NUR240 Urinary Tract Stressors: UTI Cystitis Urolithiasis Bladder Ca PKD ARF/CRF

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NUR240Urinary Tract Stressors
UTICystitisUrolithiasisBladder CaPKDARF/CRF

• Joy Borrero, RN, MSN

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Kidney Physiology

• Primary role of kidney is regulation of fluid and
  electrolyte balance, additional life preserving
  functions include
• Excretion of metabolic wastes-micturition
• Water and salt regulation
• Maintenance of acid base balance.http//www.kidn
  ey.org/
• Regulation of BP
• Stimulation of RBC production
• Regulation of calcium phosphate metabolism.

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Urinary Tract

• Upper urinary tract
• Kidneys 2 bean shaped organs, composed of
  nephrons. A complex vascular system. Each weighs
  about 8oz.
• Ureters extensions of the renal pelvis and
  empty into the bladder.
• Lower urinary tract
• Bladder, urethra and prostate gland (males).

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Renal and Urinary Terms
Azotem ia Uremia Dysuria Frequency
Hesitency Micturation Nocturia Oliguria
Polyuria Uremia Urgency Anuria
Serum creatinine Blood urea nitrogen BUN/Creatinine Ratio Glomerular Filtration Rate
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Assessment of Renal and Urinary Tract Systems

• History of disease or trauma
• Urinary patterns
• Relevant meds
• Allergies
• Fluid status-edema
• Pruritis
• BP
• LOC, level of alertness
• Pain assessment
• Numbness and tingling of extremities
• GI symptoms- anorexia, NV, diarrhea

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Urinary Tract Pain

• Kidney- dull ache in costovertebral angle and
  radiates to umbilicus
• Ureteral pain in back that radiates to abdomen,
  upper thigh, testes and labia
• Bladder- low abdominal or over suprapubic area
• Renal Colic- flank pain radiating to lower
  abdomen or epigastric area, NV

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Diagnostic Tests

• IVP
• CAT Scans
• Renal angiography
• Ultrasounds
• Cystoscopy- Dx and Tx
• Renal Bx- Open/Closed

• UA, urine electrolytes, osmolality
• CS
• Serum creatinine and BUN
• Hgb and Hct
• Creatinine clearance- 24h collection
• KUB

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Cystoscopy

• Pre procedure bowel prep, NPO if general
  anesthesia, IVF for adequate urine flow
• Post procedure BR for short period
• Pink tinged urine is comon, retention may occur
• Pain in back, bladder spasms and a feeling of
  fullness
• Encourage large amts of fluids

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Urinary tract infections-described by location in
the tract

• UTI dysuria, frequency, urgency
• Assessment flank pain, cloudy urine, possible
  fever. WBCs in urine.
• Treatment with antibiotics Fluoroquinolones(Cipro
  ), nitrofurantoin(Macrobid),
• Sulfonamides (Septra, Bactrim)
• Prevention void before and after sex.
• Wipe front to back, showers better than baths.
• No perfumes to perineal area.
• Avoid sitting in wet bathing suits
• Avoid pantyhose with slacks or tight clothing

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UTI-Lower and Upper

• Risk Factors
• Aging
• Increased incidence with DM
• Increased risk of urinary stasis
• Impaired immune response
• Females short urethra, cystocele, rectocele
• Males BPH
• Obstructions tumor, calculi, strictures

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EBP- UTI Bundles

• Assess daily for need for catheter
• Foley bag below level of bladder
• Closed system
• Secure cath to prevent movement, tugging
• Use of smallest size catheter possible

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Cystitis

• Most common UTI (superficial, bladder mucosa)
• Manifestationsdysuria, frequency, urgency,
  nocturia, foul odor urine, hematuria
• Older patientsnocturia, incontinence, confusion,
  behavioral changes, lethargy, anorexia, fever or
  hypothermia

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Dx for cystitis

• UA
• Urine for Gram Stain
• Urine for C S
• Evaluation of urinary tract

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Interventions

• Uncomplicated
• Single dose regimen
• Antispasmodics
• Recurrent or chronic
• Sulfonamides
• Antiseptics
• Analgesics
• Surgical Management

