Renal And Urinary Disorders

Renal and Urinary Disorders

Kidney function The Nephron produces Impaired urine production urine to eliminate waste and azotemia Secretes Erythropoietin ANEMIA to increase RBC Metabolism of Vitamin D Calcium and Phosphate imbalances Produces bicarbonate and secretes acids

Metabolic ACIDOSIS

Excretes excess POTASSIUM

HYPERKALEMIA

Urological Assessment • Nursing History ▫ ▫ ▫ ▫ ▫ ▫

Reason for seeking care Current illness Previous illness Family History Social History Sexual history

Urological Assessment Key Signs and Symptoms of Urological Problems EDEMA associated with fluid retention Renal dysfunctions usually produce ANASARCA

Urological Assessment Key Signs and Symptoms of Urological Problems PAIN  Suprapubic pain= bladder Colicky pain on the flank= kidney

Urological Assessment Key Signs and Symptoms of Urological Problems HEMATURIA

Painless hematuria may indicate URINARY CANCER! Early-stream hematuria= urethral lesion Late-stream hematuria= bladder lesion

Urological Assessment Key Signs and Symptoms of Urological Problems DYSURIA Pain with urination= lower UTI

Urological Assessment Key Signs and Symptoms of Urological Problems POLYURIA

More than 2 Liters urine per day

OLIGURIA

Less than 400 mL per day

ANURIA

Less than 50 mL per day

Urological Assessment Key Signs and Symptoms of Urological Problems Urinary Urgency - is a sudden, compelling urge to urinate

Urinary retention - also known as ischuria is a lack of ability to urinate

Urinary frequency - Urinating too often, at too frequent intervals, not due to an unusually large volume of urine, but rather to a decrease in the capacity of the bladder to hold urine.

Urological Assessment PHYSICAL EXAMINATION Inspection Auscultation Percussion Palpation

Urological Assessment Laboratory examination 1. Urinalysis 2. BUN and Creatinine levels of the serum 3. Serum electrolytes

Urological Assessment Laboratory examination Radiographic ▫ IVP ▫ KUB x-ray ▫ KUB ultrasound ▫ CT and MRI ▫ Cystography

Implementation Steps for selected problems Provide PAIN relief • Assess the level of pain • Administer medications usually narcotic ANALGESICS

Implementation Steps for selected problems Maintain Fluid and Electrolyte Balance • Encourage to consume at least 2 liters of fluid per day • In cases of ARF, limit fluid as directed • Weigh client daily to detect fluid retention

Implementation Steps for selected problems Ensure Adequate urinary elimination • Encourage to void at least every 2-3 hours • Promote measures to relieve urinary retention: ▫ ▫ ▫ ▫ ▫

Alternating warm and cold compress Bedpan Open faucet Provide privacy Catheterization if indicated

• STANDARDS OF CARE GUIDELINES • Patients at risk for renal impairment include those with cardiovascular disease, diabetes, and hypertension; postoperative patients; hypotensive patients; and those with prostate and other diseases of the urinary tract.

Thorough assessment of the urinary tract includes: • Hourly intake and output measurement • Assessment of color, clarity, and specific gravity of the urine • Palpation of the abdomen for suprapubic tenderness • Percussion of the flanks for costovertebral angle tenderness • Prostate examination • Subjective assessment for symptoms, such as urgency, frequency, nocturia, hesitancy, dribbling, decreased force of stream, hematuria, and incontinence

• Be alert to drugs that may impair urinary and renal function, such as nonsteroidal antiinflammatory drugs, anticholinergics, sympathomimetics, aminoglycoside antibiotics.

• Changes in Micturition (Voiding)

Changes in Amount or Color of Urine • Hematuria - blood in the urine. ▫ Considered a serious sign and requires evaluation. ▫ Color of bloody urine depends on several factors including the amount of blood present and the anatomical source of the bleeding.  Dark, rusty urine indicates bleeding from the upper urinary tract. Bright red bloody urine indicates lower urinary tract bleeding. ▫ Hematuria may be due to a systemic cause, such as blood dyscrasias, anticoagulant therapy, or extreme exercise. ▫ Painless hematuria may indicate neoplasm in the urinary tract. ▫ Hematuria is common in patients with urinary tract stone disease and may also be seen in renal tuberculosis, polycystic disease of kidneys, acute pyelonephritis, thrombosis and embolism involving renal artery or vein, and trauma to the kidneys or urinary tract.

