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110 Cards in this Set

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Urinary Tract Infections statistics
-second most common reason to access healthcare
-most common in women - 11.3 mil/yr
-most common site of nosocomial infections - 600,000/yr
-lower UTIs
-Upper UTIs
Lower UTIs
-cystitis - bladder
-prostatitis - prostate
-urethritis - urethra
Upper UTIs
-pyelonephritis - renal pelvis
-renal abscess
-interstitial nephritis - kidney
-perirenal abscess
Risk Factors for UTIs
-failure to completely empty bladder
-obstructed urinary flow
-instrumentation of urinary tract
-inflammation or abrasion of urethral mucosa
Obstructed urinary flow
-congenital abnormalities
-urethral structures
-bladder neck contracture
-compression of ureters
-neurologic abnormalities - dysfunctional bladder
Clinical Manifestations (UTI)
-Half of patients are asymptomatic
-Dysuria - painful
-Frequency - more than every 3 hours
-Suprapubic or pelvic/flank pain
Factors Contributing to UTI in Seniors
-high incidence of chronic illness
-frequent use of antimicrobial agents
-presence of infected pressure ulcers
-cognitive impairment
-immobility and incomplete emptying
-use of bedpan rather than a commode or toilet
-Most common presenting symptom is GENERALIZED FATIGUE
Diagnosis (UTI)
-urine culture and sensitivity
-CT Scan/Ultrasound - abscesses or obstructions
Medical Management (UTI)
Acute Pharmacologic Therapy
-Urinary analgesics - Pyridium (orange)
Nursing Management (UTI)
-History of s/s, voiding pattern, infrequent emptying of bladder, sexual intercourse
-Assessment of urine for volume, color, concentration, cloudiness, odor

Nursing Diagnoses
-Acute pain
-Knowledge deficit
Nursing Interventions (UTI)
-Encourage fluid intake (unless contraindicated).
-Report increased pain to physician.
-Administer analgesics and antispasmodics for pain and spasm as prescribed.
-Provide instructions about recommended voiding patterns and hygienic practices.
Patient Education (UTI)
-Shower rather than bathe
-Wipe front to back

Fluid intake
-Drink lots of water
-Avoid coffee, tea, colas, alcohol - urinary tract irritants
-cranberry juice, vitamin C

Voiding habits
-void every 2-3 hours
Acute Pyelonephritis
Signs and Symptoms
-Bacteriuria and pyuria
-Low back pain, flank pain
-Nausea & vomiting
-painful urination
-pain and tenderness at costovertebral angle
Diagnostic Studies (Acute Pyelonephritis)
-urine culture and sensitivity
-CT Scan/Ultrasound
Medical Management (Acute Pyelonephritis)
Primarily OP (outpatient)
-antibiotics - 2 weeks
-repeat urine C&S 2 weeks after antibiotics finished
Adult Voiding Dysfunction
-Incontinence - 17 million in US
-Can affect people of all ages - more common in seniors
-Risk Factors: age, gender, number of vaginal deliveries
Types of Incontinence
Stress Incontinence
involuntary loss of urine as result of sneezing, coughing or changing position (decreasing ligament and pelvic floor support)
Urge Incontinence
associated with strong urge to void that cannot be suppressed - pt can't reach toilet in time (uninhibited detrusor contraction) (smooth muscle in bladder wall)
Reflex Incontinence
due to hyperreflexia in absence of normal sensations usually associated with voiding (spinal cord injury)
Overflow Incontinence
Associated with over distention resulting from bladder's inability to empty normally (spinal cord lesions, tumors, strictures, prostatic hyperplasia)
Functional Incontinence
lower urinary tract functionally intact but other factors make it difficult for patient to recognize need to void or physical impairments prevent reaching toilet in time (Alzheimer's)
Iatrogenic Incontinence
due to extrinsic medical factors, predominantly medications (alpha-adrenergic agents cause bladder neck relaxation to point of incontinence with minimal intra-abdominal pressure)
Mixed Incontinence
Combination of different incontinences
Incontinence Assessment/Medical Management
Assessment - history, urodynamic testing

