Urinary Tract Infection (UTI)

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

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

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

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

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

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

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

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

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

10. Urinary Tract Infection (UTI) Collaborative Care • a. Eliminate causative agent • b. Prevent relapse • c. Correct contributing factors Diagnostic Tests a. Urinalysis: assess pyuria, bacteria, blood cells in urine; Bacterial count >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

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

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

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

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

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

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

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

18. Client with Urinary Calculi Background 1. Urinary calculi are stones in urinary tract • a. Nephrolithiasis: stones form in kidneys • b. Urolithiasis: stones form in urinary tract outside kidneys 2. Highest incidence in southern and Midwestern states • 3. Males more often affected than females (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

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

20. Development and location of calculi within the urinary tract

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

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

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

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

25. Percutaneous ultrasonic lithotripsy

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

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

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

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

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

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

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

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

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

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

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

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

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