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Management of Cystitis

• Increase fluid intake
• Acidify urine
• Ascorbic acid
• Avoid bladder irritants
• Antibiotics based on CS
• Patient teaching

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Upper Urinary Tract Infections

• Pyelonephritis inflammation of kidney caused by
  bacterial infection following a bladder infection
• Infection begins in lower urinary tract with
  organisms ascending into renal pelvis
• E coli causes most cases of pyelonephritis
• Affects filtration,reabsorption and secretion
  decrease in renal function

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Risk Factors

• Women over age 65
• Older men with prostate problems
• Chronic urinary stone disorder
• Spinal cord injury
• Pregnancy
• Congenital malformations
• Bladder tumors
• Chronic illness HTN, DM, chronic cystitis
• Recurrence is common

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Physical Assessment

• Patient presents with acute distress
• Hx of dysuria, frequency, urgency and other signs
  of cystitis
• Costovertebral tenderness
• Fever, chills, nausea and flank pain
• N V, malaise, fatigue
• Cloudy urine or hematuria

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Diagnostic Assessment

• UA and CS
• WBC with diff
• Blood Cultures
• Serum creatinine and BUN
• CRP-C-reactive protein
• ESR
• KUB, IVP

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Nursing Interventions

• Pain management
• Antibiotic therapy
• Increase fluid intake
• Monitor temperature
• Provide emotional support
• Assist with personal hygiene
• Follow-up urine cultures

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Assess for Complications

• Septic shock
• Renal Failure
• Hypertension

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Urolithiasis

• Etiology- presence of calculi (stones) in the
  urinary tract, by an unknown cause
• Recurrence is increased 35-50 in pt with
  family hx or if first stone occurs lt25 yrs of age
• Increased incidence in males
• Majority of stones (75) are composed of Ca
  oxalate or Ca phosphate
• Hi doses of Vitamin C
• Conditions causing urinary stasis, dehydration,
  urinary retention

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Physical Assessment

• Pain, obstruction, tissue trauma with secondary
  hemorrhage and infection
• Sharp, severe pain (renal colic) with sudden
  onset deep in lumbar region around to side
• N V
• Urinary frequency or dysuria
• Pallor, diaphoresis
• VS
• Oliguria, anuria, hematuria

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Diagnostic Assessment

• UA- RBCs, WBCs, bacteria, turbidity,odor
• Serum Ca, PO4, Uric Acid levels
• Elevated serum WBC if infection is present
• KUB, IVP, Xrays, Ultrasound

?
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Non-surgical Management

• Pain management- MSO4, NSAIDS
• Antispasmotics-Ditropan, Pro-Banthine
• Antiemetics- Zofran
• Strain all urine- send stones for analysis
• Increase fluid intake to 3000mL/day
• Client education re meds/diet

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Methods of Stone Removal

• Stenting
• ESWL- Extracorporeal Shock Wave Lithotripsy
• Retrograde ureteroscopy/cystoscopy
• Percutaneous or open ureterolithotomy/pyelolithoto
  my/nephrolithotomy

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Urinary Drainage Tubes

• Ureteral Stents
• Maintain ureteral flow in pts with ureteral
  obstruction
• Divert urine
• Promote healing of ureter
• Maintain patency of ureter after sugery
• Temporary or permanent-inserted via nephrostomy
  tube, cystoscopy or open sx.

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Nephrostomy Tubes

• Catheter is placed into renal pelvis for urine
  drainage (placed in flank area)
• Relieve obstruction, route for insertion of
  ureteral stent
• Drainage for when ureter doesnt drain
• Administer meds, biopsy
• Never clamp a nephrostomy tube-can lead to
  pyelonephritis
• Never irrigate without specific order
• Monitor urine output

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Nursing Interventions in client education

• Restrictions based on stone analysis
• Ca Phosphate- Limit foods high in animal protein,
  limit Na and Ca intake
• HCTZ- to increase Ca reabsorption
• Ca Oxalate- Limit oxalate sources spinach, black
  tea, cocoa, beets, pecans, limit Na intake
• Uric Acid Limit foods high in purines organ
  meats, poultry, fish, gravies, red wine and
  sardines. Allopurinol (Zyloprim)