Polyuria - large volume of urine voided in given time. • Volume is out of proportion to usual voiding pattern and fluid intake. • Demonstrated in diabetes mellitus, diabetes insipidus, chronic renal disease, use of diuretics.

Oliguria - small volume of urine. • Output between 100 and 500 mL/24 hours. • May result from acute renal failure, shock, dehydration, fluid and electrolyte imbalance

Anuria - absence of urine output. • Output less than 50 mL/24 hours. • Indicates serious renal dysfunction requiring immediate medical intervention.

Symptoms Related to Irritation of the Lower Urinary Tract Dysuria - pain or difficult urination. • Burning sensation seen in wide variety of inflammatory and infectious urinary tract conditions.

Frequency - voiding occurs more commonly than usual when compared with the patient's usual pattern or with a generally accepted norm of once every 3 to 6 hours. • Increasing frequency can result from a variety of conditions, such as infection and diseases of urinary tract, metabolic disease, hypertension, medications (diuretics).

Urgency - strong desire to urinate that is difficult to postpone. • Due to inflammatory conditions of the bladder, prostate, or urethra; acute or chronic bacterial infections; neurogenic voiding dysfunctions; chronic prostatitis or bladder outlet obstruction in men; and urogenital atrophy in postmenopausal women.

Nocturia - excessive urination at night, which interrupts sleep. • Causes include urologic conditions affecting bladder function, poor bladder emptying, bladder outlet obstruction, or overactive bladder. • Metabolic causes include decreased renal concentrating ability or heart failure, diabetes mellitus, and the increased urine production at rest that occurs with aging.

Strangury - slow and painful urination; only small amounts of urine voided. • Blood staining may be noted. • Seen in severe cystitis and interstitial cystitis.

Symptoms Related to Obstruction of the Lower Urinary Tract • Weak stream - decreased force of stream when compared to usual stream of urine when voiding. • Hesitancy - undue delay and difficulty in initiating voiding. May indicate compression of urethra, outlet obstruction, neurogenic bladder.

• Terminal dribbling - prolonged dribbling or urine from the meatus after urination is complete. May be caused by bladder outlet obstruction. • Incomplete emptying - feeling that the bladder is still full even after urination. Indicates either urinary retention or a condition that prevents the bladder from emptying well; leads to infection.

Involuntary Voiding • Urinary incontinence - involuntary loss of urine; may be due to pathologic, anatomical, or physiologic factors affecting the urinary tract • Enuresis - involuntary voiding during sleep. May be physiologic during early childhood; thereafter, may be functional or symptomatic of obstructive or neurogenic disease (usually of lower urinary tract) or dysfunctional voiding.

Urinary Tract Pain • Genitourinary (GU) pain is not always present in renal disease, but is generally seen in the more acute conditions of the urinary tract. • Kidney pain - may be felt as a dull ache in costovertebral angle; or may be a sharp, colicky pain felt in the flank area that radiates to the groin or testicle. Due to distention of the renal capsule; severity related to how quickly it develops.

• Ureteral pain - felt in the back and radiates to the groin or scrotum if the upper ureter is the source, to the suprapubic area, penis, and urethra if the lower ureter is the source. • Bladder pain (lower abdominal pain or pain over suprapubic area) - may be due to bladder infection or overdistended bladder.

• Urethral pain - from irritation of bladder neck, from foreign body in canal, or from urethritis due to infection or trauma; pain increases when voiding. • Pain in scrotal area - due to inflammatory swelling of epididymis or testicle, or torsion of the testicle. • Testicular pain - due to injury, mumps, orchitis, torsion of spermatic cord.

• Perineal or rectal discomfort - due to acute prostatitis, prostatic abscess. • Back and leg pain - due to cancer of prostate with metastases to bone. • Pain in glans penis is usually from prostatitis; penile shaft pain is from urethral problems.

History • What are the patient's present and past occupations? Look for occupational hazards related to the urinary tract, contact with chemicals, plastics, tar, rubber; also truck or school bus drivers. • What is the past medical and surgical history, especially in relation to urinary problems? • Is there any family history of renal disease?

