THE ASSESSMENT AND CARE FOR IMPAIRED URINARY ELIMINATION PN 134

1. THE ASSESSMENT AND CARE FOR IMPAIRED URINARY ELIMINATION PN 134

2. ASSESSMENT • Pain on urination • Pattern of urination • Strength of urine stream • Urgency, frequency, incontinence, hematuria, nocturia • Intake and output • Urine color, clarity, and odor

3. URINARY RETENTION • Urinary retention • Etiology/pathophysiology • The inability to void despite an urge to void • Clinical manifestations/assessment • Distended bladder • Discomfort in pelvic region • Voiding frequent, small amounts

4. URINARY RETENTION • Client may experience discomfort and anxiety. • Frequency of urination and voiding small amounts may occur. • Treatment: urinary analgesics and antispasmotics. • Urinary catheter may be used, or surgery if indicated. • When client able to void, check for residual urine-should be less than 50mL.

5. URINARY RETENTION • Stasis may lead to infection. • Distended bladder may result. • Caused by stress, calculus obstruction, stones, tumor, infection, medications, trauma.

6. URINARY RETENTION • Medical management/nursing interventions • Warm shower or sitz bath • Natural voiding position if possible • Urinary catheter • Surgical removal of obstruction • Analgesics

7. URINARY RETENTION • Urinary Analgesics • Pyridium, Pyridate, phenazopyridine: • Uses: relief of pain associated with lower genitourinary tract • Adverse Reactions: headache, rash, pruritis, GI disturbances, discoloration of the urine, sclera and/or skin. • Dosage range: 200 mg TID PO

9. Urinary Incontinence • Etiology/pathophysiology • Involuntary loss of urine from the bladder • Total incontinence; dribbling; stress incontinence • Secondary • Infection; loss of sphincter control; sudden change in pressure in the abdomen • Permanent or temporary

10. URINARY INCONTINENCE • Stress: leakage of urine on straining. • Urge: sudden need to urinate. • Overflow: full bladder leads to leakage. • Total: no control of voiding. • Nocturnal enuresis: night time incontinence.

11. Urinary Incontinence • Clinical manifestations/assessment • Involuntary loss of urine • Leaking with coughing, sneezing, or lifting • Medical management/nursing interventions • Treat underlying cause • Surgical repair of bladder • Temporary or permanent catheter • Bladder training • Kegal exercises

12. Urinary Tract Infections • Etiology/pathophysiology • UTIs are caused by pathogens that enter the urinary tract – with or without presence of symptoms • Bacteriuria (bacteria in the urine): the most common of all nosocomial infections; often associated with urinary catheters • Common in older people r/t bladder obstruction, insufficient bladder emptying, decreased bactericidal secretions of the prostate, increased perineal soiling in women, sexual intercourse.

13. Urinary Tract Infections • Immobility, sensory impairment, and multiple organ impairment may increase the probability of infection in the older adult • Females more susceptible because shorter urethra and proximity to vaginal and rectal area.

14. Urinary Tract Infections • Gram-negative microorganisms from the GI tract (e.g. E. Coli, Klebsiella, Proteus, or Pseudomonas) commonly cause UTIs. They ascend through the urinary meatus. • Body usually keeps infections in check by washing them from the body through voiding. • If there is incomplete emptying of the bladder or reflux of urine, the retained urine supports growth of bacteria.

15. Urinary Tract Infections • Clinical Manifestations • Urgency, frequency, burning on urination • Microscopic or gross hematuria • Cloudy or blood-tinged urine • Nocturia • Abdominal discomfort, perineal or back pain • Sudden onset incontinence or increased incontinence • Type of infection depends on location: cystitis, urethritis, nephritis, etc.

16. Urinary Tract Infection • Treatment • Pharmacology: antibiotics • Common ones: • Norflaxin (Noroxin) • Nitrofurantoin (Furadantin) • Sulfisoxazole (Gantrisin) • Trimethoprim-Sulfamethoxazole ( Bactrim, Septra)

17. Urinary Tract Infection • Diagnostic Tests: UA, C&S

19. CYSTITIS • Inflammation of the urinary bladder. • Caused by escherichia coli, candida albicans, coitus, prostatitis, diabetes mellitus. • Culture, sensitivity testing, antimicrobial medication, urinary tract analgesic. • Increase fluid intake, record I & O.

21. CYSTITIS • Encourage fluid intake. Should drink between 3-4 liters of non-caffeinated fluid a day. • Intake of meats and whole grains makes the urine more acidic and may discourage growth of bacteria in the urinary bladder. • Drinking cranberry juice

22. PYELONEPHRITIS • Bacterial infection of renal pelvis, tubules, interstitial tissue of one or both kidneys. Also known as pyelitis or nephropyelitis. • Usually associated with pregnancy, chronic health problems such as DM, polycystic or hypertensive kidney disease, insult to the urinary tract such as catheterization, infection, obstruction, or trauma

23. PYELONEPHRITIS • Kidney becomes edematous, inflamed; blood vessels congested • Urine may be cloudy and contain pus, mucous, and blood • Small abscesses may form in the kidney • Symptoms of acute condition: chills, fever, flank pain, prostration

24. PYELONEPHRITIS • Repeated episodes  chronic pyelonephritis and atrophy of the kidney with nephrons being destroyed. • Destruction of nephrons  Azotemia: retention in the blood stream of excessive amounts of nitrogenous compounds • Treat to prevent from becoming chronic

25. PYELONEPHRITIS • Diagnostic tests could be: IVP, UA and C&S, CBC, BUN, serum creatinine. • Collect urine specimens before administering antimicrobials • Pharmacology: sulfonamides (Bactrim,Cipro); antipyretics if with fever, analgesics if in pain.