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Assess for Complications

• Hydronephrosis
• Infection
• Ureteral obstruction

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Bladder Cancer

• Etiology about 54,000 new cases yearly, more
  common in gtage 60
• Industrial exposure
• Long term use of Cyclophosphamide (Cytoxan) and
  Aziothioprine (Imuran)
• Tobacco use
• Secondary to mets

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Diagnostic Assessment

• Urinalysis-presence of gross or microscopic
  hematuria
• Cystoscopy-Bladder-wash specimens and bladder
  biopsy
• CT scans and MRI to assess for mets

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Physical Assessment

• Painless hematuria- major sign
• Assess general health, exposure to cigarette
  smoke, harmful environmental agents
• Changes is urinary habits

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Nonsurgical Interventions

• Intravesical immunotherapy- instillation into the
  bladder
• Bacille Calmette-Guerin (BCG)
• Intravesical chemotherapy-mitomycin (Mutamycin),
  Doxorubicin (Adriamycin)
• Complications bladder irritation, frequency,
  dysuria, contact dermatitis
• Systemic chemotherapy

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Surgical Interventions

• Radiation used to reduce tumor size preop
• Cystoscopic tumor resection by excision,
  fulguration, laser photocoagulation
• TURBT- Transuretheral Resection of Bladder Tumor
• Simple or radical cystectomy-urinary diversion
  necessary (ileal conduit)

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Methods of Urinary Diversion After Cystectomy

• Urinary Diversion- divert urine away from kidney
  and leaves body via another route
• 1.Continent urinary diversion- ureters implanted
  into portion( pouch) of ileum (reservoir) for
  urine, stoma to abdomen
• 2.Incontinent diversions ileal conduit
• 3.Uretersigmoidostomy
• 4. Bladder reconstruction, neobladder

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Post-op Care

• Routine post op care including pain management
• Disturbed body image
• Risk for impaired skin integrity
• Assess urinary drainage
• Sexual dysfunction
• Pt and family education re meds, fluids, care of
  urinary diversion system
• Referral to www.acs.org and local support groups

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PKDPolycystic Kidney Disease

• Congenital disorder-grapelike clusters of cysts
  in the nephrons, progressive
• Affects 250,00-500,000 people in the US
• MenWomen
• SS abdominal or flank pain, HTN, nocturia,
  Increased abdominal girth, constipation, bloody
  or cloudy urine, kidney stones
• Renal insufficiency and CRF by age 50-60

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Diagnostic Assessment

• UA-proteinuria, hematuria
• Urine CS
• Rising BUN and Creatinine levels
• Decreased creatinine clearance
• Renal sonograms,CT and MRI

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Interventions

• Mainly supportive- prevent renal damage from HTN,
  UTI, obstruction
• Pain management-caution with NSAIDS and ASA
• Antibiotic tx for UTIs
• Constipation prevention
• HTN control- ACE inhibitors
• Diet management- Low NA, protein
• Emotional support

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Acute and Chronic Renal Failure
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Acute renal failure (ARF)

• Three causes of ARF
• 1. Prerenal
• 2. Intrarenal (intrinsic)
• 3. Postrenal
• 1.Prerenal- conditions that cause decreased
  cardiac output shock, CHF, pulmonary embolism,
  sepsis, anaphylaxis,hypotension

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ARF

• 2. Intrarenal - caused by damage to renal tissue.
• Causes glomeruonephritis,infection,drugs
  pyelonephritis, vasculitis, acute tubular
  necrosis (ATN), tumors
• 3. Postrenal- obstructions of outflow of urine
  calculi, tumors, atony of bladder, urethral
  stricture, trauma

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4 Phases of ARF

• Onset
• Oliguric
• Diuretic
• Recovery
• 1.Onset

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ARF

• Oliguric phase urinary output decreased.
• Renal insult,gradual accumulation of nitrogenous
  wastes (BUN and creatinine), can last hrs to 3
  weeks.
• Increasing BUN, hyperkalemia, metabolic acidosis,
  hypocalcemia, hypermagnesemia, hyperphosphatemia.
  
• As plasma levels of nitrogenous wastes increase
  changes in
• Oxygenation, metabolism, immune response,
  perception and coordination result.