What childhood diseases did the patient have? • Is there a history of urinary tract infections (UTIs)? Did any occur before age 12? • Did enuresis continue beyond the age when most children gain control? • Any history of genital lesions or sexually transmitted diseases (STDs)? • For the female patient: Number of children? Vaginal or cesarean delivery? Any forceps deliveries? When? Any signs of vaginal discharge? Vaginal/vulvar itch or irritation? Family history of pelvic organ prolapse (dropped bladder or uterus) or urinary incontinence?

DIAGNOSTIC TESTS/LABORATORY STUDIES

Tests of Renal Function • Renal function tests are used to determine effectiveness of the kidneys' excretory functioning, to evaluate the severity of kidney disease, and to follow the patient's progress. • There is no single test of renal function; best results are obtained by combining a number of clinical tests. • Renal function is variable from time to time.

Nursing and Patient Care Considerations • Renal function may be within normal limits until about 50% of renal function has been lost.

Renal concentration test • Specific gravity • Osmolality of urine Purpose/Rationale • Tests the ability to concentrate solutes in the urine. • Concentration ability is lost early in kidney disease; hence, this test detects early defects in renal function

Creatinine clearance • Provides a reasonable approximation of rate of glomerular filtration. • Measures volume of blood cleared of creatinine in 1 minute. • Most sensitive indication of early renal disease. • Useful to follow progress of the patient's renal status.

Serum creatinine • A test of renal function reflecting the balance between production and filtration by renal glomerulus. • Most sensitive test of renal function.

Serum urea nitrogen (Blood urea nitrogen [BUN]) • Serves as index of renal excretory capacity. • Serum urea nitrogen depends on the body's urea production and on urine flow. (Urea is the nitrogenous end-product of protein metabolism.) • Affected by protein intake, tissue breakdown.

Protein • Random specimen may be affected by dietary protein intake. Proteinuria >150 mg/24 hours may indicate renal disease.

Microalbumin/Creatinine ratio • Sensitive test for the subsequent development of proteinuria; >30 mcg/mg creatinine predicts early nephropathy.

Urine casts • Mucoproteins and other substances present in renal inflammation; help to identify type of renal disease (eg, red cell casts present in glomerulonephritis, fatty casts in nephrotic syndrome, white cell casts in pyelonephritis).

Prostate-Specific Antigen • PSA is an amino acid glycoprotein that is measured in the serum by a simple blood test. • An elevated PSA indicates the presence of prostate disease, but is not exclusive to prostate cancer. • Level rises continuously with the growth of prostate cancer. • Normal serum PSA level is less than 4 mg/mL. Levels less than 10 mg/mL may be indicative of benign prostatic hyperplasia (BPH) and not necessarily prostate cancer. • Patients who have undergone treatment for prostate cancer are monitored periodically with PSA levels for recurrence.

PSA

Nursing and Patient Care Considerations • No patient preparation is necessary. • Some clinicians prefer not to perform digital rectal examinations of the prostate at the same time that a PSA is drawn, to prevent artificial elevation of PSA level, although this association has not been proved.

Urinalysis • Involves examination of the urine for overall characteristics, including appearance, pH, specific gravity, and osmolality as well as microscopic evaluation for the presence of normal and abnormal cells.

• Appearance - normal urine is clear. • Cloudy urine (phosphaturia) is not always pathologic, related only to the precipitation of phosphates in alkaline urine. Normal urine may also develop cloudiness on refrigeration or from standing at room temperature. • Abnormally cloudy urine due to pus (pyuria), blood, epithelial cells, bacteria, fat, colloidal particles, phosphate, or lymph fluid (chyluria).

• Odor - normal urine has a faint aromatic odor. • Characteristic odors produced by ingestion of asparagus, thymol. • Cloudy urine with ammonia odor - urea-splitting bacteria such as Proteus, causing UTIs. • Offensive odor may be due to bacterial action in presence of pus.

