Urinary Tract Infection (UTI)

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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

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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

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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)

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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

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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

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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

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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

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Urinary Tract Infection (UTI)

• Manifestations in older adults
• 1. Change in behavior
• 2. Acute confusion
• 3. Incontinence
• 4. General deterioration in condition

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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Development and location of calculi within the
urinary tract
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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

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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

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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

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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

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Percutaneous ultrasonic lithotripsy
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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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