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ARF

• 3.Diuretic phase high output phase, up to
  10L/day. This phases lasts 1 2 weeks.
• 4.Recovery phase begins when BUN stabilizes at
  normal, client begins to return to normal
  activities.
• The mortality rate for ARF- greater than 50 and
  for those requiring dialysis, between 60 -90
• Prerenal is the most common cause and is usually
  reversible with prompt interventions

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ARF

• Lab findings
• Drug therapy prerenal fluid challenges and
  diuretics used to promote perfusion.
• Oliguric phase dopamine- small dose, continuous
  renal perfusion.

Test Normal Range
Serum Creatinine 0.6-1.2mg/dL
Serum BUN 10-20mg/dL
24hr Urine Creatinine Clearance 80-140mL/min
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ARF

• Diet high calorie diet needed for catabolic
  state, if client cannot eat enough, then TPN is
  considered.
• During the oliguric phase of ARF, the following
  diagnoses may apply
• High risk for fluid volume excess
• High risk for injury
• High risk for altered nutrition.

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ARF- Physical Assessment

• 1.Prerenal hypotension, tachycardia, decreased
  cardiac output and CVP, decreased urine output
  and lethargy.
• 2. Intrarenal and postrenal-
• Renal oliguria or anuria
• Cardiac- hypertension, tachycardia, JVD,
  increased CVP, peripheral edema, efffusions,

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ARF- Assessment

• Respiratory SOB, orthopnea, crackles, pulmonary
  edema.
• GI anorexia, nausea, vomiting, flank
  pain,metallic taste, gastritis
• Neuro- lethargy, headache, tremors, confusion,
  insomnia, seizures
• Hematology-anemia, bruising
• Weight gain. 1kgapprox 1L fluid retained

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Management and Prognosis of ARF

• Tx precipitating cause
• Fluid restriction (500-600mL) plus fluid loss
• Nutritional management
• Measures to lower serum K
• Phosphate binding agents
• TPN or enteral nutrition
• Initiation of dialysis is necessary

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Nursing Management Interventions

• Fluid volume deficit r/t
• Fluid volume excess r/t
• Nutrition Less than body requirements
• r/t
• 4, Impaired gas exchange r/t
• 5. PC Hyperkalemia r/t.
• 6. PC Metabolic acidosis r/t
• 7. PC Decreased Calcium r/t

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• The patient is a 64-year-old man. He visits the
  primary care provider because of mild lower
  abdominal pain, decreased urine output, and
  increased shortness of breath. He is 5 feet, 8
  inches tall and weighs 246 pounds. The only drugs
  he takes include a daily multivitamin, a beta
  blocker, and occasionally acetaminophen for
  headache. His past medical history includes
  kidney stones 1 year ago and mild hypertension
  over the past 5 years. Physical assessment
  reveals bilateral crackles in the lung bases.
  Vital signs are T, 98.8 F P, 96/min, R, 28/min,
  and BP, 148/92.
• 1. For which type(s) of acute renal failure is he
  at risk? Why?
• 2. Do any of his usual drugs increase his risk
  for ARF? Which one(s) and why?
• 3. Is there any specific assessment data you
  could obtain without a prescription to evaluate
  his risk for acute renal failure? If so, which
  ones and why?
•  
• The physician prescribes these interventions
• IV placement with a 20-gauge cannula, NS at 20
  mL/hr
• Accurate intake and output
• Ibuprofen 600 mg orally
• Furosemide 40 mg IV

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Chronic renal failure (CRF)

• CRF is a chronic,progressive, irreversible
  disease, leading to end stage renal disease
• Five stages
• Stage 1- diminished renal reserve, increased BP,
  increased pressure on glomerular apparatus,
  decreased ability to concentrate urine- nocturia
  and polyuria.
• Stage 2 Renal Insufficiency- metabolic wastes
  begin to accumulate

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CRF

• Stage 3- End stage renal disease, excessive
  amounts urea and creatinine in blood.
• Treatment by dialysis is necessary.
• Sodium
• Early in CRF hyponatremia, polyuria causes
  sodium depletion.
• Later, ESRD sodium retention but dilutional
  hyponatremia (masked by fluid volume excess).

