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Urinary tract infection

Kusum

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 gramnegative bacteria: Proteus, Klebsiella, Seratia,
Pseudomonas

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

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)

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

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

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

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

Urinary Tract Infection (UTI)


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

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

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 >100,000 /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

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

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

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-sulfamethoxazole
(TMP-SMZ), or quinolone antibiotic such as ciprofloxacin
(Cipro)
d. Intravenous antibiotics used include ciprofloxacin,
gentamycin, ceftriaxone (Rocephin), ampicillin

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

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

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)

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

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 (4:1)
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

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

Development and location of calculi within


the urinary tract

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

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

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

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

Percutaneous ultrasonic lithotripsy

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

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

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

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

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

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

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

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

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

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)

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

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

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