Color shows degree of concentration and depends on amount voided. • Normal urine is clear yellow or amber because of the pigment urochrome. • Dilute urine is straw-colored. • Concentrated urine is highly colored; a sign of insufficient fluid intake. • Cloudy or smoky colored may be from hematuria, spermatozoa, prostatic fluid, fat droplets, chyle. • Red or red-brown due to blood pigments, porphyria, transfusion reaction, bleeding lesions in urogenital tract, some drugs and food (beets). • Yellow-brown or green-brown may reveal obstructive lesion of bile duct system or obstructive jaundice. • Dark brown or black due to malignant melanoma, leukemia.

• pH of urine reflects the ability of kidney to maintain normal hydrogen ion concentration in plasma and extracellular fluid; indicates acidity or alkalinity of urine. • pH should be measured in fresh urine because the breakdown of urine to ammonia causes urine to become alkaline. • Normal pH is around 6 (acid); may normally vary from 4.6 to 7.5. • Urine acidity or alkalinity has relatively little clinical significance unless the patient is on a special diet or therapeutic program or is being treated for renal calculous disease.

• Specific gravity reflects the kidney's ability to concentrate or dilute urine; may reflect degree of hydration or dehydration. • Normal specific gravity ranges from 1.005 to 1.025. • In a person eating a normal diet, inability to concentrate or dilute urine indicates disease.

• Osmolality is an indication of the amount of osmotically active particles in urine (number of particles per unit volume of water). It is similar to specific gravity, but is considered a more precise test; it is also easy, only 1 to 2 mL of urine are required. Average value is 300 to 1,090 mOsm/ kg for females; 390 to 1,090 mOsm/kg for males.

Nursing and Patient Care Considerations • Freshly voided urine provides the best results for routine urinalysis; some tests may require first morning specimen. • Obtain sample of about 30 mL. • Urine culture and sensitivity tests are typically performed using the same specimen obtained for urinalysis; therefore, use clean-catch or catheterization techniques.

X-ray of Kidneys, Ureters, and Bladder • Consists of plain film of the abdomen • Delineates size, shape, and position of kidneys • Reveals deviations, such as calcifications (stones), hydronephrosis, cysts, tumors, or kidney displacement Nursing and Patient Care Considerations • No preparation is needed. • Usually done before other testing. • Patient will be asked to wear a gown and remove all metal from the X-ray field.

Intravenous Pyelogram (Intravenous Urogram) • I.V. introduction of a radiopaque contrast medium that concentrates in the urine and thus facilitates visualization of the kidneys, ureter, and bladder. • The contrast medium is cleared from the bloodstream by renal excretion.

IVP

IVP

Nursing and Patient Care Considerations • Contraindicated in patients with renal failure, uncontrolled diabetes, or multiple myeloma, in patients receiving drug therapy for chronic bronchitis, emphysema, or asthma and in patients taking metformin (Glucophage). • Patients with known iodine/contrast material allergy must have steroid/antihistamine preparation; in some cases, an anesthesiologist must be available. • Bowel preparation is necessary: ▫ Clear liquids only the day before the examination. ▫ Cathartics/laxatives are given the evening before the examination. ▫ Nothing by mouth (NPO) after midnight the day of the examination (if scheduled for afternoon, clear liquids only in the morning).

Retrograde Pyelography • Injection of opaque material through ureteral catheters, which have been passed up ureters into renal pelvis by means of cystoscopic manipulation. The opaque solution is introduced by gravity or syringe injection. • May be done when intravenous pyelography (IVP) is contraindicated or if IVP provides inadequate visualization of the collecting system.

RETROGRADE PYELOGRAPHY

Nursing and Patient Care Considerations • Contraindicated in patients with UTI, or with suspected perforation of the ureter or bladder; allergic reactions to contrast material are rare in this examination.

Cystourethrogram • Visualization of urethra and bladder by X-ray after retrograde instillation of contrast material through a catheter. • An examination of only the bladder is a cystogram; of only the urethra is a urethrogram. • Used to identify injuries, tumors, or structural abnormalities of the urethra or bladder; or to evaluate emptying problems or incontinence (voiding cystourethrogram).

VOIDING CYSTOURETHROGRAM

Nursing and Patient Care Considerations • Carries risk of infection due to instrumentation. • Allergy to contrast material is not a contraindication. • Additional X-rays may be taken after catheter is removed and patient voids (voiding cystourethrogram). • Provide reassurance to allay patient's embarrassment.