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CRF

• Potassium hyperkalemia 7 -8 meq/L, ECG
  changes and fatal dysrhythmias.
• Acid base balance Acid excretion (H ions)-
  restricted results in metabolic acidosis.
  Kussmaul respirations.
• Calcium and phosphate demineralization.
• Uremic pruritis- toxic accumulation of
  nitrogenous wastes.

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CRF- Affects all body systems

• Cardiac Alterations
• Hypertension
• CHF and LV hypertrophy
• Uremic Pericarditis
• Hematologic Alterations
• GI alterations
• MS
• Neuro
• Dermatological
• Endocrine

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Goals of Therapy

• Retain kidney function and maintain homeostasis
  as long as possible
• Improve nutrition
• Monitor electrolytes
• Manage anemia
• Control HTN
• Maintain glycemic control
• Emotional support

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ESKD Concept Map
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CRF

• Common Nursing diagnoses
• 1. Altered nutrition less than body requirements
  r/t nausea, vomiting, decreased appetite, effects
  of catabolic state, decreased LOC, altered taste,
  or dietary restrictions.

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CRF- Interventions

• Dietary restrictions limit protein intake
• Limitation of fluid intake
• Restriction of K, NA, phosphorous
• Administration of Vitamins and minerals
• Adequate calories to meet metabolic demands
• Collaborate with MD and dietician

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CRF

• Fluid volume excess r/t inability of kidney to
  maintain body fluid balance.
• Interventions Fluid restriction depends on-
• Urinary output
• Based on fluid wt. gain
• With hemodialysis, 500 -700 ml/day plus amount of
  urinary output.

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Nursing Diagnoses

• Impaired skin integrity
• Risk for injury
• Activity intolerance
• Constipation
• Diarrhea
• Anticipatory Grieving

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CRF- Drug Therapy

• Cardiac glycosides digoxin
• Monitor for signs and symptoms of toxicity and
  hypokalemia
• Vitamins and minerals- FeSo4 and Folic Acid
• Erythropoietin- Epogen, Procrit
• Phosphate Binders- Renagel, Tums
• Stool Softeners- Colace

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Assessment for patients with CRF

• Assess CV and respiratory systems
• VS, especially BP, heart sounds
• Chest pain?, Edema?, JVD?
• Dyspnea?, Crackles?
• Assess nutritional status- Protein, fluid, K, Na,
  P restrictions
• Weight gain or loss
• Anorexia, nausea, vomiting

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Assessment

• Assess renal status-
• Amount, frequency and appearance urine
• Bone Pain?
• Hyperglycemia-stress need for control
• Assess hematologic status, including_
• Petichiae, purpura, ecchymosis?
• Fatigue?, SOB?

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Assessment

• Assess GI status-
• Stomatitis
• Melena
• Assess neurological status-
• Change in mental status?
• Seizure activity?
• Sensory changes?, Lower ext. weakness?

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Assessment

• Assess Integumentary system-
• Skin integrity
• Discoloration?
• Pruritis?
• Assess lab data, including
• BUN, creatinine, creatinine clearance, CBC,
  electrolytes.

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Assessment

• Assess psychosocial status, including-
• Anxiety?
• Maladaptive behavior
• Refer to a community resource group

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Interventions to Manage ESRDPeritoneal Dialysis
and Hemodialysis

• Functions
• Rid the body of excess fluids and electrolytes
• Achieve acid-base balance
• Eliminate waste products, toxins
• Restore internal fluid balance through osmosis,
  diffusion and ultrafiltration

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Concepts of Dialysis

• Dialysate solution of electrolytes,modified
  salt, acetate, glucose and heparin
• Dialyzer- Artificial kidney with a semipermeable
  membrane (Hemodialysis) or the peritoneum as a
  semipermeable membrane (Peritoneal Dialysis)
• Diffusion-
• Osmosis-

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Peritoneal Dialysis

• May be hemodynamically unstable, cant tolerate
  anticoagulation.
• Peritonitis is a major complication.
• Procedure- surgically inserted tube into
  abdominal cavity- infusion of dialysate.
• ONE EXCHANGE
• Fill time Infuse 1-2 liters by gravity over 20
  min.
• Dwell time Dialysate dwells in abdomen over
  specified period of time.
• Drain Time- 10-15 min. Output usually 100-200mL.
  input

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PD

• Fluid then drains out by gravity.
• This effluent contains dialysate, excess water,
  electrolytes and nitrogenous wastes.
• The number and frequency of exchanges depend on
  clients condition and lab data.
• Types of PD Continuous ambulatory PD (CAPD),
  multiple bag CAPD, automated or continuous cycle.