Medical management
-Behavioral therapy - Kegel exercises, prompted voiding, voiding diary
-Pharmacologic - anticholinergics, tricyclic antidepressants, pseudoephedrine, hormone therapy
-Surgical management- lifting and stabilizing bladder or urethra, periurethral bulking, artificial urinary sphincter, TURP
Nursing Management (Incontinence)
Patient Education
-Fluid management
-Timed voiding, prompted voiding, habit retraining, bladder retraining
-Kegel or vaginal cone retention exercises
-Transvaginal or transrectal electrical stimulation - re-educates muscles to elicit a passive contraction
-Neuromodulation - inhibits detrusor over-stimulation
Urinary Retention
Results from:
-prostatic enlargement
-urethral pathology (infection, tumor, calculus)
-neurologic disorder - stroke, spinal cord injury, MS, Parkinson's
-Medications - anticholinergics, antispasmodic agents, tricyclic antidepressants, beta adrenergic blockers, estrogen
Retention Assessment Guide
-time of last voiding - volume voided?
-Voiding small amounts frequently?
-Dribbling urine?
-Complaint of pain or discomfort in lower abdomen?
-Is pelvis rounded and swollen
-Does percussion elicit dullness?
-Are other indicators present such as restlessness and agitation?
-Does post void bladder ultrasound test reveal residual urine?
Nursing Measures to Encourage Normal Voiding
-Provide privacy
-Ensure environment and position conductive to voiding
-Assist to BR rather than BSC or bedpan
-Apply warmth to relax sphincters
-Turn on water
-Stroking the abdomen or inner thighs
-dipping pt's hands in warm water
-pouring warm water over pubic area
Neurogenic Bladder
-Caused by neuro lesion, spinal cord injury, spinal tumor, herniated vertebral disk, MS, spina bifida or myelomeningocele, infection or DM

Two types:
-Spastic or Reflex
Spastic or Reflex (Neurogenic Bladder)
lesion above voiding reflex - loss of conscious sensation and cerebral motor control. Empties on reflex with minimal or no controlling influence
Flaccid (Neurogenic Bladder)
lower motor neuron lesion resulting from trauma. Bladder continues to fill and distend and have overflow incontinence. Pt. feels no bladder discomfort
Medical Management (Neurogenic Bladder)
-continuous, intermittent or self catheterization or condom caths
-Diet low in calcium to prevent calculi
-Encourage mobility and ambulation
-liberal fluid intake to reduce stasis and concentration of calcium in urine
-Bladder re-training - timed, schedule, double voiding
-Parasympathomimetic - Urecholine
Renal Calculi statistics
-renal calculi account for more than 320,000 hospital admissions per year
-Occurs primarily in 3rd to 5th decade
-Affects men more than women
Pathophysiology (Renal Calculi)
-formed when concentrations of calcium oxalate, calcium phosphate, and uric acid increase (super saturation)
-Found in both kidney and bladder and vary in size from granules to as large as an orange
Factors Favoring Stone Formation
-urinary stasis
-increased calcium concentrations in blood and urine (75% stones - calcium)

-renal tubular acidosis
-granulomatous diseases
-excessive intake of Vitamin D, milk and alkali
-Myeloproliferative diseases - leukemia, multiple myeloma
Manifestations of Renal Calculi
-S/S dependent on presence of obstruction, infection, and edema
-renal pelvis
-stone lodged in ureter - ureteral colic
-Pt can pass stone 0.5-1 cm. Larger stones have to be fragmented or removed
-Stones lodged in bladder
Renal Pelvis
intense, deep ache in costovertebral region and radiating down, hematuria, pyuria, n&v
Stone lodged in ureter (ureteral colic)
excruciating, colicky, wavelike pain, radiating down the thigh to genitalia, desire to void. May have hematuria
Stones lodged in bladder
symptoms of irritation like UTI and hematuria
Diagnostics (Renal Calculi)
Stones confirmed by:
-IV urography or retrograde pyelography
-blood chemistries
-24 hr. urine for calcium
-uric acid
-total volume
Medical Management (Renal Calculi)
-Opioid analgesics to prevent shock and syncope from excruciating pain

Nutritional therapy:
-Calcium stones - increased fluid intake - only restrict Ca with type IIK absorptive hypercalciuria (1/2 of pt)
- Thiazide Diuretic

-Uric acid stones - low purine diet - Allopurinol

-Cystine stones - Low protein diet - Captopril (Capoten)

-Oxalate stones - limit oxalate - spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran - Allopurinol & Vit. B6
Medical Management (Renal Calculi)
Interventional Procedures
-Ureteroscopy: visualizing stone & destroying it with laser, electrohydraulic lithotriptor or ultrasound and placing stent