Renal Angiography • I.V. catheter is threaded through the femoral and iliac arteries into the aorta or renal artery. • Contrast material is injected to visualize the renal arterial supply. • Evaluates blood flow dynamics, demonstrates abnormal vasculature, and differentiates renal cysts from renal tumors.

RENAL ANGIOGRAPHY

Nursing and Patient Care Considerations • Clear liquids only after midnight before the examination; adequate hydration is essential. • Continue oral medications (special orders needed for diabetic patients). • I.V. required. • May not be done on the same day as other studies requiring barium or contrast material. • Maintain bed rest for 8 hours after the examination, with the leg kept straight on the side used for groin access. • Observe frequently for hematoma or bleeding at access site. Keep sandbag at bedside for use if bleeding occurs.

Renal Scans • Radiopharmaceuticals (also called radiotracers or isotopes) are injected I.V. • Evaluates renal size, shape, position, and function or blood flow to the kidneys. • Studies are obtained with a scintillation camera placed posterior to the kidney with the patient in a supine, prone, or sitting position.

Nursing and Patient Care Considerations • The patient should be well hydrated. Give several glasses of water or I.V. fluids as ordered before scan. • Furosemide (Lasix) or captopril (Capoten) may be administered in conjunction with the scan to determine their effects.

Ultrasound • Uses high-frequency sound waves passed into the body and reflected back in varying frequencies based on the composition of soft tissues. Organs in the urinary system create characteristic ultrasonic images that are electronically processed and displayed as an image. • Abnormalities, such as masses, malformations, or obstructions, can be identified; useful in differentiating between solid and fluid-filled masses. • A noninvasive technique.

Cystoscopy • Cystoscopy is a method of direct visualization of the urethra and bladder by means of a cystoscope that is inserted through the urethra into the bladder. It has a self-contained optical lens system that provides a magnified, illuminated view of the bladder. • Uses include: ▫ To inspect bladder wall directly for tumor, stone, or ulcer and to inspect urethra for abnormalities or to assess degree of prostatic obstruction. ▫ To allow insertion of ureteral catheters for radiographic studies, or before abdominal or GU surgery. ▫ To see configuration and position of ureteral orifices. ▫ To remove calculi from urethra, bladder, and ureter. ▫ To diagnose and treat lesions of bladder, urethra, and prostate.

Nursing and Patient Care Considerations • Simple cystoscopy is usually performed in an office setting. More complicated cystoscopy involving resections or ureteral catheter insertions are done in the operating room cystoscopy suite, where I.V. sedation or general anesthesia may be used. • The patient's genitalia are cleaned with an antiseptic solution just before the examination. A local topical anesthetic (Xylocaine gel) is instilled into the urethra before insertion of cystoscope. • Because fluid flows continuously through the cystoscope, the patient may feel an urge to urinate during the examination. • Contraindicated in patients with known UTI.

Nursing interventions after cystoscopic examination: • Monitor for complications: urinary retention, urinary tract hemorrhage, infection within prostate or bladder. • Expect the patient to have some burning on voiding, blood-tinged urine, and urinary frequency from trauma to mucous membrane of the urethra. • Administer or teach self-administration of antibiotics prophylactically as ordered to prevent UTI. • Advise warm sitz baths or analgesics, such as ibuprofen or acetaminophen, to relieve discomfort after cystoscopy. Increase hydration. • Provide routine catheter care if urine retention persists and an indwelling catheter is ordered.

Urodynamics • Urodynamics is a term that refers to any of the following tests that provide physiologic and functional information about the lower urinary tract. They measure the ability of the bladder to store and empty urine. Most urodynamic equipment uses computer technology with results visible in real time on a monitor.

1. Uroflowmetry (flow rate) - a record of the volume of urine passing through the urethra per unit of time (mL/s). It is shown on graph paper and gives information about the rate and flow pattern of urination. 2. Cystometrogram - recording of the pressures exerted during filling and emptying of the urinary bladder to assess its function. Data about the ability of the bladder to store urine at low pressure and the ability of the bladder to contract appropriately to empty urine are obtained.

