kidney problem

7/30/2019 Kidney Problem

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Urinary Tract Infection (UTI)

Background

1. Bacterial infections of urinary tract are a verycommon reason to seek health services

2. Common in young females and uncommon in males

under age 503. Common causative organisms

a. Escherichia coli(gram-negative enteral bacteria)causes most community acquired infections

b. Staphylococcus saprophyticus, gram-positiveorganism causes 10 15%

c. Catheter-associated UTIs caused by gram-negative bacteria: Proteus, Klebsiella, Seratia,Pseudomonas


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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 competentureterovesical junction

f. Increased intravesicular pressure preventing

reflux g. In males, antibacterial effect of zinc in prostatic

fluid


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Pathophysiology

1. Pathogens which have colonized urethra, vagina, orperineal area enter urinary tract by ascendingmucous membranes of perineal area into lower

urinary tract2. 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)


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Risk Factors1. Aging a. Increased incidence of diabetes mellitus b. Increased risk of urinary stasis

c. Impaired immune response2. Females: short urethra, having sexual intercourse,

use of contraceptives that alter normal bacteria floraof vagina and perineal tissues; with age increasedincidence of cystocele, rectocele (incomplete

emptying)3. Males: prostatic hypertrophy, bacterial prostatitis,

anal intercourse4. Urinary tract obstruction: tumor or calculi, strictures5. Impaired bladder innervation


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Cystitis1. Most common UTI2. Remains superficial, involving bladder mucosa, which becomes

hyperemic and may hemorrhage3. 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


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Pyelonephritis1. Inflammation of renal pelvis and parenchyma

(functional kidney tissue)2. Acute pyelonephritis

a. Results from an infection that ascends to kidneyfrom lower urinary tractRisk 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


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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 acutepyelonephritis; 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


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Manifestations in older adults

1. Change in behavior

2. Acute confusion

3. Incontinence

4. General deterioration in condition


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Chronic pyelonephritisa. Involves chronic inflammation and scarring

of tubules and interstitial tissues of kidneyb. Common cause of chronic renal failurec. May develop from chronic hypertension,

vascular conditions, severe vesicourteteralreflux, obstruction of urinary tract

d. Behaviors

1. Asymptomatic 2. Mild behaviors: urinary frequency,

dysuria, flank pain


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Collaborative Care a. Eliminate causative agent b. Prevent relapse c. Correct contributing factors

Diagnostic Testsa. Urinalysis: assess pyuria, bacteria, blood cells in urine;

Bacterial count >100,000 /ml indicative of infectionb. 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 urineor catheterization


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d. Urine culture and sensitivity: identify infecting organismand most effective antibiotic; culture requires 24 72hours for results; obtain by clean catch urine orcatheterization

e. WBC with differential: leukocytosis and increased

number of neutraphils6. Diagnostic Tests for adults who have recurrent infections

or persistent bacteriuriaa. Intravenous pyelography (IVP) or excretory urography 1. Evaluates structure and excretory function of

kidneys, ureters, bladder 2. Kidneys clear an intravenously injected contrastmedium that outlines kidneys, ureters, bladder, andvesicoureteral reflux

3. Check for allergy to iodine, seafood, radiologiccontrast medium, hold testing and notify physician or

radiologist


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b. Voiding cystourethrography: instill contrast mediuminto bladder and use xray to assess bladder andurethra when filled and during voiding

c. Cystoscopy

1. Direct visualization of urethra and bladderthrough cystoscope

2. Used for diagnostic, tissue biopsy, interventions

3. Client receives local or general anesthesia

d. Manual pelvic or prostate examinations to assessstructural changes of genitourinary tract, such asprostatic enlargement, cystocele, rectocele


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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: forpyelonephritis, urinary tract abnormalities or stones,or history of previous infection with antibiotic-resistant infections; clients with severe illness mayneed hospitalization and intravenous antibiotics

c. Antibiotics commonly used for short and longercourse therapy include trimethoprim-sulfamethoxazole (TMP-SMZ), or quinolone antibioticsuch as ciprofloxacin (Cipro)

d. Intravenous antibiotics used includeciprofloxacin, gentamycin, ceftriaxone (Rocephin),

ampicillin


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Possible outcomes of treatment for UTI, determinedby follow-up urinalysis and culture

1. Cure: no pathogens in urine 2. Unresolved bacteriuria: pathogens remain

3. Persistent bacteriuria or relapse: persistentsource of infection causes repeated infection afterinitial cure

4. Reinfection: development of new infection withdifferent pathogen

f. Prophylactic antibiotic therapy with TMP-SMZ,TMP alone or nitrofurantoin (Furadantin, Nitrofan)may be used with clients who experience frequentsymptomatic UTIs

g. Catheter-associated UTI: removal of indwelling

catheter followed by 10 14 day course of antibiotictherapy


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Surgery

a. Surgical removal of large calculus from renalpelvis or cystoscopic removal of bladder calculiwhich serve as irritant and source of bacterial

colonization; may also use percutaneous ultrasonicpyelolithotomy or extracorporeal shock wavelithotripsy (ESWL)

b. Ureteroplasty: surgical repair of ureter forstricture or structural abnormality; reimplantation if

vesicoureteral reflux; clients usually return fromsurgery with catheter and ureteral stent in place for 3

