small ultrasonic transducer and fragments removed
    through nephroscope
  • 3. Laser lithotripsy stone is disintegrated by
    use of laser beams nephroscope or ureteroscope
    used to guide laser probe
  • 4. Stent may be inserted into affected ureter
    after procedure to maintain patency after
    lithotripsy procedures

28
Client with Urinary Calculi
  • Surgery
  • 1. May be indicated as treatment depending on
    stone location, severe obstruction, infection,
    serious bleeding
  • 2. Types
  • a. Ureterolithotomy incision into affected
    ureter to remove calculus
  • b. Pyelolithotomy incision into and removal of
    stone from kidney pelvis
  • c. Nephrolithotomy surgery to remove staghorn
    calculus in calices and renal parenchyma
  • d. Cystoscopy crushing and removal of bladder
    stones through cystocope stone fragments
    irrigated out of bladder with acid solution

29
Client with Urinary Calculi
  • Nursing Care
  • 1. Focus on comfort during renal colic,
    diagnostic procedures, ensure adequate urine
    output, prevent future stone formation
  • 2. Health promotion adequate fluid intake for
    all clients, adequate weight-bearing activity to
    prevent bone resorption, hypercalcuria,
    prevention of UTI
  • Nursing Diagnoses
  • 1. Acute Pain
  • a. Adequate pain management
  • b. Intensity of pain can cause vaso-vagal
    response client may experience hypotension,
    syncope client safety must be maintained

30
Client with Urinary Calculi
  • Impaired Urinary Elimination
  • a. Teaching client and strain all urine send
    recovered stones for analysis
  • b. Complete obstruction causes hydronephrosis on
    involved side other kidney continues forming
    urine monitor BUN, Creatinine
  • c. Maintain patency and integrity of all
    catheters all catheters need to be labeled,
    secured, and sterility maintained
  • 3. Deficient Knowledge Client participation in
    treatment and prevention
  • Home Care
  • 1. Education regarding management current
    treatment and prevention
  • 2. Clients may be discharged with catheters,
    tubes, dressings home care referral

31
Urinary Tract Tumor
  • Background
  • 1. Malignancies in urinary tract 90 bladder 8
    renal pelvis 2 ureter, urethral 5 year
    survival rate for bladder cancer is 94
  • 2. Bladder cancer 4 times higher in males than
    females 2 times higher in whites than blacks
    occurs over age 60
  • B. Risk factors
  • 1. Carcinogens in urine
  • a. Cigarette smoking
  • b. Occupational exposure to chemicals and dyes
  • 2. Chronic inflammation or infection of bladder
    mucosa

32
Urinary Tract Tumor
  • Pathophysiology
  • 1. Tumors arise from epithelial tissue which
    composes the lining
  • 2. Tumors arise as flat or papillary lesions
  • 3. Poorly differentiated flat tumor invades
    directly and has poorer prognosis
  • 4. Metastasis commonly involves pelvic lymph
    nodes, lungs, bones, liver
  • Manifestations
  • 1. Painless hematuria is presenting sign in 75
    cases may be gross or microscopic and may be
    intermittent
  • 2. Inflammation may cause manifestations of UTI
  • 3. May have few outward signs until obstructed
    urine flow or renal failure occurs

33
Urinary Tract Tumor
  • Collaborative Care
  • 1. Removal or destruction of cancerous tissue
  • 2. Prevent invasion or metastasis
  • 3. Maintain renal and urinary function
  • Diagnostic Tests
  • 1. Urinalysis diagnosis of hematuria
  • 2. Urine cytology microscopic examination of
    cells for tumor or pre-tumor cells in urine
  • 3. Ultrasound of bladder detection of bladder
    tumor
  • 4. IVP evaluation of structure and function of
    kidneys, ureters, bladder
  • 5. Cystoscopy, ureteroscopy direct
    visualization, assessment, and biopsy of
    lesion(s)
  • 6. CT scan or MRI determine tumor invasion,
    metastasis

34
Urinary Tract Tumor
  • Medications
  • 1. Immunologic or chemotherapeutic agent
    administered by intravesical instillation used as
    primary treatment of bladder cancer or to prevent
    recurrence following endoscopic removal of tumor
  • 2. Agents include Bacillus Calmette-Guerin
    (BCGLive, TheraCys), doxorubicin, mitomycin C
  • 3. Adverse reactions include bladder irritation,
    frequency, dysuria, contact dermatitis
  • Radiation Therapy
  • 1. Adjunctive therapy used treatment of urinary
    tumors
  • 2. Used to reduce tumor size prior to surgery,
    palliative treatment

35
Urinary Tract Tumor
  • Surgery
  • 1. Cystoscopic tumor resection by
  • a. Excision
  • b. Fulguration destruction of tissue using high
    frequency electric current
  • c. Laser photocoagulation light energy to
    destroy tumor
  • 2. Radical cystectomy standard treatment to
    treat invasive cancers removal of bladder and
    adjacent muscles and tissues
  • a. Males includes prostate and seminal vessels
  • b. Females hysterectomy, salpingo-oophorectomy
  • 3. Client needs to have urinary diversion done to
    provide for urine collection and drainage through
    ileal conduit or continent urinary diversion
    (ureters are implanted in portion of ileum which
    is surgically made into a reservoir for urine and
    stoma brought to surface of abdomen)

36
Urinary Tract Tumor
  • Nursing Care
  • 1. Treatment with recovery from initial treatment
  • 2. Continual care for recurrence
  • 3. Management for elimination
  • 4. Coping with cancer diagnosis
  • Health Promotion
  • 1. Encouragement of clients not to smoke
  • 2. Smoking cessation programs
  • 3. Periodic examination of urinalysis and
    possibly urine cytology

37
Urinary Tract Tumor
  • Nursing Diagnoses
  • 1. Impaired Urinary Elimination
  • 2. Risk for Impaired Skin Integrity
  • a. Urine is irritating to skin around stoma
  • b. Care includes using appliance with adhesives
    and sealants
  • c. Urine will have shreds of mucus in it from
    bowel
  • d. Collection bag emptied frequently (every 2
    hours) during day
  • e. Connected to bedside drainage bag while asleep
  • 3. Disturbed Body Image
  • a. Abdominal stoma requiring drainage appliance
    or regular catheterization of stoma to drain
    urine
  • b. Removal of reproductive organs has made client
    sterile
  • c. Side effects from chemotherapy or radiation
  • d. Risk for infection

38
Urinary Tract Tumor
  • Home Care
  • 1. Involves continual surveillance for cancer
    recurrence
  • 2. If client has had urinary diversion surgery
    requires teaching regarding stoma and skin care
  • 3. Home care referral
  • 4. Smoking cessation
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