-Extracorporeal shock wave lithotripsy (ESWL) - break stones in calyx of kidney

-Percutaneous nephrolithotomy - nephroscope inserted percutaneously into renal parenchyma and stone extracted with forceps or ultrasound probe used to pulverize stone

Chemolysis- stone dissolution with chemicals (alkylating agents, acidifying agents)
Nursing Management (Renal Calculi)
-Pain relief - opioids
-fluid intake
-strain all urine
-signs of infection
-frequent vital signs
-patient education: fluid and dietary intake, how to strain urine, signs of infection
Bladder Cancer statistics
-most common in 50-70 y/o
-more men than women
-more in Caucasians than African Americans
-4th leading cause of cancer in men - 13,000 deaths annually
Risk Factors (Bladder Cancer)
-cigarette smoking
-exposure to environmental carcinogens (dyes, rubber, leather, ink, or paint)
-recurrent or chronic bacterial infection of urinary tract
-bladder stones
-high urinary pH
-high cholesterol intake
-pelvic radiation therapy
-cancer of prostate, colon, and rectum in males
Treatment (Bladder Cancer)
Dependent on grade and stage and multicentricity, pt age and physical status

-Surgical: Transurethral resection followed by intravesical admin. of BCG, Cystectomy-simple or radical

-Pharmacologic: Chemo- methotrexate, 5-FU, vinblastine, doxorubicin and cisplatin

-Radiation therapy
Urinary Diversions
Urine diverted from bladder to new exit site.

-Ileal Conduit
-Cutaneous ureterostomy
Ileal Conduit
ureter implanted into ileal segment and then to surface
bladder sutured to abd. wall and creates stoma for drainage
catheter inserted into renal pelvis
Continent Urinary Diversions
-Kock pouch
-Modified Kock
(Continent Urinary Diversions)
-ureters attached to segment of ileum and cecum. Stoma catheterized
Kock pouch
(Continent Urinary Diversions)
-ureters connected to small bowel and develops continence mech/valve. Stoma catheterized
Modified Kock
(Continent Urinary Diversions)
-attach 1 end of pouch to urethra in males only for more normal voiding
(Continent Urinary Diversions)
-ureters connected to sigmoid colon and through rectum
Benign Prostatic Hypertrophy/Hyperplasia (BPH) statistics
-Half of men 50 y/o and 80% of those 80 y/o
-BPH is responsible for 375,000 hospital stays/year
-African Americans develop BPH at a younger age (40)
Risk Factors (BPH)
-heavy alcohol consumption
-heart disease

Hypertrophied lobes of the prostate obstruct the vesical neck causing incomplete emptying of the bladder and urinary retention. Estradiol may have an effect.
Manifestations (BPH)
-abdominal straining with urination
-decrease in volume and force
-interruption of urinary stream
-sensation of incomplete emptying
-recurrent UTIs
-azotemia: concentration of urea and other nitrogenous wastes in the blood
-renal failure can occur
Treatment (BPH)
If pt presents ot ER with inability to void - catheterize - may need stylet

-Alpha-adrenergic blockers (Hytrin, Cardura, Flomax): relax smooth muscle of bladder neck and prostate

-Antiandrogen agents (Proscar, Avodart)

-Saw palmetto: herbal product

-Transurethral Incision of Prostate (TUIP)
-Transurethral Prostatectomy (TURP)
-Transurethral needle abalation
-Microwave thermotherapy
Nursing Management (BPH)
-Usual postop monitoring
-Monitor for excessive bleeding
-Force fluids unless contraindicated
-May have continuous bladder irrigations
-Catheter until bleeding has stopped
-May have difficulty voiding after cath removed
Prostate Cancer statistics
-Most common cancer in men other than nonmelanoma skin cancer - highest in African American men
-2nd most common cause of cancer death in men (lung CA first)
-Survival rate - 98% at 5 yrs, 84% at 10 yrs, 56% 15 yrs
-Rare in Asia, Africa, Central/South America
-Incidence increases after 50 y/o and in men who have high dietary intake of red meat and fat
Clinical manifestations (Prostate Cancer)
-Difficulty and frequency of urination
-Decreased in size and force of stream
-Back, hip perineal pain from metastasis
-Weight Loss
Diagnosis (Prostate Cancer)
-Digital rectal exam
-Prostate specific antigen (PSA)
-ACS recommends every man 50 y/o and older have annual rectal exam and PSA
-Bone scans
Treatment (Prostate Cancer)
---radical prostatectomy