26. Immunological Disorders of the Kidney • Nephrotic syndrome • Etiology/pathophysiology • Physiologic changes of the glomeruli interfere with selective permeability • Clinical manifestations/assessment • Proteinuria; hypoalbuminemia • Generalized edema • Anorexia • Fatigue • Oliguria

27. Nephrotic Sydrome • http://www.youtube.com/watch?v=-ebByDNbTWI

28. Immunological Disorders of the Kidney • Medical management/nursing interventions • Corticosteroids • Diuretics • Diet • Low sodium • High protein

29. Immunological Disorders of the Kidney • Nephritis (acute glomerulonephritis) • Etiology/pathophysiology: in taking a health hx., will usually find that an infectious disease process triggers an immune response. • Frequently a beta-hemolytic streptococcus (2-3 weeks prior) • The immune response  inflamed glomeruli excretion of RBCs and protein in the urine

30. Immunological Disorders of the Kidney • Clinical manifestations/assessment • Edema of the face – esp. around eyes • Pallor • Malaise • Anorexia • Dyspnea with exertion • Hematuria – “cola” colored  frank bleeding • Changes in voiding patterns • Oliguria; dysuria

31. Immunological Disorders of the Kidney • Diagnostic Tests: Blood tests will usually show: elevated BUN, serum Creatinine, potassium, ESR, and antistreptolysin-O titer. • Urinalysis will show presence of RBCs, casts, and protein • Treatment includes drug therapy, diet, and rest. • Treat to prevent renal complications, cardiac complications, and complications to cerebral functioning.

32. Immunological Disorders of the Kidney • Medical management/nursing interventions • Antibiotics • Treat primary symptoms • Diuretics • Antihypertensives • Diet • Protein and sodium restrictions • Increase calories

33. Immunological Disorders of the Kidney • Pharmacology • Prophylactic antimicrobial therapy possible • Drug of choice is Penicillin • Diuretic and antihypertensive drugs may be ordered • Corticosteroids, chemotherapeutic drugs, and/or immunosuppressive drugs to control inflammatory response.

34. Immunological Disorders of the Kidney • Nursing Interventions • Focus is on control of symptoms and prevention of complications • Monitor level of consciousness if BUN is elevated • VS , I/O • Bedrest and fluid adjustments are guided by urine output until diuresis is adequate • Level of Activity: depends on the degree of edema, BP, proteinuria, and hematuria – all of which increase with excessive activity

35. Immunological Disorders of the Kidney • Patient Teaching • Nature of illness • Effect of diet and fluids on fluid balance and sodium retention • Diet: prescribed sodium and fluid restriction • Info on protein restriction/ CHO sources for energy • Medication • Pacing daily activities • Avoiding trauma and infections • S/Sx that require medical attention • Importance of medical follow up

37. Immunological Disorders of the Kidney • Nephritis /Chronic Glomerulonephritis) • Etiology/pathophysiology • Slow, progressive destruction of glomeruli • Commonly caused by other chronic illnesses • Diabetes mellitus • Systemic lupus erythematosus

38. Immunological Disorders of the Kidney • Clinical manifestations/assessment • Malaise; morning headaches • Dyspnea with exertion • Visual and digestive disturbances • Generalized edema • Weight loss • Fatigue • Hypertension • Anemia • Proteinuria

39. Immunological Disorders of the Kidney • Chronic Glomerulonephritis (cont.) • Medical management/nursing interventions • Same as acute glomerulonephritis • Bedrest, dietary modification, medication • Goal: prevent further renal damage; prevent cerebral and cardiac complications • Renal dialysis • Kidney transplant

40. Immunological Disorders of the Kidneys • Pharmacology • Antimicrobial therapy given prophylactically • Diuretics and antihypertensive drugs ordered

41. PHARMACOLOGY • Types of diuretics: • Thiazides: hydrochlorothiazide • Loop diuretics • Potassium sparing diuretics • Osmotic diuretics • Carbonic Anhydrase inhibitor diuretics

42. PHARMACOLOGY • Diuretics: • -drug that increases the secretion of urine. • -kidney disease often causes excess fluid retention • (edema). • -many different types of diuretics used for different • purposes.

43. PHARMACOLOGY • Antihypertensives • methydopa (Aldomet) • minoxidil ( Loniten) • hydralazine HCL ( Apresoline) • Monitor BP, pulse, postural hypotension, and K, Na,Cl, and CO2 and I&O

44. PHARMACOLOGY • Phosphate binding antacids: aluminum hydroxide gel ( Amphogel) • Potassium exchange: sodium polystrene • Electrolyte Replacement: calcitrol (Rocaltrol)