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PD- Complications

• Peritonitis, manifested by
• Cloudy outflow (effluent)
• Rebound abdominal tenderness
• Abdominal pain
• General malaise
• Nausea, vomiting
• Intervention send C and S, Tx. with appropriate
  Antibiotic.

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PD- Complications

• Pain pain initially
• Exit site and tunnel infection
• Insufficient flow of dialysate
• Dialysate leakage.Dyspnea
• Formation of fibrin clots
• Altered body image

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Care of the Tenckhoff Catheter

• Mask for yourself and client
• Put on clean gloves. Remove the old dressing,
  remove contaminated gloves.
• Assess area for signs of infection, swelling,
  redness, or discharge around catheter site.
• Use aseptic technique
• Sterile field, 2 4x4s, cotton swabs soaked in
  providone iodine, put on sterile gloves.
• Use cotton swabs to clean around catheter site,
  in a circular motion.
• Apply pre-cut gauze pads over catheter site.
• Tape edges of gauze pads.

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Care of patient during PD

• Before treatment monitor vitals, weight, lab
  values.
• During dialysis continually monitor pt., VS
  taken regularly, assess for pain, assess catheter
  site for leaking.. Monitor dwell time, and
  document.
• Record amount outflow, note clarity of effluent,
  I and O.

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Hemodialysis

• http//kidney.niddk.nih.gov/kudiseases/pub/
• Vascular access AV fistula,anastomosis of an
  artery and a vein or AV shunt
• Temporary double lumen catheter in subclavian, IJ
  or femoral vein
• Pre-dialysis Interventions-
• Assess patency bruit, thrill,distal pulses
• Common complications of access-
• Thrombosis or stenosis, infection, aneurysm
  formation, ischemia, bleeding
• Determime if meds should be held

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Post Dialysis Nursing Care

• Assess for Complications
• Hypotension
• Headache
• Nausea, vomiting
• Malaise
• Dizziness
• Muscle cramps
• Monitor BUN/Creat/Lytes/Hct
• LOC
• Bleeding

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HD

• Heparinization used for dialysis
• All invasive procedure avoided 4-6 hrs. after
  dialysis.
• Nurse monitors for signs of hemorrhage during
  dialysis and 1 hr. after.
• Complications Disequilibrium syndrome
• Infectious diseases can be transmitted,
  hepatitis and HIV

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HD

• Nursing Care- Get report.
• Weigh client before and after dialysis
• Know the clients dry weight
• Measure vitals, observe for bleeding
• Assess LOC, HA?, nausea? Vomiting?

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Renal Transplantation

• Candidates must be
• Free from medical problems
• Usually age 40 70 years old.
• Candidates excluded
• Active infection
• IV drug abuse
• Malignant neoplasm
• Severe obesity
• Acute vascultitis
• Severe psych problems
• Long standing pulmonary disease
• Advanced cardiac disease

83
Renal Transplantation

• Donors- Absence of systemic disease/ infection
• No history of cancer
• Absence hypertension and renal disease
• Adequate renal function diagnostic tests.

84
Renal Transplantation

• Complications-
• Rejection- immunosuppressive drug therapy,
  corticosteroids.
• Renal artery stenosis HTN, bruit, decreased
  renal function.
• Post op care- Monitor vitals, renal function, I
  and O, urine output, color.
• Diuretics may be ordered.

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Renal Transplantation

• Daily weights
• Carefully monitor I and O.
• Monitor for electrolyte imbalances.
• Patient teaching for discharge regarding meds,
  diet, wound care,signs of infection and
  rejection, and follow up care with PMD.

86
Review of Terminology

• Acute Renal Failure
• Usually temporary and may be reversed, leaving no
  permanent or serious damage to kidneys
• Sudden loss of the ability of the kidneys to
  excrete wastes, concentrate urine and conserve
  electrolytes

• Chronic Renal Failure
• Long term and irreversible
• Usually occurs over a number of years as the
  internal structures of the kidney are slowly
  damaged