3. Sphincter electromyelography (EMG) measures the activity of the pelvic floor muscles during bladder filling and emptying. EMG activity may be measured using surface (patch) electrodes placed around the anus or with percutaneous wire or needle electrodes. 4. Pressure-flow studies involve all of the above components, along with the simultaneous measurement of intra-abdominal pressure by way of a small tube with a fluid-filled balloon that is placed in the rectum. This permits better interpretation of actual bladder pressures without the influence of intra-abdominal pressure.

5. Video urodynamics use all of the above components. The fluid used to fill the bladder is contrast material, and the entire study is performed under fluoroscopy, providing radiographic pictures in combination with the recording of bladder and intra-abdominal pressures. Video urodynamics are reserved for patients with complicated voiding dysfunction.

Nursing and Patient Care Considerations • Contraindicated in patients with UTI. • Frequently performed by nurses; essential to provide information and support throughout the test to ensure clinically significant results. • Patients will have burning on urination afterward (due to instrumentation); encourage fluids. • Short-term antibiotics are commonly given to prevent infection

Needle Biopsy of Kidney • Performed by percutaneous needle biopsy through renal tissue with ultrasound guidance or by open biopsy through a small flank incision; useful in securing specimens for electron and immunofluorescent microscopy to determine diagnosis, treatment, and prognosis of renal disease

• Nursing and Patient Care Considerations • Prebiopsy nursing management ▫ Ensure that coagulation studies are carried out to identify the patient at risk for postbiopsy bleeding and that serum creatinine, urinalysis, and urine culture are done. ▫ Ensure that patient fasts for several hours before the procedure, as ordered. ▫ Establish an I.V. line, as ordered. ▫ Describe the procedure to the patient, including holding breath (to prevent movement of the thorax) during insertion of the biopsy needle.

Instruct the patient on the following after biopsy: • Avoid strenuous activity, strenuous sports, and heavy lifting for at least 2 weeks. • Notify health care provider if any of the following occur: flank pain, hematuria, lightheadedness and fainting, rapid pulse, or any other signs and symptoms of bleeding. • Report for follow-up 1 to 2 months after biopsy; will be checked for hypertension, and the biopsy area is auscultated for a bruit.

CATHETERIZATION • Catheterization may be done to relieve acute or chronic urinary retention, to drain urine preoperatively and postoperatively, to determine the amount of residual urine after voiding, or to determine accurate measurement of urinary drainage in critically ill patients.

DIALYSIS • Dialysis refers to the diffusion of solute molecules through a semipermeable membrane, passing from the side of higher concentration to that of lower concentration. • The purpose of dialysis is to maintain the life and well-being of the patient. • It is a substitute for some kidney excretory functions but does not replace the kidneys' endocrine and metabolic functions.

Methods of dialysis include: • Peritoneal dialysis. ▫ Intermittent peritoneal dialysis (acute or chronic) ▫ Continuous ambulatory peritoneal dialysis. ▫ Continuous cycling peritoneal dialysis uses automated peritoneal dialysis machine overnight with prolonged dwell time during day.

Hemodialysis Hemodialysis • Hemodialysis is a process of cleansing the blood of accumulated waste products. It is used for patients with end-stage renal failure or for acutely ill patients who require short-term dialysis.

Methods of Circulatory Access • Arteriovenous fistula (AVF) - creation of a vascular communication by suturing a vein directly to an artery

AV fistula

• Arteriovenous graft - arteriovenous connection consisting of a tube graft made from autologous saphenous vein or from polytetrafluoroethylene. Ready to use in 2 to 3 weeks.

• Central vein catheters - direct cannulation of veins (subclavian, internal jugular, or femoral); may be used as temporary or permanent dialysis access.

Central venous catheter

Complications of Vascular Access • Infection • Catheter clotting • Central vein thrombosis or stricture • Stenosis or thrombosis • Ischemia of the hand (steal syndrome) • Aneurysm or pseudoaneurysm

Lifestyle Management for Chronic Hemodialysis • Dietary management involves restriction or adjustment of protein, sodium, potassium, or fluid intake. • Ongoing health care monitoring includes careful adjustment of medications that are normally excreted by the kidney or are dialyzable.