---teletherapy - external beam radiation tx
---Intensity-modulated radiation therapy (IMRT)
---Brachytherapy - implantation of interstitial radioactive seeds

-Hormonal therapy
---Orchiectomy - removal of testes (testosterone)
---Nonsteroidal antiandrogen bicalutamide (Casodex) and/or DES - diethylstilbesterol to inhibit response to androgenic activity

Nursing Management (Prostate Cancer)
-Routine postoperative care
-Monitor postop complications
---deep vein thrombosis
---obstructed catheter
---complications with catheter removal
---sexual dysfunction

-Patient education
---Management of cath at home
---wound care
---S/S to report
---perineal exercises
Acute Renal Failure (ARF)
-Reversible syndrome with sudden and almost complete loss of kidney function over period of hours to days.
-Increase in serum creatinine and BUN

May have:

-Mortality rate 60-80%
Urine less than 400 cc/day
Urine greater than 400 cc/day
Urine less than 50 cc/day
Categories of ARF
-(60-70%) - impaired blood flow to kidney and decreased GFR
-Parenchymal damage to glomeruli or kidney tubules (ATN) usually from nephrotoxic agents (aminoglycosides, radiocontrast agents = 30%)

-Burns, crushing injuries, infections, transfusion reactions
Obstruction distal to kidney
Phases of ARF
-begins with insult; ends when oliguria develops
-increase in serum concentration of substances excreted by kidneys. Uremic symptoms first appear and hyperkalemia develops
-gradual increase in output; labs stop increasing; uremic symptoms may still exist
-improvement of renal function - may take 3-12 months
Manifestations of ARF
SEE Table 44-2 in textbook

Prerenal- hypoperfusion
Intrerenal- parenchymal damage
Postrenal- Obstruction
Diagnosis (ARF)
-low specific gravity of urine - inability to concentrate urine
-Ultrasound - anatomical changes in kidney
-Increase BUN - rate dependent on degree of catabolism
-Increased creatinine - indicates glomerular damage
-Metabolic acidosis
-Decrease in serum pH
-Anemia - reduced erythropoietin production
Prevention of ARF
-Provide adequate hydration
-Prevent/treat shock promptly
-Monitor CVP and arterial pressures and hourly I&O of critically ill pts
-Treat hypotension promptly
-Continually assess renal function
-Ensure appropriate blood administration to pts
-Prevent & treat infections promptly
-Pay attention to wounds, burns and other precursors of sepsis
-meticulous cath care and d/c caths asap
-Closely monitor medications excreted by kidney
Medical Management (ARF)

-Maintaining fluid balance
-treat underlying cause immediately
-If hypovolemia due to hypoproteinemia - administer Albumin
---Hyperkalemia - Kayexalate
---Reduce medication dosages
---Other agents to treat symptomatology
---Weigh daily to determine nutritional deficiencies and correct
if hypovolemia due to hyoproteinemia - give Albumin
Nursing Management (ARF)
-Monitor fluid and electrolyte balance
---EKG patterns
---IVs in smallest volume possible
-Bedrest to decrease metabolic rate
-Turn, cough, deep breathe
-Prevent infection - strict asepsis with cath, lines, wounds, etc.
-Skin care - dry, excoriated, itchy (uremic frost)
-Provide support - life threatening - may require dialysis
Chronic Renal Failure (ESRD) statistics
Incidence has increased 8%/yr for past 5 years
-280,000 CRF
-65% on hemodialysis
-28% have functioning transplants
-7% receiving peritoneal dialysis
Pathophysiology [Chronic Renal Failure (ESRD)]

Progressive, irreversible deterioration in renal function resulting in uremia or azotemia
Azotemia- medical condition characterized by abnormal levels of nitrogen-containing compounds, such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood.
Conditions resulting in ESRD
-Diabetes mellitus (leading cause)
-Chronic glomerulonephritis
-obstruction of urinary tract
-polycystic kidney disease
-vascular disorders
-medications or toxic agents
Stages of Chronic Kidney Disease
Chart 44-3 in textbook