5 days


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Nursing Care: Health promotion to prevent UTIa. Fluid intake 2 2.5 L daily, more if hot weather or

strenuous activity is involvedb. Empty bladder every 3 4 hoursc. Females 1. Cleanse perineal area from front to back 2. Void before and after sexual intercourse 3. Maintain integrity of perineal tissuesa. Avoid use of commercial feminine hygiene products

or douchesb. Wear cotton underweard. Maintain acidity of urine (use of cranberry juice,

take Vitamin C, avoid excess milk and milk products,sodium bicarbonate)


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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 antibiotictherapy

Home Care: Teaching: prevention of infectionand use alternatives to indwelling catheterwhenever possible


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Client with Urinary CalculiBackground

1. Urinary calculi are stones in urinary tract a. Nephrolithiasis: stones form in kidneys b. Urolithiasis: stones form in urinary tract outside

kidneys2. Highest incidence in southern and Midwestern states

3. Males more often affected than females (4:1) 4. Most common in young and middle adultsB. 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


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Client with Urinary Calculi

Pathophysiology1. Factors leading to lithiasis include supersaturation (highconcentration of insoluble salt in urine), pH of urine

2. Types of calculia. Calcium stones (calcium oxalate, calcium phosphate) 1. Associated with high concentrations of calcium in blood

or urine 2. Genetic linkb. Uric acid stones 1. Associated with high concentration of uric acid in urine 2. Genetic link

3. More common in males 4. Associated with goutc. Sturvite stones 1. Associated with UTI caused by bacteria Proteus 2. Stones are very large 3. Staghorn stones in renal pelvis and calycesd. Cystine stones: Associated with genetic defect


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Development and location of calculi within

the urinary tract


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Manifestations: depends upon size and location of stones1. 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 hematuria3. Calculi affecting ureter, causing ureteral spasm

a. Renal colic: acute, severe flank pain of affected side,radiates to suprapubic region, groin, and externalgenitals

b. Nausea, vomiting, pallor, cool, clammy skin 4. Manifestations of UTI may occur with urinary calculi


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Complications1. Obstruction: manifestations depend upon speed of

obstruction development; can ultimately lead torenal failure

2. Hydronephrosis: distention of renal pelvis andcalyces; 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 orflank c. Other manifestations: hematuria, signs of UTI, GI

symptoms


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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 diagnosestone type

2. Chemical analysis of stone: All urine must be

strained and saved; stones or sediment sent foranalysis

3. 24-urine collection for calcium, uric acid, oxalateto identifiy possible cause of lithiasis

4. Serum calcium, phosphorus, uric acid: identify

factors in calculi formation


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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


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Percutaneous ultrasonic lithotripsy


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3. Medications to inhibit further lithiasis according toanalysis 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 ofurine 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 acidstones


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Lithotripsy: Use of sound or shock waves to crush stones 1. Extracorporeal shock-wave lithotripsy: acoustic

shock waves aimed under fluoroscopic guidance topulverize stone into fragments small enough to beeliminated 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 andfragments removed through nephroscope

3. Laser lithotripsy: stone is disintegrated by use of

laser beams; nephroscope or ureteroscope used to guidelaser probe

4. Stent may be inserted into affected ureter afterprocedure to maintain patency after lithotripsyprocedures


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Surgery1. May be indicated as treatment depending on stone

location, severe obstruction, infection, seriousbleeding

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 staghorncalculus in calices and renal parenchyma d. Cystoscopy: crushing and removal of bladder

stones through cystocope; stone fragments irrigatedout of bladder with acid solution


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Nursing Care 1. Focus on comfort during renal colic, diagnostic

procedures, ensure adequate urine output, preventfuture stone formation

2. Health promotion: adequate fluid intake for allclients, adequate weight-bearing activity to preventbone 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; clientsafety must be maintained


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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 sterilitymaintained

3. Deficient Knowledge: Client participation intreatment and prevention

Home Care 1. Education regarding management current treatment

and prevention 2. Clients may be discharged with catheters, tubes,

dressings; home care referral


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Urinary Tract Tumor

Background

1. Malignancies in urinary tract: 90% bladder; 8%renal pelvis; 2% ureter, urethral; 5 year survival ratefor bladder cancer is 94%

2. Bladder cancer: 4 times higher in males thanfemales; 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 bladdermucosa


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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


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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


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Urinary Tract Tumor

Medications 1. Immunologic or chemotherapeutic agent

administered by intravesical instillation used asprimary treatment of bladder cancer or to preventrecurrence 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


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Urinary Tract Tumor

Surgery1. Cystoscopic tumor resection by a. Excision b. Fulguration: destruction of tissue using high

frequency electric current

c. Laser photocoagulation: light energy to destroytumor

2. Radical cystectomy: standard treatment to treat invasivecancers; removal of bladder and adjacent muscles andtissues

a. Males: includes prostate and seminal vessels b. Females: hysterectomy, salpingo-oophorectomy3. Client needs to have urinary diversion done to provide for

urine collection and drainage through ileal conduit orcontinent urinary diversion (ureters are implanted inportion of ileum which is surgically made into a reservoirfor urine and stoma brought to surface of abdomen)


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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 possiblyurine cytology


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Urinary Tract TumorNursing Diagnoses1. Impaired Urinary Elimination2. 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 asleep3. 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


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Urinary Tract Tumor

Home Care

1. Involves continual surveillance forcancer recurrence

2. If client has had urinary diversionsurgery requires teaching regardingstoma and skin care

3. Home care referral

4. Smoking cessation

kidney problem

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