• Surveillance for complications. ▫ Arteriosclerotic cardiovascular disease, heart failure, disturbance of lipid metabolism (hypertriglyceridemia), coronary heart disease, stroke ▫ Anemia and fatigue ▫ Gastric ulcers and other problems ▫ Bone problems (renal osteodystrophy, aseptic necrosis of hip) from disturbed calcium metabolism ▫ Hypertension ▫ Psychosocial problems: depression, suicide, sexual dysfunction

Continuous Ambulatory Peritoneal Dialysis • Continuous ambulatory peritoneal dialysis (CAPD) is a form of intracorporeal dialysis that uses the peritoneum for the semipermeable membrane

Advantages Over Hemodialysis • Physical and psychological freedom and independence • More liberal diet and fluid intake • Relatively simple and easy to use • Satisfactory biochemical control of uremia

Complications • Infectious peritonitis, exit-site and tunnel infections. • Noninfectious catheter malfunction, obstruction, dialysis-sate leak. • Peritoneal pleural communication, hernia formation. • GI bloating, distention, nausea. • Hypervolemia, hypovolemia. • Bleeding at catheter site.. • Obstruction may occur if omentum becomes wrapped around the catheter or the catheter becomes caught in a loop of bowel.

LOWER URINARY TRACT INFECTIONS • A UTI is caused by the presence of pathogenic microorganisms in the urinary tract with or without signs and symptoms. Lower UTIs may predominate at the bladder (cystitis) or urethra (urethritis).

Urinary Tract Infection (UTI)

•Bacterial invasion of the kidneys or bladder (CYSTITIS) usually caused by Escherichia coli

Urinary Tract Infection (UTI) • Predisposing factors include 1. Poor hygiene 2. Irritation from bubble baths 3. Urinary reflux 4. Instrumentation 5. Residual urine, urinary stasis

Urinary Tract Infection (UTI) PATHOPHYSIOLOGY • The invading organism ascends the urinary tract, irritating the mucosa and causing characteristic symptoms ▫ ▫ ▫ ▫

Ureter= ureteritis Bladder= cystitis Urethra=Urethritis Pelvis= Pyelonephritis

• Women are more susceptible to developing acute cystitis because of shorter length of urethra, anatomical proximity to vagina, periurethral glands, and rectum (fecal contamination), and the mechanical effect of coitus. • Poor voiding habits may result in incomplete bladder emptying, increasing the risk of recurrent infection. • Acute infection in women most commonly arises from organisms of the patient's own intestinal flora (Escherichia coli).

In men, obstructive abnormalities (strictures, prostatic hyperplasia) are the most frequent cause.

Assessment findings

Urinary Tract Infection (UTI)

Urinary Tract Infection (UTI)

Assessment findings • Low-grade fever • Abdominal pain • Enuresis • Pain/burning on urination • Urinary frequency • Hematuria

Urinary Tract Infection (UTI)

Assessment findings: Upper UTI • Fever and CHIILS • Flank pain • Costovertebral angle tenderness

Urinary Tract Infection (UTI)

Laboratory Examination 1. Urinalysis 2. Urine Culture

Urinary Tract Infection (UTI) Nursing interventions • Administer antibiotics as ordered • Provide warm baths and allow client to void in water to alleviate painful voiding. • Force fluids. Nurses may give 3 liters of fluid per day • Encourage measures to acidify urine (cranberry juice, acid-ash diet).

Urinary Tract Infection (UTI) • Provide client teaching and discharge planning concerning a. Avoidance of tub baths b. Avoidance of bubble baths that might irritate urethra c. Importance for girls to wipe perineum from front to back d. Increase in foods/fluids that acidify urine.

Urinary Tract Infection (UTI) Pharmacology 1. Sulfa drugs ▫ Highly concentrated in the urine ▫ Effective against E. coli!

2. Quinolones

• Bacteriuria refers to the presence of bacteria in the urine (105 bacteria/mL of urine or greater generally indicates infection). • In asymptomatic bacteriuria, organisms are found in urine, but the patient has no symptoms. Recurrent UTIs may indicate the following: • Relapse - recurrent infection with an organism that has been isolated during a prior infection • Reinfection - recurrent infection with an organism distinct from previous infecting organism

Complications • Pyelonephritis • Hematogenous spread resulting in sepsis

Nursing Diagnoses • Acute Pain related to inflammation of the bladder mucosa • Deficient Knowledge related to prevention of recurrent UTI

THE END