1- minimal kidney damage with normal glomerular filtration rate
2- mild w/ mildly decreased GFR
3- Moderate with moderate
4- severe with severe decrease
5- failure, ESRD with no GFR
Clinical Manifestations - Cardiovascular [Chronic Renal Failure (ESRD)]
-hypertension - Na+ and water retention
-heart failure
-pulmonary & peripheral edema
-pericarditis from uremic toxins
- orthostatic hypotension
Clinical Manifestations - Dermatological [Chronic Renal Failure (ESRD)]
-uremic frost: White crystals in and on the skin
-decreased skin turgor
- yellow cast to skin
- bruising
Clinical Manifestations - Gastrointestinal [Chronic Renal Failure (ESRD)]
-uremic fetor: Ammonia odor to breath
Clinical Manifestations - Neurologic [Chronic Renal Failure (ESRD)]
-altered LOC
-inability to concentrate
-muscle twitching
-peripheral neuropathy
More Clinical Manifestations (CRF)
Chart 44-4 in Textbookl-
Renal-polyuria, nocturia, oliguria, anuria, proteinuria, hematuria and dilute urine color
Medical Management: Pharmacologic [Chronic Renal Failure (ESRD)]
-Phosphate binding agents
-calcium supplements
-cardiac medications
-anti-seizure medications
-erythropoietin (Epogen)
Medical Management: Nutrition [Chronic Renal Failure (ESRD)]
-Careful regulation of protein, fluid, sodium, potassium intake (high biologic value proteins) (fluid intake based on output from previous day)
-vitamin supplementation
-removes fluid and uremic waste products when kidneys unable to
-Most common
-Synthetic semipermeable membrane replacing renal glomeruli and tubules as filter
-usually 3x per week for 3-4 hours
-uses principles of diffusion, osmosis and ultrafiltration
Vascular Access Devices
-Double lumen large bore cath into subclavian, internal jugular or femoral vein - used no more than 3 weeks

---Double lumen cuffed cath (Quinton)

-arteriovenous fistula (AV fistula)
---Anatamose artery to a vein (side to side or end to side)
---Accessed with needles

-Arteriovenous Graft (AV Shunt)
---Placing synthetic graft between artery and vein
---Graft can be used within 10 days
Complications of Dialysis
-Bleeding - exsanguination (= The fatal process of total blood loss.)
-gastric ulcers
-sleep disturbances
-painful muscle cramping
-air embolism
-chest pain
-dialysis disequilibrium - CSF shifts
Nursing Management of ARF or CRF (ESRD)
-Monitor weight, vs, cardiovascular status
-Monitor fluid & electrolyte balance
-Monitor nutritional status
-Administer appropriate medications
---Need to distinguish dialyzable meds from those which are not removed by dialysis
---Clarify meds given during or after dialysis
-Address psychosocial needs
---Lifestyle altered with dialysis
-Patient education
---Diet, meds, dialysis, restrictions in activity
-Discharge planning
Continuous Renal Replacement Therapy (CRRT)
-Therapy for ACR (acute or chronic renal failure), ESRD pts who are too clinically unstable for hemodialysis
-CRRT does not produce rapid fluid shifts and does not require dialysis machine
-Hemofilter used in all methods
Types of Continuous Renal Replacement Therapy
-Continuous Venovenous Hemofiltration
-Continuous Venovenous Hemodialysis
-Peritoneal Dialysis
Continuous Venovenous Hemofiltration (CVVH)
-Blood from double lumen pumped through hemofilter and returned by same cath
-Removes fluid slowly from the blood
Continuous Venovenous Hemodialysis
-Same as hemofiltration, but uses concentration gradient to facilitate removal of toxins
Peritoneal Dialysis
-Peritoneum serves as semipermeable membrane. Dialysate introduced into abdomen, sits in abdomen and toxins removed by diffusion, then drained. Takes 36-48 hrs to do what hemodialysis does in 6-8 hours
---Acute Intermittent
---Continuous Ambulatory Peritoneal Dialysis (CAPD)
Continuous Ambulatory Peritoneal Dialysis (CAPD)
-peritoneal cath implanted through abdominal wall
-Dacron cuffs and tunnel approach decreases infection
-Dialysate flows by gravity into peritoneal cavity, dwells and drained.
Complications of Peritoneal Dialysis
Nursing Management of Dialysis Patient
-Protecting Vascular Access!
-Caution with IV rates to prevent hypervolemia
-Monitor s/s of uremia/azotemia
-Monitor for cardiac and respiratory complications (fluid overload, heart failure, pulmonary edema, pericarditis)
-Monitor diet and electrolyte levels
-pain relief
-prevent infection
-administer medications cautiously - monitor therapeutic levels
Protecting Vascular Access
-No blood draws or BP in affected limb
-Assess bruit or thrill over site q 8 hrs
-Assess for s/s of infection